The Crisis of Youth Mental Health

Author Article

(Illustration by Mike McQuade)

One in five children in the United States has a diagnosable mental health condition. Unfortunately, access to care for these children is poor: At least 85 percent of those in need of treatment do not get it.1 More than half of mental illness emerges before age 14, so getting children the help they need, in addition to ameliorating their immediate suffering, can also prevent future pain. The result of not getting help can be dire, as suicide is now the second leading cause of death for those between ages 10 and 34.2

Mental illness exacts a staggering cost on society. It leads most measures of economic burden for noncommunicable diseases. The World Economic Forum issued a report that mental illness has a greater impact on economic output than cancer, heart disease, or diabetes.3 The report’s authors estimate the worldwide cost of mental illness to be $16 trillion between 2011 and 2030. Other recent research has indicated that untreated anxiety and depression costs society $1.15 trillion annually.4

While the economic burden of mental illness is staggering, the total spending devoted to addressing it is shockingly low.5 In low-income countries, outlays are minuscule: less than 1 percent of total health budgets. But even in high-income countries such as the United States, the expenditure on mental health as a percent of total health budgets is grossly inadequate, given the prevalence of mental illness. Overall, it is widespread in children, its cost to society in terms of pain and suffering and financial burden is enormous, and its overall funding is insufficient.

Those who work in mental health call the shortfall between the percentage of people with a mental health condition and those who receive help the “treatment gap.” Its persistence indicates a problem that government and business have failed to address. It is especially important to prevent children and adolescents from falling into the gap, because of the compounded costs of untreated mental illness that continues into adulthood. Private philanthropy is in a unique position to lead the effort, in collaboration with government, business, and the nonprofit sectors, to ensure that all children needing mental health treatment receive it. The availability of proven or promising interventions, growing public awareness of the importance of mental health, and the projections of significant private philanthropic funds becoming available in the next decade make this an opportune time for private philanthropy to lead the effort to close the gap.

Mind the Gap

Why do children in need of mental health treatment not get it? The World Health Organization (WHO) outlines three primary components of access to health care: physical accessibility, financial affordability, and acceptability.6 Physical accessibility involves health care’s geographical proximity and availability at convenient times for the people who need it. Affordability means that those who want health care can get it without financial hardship. Acceptability means that people believe health care is effective and respectful of their social and cultural background.

During the past 30 years, health care has focused on “evidence-based medicine,” which incorporates available scientific research into clinical decision making to ensure optimal patient care. This focus has spawned hundreds of scientifically tested, evidence-based mental health treatments, most of which use individual psychotherapy to address specific clinical problems, such as depression or anxiety. For the past two decades, mental health treatment researchers have been optimistic that implementation science might help improve physical access to evidence-based care. Implementation science is the study of systematically developing and testing strategies for spreading, scaling, and sustaining evidence-based treatments. But implementation science has had, at best, marginal effects on access to evidence-based mental health care. For example, a recent study showed that for children using publicly funded services in the United States, only 2 percent received an evidence-based treatment based on scientific research.7

Click to enlarge. SOURCE: Adapted from David E. Bloom, et al., “The Global Economic Burden of Non-communicable Diseases,” Geneva: World Economic Forum, 2011.

Some states, such as Connecticut, have invested considerable public funds into increasing access to evidence-based treatments and have achieved better results.8 For example, at the children’s behavioral health agency that I lead, the Child Guidance Center of Southern Connecticut, 8 percent of the 1,386 children we served in 2017 received an evidence-based treatment that adhered to strict standards that the developers of these treatments established. Although this figure is four times the US average, most of the children we served are not getting these treatments. Instead, they are receiving individual psychotherapy that, while helpful, may not always be as effective as
evidence-based practice. Unfortunately, even in a state like Connecticut, where evidence-based treatments are more geographically accessible, there are often wait lists for these treatments that render them inaccessible for the vast majority of children.

The numbers we serve at the Child Guidance Center with an evidence-based model are relatively small because it requires such extensive staff training and consultation. None of the state grants we receive to implement and sustain evidence-based practices comes close to covering the costs of these practices. Researchers who recently examined the costs of sustaining one evidence-based treatment in Connecticut calculated an incremental per-patient annual expense of $1,896.9 For the Child Guidance Center of Southern Connecticut to treat all children in need of outpatient or home-based services with an evidence-based practice like the one these researchers highlighted, it would cost an additional $2,627,856 (1,386 patients at $1,896 each). This expense would increase our $5.2 million annual budget by more than 50 percent and would require twice the amount of funding we currently receive from the state of Connecticut to deliver these services. We serve a small percentage of the roughly 56,200 Connecticut children who receive behavioral health care through Medicaid. To cover all of these publicly funded children with evidence-based treatment would cost an additional $106,555,200 annually. No state is flush enough in these austere times to absorb that kind of incremental cost. Thus, evidence-based treatments as they are currently delivered are not affordable.

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While there is considerable scientific support for evidence-based psychosocial interventions for children’s mental health problems, this research is based primarily on studies of non-Hispanic white children. There is much less evidence supporting these interventions for ethnic minority youth.10 Cultural factors, such as perceived stigmas and different conceptions of mental illness or treatment, likely influence the effectiveness of existing evidence-based interventions, as does a dramatic shortage of ethnic-minority mental health clinicians. Approximately 90 percent of mental health clinicians in the United States are non-Hispanic white, but 30 percent of people in the United States belong to a racial or ethnic minority.11 In states that have growing immigrant populations, such as Connecticut, competition is fierce among nonprofit mental health agencies seeking to hire qualified bilingual clinicians, because there simply aren’t enough of them to serve the expanding population. Consequently, the acceptability of evidence-based mental health interventions among racial or ethnic minority populations is inconsistent.

The shortage of racial and ethnic minority mental health clinicians is part of a much larger problem. Given the prevalence of mental health needs, there are not enough clinicians of any race or culture. Recent estimates of the number of mental health clinicians range between 550,000 and 700,000, which is clearly not enough when 25 percent of people in the United States—approximately 80 million people—have a mental health disorder.12 In addition, most providers do not treat children, which is why only 15 percent of children who need treatment get it. Alan Kazdin, an internationally renowned psychologist and longtime developer and advocate of evidence-based treatments, has concluded that using the dominant model of psychosocial treatment—individual psychotherapy with a mental health professional in an office-based setting—to address the treatment gap is not possible. He writes:

Expanding the workforce to deliver treatment with the usual, in person, one-to-one model of care with a trained mental health professional is not likely to have a major impact on reaching the vast number of people in need of services. The increased person power is not likely to provide treatments where they are needed, for the problems that are needed, and attract the cultural and ethnic mix of clientele that are essential. 13

Kazdin is not suggesting that we stop providing individual, evidence-based treatments. Rather, he argues that we also need to develop new models of delivery to reach the vast majority of those who need help but are unlikely to receive individual therapy. The mental-health-care sector needs to develop innovative treatment delivery models and to test and implement existing new models. But to do so, it needs far more funding than it is currently receiving.

The State of Funding

Getting a handle on mental health research funding is not easy. Analysts have used several methods to determine its status, one of which is to study bibliographic funder acknowledgments from published mental health research articles. In 2016, the RAND Corporation conducted a bibliographic study of the acknowledgments in 220,000 mental health research publications between 2009 and 2014.14 The report found 1,900 funders that had more than 10 acknowledgments. Charities, foundations, and nonprofits represented 39 percent of these funders, government 33 percent, and academia 28 percent. The high percentage for papers funded by charities, foundations, and nonprofits suggests that foundations and charities may affect the field of mental health research more than public support does.

Researchers have also examined government and private funding of mental health research in the United States and the United Kingdom. The results reveal a startling lack of funding relative to the burden of mental illness. The largest funder of research in children’s mental health in the United States, the National Institute of Mental Health (NIMH), decreased funding for child and adolescent services and intervention research by 42 percent from 2005 to 2015 ($52 million to $30 million annually).15 Over the same period, the overall NIMH budget was flat and funding for neuroscience and basic behavioral research increased by 28 percent. Perhaps even more important, the $30 million dedicated to child and adolescent mental health represented only a 2.1 percent share of the total NIMH budget authority of $1.4 billion for 2015. This amount is disproportionately small, given that mental illness leads all measures of the economic cost of noncommunicable diseases.

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The data from private philanthropic support for mental health research in the United States are not much better. While funding increased in absolute dollars from 2006 to 2015, it decreased as a percentage of foundation funding of health care, from 6.2 percent to 5.6 percent.16 These downward funding trends are consistent with earlier researchers who reported that from 1998 to 2006, philanthropic support for mental health funding decreased as a percentage of foundation funding of health care, from 10.5 percent to 6.3 percent.17 More important, as a percentage of overall foundation funding of mental health, support for children’s mental health decreased from 37.1 percent to 34.2 percent and support for children’s mental health research decreased from 3.8 percent to 1.6 percent.

