A fellow widow’s reactions to the book, “Option B”

Sheryl Sandberg coauthored a wonderful book, “Option B: Facing Adversity, Building Resilience, and Finding Joy”, about how to develop resilience in the face of loss. Sheryl lost her husband unexpectedly three years ago, and is very candid in this book about what she experienced and what she learned about grief and herself.

As a psychiatrist and author and widow myself, I applaud her for her contribution to the literature about grief. When I lost my husband unexpectedly almost 8 years ago, I searched for a book such as this one. Sheryl is the perfect person to write such a book, since she already has the platform to reach many people through her previous successes. She was wise and fortunate to coauthor with Adam Grant, and to include many practical suggestions about how to develop coping skills. She also speaks to all of us about how we can best support each other at times of crisis.

I have been a psychiatrist for over 30 years, and have treated many patients with losses. With loss comes grief, but also in some cases losses can precipitate clinical depression. I have evolved in my own understanding of grief in the last 7 years. My experience of grief was similar to Sheryl’s, shocking in its intensity. I, too, feared that I would never recover and searched for what to do to handle my emotions in a healthy manner. I, too, was fortunate to have much support and to be able to move forward with my life.

“Option B” does not mention the possibility of developing clinical depression, or the possibility of getting “stuck” in what is sometimes called “complicated grief”. It is important to know that some individuals respond to loss by developing more serious problems. Grief and clinical depression may be difficult to distinguish unless you know what to look for.  In both conditions, it is common to have loss of appetite, difficulty sleeping, difficulty concentrating, and to feel overwhelmed at times.

Here are the key differences.  Grief comes and goes in waves, versus clinical depression is more continuous. With grief there are periods of respite, when you can still feel some pleasure and appreciate the comfort others may offer, versus depression tends to be more continuous. With grief often comes yearning for the lost one and sometimes looking forward to seeing that person after death, but not actual suicidal thoughts. With depression sometimes suicidal thoughts may develop, and suicide is the very serious risk that accompanies depression. Depression (but not grief) can also bring feelings of worthlessness and lowered self-esteem.

I discuss these differences in my book, “Finding Your Emotional Balance: A Guide for Women”. Both grief and depression can be very intense experiences, and I fully agree with the recommendations made in “Option B” for coping with grief. I also encourage those who have losses to be aware of their potential for developing depression, and to seek help if needed.

Why We Should Not Mock PMS

Donald Trump forged new ground in the presidential debates this year in terms of calling attention to women’s menstrual periods with his derogatory response to Megyn Kelly.  His comments on her “blood coming out of her wherever” bring to mind many other mocking comments I have heard over the years about a menstrual-related disorder.

Is there any other condition in all of Medicine that has been ridiculed as much as Premenstrual Syndrome (PMS)?  I have a whole collection of coffee mugs, bumper stickers, and jokes that have been given to me because of my longstanding interest in this topic.

I think I know why it is mocked.  PMS is not one problem, but a whole spectrum of conditions that range from being totally normal and mildly uncomfortable to a condition that is disabling and possibly life-threatening.  The distinctions are not clear in the minds of many, so it is easy to make fun of something that is not well-understood and that does not seem that serious.

Almost every woman who has menstrual cycles knows when her menstrual period is about to occur, 95% have at least one symptom. She may feel that her breasts are more tender, that she is more bloated, that she is more irritable, that her sleep is off.  That does not mean that she has an illness, certainly not a psychiatric condition.

About 30-50% of women have 2-3 symptoms, enough to qualify for the diagnosis of PMS.  They may have physical and/or emotional symptoms, but are able to function well and rarely mention this to their doctors.

In contrast, a small percentage of women (3-5%) have severe problems premenstrually, to the point where they have difficulty functioning and may even become suicidal.  These women sometimes call in sick at this time of the month, or may have big blowups with their loved ones.  In psychiatry this small percentage of women who have 5 or more symptoms premenstrually is now diagnosed as having “Premenstrual Dysphoric Disorder” (PMDD).

