Jul 28

It’s not enough to just get up and move

By Dr. Micaela Wexler
Last month (June 2013) the American Medical Association voted to classify obesity as a disease, a decision which will hopefully lead to a more comprehensive view of this public health issue which affects one third of all Americans, instead of our current narrow focus. As a psychiatrist, it is difficult for me to stand by while the link between obesity and depression is ignored. In recent years, solutions have been focused almost exclusively on diet. Our simplistic view of obesity is evidenced by the widespread support for Michelle Obama’s “Let’s Move” campaign. This campaign, and others like it are, at best, short sighted, and at worst, cruel and harmful, especially with regards to children and adolescents. While there is nothing wrong with promoting exercise and healthy eating, especially among young people, focusing solely on diet and exercise ignores other issues which need to be addressed in order to successfully treat this growing health crisis.
The most harmful aspect of these campaign is that it adds to the view that obesity is a moral failing, which contributes to an unhealthy treatment of people with weight issues. At the Building a Healthier Future Summit, this past March, Obama charmed her audience with the following, “We can’t lie around on the couch eating French fries and candy bars, and expect our kids to eat carrots and run around the block. But, too often, that’s exactly what we’re doing.”
This view of people with obesity is not only demeaning, but flies in the face of research which shows obesity has many causes: genetics, hormonal influences, mental health status in addition to poor diet and exercise. Multiple studies have shown a correlation between maternal obesity and obesity in offspring. Children born to obese mothers start to have weight problems as early as toddlerhood. Once obesity has set in, hormonal and metabolic conditions in the body make weight loss challenging. Limiting focus to diet and exercise doesn’t take into account the many people who are getting up and moving, like families whose children are involved in sports, but who still find themselves battling obesity. Ignoring these various causes leads to ignoring potential solutions.
As a rural psychiatrist, I am confronted with the challenge of obesity, which is more widespread. A study done by Christie Befort, PhD, published in the fall 2012 issue of the Journal of Rural Health, shows that obesity is significantly higher for adults from rural areas of the United States. The study compared 7,325 urban adults with 1,490 rural adults, and found that after controlling for factors such as demographic, diet and physical activity variables, the obesity prevalence among rural adults was 39.6% versus 33.4% among urban adults.
Studies have established that obesity tends to cluster in families, in part due to genetics. For example, in 1990, a study published in the NEJM comparing the body mass index of identical and fraternal twins reared apart and reared together showed that genetic influences on body mass index are substantial. Although no single gene can account for obesity, as many as 50 genes have been found that are associated with obesity, affecting things such as metabolism, food cravings, fat accumulation and fat storage, to name a few.
The link between depression and obesity is well known in psychiatry. Ignoring this link is especially dangerous when it comes to children and adolescents. A meta analysis study published in JAMA in March 2010 shows a reciprocal link between obesity and depression, ie, depression can lead to obesity and vice versa. (1) A study of Dutch teenagers, published in Obesity in March 2010, showed a clear association between weight status and suicidal behavior in obese adolescents. (2) The same link was found in a later study done on Korean teenagers. (3)
A person who is depressed undergoes physiological changes which affect interest, sleep, appetite sexual drive and thought process. They most likely do not possess the motivation to “get up and move.” Changes in eating patterns, along with a disconnect between food intake and hunger are common in people with depression. Depression itself has been shown to cause weight gain and fatigue; metabolic changes that occur during depression make the body less responsive to diet and exercise. People with depression tend to lose their perspective when dealing with problems in their life. They tend to carry a great deal of shame, as do people with obesity.
As with obesity, the incidence of depression is significantly higher among rural residents than among urban residents. (4). This difference becomes more pronounced with regards to suicide, especially teen suicide. (5) Currently, in the rural setting, the stigma for mental illness is a major challenge in addressing the issue of depression. The same is true for obesity, with many obese people having internalized society’s view that people are that way because they are lazy. Perhaps with the AMA classification, people with obesity will feel more empowered to reach out for help. As the veil of shame is lifted on obesity, so may it also lift when it comes to depression. Addressing the link between depression and obesity will go a long way in decreasing morbidity and mortality among our youth. Then maybe it won’t be so hard for people to get up and move.