We find the same tale in the United Kingdom. The private British mental health charity MQ found that UK government funding for mental health research for children and adults was 5.5 percent of the total budget. By comparison, cancer research was nearly four times higher, at 19.6 percent.18 MQ also reported that mental health research accounts for just 3.1 percent of charity-funded research, compared with more than 30 percent for cancer, 13.5 percent for infection, and 7.6 percent for cardiovascular research. For every £1 the UK government spends on cancer research, the general public invests £2.75; for heart and circulatory problems, it’s £1.35. By contrast, for mental health research, the figure is £0.003, or a third of a penny.

New Delivery Models

Such a paucity of research funding should concern everyone in the health-care industry, given the widespread incidence of children’s mental illness and the high percentage of children who are not getting help. We can address this treatment gap by developing service-delivery models other than individual therapy and medication, but the effort will require more investment to drive the spread of these models.

Private philanthropy is especially suited to addressing the mental health treatment gap for children. As philanthropist Laura Arrillaga-Andreessen said in an interview with Forbes magazine,

Philanthropy is often seen as society’s risk capital. That means the onus is on philanthropists, nonprofit leaders, and social entrepreneurs to innovate. But philanthropic innovation is not just about creating something new. It also means applying new thinking to old problems, processes, and systems. 19

The mental health treatment gap in children is a prototypical example of a complex problem that requires new thinking, because the current service-delivery model—individual psychotherapy and medication—is ineffective in reaching the vast majority of kids. Unlike the business sector, which is accountable to shareholders; government, which is accountable to voters and special interest groups; and public charities, which are accountable to donors, private foundations need only meet their legal requirement within IRS regulations to disperse at least 5 percent of their endowments annually to tax-exempt causes. Private philanthropy is therefore in a position to take big risks. In addition, because of philanthropies’ capacity to fund, they can convene a variety of important parties, such as government funders and regulators, private industry, policy-
makers, and advocacy groups.20 The ability to convene and the freedom to take risks places private philanthropy in an ideal position to catalyze solutions to complex, multisystem problems like this one.

In his 2018 book, Innovations in Psychosocial Interventions and Their Delivery, Alan Kazdin proposes eight characteristics to guide the development and implementation of mental health service-delivery models to address the treatment gap.21 I have highlighted the three features that I believe are most important for funders: scalability, affordability, and acceptability. These characteristics offer a way for funders to weigh the impact that different service-delivery models might have in closing the treatment gap, and to compare and contrast the relative strengths and weaknesses of different models, because closing the treatment gap will require integrating many different service-delivery models. (No one model will address all problems or all populations.) Not coincidentally, affordability and acceptability are also two of the three components of the WHO’s definition of access to treatment described earlier. Ultimately, closing the treatment gap is about making mental health interventions accessible to all who need them. 
Several systemic changes in health care have already begun to foster new models of delivery that may improve the accessibility of care for children struggling with mental health problems. For example, health insurers and payers, including Medicare and Medicaid, have begun moving from volume to value—from reimbursement based on fees for service (e.g., a session of individual therapy) to reimbursement based on population health outcomes. Population health emphasizes scalability at the outset of designing ways to improve children’s mental health. Focusing on the mental health of entire populations fosters prevention and early intervention in children, because these practices are likely to be less expensive than waiting until mental health problems arise or become more severe.

We now have the opportunity to build on these changes by furthering the adoption of new models. Specifically, funders should consider four innovative models of delivery to reach children struggling with mental health needs. Private foundations have begun incubating all of these innovative models, yet the time is ripe for philanthropy to play a much larger role in funding these models to close the treatment gap once and for all. Let’s consider them in turn.

Task Shifting

Task shifting is the process of delegating tasks, when appropriate, to less specialized health workers. Other countries have used task shifting for decades to improve access to care. In the United States, the change to value-based purchasing is driving health-care delivery systems to employ task shifting to both improve access and lower costs. Most people have become familiar with task shifting through visits to their doctor’s office, where they are seen first by a medical assistant, then by a nurse or physician’s assistant, and then, finally, for a few minutes by a physician.22

A particularly innovative example of task shifting is Project Echo, which trains primary-care clinicians to provide specialty services by linking these clinicians via videoconference to multidisciplinary teams of specialists in academic medical centers. Project Echo’s first test of its model, with hepatitis C in rural New Mexico, was so successful that the prototype has been expanded to cover more than 100 diseases, including adult psychiatric and substance-use disorders. The Robert Wood Johnson Foundation has funded Project Echo to treat behavioral health problems in pediatric care.23 Project Echo aims to reduce disparities in access to care, expand the workforce of behavioral health clinicians, and diffuse best practices. However, as some researchers have cautioned, more research is needed to evaluate the clinical outcomes and cost effectiveness of Project Echo for diseases besides hepatitis C.

Click to enlarge.

Task shifting can also train laypersons to treat mental health needs, such as depression and anxiety, in low- and middle-income countries where few specialized providers exist.24In the United States, the professionalization of lay counselors into “peer specialists” is another example of task shifting. In March 2017, Mental Health America, in collaboration with the Florida Certification Board and Kaiser Permanente, developed the National Certified Peer Specialist Certification, which requires background checks, work experience, training, a certification test, and continuing education. In Connecticut, Beacon Health Options, the state’s administrative care organization for Medicaid, has employed peer specialists to reduce psychiatric inpatient days by 57 percent for children transitioning to a different level of care.25

Wider implementation of these interventions in the United States has been hampered by state licensing departments that are designed to protect the public from fraudulent practice and by mental health professional associations that exist to promote the reputation and financial viability of their professional members. As a result, many children who could be served will continue to go without treatment. Private foundations could play a role in advocating for change within professional associations, since foundations cannot lobby for changes in legislation. Because the treatment gap is so large, professional associations can endorse the use of lay therapists without adversely affecting the livelihoods of their professional constituents.

Task shifting shows promise along Kazdin’s three dimensions for new models. It makes care more affordable, by offering service considerably less expensive than the dominant model of individual psychotherapy conducted by a mental health professional. In addition, the fact that lay counselors and peer specialists have been well received by consumers suggests that their acceptability is high.26 The scalability of these models is yet to be fully evaluated, but the rapid expansion of task shifting and the growth of innovative models such as Project Echo imply that the scalability of task shifting is promising.

Digital Self-Help Technology

Digital technology—computers, the Internet, mobile devices, and apps—offers considerable promise as a delivery model that sidesteps stigmas and could expand access to evidence-based mental health care.27 Digital versions of a range of evidence-based psychotherapies are available, including Internet-based cognitive behavioral interventions for anxiety, depression, and post-traumatic stress disorder that focus on modifying unhealthy ways of thinking and improving behavioral coping skills.28 In addition, online self-help interventions exist to prevent anxiety and depression, such as MoodGym, which was designed for people ages 15 to 25 and has helped more than one million users. MoodGym has five interactive modules with information, exercises, and quizzes that focus on feelings, thoughts, and relationships. The modules are based on cognitive behavioral therapy and interpersonal therapy, which emphasizes changing social and familial difficulties. Clinician-supported digital interventions have been found as effective as face-to-face treatment.29 In addition, virtual reality treatment has proven effective for a number of child mental health conditions, including anxiety, depression, attention deficit hyperactivity disorder, eating disorders, and autism.30

Estimates of new philanthropic funding becoming available are sizable. But funding for children’s mental health is trending downward.

In 2014, the Colorado Health Foundation made its first program-related investment in MyStrength, an evidence-based online mental health treatment platform designed to expand access to mental health and wellness interventions for a range of clinical problems. The foundation structured its investment in this for-profit company as a $1.5 million senior loan agreement. Private foundations can use a range of program-related investments, including equity investments, investing in intermediary funders, loans, and recoverable grants, to fund early-stage for-profit companies that are expanding access to mental health care for children. The Bill & Melinda Gates Foundation has used many of these vehicles to foster the development and spread of health-care innovation and to prevent the spread of disease.

The digital self-help model is affordable and scalable, because more than 50 percent of the world’s population has Internet access, but the acceptability of these treatments needs further evaluation. Translation of digital interventions into different languages and cultures is an area for further study and funding.

Integration of Behavioral Health and Primary Care

Another market force influencing the development of new delivery models is the Affordable Care Act (ACA), which then-president Barack Obama signed into law in 2010. The ACA provided incentives for practices to adopt a patient-centered medical home, an integrated-care delivery model with the physician at the center of a team that included behavioral health specialists. ACA funding has also encouraged the further integration of medical and behavioral health care.