Yet another group of women think that they have PMS, but when they pay more attention to when in the month their symptoms occur, they realize that they actually have depression throughout the month that worsens premenstrually. These women can be said to have “Premenstrual Exacerbation of Depression” (PMED).

So how can women cope if they have PMS or PMDD or PMED?  What does the evidence show?

Lifestyle interventions are usually the first suggestion for women who have PMS.  They may benefit from exercise and modifying their diet (i.e. less caffeine and sugar).  Simply charting their symptoms on a calendar may be helpful, since it will give them more insight into their feelings and help them have more a sense of control.  Relaxation methods and meditation may be helpful as well.

The more severe problem of PMDD has been well-studied in recent years, and at this point the treatment of choice when lifestyle interventions are not enough are the family of medications known as the Selective Serotonin Reuptake Inhibitors (SSRIs), such as fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa), paroxetine (Paxil), and escitalopram (Lexapro).  Multiple studies have compared the SSRIs with placebo and found that the SSRIs are effective for PMDD.

Interestingly, the SSRI medications can also work for PMDD even when they are only taken for the week prior to the onset of the menstrual period. This has now been well-demonstrated using a variety of SSRI medications.

Some of the newer contraceptives may also have benefit for PMDD, especially if they contain the progestin drosperinone.

For women who have PMED, they may benefit from treatment for depression that includes a variable dose strategy.  In other words, instead of taking the same dose of antidepressant all month long, they may benefit from slightly increasing the dose of antidepressant just before the menstrual period.

Very severe cases of PMDD that do not respond to the treatments above may benefit from medication or surgery that induces menopause, but they will then experience the side effects that come with that state including hot flashes and risk of osteoporosis.

So despite the abundance of PMS jokes, severe PMDD and PMED are not funny.  The good news is that we have much more research and news of effective treatments in recent years.

 

 

10 Lessons on Grief

Those of us who experience loss may struggle to know how to cope, what to do to heal, how to move forward with our lives when we want so badly to hold on to the person we have lost.

I know this.  I lost my husband after 32 years together several years ago.  Even though I am a psychiatrist with many years of experience, on the day when I found my husband dead in our bed I did not fully understand the emotional journey that I was about to take.

Here are some of the lessons I learned:

1. After a loss, accept support when it is offered.  I was lucky, as are many widows, that family and friends sought to comfort me.  The year after my husband died was my “year of the hugs”.  Even a trip to the grocery store sometimes included a hug from an acquaintance who knew of my loss.  Appreciate the kindness in others when you are able.
2. At the same time, allow yourself to say no to invitations at times if you do not want to go or simply want to be alone.  You may feel that your friendships are shifting.  You may feel the absence of your loved one more keenly in certain settings, and want to avoid that.  Give yourself permission to say no without guilt when you want.
3. Allow yourself the freedom to cry, to be angry, to howl with despair.  Going through the emotions of grief can help you to get past it.  I howled at times so much that my dog barked at me.
4. Expect that your grief will come and go in “waves“, and for a long time.  There is no one timetable for grief.  Just as every relationship is unique, the experience of grief is unique.  Reminders and holidays may serve as triggers, so prepare yourself by planning ahead.
5. Expect that a dominant emotion you will feel is yearning.  You may ache for the loved one you lost, so much so that it feels like a physical pain.
6. Focus on taking care of yourself while you grieve.  Exercise regularly, a simple 30 minute walk any given day can help you to feel better. Consider writing in a journal, it may help you to get your feelings out (especially if you have lost your confidante).  Eat healthy, and do not seek to escape your pain through alcohol or drug use.  That will only make things worse for you in the long run.
7. Seek others who know grief, they have wisdom to share.  I found new friendships and much support from other widows, widowers, and those with other losses.  It is comforting to know that you are not alone in your suffering, and also to know that over time the pain does diminish.
8. Monitor yourself for the possible development of depression.  Both grief and depression can lead to changes in sleep, appetite, energy, and concentration.  The distinction between grief and depression can be difficult to determine, but some clues that your grief has turned into depression would be that you lose the ability to feel any pleasure, are unable to function, and/or develop thoughts of suicide.  Seek help if these symptoms occur, there are many good treatments for depression.
9. Do not push yourself to heal too rapidly.  A “rule of thumb” I heard was that it would be best not to make any major decisions (e.g. about selling a house, moving, quitting a job, or starting a new relationship) for a year after a significant loss.  I do not think we need such generalized rules, each of us is different, but beware of making big changes too quickly while you are still grieving.
10. Pay attention to your spirituality.  Loss can lead to valuable time for reflection, and can help you to deepen your appreciation for living.  Have faith in the future, hard as it is to imagine.  Over time the “fog” of grief will lift, but you will never forget your loved one, nor would you want to.