1) Overweight, Obesity, and Depression
A Systematic Review and Meta-analysis of Longitudinal Studies FREE
Floriana S. Luppino, MD; Leonore M. de Wit, MS; Paul F. Bouvy, MD, PhD; Theo Stijnen, PhD; Pim Cuijpers, PhD; Brenda W. J. H. Penninx, PhD; Frans G. Zitman, MD, PhD

2) Weight status, psychological health, suicidal thoughts, and suicide attempts in Dutch adolescents: results from the 2003 E-MOVO project.
van Wijnen LG, Boluijt PR, Hoeven-Mulder HB, Bemelmans WJ, Wendel-Vos GC.

3) The relationship of weight-related attitudes with suicidal behaviors in Korean adolescents. Kim JS, Lee K. Department of Family Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea.

4) Rural-urban differences in depression prevalence: implications for family medicine.
Probst JC, Laditka SB, Moore CG, Harun N, Powell MP, Baxley EG.
South Carolina Rural Health Research Center, University of South Carolina, 220 Stoneridge Drive, Columbia, SC 29210, USA. jprobst@gwm.sc.edu
Fam Med. 2006 Oct;38(9):653-60.

5) A review of the literature on rural suicide

Jul 14

How do I help my mom get over my brother’s suicide?

By Dr. Micaela Wexler
Sadly, as a rural psychiatrist, I have heard several versions of this question. Each time I have heard it, it has been a painful reminder that there really is not much support for families who have lost a loved one to suicide, especially in the rural setting.

When a family loses a loved one to suicide, each member experiences the trauma in their own way. The father might be numb, and in denial. The mother can be incapacitated by her guilt and loss, fearful of losing her remaining children. And, the siblings may be angry; I have heard more than one sibling express a common, and untrue myth about suicide: that the person was motivated by selfishness, and did it to intentionally hurt those left behind.

My patients who have lost a child to suicide are the most bewildered people I have encountered as a psychiatrist. I have tried to put myself in their shoes, and have found those attempts nothing short of overwhelming. I feel I would be pulverized if such an event happened in my life; I would not be able to keep from blaming myself. I don’t feel I would be able to continue living. These are the very thoughts that these parents have shared with me, in the immediate aftermath of a child’s suicide.

However, as a psychiatrist, I know that with the proper support, these thoughts will pass as the parents heal. I have watched parents survive this most horrible of events; I have been a witness as they have made the journey through their grief and learned to live again; I have watched as the healing allows them to eventually continue to advocate for their child by increasing society’s understanding of this monumental problem.

“Where did I go wrong?”
Parents feel a deep sense of guilt, both their own guilt and the guilt which society puts on parents. The guilt is incapacitating in those early days. Mothers will spend hours upon hours day after day trying to go over every single decision they have ever made regarding their child. They will reach far into their history, examining even the most trivial events. Their surviving children will have little patience for this, most likely because it is painful for them to see their parents punishing themselves. Or, they will feel resentful that so much attention is being given to the one child. Hearing their parents express this guilt makes surviving children even angrier at their siblings for doing something so “selfish.”

Surviving siblings are in need of support themselves, and will naturally turn to the people, their parents, they have always turned to first in times of great need, only to find these people completely unable to help them. In those early weeks, it would be ideal for siblings to turn to someone other than their parents for support, and for parents to find someone besides their surviving children with whom to share their grief. However, suicide carries such an immense stigma that it is rarely possible for families to do what is ideal. What happens instead is the surviving family members turn to the only people available, which can result in them further injuring themselves and each other.

This is one of the most common questions a psychiatrist will hear. Parents will look for any clue possible to explain why their child did this. Their deep need to answer this question will cause them to overburden their surviving children, convinced they hold the key to this secret. This pushes the surviving children, who have not had time to process the loss themselves, to come up with an answer: selfishness. And, so one of the more destructive myths about suicide is given more life.