Federally Qualified Health Centers (FQHCs) are perhaps the most widespread example of integrated care. Many FQHCs provide fully integrated medical, dental, and behavioral health care for children and adults, facilitating “one-stop shopping” where entire families can get treatment for multiple needs at the same site at the same time. Research has found that primary care providers, rather than specialists, treat roughly three-quarters of children’s mental health needs, so integrating care makes sense.31 In addition, it can decrease stigmas surrounding mental health needs, because a “warm handoff” from a pediatrician to a mental health provider can reinforce the principle that “mental health is health.” 32

In smaller primary-care practices where it is not feasible to have on-site child psychiatrists or psychiatric advanced-practice registered nurses, more than 30 states have adopted the Massachusetts Child Psychiatry Access Program model, wherein pediatricians and other primary-care providers can talk to a team of child psychiatrists, licensed mental health clinicians, and resource coordinators for medication consultation, referral, and treatment recommendations, regardless of the client’s insurance. The National Network of Child Psychiatry Access Programs is a nonprofit member organization that provides methods and consultation to support the implementation of this model throughout the United States. Further foundation funding to design and implement innovative models like this could enhance the integration of mental health and pediatric care to reach more children with mental health needs.

Accountable Communities for Health

Value-based purchasing has spurred public and private health-care payers’ interest in the social determinants of health (SDOH). They increasingly recognize that improving the health of entire populations requires addressing the social determinants, within the communities where people live, work, and raise their children, believed to account for as much as 60 percent of the factors responsible for premature death.33 Addressing the SDOH calls for collaboration among multiple service systems, including health care, housing, public health, social services, and job training.

Accountable Communities for Health (ACHs) are community-based partnerships that bring together these systems to address the SDOH. In 2016, the US Department of Health and Human Services funded a five-year, $157 million program to develop the ACH model in 31 communities throughout the United States. A number of private funders, including the Robert Wood Johnson Foundation, the Kresge Foundation, the W. K. Kellogg Foundation, and the California Endowment, have also embraced this model for improving health. The California Endowment is one of several private foundations invested in the California Accountable Communities for Health Initiative, a public-private partnership to develop ACHs in 15 California communities. At the national level, these foundations have joined with public funders, including the Center for Medicare and Medicaid Innovation, the Centers for Disease Control and Prevention, and the Health Resources and Services Administration in the Funders Forum on Accountable Health, a vehicle sponsored by George Washington University’s Milken Institute School of Public Health, to share ideas and develop ways to assess the impact of ACHs.

The National Academy of Medicine recently proposed the concept of an ACH focused on children and families.34 ACHs offer considerable promise in using prevention and early intervention to improve children’s mental health and reduce the economic and psychological burden of mental illness. In a recent blog post for Health Affairs, Benjamin F. Miller, chief strategy officer of Well Being Trust, and Anne De Biasi, director of policy development at Trust for America’s Health, highlighted the need for foundations to fund policy initiatives that close the “prevention gap” in mental health, which emerges prior to the first symptom of a mental health condition.35 All three of the new delivery models we have discussed—task shifting, digital self-help technology, and the integration of behavioral health and primary care—could be integrated within an ACH to prevent and treat the emergence of mental health conditions. Although it is too early in the development of ACHs to evaluate their long-term effectiveness, their potential to improve the SDOH makes them a promising model in the quest to close the mental health treatment gap.

An Opportune Time

Estimates of new philanthropic funding becoming available in the next decade are sizable. According to a recent analysis by LOCUS Impact Investing and the Center for Rural Entrepreneurship, “If only 5 percent of the $9 trillion in assets projected to pass from Americans’ estates over the next decade were captured by philanthropy, it would create the equivalent of 10 Gates Foundations” and would generate an additional $22.5 billion in grantmaking annually.36 In spite of this anticipated increase, funding for children’s mental health is trending downward. This is unacceptable.

There has never been a better time for private foundations to invest in solutions to close the mental health treatment gap for children and adolescents. They have the capital, and there are many ideas worth funding. New delivery models that are scalable, affordable, and acceptable to the children and families they serve and that address the social determinants of health will require collaboration among many parties, including government funders and regulators, private industry, policymakers, and advocacy groups. Private philanthropy is in an ideal position to convene them to help drive the further development and spread of these delivery models.

Mental Self-Harm: 3 Ways We All Constantly Abuse Ourselves

Author Article

Two SwordsGETTY

The concept of Self-Harm is generally confined to acts of physical self-abuse, but observation of our own inner dynamics, reveals the same phenomenon taking place mentally, well before it manifests in our behaviour.

In this article we explore three ways in which all but the most self-aware and emotionally intelligent are constantly compromising their mental health by indulging in addictive, repetitive and habitual cycles of thinking and feeling:

1. Imagination – To illustrate how we abuse our imaginations, a thought exercise may help: Stop whatever you’re doing and look at all the man-made artefacts that you’re surrounded by: tables, chairs, buildings, computers, cars etc. Each of these began life in someone’s imagination as a thought. It was conceived as a concept in the womb of a mind – the imagination. In many cases these creations are the results of millions of human imaginations interacting over decades, centuries and millennia.

Our imaginations are, arguably, the single most powerful faculty that we are in possession of, to do with what we will. Your imagination is available to you at every waking moment of your life, to create whatever thought-form you desire, with no exceptions.

But, of course, your imagination doesn’t care how it’s used – it is just a tool. So when you use it to create scenarios in which you imagine yourself to be less than you are, this is problematic.

Using your imagination to create a self-image that is not professionally competent, in spite of your achievements, Imposter Syndrome, is a common form of abuse that most of us will experience.

Another is the creation of imagined situations that we fear – the worst case scenario – sometimes masquerading as planning. The continued imagination of these outcomes with their attendant feelings – worry or anxiety – has a causal link to depression.

But perhaps the most damaging way in which we use our imaginations against ourselves is through the creation of self-images that deny our full potential: I can’t do thatI don’t deserve this; they have all the luck.

2. Sympathy – originally meaning affected by like feelings, Sympathy is the admission of others’ feelings into one’s own experience, rather like open guitar strings will vibrate in sympathy with a human voice. But the problem is fundamental: how can we ever be quite certain that we are feeling what the other is feeling? And even if we were able to experience another’s feelings, to what end?

A surgeon needs no personal experience of a heart attack to perform heart surgery. A psychologist need not be a psychopath to work with one. The fact that I cannot feel someone’s emotions does not mean that I don’t want to help them. That I am aware of their distress is enough to evoke a compassionate response.

Sympathy is an abuse of one’s own feeling system and can all too easily degenerate into ownership of, and responsibility for others’ challenges. This syndrome not only burdens the sympathiser with feelings they are not entitled to, it also interferes with the other’s ability to respond accordingly.

3. Criticism – entertaining negativity about your circumstances, yourself and your relationships is another form of self-abuse. The etymology of the word critic suggests a sense of separation into parts, and a discrimination between those parts. Hence the symbology of the sword of justice. A similar metaphor is used with regard to the intellect which is intended to be sharp, as in a rapier wit.

So when the criticism is turned upon oneself, the sharp mind can inflict the most appalling damage on itself , reducing self-worth, self-esteem and self-confidence, to ultimately create a psychopathology.

Yet criticism of others, although superficially different, does not protect the critic who still chooses to immerse themselves in negativity of their own creation. And, of course, if the criticism is projected, then the source is the same.

So why do we habitually engage in these practices that destroy our well-being? One answer is that the western system of education prizes the intellect above everything, and that little else gets a look-in.

And so, if all you have is a hammer, everything looks like a nail… or rather:

If you live by the sword, you die by the sword.

4 Mental-Health Journaling Prompts For The Reflective Soul Who Doesn’t Know Where To Start

Author Article

There’s something so inexplicably satisfying about cracking open a brand-new journal. It’s a blank canvas on which you can record your thoughts, your worries, your dreams, and so much more. But beyond simply being a place to chronicle the events of your life and everything you feel about those goings-on, journaling is a great way to nourish your mental health. I may be going out on a limb here, but I’d venture to say that you’d be hard-pressed to find a mental-health professional who wouldn’t recommend journaling as a tool for general healing, coping with depression, and reducing anxiety.

Still, journaling can seem like a daunting task—especially if you’re not in the habit of writing about your feelings regularly. The good news? According to New York–based holistic psychotherapist Alison Stone, LCSW, there’s no such thing as a right or a wrong way to journal—and there’s not a specific amount you have to do it, either.

“For some people, it might be daily, while for others it might be weekly,” Stone says. “Experiment with not only what gives you the most benefit, but what is realistic for you to commit to on a regular basis.”