 

 

Five Steps to Survive the Holiday Blues

 

I was a Christmas baby, was given a Christmas-y name, and have always considered it “my” time of year. And yet this was the period of the year that I most dreaded after losing my husband.

The holidays are supposed to be the happiest time of the year. But for many they are the hardest. For some they can trigger depression and anxiety.

For those who are alone, who have suffered losses, whose relationships are not what they want them to be, it can be very difficult to get through this “merry” time of year. They may long for holidays past, and feel surges of grief for those who are gone. Loneliness may feel more intense.

I hear it from my patients every year. Some feel sad that their lives are not what they want them to be. They compare themselves to others that they see around them and the idealized images depicted in the media. They wince inside as they hear others talk about their holiday celebrations.

Others are overextended both emotionally and financially at this time of year. They feel drained, exhausted, and eager for the holidays to pass. They may feel obligated to attend gatherings that they do not enjoy. They dread the possibility of family conflicts. They may feel inadequate as they encounter family and friends. They may eat too much, drink too much, sleep too little, and neglect to exercise.

Here are strategies on how to get through the holidays emotionally intact:

 

1. Plan ahead.   Seek balance between times with others and time alone. We vary in terms of what we need to refuel ourselves. Think about what your individual needs are. Avoid the urge to withdraw excessively, or the sense of obligation to do too much. Say no to invitations if you do not want to go, without guilt, and leave parties when you are ready. You have the right to make choices.

 

2. Set limits, on your spending, your eating, your drinking. Make a budget and stick to it. Be conscious about your diet and alcohol consumption.   Many who are down are tempted to drink and eat more, and may temporarily feel better while drinking, but it tends to worsen the mood and can lead to depression.

 

3. Make time to exercise.  A daily walk can do wonders for your mood. If it is too cold outside, you could find indoor locations (e.g. the mall) where you could walk. Something as simple as a 30-minute walk can really boost your spirits.

 

4. Reach out to others.   Invite a lonely neighbor to do something with you. Consider volunteering. There are many others who struggle with the holidays, too, and you can get a boost from the pleasure of helping others.  Don’t wait for others to approach you, let your friends and family know if you would like to do more with them during this time of year.

 

5. Indulge yourself in healthy pleasures. Read that book you’ve been wanting to find time for. Watch movies during your off time. Consider taking a drive or a trip somewhere.

 

I have both personal and professional experiences that have opened my eyes to the emotional challenges that we face throughout our lifetimes. This motivated me to spend my life as a psychiatrist specializing in women’s mental health, and to write the new self-help book Finding Your Emotional Balance: A Guide for Women. During the stressful periods of our lives, we can find ways to keep ourselves balanced with some healthy strategies.

 

Overcoming the Stigma of Mental Illness Across Three Generations

I am the daughter of depression. I was raised to keep my mother’s depression a secret, but now have a daughter of my own who has helped me to break my silence about my own depression.

I am a psychiatrist, professor, and former chair of a psychiatry department at a medical school for over a decade. I have specialized in women’s mental health throughout my career.

I also have a history of severe depression in my 20s and of devastating grief in my 50s after the unexpected loss of my beloved husband after 32 years together.