These families need to learn as much as possible about suicide, so they can understand the true causes, and stop blaming themselves. What I have learned as a child psychiatrist about suicide is that the “why” has nothing to do with selfishness, and everything to do with deep, emotional pain. Research on suicide has shown us that the person has to become sufficiently accustomed to pain to be able to consider something most of us would find too agonizing to carry out. This pain has many sources.

With time, parents will come to understand that they were not, could not, have been the source of so much pain. As a psychiatrist who provides emergency psychiatric care, I treat suicidal patients on a regular basis. What I often hear is that the parents are one of the few sources of comfort in their child’s life.

“What did I miss?”
Parents are convinced they should have seen the signs. Even parents who sought psychiatric help for their children for many years believe they should have been able to prevent their child’s suicide. This causes them to become frightened of “missing something again” with their other children.

Suicide is partly the result of irrational thinking, and this thinking leads children to believe they are causing too much suffering to their parents by being alive. Mental illness carries such a stigma that some people feel their parents are over burdened from having a mentally ill child, and will feel relieved when that child is gone. In their efforts to spare their parents more pain, these children will do everything they can to hide their plans, and their pain, from their parents. I have had suicidal patients in great emotional turmoil tell me they feel good only when they are with their parents, and will genuinely show no signs around them for this reason.

Another sentiment my suicidal patients express is a feeling they are a burden to their parents. This is especially true of gay teenagers who are not out to their parents: they feel they are too great a source of future pain to their parents, which contributes to their suicidal feelings.

With time, as they go through the grieving process, many parents come to understand that they truly were their child’s best, and many times only, advocate. Parents need the space and support, as well as knowledge about suicide, to make this important realization.

“They gave him everything they had.”
The financial toll on parents is a topic I have seen seldom mentioned among my psychiatric colleagues. The costs come from many sources. Chances are the family member lost to suicide was already receiving psychiatric care, placing a financial burden on the parents. The rescue attempt itself can result in astronomical medical costs, especially if the suicide is a teenager or young adult, since every effort will be made to save the patient.

In the case of one family I was familiar with, the suicide (which occurred years ago) took place by gunshot, in the home. That family faced costs in the clean up. The home lost value due to a suicide taking place there. This was compounded by the family’s inability to properly maintain the home during the grieving process. Most people who commit suicide have a compromised financial situation: they generally do not leave assets, many leave behind significant amounts of debt, and surprisingly few have insurance, including burial insurance. The parents are also left with one less child to share in the costs of their care in their later years.

If the surviving family members are able to heal and stay together, ie, adult children moving back in with parents, this has the potential to soften the financial blow. This is one of the advantages families in the rural setting do seem to have. The loss of value to the home will not be as relevant if they are all able to continue living in it for an extended amount of time. With time, they will form new memories in their home, and it will stop being a house where someone shot themselves and become, once again, a home where a family lived, and loved together.

Support in the form of therapy, education and medications, if needed, will go a long way in helping a family properly heal. This, unfortunately, is often in short supply in the rural setting. This is unfortunate because family members who have been given proper support and treatment are society’s greatest hope in helping to prevent future tragedies.

If you have lost a child to suicide, regardless of your child’s age, I highly recommend the following web site: childsuicide.org It is the best resource I have found online for parents dealing with this tragedy.

Jul 12

Lost a family member to suicide? There is help.

By Dr. Micaela Wexler
If you have lost a family member to suicide, you should know that you and your surviving family members are at an increased risk for suicide. All family members should know the warning signs for suicide. An easy mnemonic has been developed by the American Association of Suicidology: IS PATH WARM (Ideation, Substance Abuse, Purposelessness, Anxiety, Trapped, Hopelessness, Withdrawal, Anger, Recklessness, Mood Swings).

If you are wishing you were dead yourself, or feel you have these signs, you must get help immediately. Call 911 if you don’t know what to do. Or, call one of the following numbers:

If you just need someone to talk to, you should also call those numbers. They can point you to resources in your area.