“Journaling is great for enhancing self-awareness through helping us detect and track patterns of behavior, thoughts, and feelings.” —Alison Stone, LCSW

In other words, if you want to let your thoughts flow freely every day for an hour, great. If it feels more natural to you to express yourself with a combination of words and pictures, bullet-journal-style, once a week, that’s great, too. Maybe you’re all about going out and buying a gorgeous journal that you feel excited to open all the time. Or maybe the thought of writing your feelings by hand is exhausting to you, and you’d prefer to dump them all in a Google Doc. Great, all-around, because, as is the case with so many things in life, the best thing you can do is listen to your own specific wants and needs to do what is authentically best for you.

And, no matter how or how often you choose to journal, there’s no question that it’s great for mental health. Below are a few of the heavy-hitting reasons why.

1. Journaling enhances self-awareness

Sometimes, it can be hard to pinpoint why we do, think, or feel certain ways about certain things. When you start journaling regularly, all of these things become a lot clearer. “Journaling is great for enhancing self-awareness through helping us detect and track patterns of behavior, thoughts, and feelings,” Stone explains.

For example, say you’re a single person (who doesn’t want to be single) whose anxiety spikes at night when you just happen to be scrolling mindlessly through Instagram, double-tapping photos of happy couples. In this case, a regular journaling habit may help you identify a pattern and lead you to change your behavior around Instagram.

2. Journaling can help alleviate stress

By simply jotting things down on paper, whether it’s feelings of anxiety and stress around a specific situation or just getting out the events of the day, journaling can help you get your thoughts and feelings out of your head. This simple act can make it easier to stop obsessing. “Doing this can help get rid of stress, clarify goals, and reduce symptoms of anxiety,” Stone says.

3. Journaling helps cultivate gratitude

Research has shown that gratitude can do quite a bit for our brains, happiness, and overall mental health. And according to Stone, journaling regularly is an effective means for identifying the things you’re grateful for. “This is an excellent benefit to journaling, because gratitude is a crucial part of overall mental health.”

If gratitude doesn’t flow out of you naturally during your day-to-day journaling habit, no big deal. Hey, a journal full of complaints and stressors is still helpful for identifying the things in your life that aren’t serving you—and that’s certainly productive. Still, try setting aside a few minutes of your journaling time to list out the things you’re grateful for.

Need a few prompts to get started on your healing journaling journey? Here are four that just may do wonders for your mental health.

If you’re anxious…

Anxiety is very, very prevalent in the United States. In fact, the condition impacts a whopping 40 million adults, according to the Anxiety and Depression Association of America. While there are a number of effective ways to treat your anxiety, journaling is a great one to start with. In this case, here are two journaling prompts Stone suggests trying:

“When I’m feeling acutely anxious, three strategies I know work for me are…”

and:

“One example of how I successfully navigated my anxiety in a stressful situation in the past is…”

If you’re struggling with depression…

When you’re in the throes of depression, journaling just may be the last activity you’re jonesing to see out. Sure, zonking out with Netflix buzzing in the background or sleeping the day away may sound more appealing. But if you do have it in you to crack open your journal, doing so can help quite a bit. Here are the two prompts Stone suggests starting with:

“Even though I feel down, two to three things I feel thankful for are…”

and:

“One reasonable goal I have for myself this week is…”

So there you have it: Journaling can be a supplemental tool to help you along on your mental-health journey—so get started today. But if you haven’t already, do first seek the help of a professional to devise a personalized plan to treat your condition.

Journaling call also help you crush your fitness goals, and plan dreamy vacations.

Lucid Dreamers May Help Unravel the Mystery of Consciousness

Author Article

We spend around six years of our lives dreaming – that’s 2,190 days or 52,560 hours. Although we can be aware of the perceptions and emotions we experience in our dreams, we are not conscious in the same way as when we’re awake. This explains why we can’t recognize that we’re in a dream and often mistake these bizarre narratives for reality.

But some people – lucid dreamers – have the ability to experience awareness during their dreams by “re-awakening” some aspects of their waking consciousness. They can even take control and act with intention in the dream world (think Leonardo DiCaprio in the film Inception).

Lucid dreaming is still an understudied subject, but recent advances suggest it’s a hybrid state of waking consciousness and sleep.

Sleep paralysis. My Dream, My Bad Dream, 1915. (Credit: Fritz Schwimbeck/Wikimedia)

Lucid dreaming is one of many “anomalous” experiences that can occur during sleep. Sleep paralysis, where you wake up terrified and paralyzed while remaining in a state of sleep, is another. There are also false awakenings, where you believe you have woken up only to discover that you are in fact dreaming. Along with lucid dreams, all these experiences reflect an increase in subjective awareness while remaining in a state of sleep. To find out more about the transitions between these states – and hopefully consciousness itself – we have launched a large-scale online survey on sleep experiences to look at the relationships between these different states of hybrid consciousness.

Lucid Dreaming and the Brain

About half of us will experience at least one lucid dream in our lives. And it could be something to look forward to because it allows people to simulate desired scenarios from meeting the love of their life to winning a medieval battle. There is some evidence that lucid dreaming can be induced, and a number of large online communities now exist where users share tips and tricks for achieving greater lucidity during their dreams (such as having dream totems, a familiar object from the waking world that can help determine if you are in a dream, or spinning around in dreams to stop lucidity from slipping away).

recent study that asked participants to report in detail on their most recent dream found that lucid (compared to non-lucid) dreams were indeed characterized by far greater insight into the fact that the sleeper was in a dream. Participants who experienced lucid dreams also said they had greater control over thoughts and actions within the dream, had the ability to think logically, and were even better at accessing real memories of their waking life.

Another study looking at people’s ability to make conscious decisions in waking life as well as during lucid and non-lucid dreams found a large degree of overlap between volitional abilities when we are awake and when we are having lucid dreams. However, the ability to plan was considerably worse in lucid dreams compared to wakefulness.

Lucid and non-lucid dreams certainly feel subjectively different and this might suggest that they are associated with different patterns of brain activity. But confirming this is not as easy as it might seem. Participants have to be in a brain scanner overnight and researchers have to decipher when a lucid dream is happening so that they can compare brain activity during the lucid dream with that of non-lucid dreaming.

Ingenious studies examining this have devised a communication code between lucid dreamer participants and researchers during Rapid Eye Movement (REM) sleep, when dreaming typically takes place. Before going to sleep, the participant and the researcher agree on a specific eye movement (for example two movements left then two movements right) that participants make to signal that they are lucid.

The prefrontal cortex. (Credit: Natalie M. Zahr, Ph.D., and Edith V. Sullivan, Ph.D. – Natalie M. Zahr, Ph.D., and Edith V. Sullivan, Ph.D.)

By using this approach, studies have found that the shift from non-lucid to lucid REM sleep is associated with an increased activity of the frontal areas of the brain. Significantly, these areas are associated with “higher order” cognitive functioning such as logical reasoning and voluntary behaviour which are typically only observed during waking states. The type of brain activity observed, gamma wave activity, is also known to allow different aspects of our experience; perceptions, emotions, thoughts, and memories to “bind” together into an integrated consciousness. A follow-up study found that electrically stimulating these areas caused an increase in the degree of lucidity experienced during a dream.

Another study more accurately specified the brain regionsinvolved in lucid dreams, and found increased activity in regions such as the pre-frontal cortex and the precuneus. These brain areas are associated with higher cognitive abilities such as self-referential processing and a sense of agency – again supporting the view that lucid dreaming is a hybrid state of consciousness.

Tackling the Consciousness Problem

How consciousness arises in the brain is one of the most perplexing questions in neuroscience. But it has been suggestedthat studying lucid dreams could pave the way for new insights into the neuroscience of consciousness.

This is because lucid and non-lucid REM sleep are two states where our conscious experience is markedly different, yet the overall brain state remains the same (we are in REM sleep all the time, often dreaming). By comparing specific differences in brain activity from a lucid dream with a non-lucid one, then, we can look at features that may be facilitating the enhanced awareness experienced in the lucid dream.

Furthermore, by using eye signaling as a marker of when a sleeper is in a lucid dream, it is possible to study the neurobiological activity at this point to further understand not only what characterizes and maintains this heightened consciousness, but how it emerges in the first place.

This article was originally published on The Conversation. Read the original article.