My first exposure to mental illness came as a child, watching my mother as she struggled with severe depression for many years, went in and out of hospitals, but never really recovered. We were taught not to talk about my mother’s mental illness. I never invited friends to our home, and kept the secret of what was wrong with her (which none of us fully understood). I watched my father despair as he tried to help her. She died when I was 18 years old, but she had really lost her life years earlier due to her illness.

My own terrible bout of depression caused me to take a leave of absence from medical school and rethink my life goals. After a combination of stressors, I succumbed to a horrible depression. I was unable to concentrate on my work or to function normally. My depression progressed to the point where I barely recognized myself. I lost my ability to enjoy life, instead felt tortured with depressive thoughts.

It was very humbling to go through my own illness, but it also inspired me. I have known firsthand how depression can rob you of your sense of yourself, how it can suck out of you all that seems to be you.

Fortunately, I received good treatment and recovered. I eventually returned and had to start over at the beginning in medical school. By the time I went back, I had a new goal: to become a psychiatrist and do everything I could with my life to understand and help others like my mother and myself who suffered from mental illness. In addition, I hoped to do psychiatric research, and to find ways to advance our field.

But I also made my past history of depression my secret. I realize now that I bought into the stigma that surrounds our field through my own silence. I had a fresh start when I started over in medical school, and made a point to move away from Memphis (where I went to medical school) for my residency at Duke. I later treated adolescents and adults in a practice in Chicago, came to East Tennessee State University for a faculty position, became chair of our department and served for eleven years. Throughout this period, I did not disclose my own psychiatric history, but privately yearned for an opportunity to tell my tale with the anticipation that I might help others have more hope.

My husband and I were blessed with two wonderful children. Our son is now a Ph.D. in Biochemistry like his father, and our daughter is now an M.D. doing a psychiatry residency. My husband and I shared with our children my psychiatric history when they were old enough to understand. My daughter wrote in her essay for residency that the news of my mental illness was a big surprise to her. She has developed a personal mission to combat stigma, and both of my children are a source of encouragement to me as I break my silence now.

For many years I have dreamed of writing a book about mental illness from the many perspectives I have acquired. When I had the opportunity to take a sabbatical from my university position, I seized the chance to fulfill my dream of writing a book.  I have just published a book Finding Your Emotional Balance: A Guide for Women, describing what I have learned both personally and professionally about how to help women find and maintain emotional balance at every stage of their lives.

All of us have stressors and may at times lose our balance, but there are many ways that we can be helped to lead more fulfilling lives.  In my book I discuss the various life stages of women from adolescence to the senior years and the challenges that come with each, using vignettes to illustrate a variety of mental health problems that can develop throughout life.  I also describe treatments including medications and other interventions such as therapy and lifestyle changes.

I sincerely hope that I can use my life’s experience to reach many other women and help them to understand themselves, overcome any stigma that might prevent them from seeking help when they need it, and to find balance in their lives.

You may purchase my book now at Amazon: http://tinyurl.com/p9jcf3m or from Johns Hopkins University Press: http://tinyurl.com/osyd5cu

 

 

 

 

Why I wrote a book on women’s mental health

I am a psychiatrist, professor, former chair of a psychiatry department at a medical school for over a decade.

I also have a history of severe depression in my 20s  and of devastating grief in my 50s after the unexpected loss of my beloved husband after 32 years together.

For many years I have dreamed of writing a book about mental illness from the many perspectives I have acquired. I have lived a life filled with experiences that have taught me. I grew up with a mother who had severe depression and never fully recovered, she died when I was 18 years old. I watched her go in and out of psychiatric hospitals, and I watched my father despair as he tried to help her. My own terrible bout of depression caused me to take a leave of absence from medical school and rethink my life goals. It was very humbling to go through my own illness, but it also inspired me.

I eventually returned and had to start over in medical school. By the time I went back, I had a new goal: to become a psychiatrist and do everything I could with my life to understand and help others like my mother and myself who suffered from mental illness. I also hoped to do research, and to find ways to advance our field.  I have specialized in women’s mental health throughout my career.