Websites where you can go for help:

www.suicidology.org – American Association of Suicidology – has a section for survivors

allianceofhope.org - provides an online support group. They have different forums for the different types of survivors, ie parents, children, co-workers.

www.suicide.org – a list of resources for those at risk as well as resources for those who have lost a loved one to suicide.

www.suicide.com – created by a suicide attempt survivor to help people who are suicidal

attemptsurvivors.com – a good blog to help understand the WHY behind suicide, blog posts written by people who have survived a suicide attempt

No Time To Say Good-bye, surviving the suicide of a loved one, by Carla Fine – carlafine.com – the best book on this subject which I have read

It is normal to feel intense emotions: guilt, fear, anger, hopelessness. A death from suicide is different from any other death because it is a violent choice. Many family members find it difficult to get through each day after a loved one commits suicide.

Regardless of how you feel, suicide is NOT done to punish those left behind. A person commits suicide due to unbearable emotional pain.

While it is true that there are known warning signs for suicide, some people may give no warning at all: they may seem peaceful or happy before committing suicide. This is common for people who have decided and planned out their suicide, because they feel they have finally discovered a way out of their pain. These suicides are the most shocking and devastating for families.

Other people who commit suicide do give signs that families don’t notice until it is too late. The following are some of these signs:
- a preoccupation with death or the afterlife
- sadness, hopelessness, loss of interest in life or those around them
- giving away belongings
- sudden change from severe sadness to seeming to be at peace
- sudden interest in “clearing the air” about past conflicts, events
- hints about suicide
- reckless behavior
- self injurious behavior
- previous suicide attempts
- loss of appetite, weight, energy, decrease in activities
- constant negative comments about themselves

If you realize your loved one was showing these signs, you should not blame yourself. These signs are subtle, easy to miss. Suicide is difficult for most people to talk about or confront. And, many people who are not suicidal also show these signs.

Every member of the family will react to the suicide in a different way. There is no correct way to respond.

If the loved one was a teenager or child, the younger siblings will need extra care and attention.

In the immediate aftermath of a suicide, other family members, especially the PARENTS, will not be good sources of support.

Do not suffer alone. Go to the resources I’ve listed. Or contact me. I am not able to provide care through my web site, but I might be able to point you to someone who can.

And, a reminder: if you need IMMEDIATE help, call 911.

Jul 06

“My kid isn’t gay! Why should I care about gay rights?!”

By Dr. Micaela Wexler
EVERY parent should care about gay rights because the way gay teenagers are treated, and the way they react to this mistreatment affects ALL teenagers. Let’s start with the most grim of those reactions: suicide.