Staying Awake: The Surprisingly Effective Way to Treat Depression

Heathline Article

The first sign that something is happening is Angelina’s hands. As she chats to the nurse in Italian, she begins to gesticulate, jabbing, moulding and circling the air with her fingers. As the minutes pass and Angelina becomes increasingly animated, I notice a musicality to her voice that I’m sure wasn’t there earlier. The lines in her forehead seem to be softening, and the pursing and stretching of her lips and the crinkling of her eyes tell me as much about her mental state as any interpreter could.Angelina is coming to life, precisely as my body is beginning to shut down. It’s 2am, and we’re sat in the brightly lit kitchen of a Milanese psychiatric ward, eating spaghetti. There’s a dull ache behind my eyes, and I keep on zoning out, but Angelina won’t be going to bed for at least another 17 hours, so I’m steeling myself for a long night. In case I doubted her resolve, Angelina removes her glasses, looks directly at me, and uses her thumbs and forefingers to pull open the wrinkled, grey-tinged skin around her eyes. “Occhi aperti,” she says. Eyes open.This is the second night in three that Angelina has been deliberately deprived of sleep. For a person with bipolar disorder who has spent the past two years in a deep and crippling depression, it may sound like the last thing she needs, but Angelina – and the doctors treating her – hope it will be her salvation. For two decades, Francesco Benedetti, who heads the psychiatry and clinical psychobiology unit at San Raffaele Hospital in Milan, has been investigating so-called wake therapy, in combination with bright light exposure and lithium, as a means of treating depression where drugs have often failed. As a result, psychiatrists in the USA, the UK and other European countries are starting to take notice, launching variations of it in their own clinics. These ‘chronotherapies’ seem to work by kick-starting a sluggish biological clock; in doing so, they’re also shedding new light on the underlying pathology of depression, and on the function of sleep more generally.“Sleep deprivation really has opposite effects in healthy people and those with depression,” says Benedetti. If you’re healthy and you don’t sleep, you’ll feel in a bad mood. But if you’re depressed, it can prompt an immediate improvement in mood, and in cognitive abilities. But, Benedetti adds, there’s a catch: once you go to sleep and catch up on those missed hours of sleep, you’ll have a 95 per cent chance of relapse.The antidepressant effect of sleep deprivation was first published in a report in Germany in 1959. This captured the imagination of a young researcher from Tübingen in Germany, Burkhard Pflug, who investigated the effect in his doctoral thesis and in subsequent studies during the 1970s. By systematically depriving depressed people of sleep, he confirmed that spending a single night awake could jolt them out of depression.

Benedetti became interested in this idea as a young psychiatrist in the early 1990s. Prozac had been launched just a few years earlier, hailing a revolution in the treatment of depression. But such drugs were rarely tested on people with bipolar disorder. Bitter experience has since taught Benedetti that antidepressants are largely ineffective for people with bipolar depression anyway.

His patients were in desperate need of an alternative, and his supervisor, Enrico Smeraldi, had an idea up his sleeve. Having read some of the early papers on wake therapy, he tested their theories on his own patients, with positive results. “We knew it worked,” says Benedetti. “Patients with these terrible histories were getting well immediately. My task was finding a way of making them stay well.”

So he and his colleagues turned to the scientific literature for ideas. A handful of American studies had suggested that lithium might prolong the effect of sleep deprivation, so they investigated that. They found that 65 per cent of patients taking lithium showed a sustained response to sleep deprivation when assessed after three months, compared to just 10 per cent of those not taking the drug.

Since even a short nap could undermine the efficacy of the treatment, they also started searching for new ways of keeping patients awake at night, and drew inspiration from aviation medicine, where bright light was being used to keep pilots alert. This too extended the effects of sleep deprivation, to a similar extent as lithium.

“We decided to give them the whole package, and the effect was brilliant,” says Benedetti. By the late 1990s, they were routinely treating patients with triple chronotherapy: sleep deprivation, lithium and light. The sleep deprivations would occur every other night for a week, and bright light exposure for 30 minutes each morning would be continued for a further two weeks – a protocol they continue to use to this day. “We can think of it not as sleep-depriving people, but as modifying or enlarging the period of the sleep–wake cycle from 24 to 48 hours,” says Benedetti. “People go to bed every two nights, but when they go to bed, they can sleep for as long as they want.”

San Raffaele Hospital first introduced triple chronotherapy in 1996. Since then, it has treated close to a thousand patients with bipolar depression – many of whom had failed to respond to antidepressant drugs. The results speak for themselves: according to the most recent data, 70 per cent of people with drug-resistant bipolar depression responded to triple chronotherapy within the first week, and 55 per cent had a sustained improvement in their depression one month later.

And whereas antidepressants – if they work – can take over a month to have an effect, and can increase the risk of suicide in the meantime, chronotherapy usually produces an immediate and persistent decrease in suicidal thoughts, even after just one night of sleep deprivation.

§

Angelina was first diagnosed with bipolar disorder 30 years ago, when she was in her late 30s. The diagnosis followed a period of intense stress: her husband was facing a tribunal at work, and they were worried about having enough money to support themselves and the kids. Angelina fell into a depression that lasted nearly three years. Since then, her mood has oscillated, but she’s down more often than not. She takes an arsenal of drugs – antidepressants, mood stabilisers, anti-anxiety drugs and sleeping tablets – which she dislikes because they make her feel like a patient, even though she acknowledges this is what she is.

If I’d met her three days ago, she says, it’s unlikely I would have recognised her. She didn’t want to do anything, she’d stopped washing her hair or wearing make-up, and she stank. She also felt very pessimistic about the future. After her first night of sleep deprivation, she’d felt more energetic, but this largely subsided after her recovery sleep. Even so, today she felt motivated enough to visit a hairdresser in anticipation of my visit. I compliment her appearance, and she pats her dyed, golden waves, thanking me for noticing.

At 3am, we move to the light room, and entering is like being transported forward to midday. Bright sunlight streams in through the skylights overhead, falling on five armchairs, which are lined up against the wall. This is an illusion, of course – the blue sky and brilliant sun are nothing more than coloured plastic and a very bright light – but the effect is exhilarating nonetheless. I could be sitting on a sun lounger at midday; the only thing missing is the heat.

When I’d interviewed her seven hours earlier, with the help of an interpreter, Angelina’s face had remained expressionless as she’d replied. Now, at 3.20am, she is smiling, and even beginning to initiate a conversation with me in English, which she’d claimed not to speak. By dawn, Angelina’s telling me about the family history she’s started writing, which she’d like to pick up again, and inviting me to stay with her in Sicily.

How could something as simple as staying awake overnight bring about such a transformation? Unpicking the mechanism isn’t straightforward: we still don’t fully understand the nature of depression or the function of sleep, both of which involve multiple areas of the brain. But recent studies have started to yield some insights.

The brain activity of people with depression looks different during sleep and wakefulness than that of healthy people. During the day, wake-promoting signals coming from the circadian system – our internal 24-hour biological clock – are thought to help us resist sleep, with these signals being replaced by sleep-promoting ones at night. Our brain cells work in cycles too, becoming increasingly excitable in response to stimuli during wakefulness, with this excitability dissipating when we sleep. But in people with depression and bipolar disorder, these fluctuations appear dampened or absent.

Depression is also associated with altered daily rhythms of hormone secretion and body temperature, and the more severe the illness, the greater the degree of disruption. Like the sleep signals, these rhythms are also driven by the body’s circadian system, which itself is driven by a set of interacting proteins, encoded by ‘clock genes’ that are expressed in a rhythmic pattern throughout the day. They drive hundreds of different cellular processes, enabling them to keep time with one another and turn on and off. A circadian clock ticks in every cell of your body, including your brain cells, and they are coordinated by an area of the brain called the suprachiasmatic nucleus, which responds to light.

“When people are seriously depressed, their circadian rhythms tend to be very flat; they don’t get the usual response of melatonin rising in the evening, and the cortisol levels are consistently high rather than falling in the evening and the night,” says Steinn Steingrimsson, a psychiatrist at Sahlgrenska University Hospital in Gothenburg, Sweden, who is currently running a trial of wake therapy.

Recovery from depression is associated with a normalisation of these cycles. “I think depression may be one of the consequences of this basic flattening of circadian rhythms and homeostasis in the brain,” says Benedetti. “When we sleep-deprive depressed people, we restore this cyclical process.”

But how does this restoration come about? One possibility is that depressed people simply need added sleep pressure to jump-start a sluggish system. Sleep pressure – our urge to sleep – is thought to arise because of the gradual release of adenosine in the brain. It builds up throughout the day and attaches to adenosine receptors on neurons, making us feel drowsy. Drugs that trigger these receptors have the same effect, whereas drugs that block them – such as caffeine – make us feel more awake.

To investigate whether this process might underpin the antidepressant effects of prolonged wakefulness, researchers at Tufts University in Massachusetts took mice with depression-like symptoms and administered high doses of a compound that triggers adenosine receptors, mimicking what happens during sleep deprivation. After 12 hours, the mice had improved, measured by how long they spent trying to escape when forced to swim or when suspended by their tails.