When I had the opportunity to take a sabbatical from my university position, I seized the chance to fulfill my dream of writing a book.  I am excited that my book Finding Your Emotional Balance: A Guide for Women will be published in December 2015 by Johns Hopkins University Press.

All of us have stressors and may at times lose our balance, but there are many ways that we can be helped to lead more fulfilling lives.  In my book I discuss the various life stages of women and the challenges that come with each, using vignettes to illustrate a variety of mental health problems that can develop throughout life.  I also describe treatments including medications and other interventions such as therapy and lifestyle changes.

I started this blog during my sabbatical in 2012, when I began the book.  Now I return, and will continue discussions about women’s mental health.  I invite you to join me, and to give me topics of your interest and concern.

I also have a new website, http://www.merrynoelmiller.com, and invite you to check it out!

Heart and mind

Welcome to new and returning blog visitors!  I am exploring topics related to women’s mental health on this blog, and welcome your suggestions, questions, and responses.

This week I’d like to discuss the incredible interaction between the heart and the mind.

Researchers have found that the mood has a big influence on heart disease. After a heart attack, 20 to 30% of people develop depression.  Those who get depressed have a worse outcome for their heart disease including higher mortality rates.  Treatment of their depression improves their outcome for heart disease as well as their mood.

So heart disease can cause depression.  Can depression cause heart attacks?

It seems so.  Studies have found that people with depression have much higher risks for heart attack.  Even mild forms of depression increase the risk for heart disease.  Women have twice the risk for depression compared to men.

Think about that.  There is a physical connection between the heart and the mind.  Taking care of yourself emotionally and spiritually can potentially help your heart as well.  If you are depressed, getting treatment for your depression can protect you from heart disease.  That treatment may consist of therapy and/or medication such as antidepressants.

The good news is that effective treatments are available that can simultaneously help your mood and your heart!

Learning to accept our bodies

A few weeks ago a study revealed that more women over 50 are being diagnosed with eating disorders.  These disorders usually first present at adolescence, when girls are struggling with their self-concept.  How sad that older women are also turning to unhealthy eating behaviors!

Learning to accept ourselves and develop a healthy lifestyle is a lifelong challenge. Typically the adolescent years are the time when doubts about body image become most prominent, and eating disorders are most likely to begin during that period. There are many theories about what causes eating disorders, but most theorists agree that the media’s unrealistic emphasis on thinness is part of the problem.  In the last several decades, there has been a marked rise in eating disorders that parallels the shift from full-figured ideals such as Marilyn Monroe toward the very thin models that are common on TV and in fashion magazines.

Recently an eighth-grader stepped forward to challenge the fashion industry. She started an online petition to Seventeen magazine and recruited 28,000 teenagers asking that photographs of models in their magazine no longer be artificially altered.  They recognized the destructive impact of such false ideals. They succeeded in their effort, and Seventeen responded with a pledge not to digitally alter body sizes or face shapes. The entire Seventeen staff signed a “Body Peace Treaty” promising not to alter shapes and to include only images of “real girls and models who are healthy.”

I have been asked many times what we can do to prevent eating disorders from developing.  What those young women did with Seventeen is a great example of preventative behavior.  The ideals of beauty that are presented to us by the media are often unrealistic, and we do not have to accept them.  We can choose to strive for health, not distorted images that promote excessive thinness or perfection. We can tell ourselves and teach our daughters to see through the unhealthy ideals promoted by the media. Do you know of other examples of similar efforts to challenge our media?

Congratulations to these young women and to Seventeen magazine for their healthy response!

Caregiving and the “sandwich generation”

I am currently reading a delightful memoir by Anna Quindlen entitled “Lots of Candles, Plenty of Cake”.  She discusses the dilemmas of today’s “sandwich generation”, those of us who have both elderly parents and children over the age of 18 who still need our support.  Thanks to medical advances, the average lifespan has increased considerably.  This means that more of us than ever before are lucky enough to have parents still living when we are in our 50s and 60s and even 70s. Often our parents need our help.  In addition, a shift has occurred so that more adult children are still living with their parents or having difficulty becoming fully independent and “launched”.