We also know sleep deprivation does other things to the depressed brain. It prompts changes in the balance of neurotransmitters in areas that help to regulate mood, and it restores normal activity in emotion-processing areas of the brain, strengthening connections between them.

And as Benedetti and his team discovered, if wake therapy kick-starts a sluggish circadian rhythm, lithium and light therapy seem to help maintain it. Lithium has been used as a mood stabiliser for years without anyone really understanding how it works, but we know it boosts the expression of a protein, called Per2, that drives the molecular clock in cells.

Bright light, meanwhile, is known to alter the rhythms of the suprachiasmatic nucleus, as well as boosting activity in emotion-processing areas of the brain more directly. Indeed, the American Psychiatric Association states that light therapy is as effective as most antidepressants in treating non-seasonal depression.

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Staying awake: the surprisingly effective way to treat depressionShare on Pinterest
© Eva Bee for Mosaic

In spite of its promising results against bipolar disorder, wake therapy has been slow to catch on in other countries. “You could be cynical and say it’s because you can’t patent it,” says David Veale, a consultant psychiatrist at the South London and Maudsley NHS Foundation Trust.

Certainly, Benedetti has never been offered pharmaceutical funding to carry out his trials of chronotherapy. Instead, he has – until recently – been reliant on government funding, which is often in short supply. His current research is being funded by the EU. Had he followed the conventional route of accepting industry money to run drug trials with his patients, he quips, he probably wouldn’t be living in a two-bedroom apartment and driving a 1998 Honda Civic.

The bias towards pharmaceutical solutions has kept chronotherapy below the radar for many psychiatrists. “A lot of people just don’t know about it,” says Veale.

It’s also difficult to find a suitable placebo for sleep deprivation or bright light exposure, which means that large, randomised placebo-controlled trials of chronotherapy haven’t been done. Because of this, there’s some scepticism about how well it really works. “While there is increasing interest, I don’t think many treatments based on this approach are yet routinely used – the evidence needs to be better and there are some practical difficulties in implementing things like sleep deprivation,” says John Geddes, a professor of epidemiological psychiatry at the University of Oxford.

Even so, interest in the processes underpinning chronotherapy is beginning to spread. “Insights into the biology of sleep and circadian systems are now providing promising targets for treatment development,” says Geddes. “It goes beyond pharmaceuticals – targeting sleep with psychological treatments might also help or even prevent mental disorders.”

In the UK, the USA, Denmark and Sweden, psychiatrists are investigating chronotherapy as a treatment for general depression. “A lot of the studies that have been done so far have been very small,” says Veale, who is currently planning a feasibility study at Maudsley Hospital in London. “We need to demonstrate that it is feasible and that people can adhere to it.”

So far, what studies there have been have produced mixed results. Klaus Martiny, who researches non-drug methods for treating depression at the University of Copenhagen in Denmark, has published two trials looking at the effects of sleep deprivation, together with daily morning bright light and regular bedtimes, on general depression. In the first study, 75 patients were given the antidepressant duloxetine, in combination with either chronotherapy or daily exercise. After the first week, 41 per cent of the chronotherapy group had experienced a halving of their symptoms, compared to 13 per cent of the exercise group. And at 29 weeks, 62 per cent of the wake therapy patients were symptom-free, compared to 38 per cent of those in the exercise group.

In Martiny’s second study, severely depressed hospital inpatients who had failed to respond to antidepressant drugs were offered the same chronotherapy package as an add-on to the drugs and psychotherapy they were undergoing. After one week, those in the chronotherapy group improved significantly more than the group receiving standard treatment, although in subsequent weeks the control group caught up.

No one has yet compared wake therapy head-to-head with antidepressants; neither has it been tested against bright light therapy and lithium alone. But even if it’s only effective for a minority, many people with depression – and indeed psychiatrists – may find the idea of a drug-free treatment attractive.

“I’m a pill pusher for a living, and it still appeals to me to do something that doesn’t involve pills,” says Jonathan Stewart, a professor of clinical psychiatry at Columbia University in New York, who is currently running a wake therapy trial at New York State Psychiatric Institute.

Unlike Benedetti, Stewart only keeps patients awake for one night: “I couldn’t see a lot of people agreeing to stay in hospital for three nights, and it also requires a lot of nursing and resources,” he says. Instead, he uses something called sleep phase advance, where on the days after a night of sleep deprivation, the time the patient goes to sleep and wakes up is systematically brought forward. So far, Stewart has treated around 20 patients with this protocol, and 12 have shown a response – most of them during the first week.

It may also work as a prophylactic: recent studies suggest that teenagers whose parents set – and manage to enforce – earlier bedtimes are less at risk of depression and suicidal thinking. Like light therapy and sleep deprivation, the precise mechanism is unclear, but researchers suspect a closer fit between sleep time and the natural light–dark cycle is important.

But sleep phase advance has so far failed to hit the mainstream. And, Stewart accepts, it’s not for everybody. “For those for whom it works, it’s a miracle cure. But just as Prozac doesn’t get everyone better who takes it, neither does this,” he says. “My problem is that I have no idea ahead of time who it’s going to help.”

§

Depression can strike anyone, but there’s mounting evidence that genetic variations can disrupt the circadian system to make certain people more vulnerable. Several clock gene variations have been associated with an elevated risk of developing mood disorders.

Stress can then compound the problem. Our response to it is largely mediated through the hormone cortisol, which is under strong circadian control, but cortisol itself also directly influences the timing of our circadian clocks. So if you have a weak clock, the added burden of stress could be enough to tip your system over the edge.

Indeed, you can trigger depressive symptoms in mice by repeatedly exposing them to a noxious stimulus, such as an electric shock, from which they can’t escape – a phenomenon called learned helplessness. In the face of this ongoing stress, the animals eventually just give up and exhibit depression-like behaviours. When David Welsh, a psychiatrist at the University of California, San Diego, analysed the brains of mice that had depressive symptoms, he found disrupted circadian rhythms in two critical areas of the brain’s reward circuit – a system that’s strongly implicated in depression.

Staying awake: the surprisingly effective way to treat depression
© Eva Bee for Mosaic

But Welsh has also shown that a disturbed circadian system itself can cause depression-like symptoms. When he took healthy mice and knocked out a key clock gene in the brain’s master clock, they looked just like the depressed mice he’d been studying earlier. “They don’t need to learn to be helpless, they are already helpless,” Welsh says.

So if disrupted circadian rhythms are a likely cause of depression, what can be done to prevent rather than treat them? Is it possible to strengthen your circadian clock to increase psychological resilience, rather than remedy depressive symptoms by forgoing sleep?

Martiny thinks so. He is currently testing whether keeping a more regular daily schedule could prevent his depressed inpatients from relapsing once they’ve recovered and are released from the psychiatric ward. “That’s when the trouble usually comes,” he says. “Once they’re discharged their depression gets worse again.”

Peter is a 45-year-old care assistant from Copenhagen who has battled with depression since his early teens. Like Angelina and many others with depression, his first episode followed a period of intense stress and upheaval. His sister, who more or less brought him up, left home when he was 13, leaving him with an uninterested mother and a father who also suffered from severe depression. Soon after that, his father died of cancer – another shock, as he’d kept his prognosis hidden until the week before his death.

Peter’s depression has seen him hospitalised six times, including for a month last April. “In some ways being in hospital is a relief,” he says. However, he feels guilty about the effect it has on his sons, aged seven and nine. “My youngest boy said he cried every night I was in hospital, because I wasn’t there to hug him.”

So when Martiny told Peter about the study he had just started recruiting for, he readily agreed to participate. Dubbed ‘circadian-reinforcement therapy’, the idea is to strengthen people’s circadian rhythms by encouraging regularity in their sleep, wake, meal and exercise times, and pushing them to spend more time outdoors, exposed to daylight.

For four weeks after leaving the psychiatric ward in May, Peter wore a device that tracked his activity and sleep, and he completed regular mood questionnaires. If there was any deviation in his routine, he would receive a phone call to find out what had happened.

When I meet Peter, we joke about the tan lines around his eyes; obviously, he’s been taking the advice seriously. He laughs: “Yes, I’m getting outdoors to the park, and if it’s nice weather, I take my children to the beach, for walks, or to the playground, because then I will get some light, and that improves my mood.”

Those aren’t the only changes he’s made. He now gets up at 6 every morning to help his wife with the children. Even if he’s not hungry he eats breakfast: typically, yoghurt with muesli. He doesn’t take naps and tries to be in bed by 10pm. If Peter does wake up at night, he practises mindfulness – a technique he picked up in hospital.

Martiny pulls up Peter’s data on his computer. It confirms the shift towards earlier sleep and wake times, and shows an improvement in the quality of his sleep, which is mirrored by his mood scores. Immediately after his release from hospital, these averaged around 6 out of 10. But after two weeks they’d risen to consistent 8s or 9s, and one day, he even managed a 10. At the beginning of June, he returned to his job at the care home, where he works 35 hours a week. “Having a routine has really helped me,” he says.

Staying awake: the surprisingly effective way to treat depression
© Eva Bee for Mosaic

So far, Martiny has recruited 20 patients to his trial, but his target is 120; it’s therefore too soon to know how many will respond the same way as Peter, or indeed, if his psychological health will be maintained. Even so, there’s mounting evidence that good sleep routine can help our mental wellbeing. According to a study published in Lancet Psychiatry in September 2017 – the largest randomised trial of a psychological intervention to date – insomniacs who underwent a ten-week course of cognitive behavioural therapy to address their sleep problems showed sustained reductions in paranoia and hallucinatory experiences as a result. They also experienced improvements in symptoms of depression and anxiety, fewer nightmares, better psychological wellbeing and day-to-day functioning, and they were less likely to experience a depressive episode or anxiety disorder during the course of the trial.

Sleep, routine and daylight. It’s a simple formula, and easy to take for granted. But imagine if it really could reduce the incidence of depression and help people to recover from it more quickly. Not only would it improve the quality of countless lives, it would save health systems money.

In the case of wake therapy, Benedetti cautions that it isn’t something people should try to administer to themselves at home. Particularly for anyone who has bipolar disorder, there’s a risk of it triggering a switch into mania – although in his experience, the risk is smaller than that posed by taking antidepressants. Keeping yourself awake overnight is also difficult, and some patients temporarily slip back into depression or enter a mixed mood state, which can be dangerous. “I want to be there to speak about it to them when it happens,” Benedetti says. Mixed states often precede suicide attempts.

A week after spending the night awake with Angelina, I call Benedetti to check her progress. He tells me that after the third sleep deprivation, she experienced a full remission in her symptoms and returned to Sicily with her husband. That week, they were due to be marking their 50th wedding anniversary. When I’d asked her if she thought her husband would notice any change in her symptoms, she’d said she hoped he’d notice the change in her physical appearance.

Hope. After she has spent more than half her life without it, I suspect its return is the most precious golden anniversary gift of all.

This article first appeared on Mosaic and is republished here under a Creative Commons licence.

How to Use Humor to Become Happier and More Successful

Author Article

There are many times in life when a person with a sense of humor lightens the mood of a meeting, family gathering, or party. You may actually look forward to going to work if you know you can count on having a good laughor two at some point during the day. The endless meetings or tedious job tasks that are part of your workload are made more tolerable if these witty folks infuse their observations into the situation. If the person is the boss, even better. You can’t help but admire leaders who don’t take everything all that seriously, including themselves. Similarly, outside of work you may highly value your friends and family members who can either tell a good joke or make light of what might otherwise be a serious occasion, at least from time to time.

In a new study, University of Arizona’s Jonathan B. Evans and colleagues (2019), noted that although humor has the potential to create an environment conducive to positive outcomes, at work and elsewhere, this potential may fail to be realized. If a joke falls flat, the person telling it can look inept or even cruel.  Telling jokes can also influence the way you’re perceived by the people who you’re trying to entertain. Based on a model known as “parallel-constraint-satisfaction” theory, which proposes that stereotypes affect the way people interpret the behavior of others, Evans and his colleagues hypothesized that men would benefit and women would be penalized when using humor specifically in the workplace. Men will gain status when they make jokes, and women will lose.

This proposal may ring true if you think about comments over the years suggesting that women can’t be funny. Rather than add to this debate, however, the Arizona researchers looked not at what’s funny or not, but how telling jokes affects they way the joke-teller is perceived which, in turn, influence the joke’s impact. Think about times when you’ve been in a meeting or group setting in which a man constantly makes wisecracks while everyone else is trying to stay task-focused. Try as you might, you find yourself unable to suppress a giggle now and then. You don’t think any less of the jokester and, in fact, find your estimation of him rising as he shows his humorous side. Now imagine that it’s a woman in the role of jester. Do you still think of her as gaining in status, or does she just seem silly?

Parallel-constraint-satisfaction-theory (PCST) proposes that people evaluate a target along multiple dimensions simultaneously, influencing the way they evaluate others. With humor, the joke-teller can be seen as either serving a positive purpose by alleviating tension or as disruptive by distracting people from the task at hand. Gender interacts with this dimension, with male stereotype of a man being high in agency (individual drive) and rationality with women seen as low in personal agency and rationality. Men therefore have the humor-as-functional perception working in their favor but women, seen as irrational and flighty, are perceived as disruptive and even non-funny.

In the first of two studies, Evans et al. asked 96 online participants to rate the disruptiveness and functionality of humor as shown by either a male or female manager performing in an online video. The manager was described in the research materials as a highly successful and talented individual. As the research team predicted, participants rated as more disruptive and less functional the same jokes expressed by women as by men. In the second study, 216 online participants watched videos of either a man or a woman either telling jokes or not telling jokes. Following the presentation of the video, participants then rated the managers on their status, performance and leadership capability.

As the authors predicted, participants rated female joke-tellers as lower in status, which in turn led participants to view them as lower in performance and leadership capability than men. They note that, like an elbow nudge, humor’s meaning can be ambiguous. We impose onto that behavior, they maintain, our stereotypes about the joke-teller. There is no reason that the same jokes, whether told by a male or female, should have the same impact on those hearing the jokes. By supporting the PCST approach, the Arizona researchers showed that humor’s perception is bent by the gender of the joke-teller.

Thus, being sarcastic and teasing violates the female gender stereotype but fits perfectly with that of the male’s. Evans and his fellow researchers maintain that they have added to the literature regarding the lower proportion of female than male CEO’s. If men can get to the top by being funny, but women lower their status potential by engaging in the very same behavior, this would provide yet another cause of the glass ceiling for female executives.

To sum up, humor’s ability to provide fulfillment should be gender-neutral, but since the Evans et al. study suggests it’s not, perhaps there can come a time when, in the words of the authors, “increased awareness can help reduce its occurrence.” Give the female joke-teller some slack, and you’ll be part of that long-overdue impetus for change.

5 Motivational Life Mantras For A Happy And Successful Life

Author Article

1) Before You Tell Your Thoughts, Think A Bit:

Speaking the wrong words at the wrong time can increase your troubles.

Ultimately, we all need self-discipline. It is a simple solution that we can easily cope with the difficulties in life, by changing our attitude. And keep love relationships for life.

2) Avoid Criticism And Do Not Make Fun Of Others:

There are two types of effects of our sensation and its outbreak. If you send positive thoughts in the form of love, affection, kindness, compassion, welfare, then it will make your relationship even more beautiful and stronger. On the contrary, those who use anger, hatred, anxiety, criticism, molestation, negative thinking and bad words, their relationship seems to be diminishing. And in this concern, love and happiness always go away from the human life. In the relationship between two people, both should have the power to understand each other, and there should be ego and hatred in each other.

3) Do You Feel Easily Miserable And Are Happy With You?

I believe that keeping good and bad habits to a limited place can lead you to the wrong path. The people have a habit of adopting bad habits early and developing them, while good habits only take place after a lot of difficult and lots of attempts. And that is why we are annoyed with each other. We should bring our inner feeling to our mind. Considering the inner feeling, we should bring positive feelings out and destroy negative feelings.

Contrary to the feeling of happiness, love, attraction, meditation, kindness and compassion, we all see it in our own nature. Our nature reflects our qualities and our happiness depends on our nature.

The easiest solution to remove the sour taste in the relationship is to humiliate your temperament and whether the situation is favorable or the opposite is always a smile. To be happy, you need to change your nature.

4) Change Your Definition:

Make your definition so much that you can easily feel happy and can be very happy. Make sure your best day is today, today you can easily live the life you want. Always remember these things, then happiness, love, freedom will always be there in your life.

If someone asks you how you live happily and enthusiastic? So your answer, “I am so happy because I live in today and easily breathe and I feel happy”.

Your attitude will help you to live a happy life. And you will always be living in the atmosphere of love, charm, helper and kindness, compassion, so that both your health and your property will be safe.

Apart from being easily happy, there is one more thing that you should be in, and it is not that easy to be unhappy. It is impossible for any person to make you sad. Make sure to limit your frustration to a limit. You will be disappointed if you lose more than $ 1 million in the day, if you have any such event in your life then you should be disappointed. If you use these limitations in your life then you will never be easily dissatisfied. And you will be able to live happily throughout life.