As Quindlen puts it, “The irony is rich–the women’s movement taught us we could be more than caregivers, and now we’re caregivers to more people than ever before.”

In addition to elderly parents and unlaunched children, women also often serve as caregivers for others in their lives.  Sometimes it is their spouse, or their partner.  It may be a sibling or a friend.  Sometimes they care for the family member who has developed a severe illness.  They may care for the friend who is suddenly grief-stricken after a loss.  Women often nurture, and care for those who need caring.

Caregiving has many rewards, and gives life much of its richness and meaning.  But sometimes the burden of caregiving can be physically and emotionally depleting.  So what can be done to make sure that the caregivers of our world are cared for as well?

Here are some ideas on how to take care of yourself if you are a caregiver:

1.  Ask for help. Is there a friend or family member who can relieve you, or can share some of your responsibilities?

2.  Look for ways that you can set limits.  Are there some activities on your calendar that can be reduced or eliminated?  Give yourself permission to say “no” without guilt.

3.  Seek ways to give yourself breaks, even something as simple as taking a walk or reading a book.  A meal with a friend is even better.

4.  Seek someone to confide in.  It can help alot just to be able to vent, to discuss the stress that you feel as you try to take care of those you love.

5.  Write in a journal about how you feel.  Try to use your journal to direct your thinking in a positive direction.  One exercise that can help is to use your journal to identify what you are grateful for each day.

6.  Give yourself an emotional pat on the back for what you are doing to care for another.  Let yourself feel good that you have helped someone.

What other suggestions do you have for how to help caregivers?

MM

The Psychology of Women

Welcome back again!  Thanks for all the interest in my blog, and for your thoughtful responses!

This week I’d like to look at the flip side of last week’s topic.  We discussed women’s fear of independence last week, a fear that limits some women’s lives.

The flip side of that topic to me is the idea that women may be overly blamed for being “dependent” when they value other people and spend much effort sustaining their relationships.  Caring for others is not unhealthy!

There is a relatively recent school of thought called Relational Theory that focuses on the importance to women of relationships with other people.   This theory proposes that connection to other people is a key ingredient for women in order to have a sense of well-being.

Older theories about human development said that healthy maturation required going through a separation process during adolescence, away from childlike dependence on the parents toward eventually becoming independent adults. Relational theory says that the psychology of women may not fit with these older theories and that women value relationships more than independence.  Women are not unhealthy just because we value relationships.  It is a big part of who we are.  We thrive on connections with others, and are more likely to be depressed and dissatisfied with our lives if we lack or lose our connections.

Of course it is always dangerous to generalize.  Men need to be connected to others, too.  Some women do not seem highly motivated for relationships.  But the idea is that men tend to be more achievement-oriented and women are more relationship-oriented.

So why would this concept be important to know?  What relevance does it have for women today?

For one thing, women who lack support from others are much more likely to be depressed.  If a woman is isolated and lacks a confidante, she may benefit from actively seeking support. Research has shown that the presence of a confiding relationship has been found to protect against depression!

In addition, if a woman loses support or a key relationship, this is a big stressor for her and may lead to depression.  This could happen through divorce or a breakup or death, as well as through a move or other events that lead to estrangement or separation from supporters. In such situations, it is important to pay attention to relationships and strive to develop a good support network.  It is best not to rely just on one person for support, but instead to have a set of people.

Another consequence of this need for relationships is that women put much of their energy into maintaining relationships with others and care-taking activities, and are likely to be stressed if their relationships are not going well or if their loved ones are not doing well.

So does this ring true to you?   Can you suggest ways in which relationships help or hurt women?  How can we use this knowledge to prevent depression in different circumstances?

Please share your thoughts!