5) Use These Conditions:

You make all the changes just to make positive changes in life. To increase these habits you need to be humble, honest and consistent. All the time, you should be aware of this new definition of life. Write all these terms on many pages and put them at different places in the house. So that your attention will turn to them again and again. You can also keep all these terms as wallpaper of your computer, laptop or mobile phone.

Doing so will change your bad habit in good habits in just a few days, and you will find yourself the happiest person in this world. You can always be happy with doing this. And you can also learn how to please others with your attitude.

And there will be no place for anger, hatred, despair and trouble in this world.

Always remember one thing ….

Love and happiness win everywhere.

15 Signs That You’re An Introvert With High-Functioning Anxiety

Author Article

Anxiety is the voice in the back of your head that says, “something bad is going to happen.” It’s what keeps you awake at 2 a.m. thinking about something embarrassing you did — five years ago.

Not all introverts have anxiety, and extroverts and ambiverts can struggle with it, too. To be clear, introversion and anxiety aren’t the same thing. Introversion is defined as a preference for calm, minimally stimulating environments, whereas anxiety is a general term for disorders that cause excessive fear, worrying, and nervousness.

However, for many introverts, anxiety is a regular part of their lives. And indeed, anxiety is more common among introverts than extroverts, according to Dr. Laurie Helgoe.

What Is High-Functioning Anxiety?
Sometimes anxiety is obvious (think: panic attacks and sweaty palms), but that’s not always the case. Many people live with a secret form of anxiety called “high-functioning anxiety.” Outwardly, they appear to have it all together. They may even lead very successful lives. No one can tell from the outside that they’re driven by fear. Sometimes they don’t even realize it themselves.

Do you have high-functioning anxiety? Although not an official diagnosis, high-functioning anxiety is something countless people identify with. It’s closely related to Generalized Anxiety disorder, which affects 6.8 million adults in the U.S., women being twice as likely to experience it as men.

Symptoms of High-Functioning Anxiety
Here are fifteen common symptoms of high-functioning anxiety.

1. You’re always prepared.
Your mind frequently jumps to the worst-case scenario in any given situation. As a result, you may find yourself over-preparing. For example, you might pack underwear and makeup in both your checked luggage and your carry-on, just in case the airline loses your suitcase. People see you as being the reliable one — and often your preparations do come in handy — but few people (if any!) know that your “ready for anything” mentality stems from anxiety.

2. You may be freaking out on the inside, but you’re stoic on the outside.
Interestingly, many people with high-functioning anxiety don’t reveal just how nervous they are, which is another reason why it’s often a secret anxiety. You may have learned to compartmentalize your emotions.

3. You see the world in a fundamentally different way.
Your anxiety isn’t “just in your head.” Researchers from the Weizmann Institute of Science in Israel found that people who are anxious see the world differently than people who aren’t anxious. In the study, anxious people were less able to distinguish between a safe stimulus and one that was earlier associated with a threat. In other words, anxious people overgeneralize emotional experiences — even if they aren’t threatening.

4. You constantly feel the need to be doing something.
Which can be a real problem if you’re an introvert who needs plenty of downtime to recharge. This doesn’t necessarily mean you’re attending lots of social events; instead, you may feel a compulsion to always be getting things done or staying on top of things. Staying busy distracts you from your anxiety and gives you a sense of control.

5. You’re outwardly successful.
Achievement-oriented, organized, detail-oriented, and proactive in planning ahead for all possibilities, you may be the picture of success. Problem is, it’s never enough. You always feel like you should be doing more.

6. You’re afraid of disappointing others.
You might be a people-pleaser. You’re so afraid of letting others down that you work hard to make everyone around you happy — even if it means sacrificing your own needs.

7. You chatter nervously.
Even though you’re an introvert who prefers calm and quiet, you chatter on and on — out of nervousness. For this reason, sometimes you’re mistaken for an extrovert.

8. You’ve built your life around avoidance.
You’ve shrunk your world to prevent overwhelm. You stick to routines and familiar experiences that give you a sense of comfort and control; you avoid intense emotional experiences like travel, social events, conflict, or anything else that might trigger your anxiety.

9. You’re prone to rumination and overthinking.
You do a lot of negative self-talk. You often replay past mistakes in your mind, dwell on scary “what if” scenarios, and struggle to enjoy the moment because you’re expecting the worst. Sometimes your mind races and you can’t stop it.

10. You’re a perfectionist.
You try to calm your worries by getting your work or your appearance just right. This can bring positive results, but it comes at a cost. You may have an “all-or-nothing” mentality (“If I’m not the best student, then I’m the worst”). You may have unrealistic expectations of yourself, and a catastrophic fear of falling short of them.

11. You have aches, repetitive habits, or tics.
According to psychotherapist Annie Wright, your anxiety might manifest physically in your body as frequent muscle tension or aches. Similarly, you might unconsciously pick at the skin around your nails, tap your foot, scratch your scalp, or do other repetitive things that get your nervous energy out — even if you appear composed in other ways.

12. You’re tired all the time.
Your mind is always going, so you have trouble falling asleep or staying asleep. Even when you sleep well, you feel tired during the day, because dealing with a constant underlying level of anxiety is exhausting.

13. You startle easily.
That’s because your nervous system is in over-drive. A slammed door, an ambulance siren, or other unexpected sounds really rattle you.

14. You get irritated and stressed easily.
You’re living with constant low-level stress, so even minor problems or annoyances have the power to frazzle you.

15. You can’t “just stop it.”
Anxiety isn’t something you can tell yourself to just stop doing. In fact, the above-mentioned researchers from the Weizmann Institute of Science found that people who are anxious have somewhat different brains than people who aren’t anxious. They noted that people can’t control their anxious reactions, due to a fundamental brain difference. (However, you can learn to cope with your anxiety and greatly lessen it — see the resources below).

When something scares us but we never get over that fear, we become traumatized. When we’re traumatized, our lives start reflecting that. We begin restricting and isolating. We build our habits around what we think will ensure we avoid any more pain. The traditional teaching is that to heal is to return to what we…

via This Is What It Means To Heal Completely, Because It’s Not About Going Back To The Person You Were — Thought Catalog

What Are the Signs of Damaged Emotions?

Author Article
Healthy emotions are vital for well-being and harmonious relationships. Emotional damage can occur as a result of mental illness, trauma or a combination of both factors, and may impair a person’s ability to form relationships and handle everyday stressors. Learning to recognize the signs of damaged emotions allows you to identify problems sooner and alter the behaviors that perpetuate them.

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Trust Issues
While blind trust can be dangerous in some situations, an inability to trust loved ones can be a sign of emotional damage. According to AT Health, children who are abandoned by their parents often experience trust issues in adulthood, making it difficult to form close interpersonal relationships.

Lack of trust can result from painful past experiences, including acts of betrayal. Examples of situations that could trigger trust issues include abandonment as a child, romantic infidelity or a variety of forms of dishonesty.

Low Self-Esteem
Self-esteem refers to the way in which people view themselves and their worth. Low self-esteem can result from internal sources like mental health conditions or external causes like bullying. The “New York Times” lists low self-esteem as a common symptom of depression.

Signs of low self-esteem include shyness, anxiety about one’s appearance or competence, feelings of worthlessness and unnecessary guilt or shame. It’s possible to use positive affirmations to help raise self-esteem by reaffirming positive attributes.

Anger and Aggression
While unpleasant, anger is a natural emotional response that can be useful when channeled effectively. When managed improperly, anger is capable of tearing apart relationships and leading to frequent altercations between individuals.

Inappropriate anger can masquerade as jealousy, manipulation, suspicion or passive-aggressiveness. If allowed to continue unchecked, anger may even deteriorate into verbal or physical abuse. Long-term suppression of unpleasant emotions like anger can lead to inappropriate behaviors, reinforcing the need to handle anger as it arises.

Self-Destructive Behavior
Emotional damage often manifests as self-destructive or self-defeating behavior. Eating disorders, substance abuse and self-mutilation are examples of self-destructive behavior.

According to the American Humane Association, destructive behaviors like alcohol and drug abuse, suicide attempts and withdrawal can all result from emotional abuse.

Treatment Options
Many options exist for healing emotional damage. Counseling or group therapy can help patients work through unpleasant emotions and get to the heart of their issues. Trained mental health professionals offer solutions by teaching patients stress management techniques and coping skills to help deal with daily problems. When emotional damage affects married couples or families, couples counseling and family therapy may be helpful.

In cases of mental illness, medications like antidepressants and anti-anxiety drugs may be prescribed in conjunction with talk therapy.

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