Teenagers who identify as gay, lesbian, bisexual or transgender (GLBT) have the highest suicide rate of any population in our society. According to a study done by the Centers for Disease Control and Prevention (CDC), the numbers of lesbian, gay and bisexual youth who attempt suicide every year may be as high as one out of three. This is regardless of whether they are in or out of the closet.
Those statistics alone should be reason for every parent to care, because as a psychiatrist I can tell you teenage suicide affects all teenagers.
But, there are other important reasons why every parent should support gay rights. One out of every four LGBT youth experiences bullying, which ranges from severe physical attacks to verbal abuse. Bullying, like suicide, affects all kids. It creates an atmosphere of vulnerability for everyone. We should want a world for our children in which people are not attacked simply for who they are, in which people are allowed to love whomever they want, and to have that love celebrated. We should want a world for our children which promotes diversity and acceptance. How does the child with a mental health or physical challenge feel watching gay children being attacked and not defended? How does a teenager who is slow to develop or who is not conventionally attractive, or is overweight, feel hearing the words “faggot” or “dyke” used as slurs? Don’t you think they feel vulnerable on some level?
And, how do you know your own child won’t be bullied for being gay? Children are often bullied for many reasons which are cloaked under the homophobic label. There have been several well publicized cases of children being bullied who never identified as being gay. Carl Walker Hoover, was only 11 years old when he committed suicide in 2009 after being the victim of anti-gay bullying. He was an athlete and a Boy Scout, and there was no evidence he had ever asserted his sexual preference.
That leads me to what I hear as a psychiatrist: parents are often the last people an LGBT child will come out to. Your child may very well be gay, and you may not even know it. Especially if you don’t support gay rights.
So, now that you know you should, as a parent, support gay rights, no matter what, the next natural question is HOW?
First, watch your language. Do you say “that’s so GAY?” Do you use the word “faggot?” “Queer?” “Homo?”
If so, then it will be easy. Just stop. Get the gay slur jar going: a quarter for every time one of your kids catches you using those words. If three kids catch you all at once, then you’re out three quarters. By doing something like this, you are going a long way to supporting gay rights: you are communicating to your children that homophobic behavior is wrong, and maybe, they might think twice about doing it themselves. Children raised in a home where cursing is not allowed tend to have better manners and better language. Why not extend that to homophobic slurs?
If you don’t use those words, you’re not home free. You might still be guilty of homophobic language. What was your reaction to the repeal of DOMA? Was it negative? Do you express to your kids that marriage should only be between a man and a woman? Why? Don’t you think that’s homophobic? If you really believe this, why can’t you keep it to yourself? Why do your kids have to hear it? I’m sure there are all sorts of beliefs, like your thoughts on S&M sex, for example, that you don’t share with your children. Why share your anti gay marriage thoughts with them? It’s not going to affect who they marry, any more than your thoughts about your friend’s husband will affect who they have sex with. But, keeping it to yourself if you don’t agree with it might help stop anti-gay bullying.
Do you lie about friends or relatives who are gay: “They’re just friends.”
Do you even HAVE gay friends? They’re out there: why haven’t you included them in your social circle?
Maybe there is someone at work who is gay, or someone on TV, and you make rude comments. Doing that is anti-gay, and contributes to anti-gay bullying.
Or, maybe you just make comments like, “I don’t care if people are gay, they should just keep it to themselves.” If you don’t CARE, then why does it MATTER if they keep it to themselves? I truly do NOT care if people dye their hair. I truly do not expect my 82 year old neighbor to keep that to herself. (I, however, will be keeping my own hair dye decisions to MYSELF, thank you very much.)
Maybe you are not one of those people who has to change their language. Maybe you have always been open minded and accepting, and your children know this. Wonderful! You are ready to really step it up for gay rights! Did you attend a gay pride event last month? Oops! You didn’t? Why not? You don’t have to be gay to attend a gay pride week event. How did you not know that? Well, there’s always next year. You have a WHOLE YEAR to plan. And, to TALK about it with your kids! They can help you plan. You can all do research on which gay pride event you want to attend. I hear Seattle has a great gay pride celebration with all sorts of family friendly activities. This would be a great vacation option for the family, and great material for that “how I spent my vacation” essay. Great way to set the tone for the new school year.
What about your bookshelf: are there books about gay topics? Go to the gay section of the book store and buy the book with the most prominent title. You don’t even have to read it. (Your kid might, so you should probably look through it. And, I wouldn’t recommend how-to books on gay sex – that might really freak them out.)
And, it doesn’t stop there. Supporting gay rights can actually be really fun, when you consider all the artists, musicians and fashion designers who are gay! Wait! Have you been wanting a Michael Kors watch or a Marc Jacobs bag? Well, now you HAVE to go out and get one. It’s your duty as a parent.

Jul 04

My Child is Oppositional! What do I do?

By Dr. Micaela Wexler
No one wants to hear this about their child, and when they do, the message parents hear is: I’ve failed! The name has a very negative connotation, with three strong words, one after the other. Oppositional. Defiant. Disorder. It is painful to hear those words said about your child. It doesn’t help that society puts a great deal of pressure on parents to “control” their children, and that the media gives a disproportionate amount of attention to children who are “out of control.” When parents hear this about their child, they experience one or more of the following: anxiety, guilt, fear, anger, helplessness, sadness, or all of these feelings at once. It is easy for them to become overwhelmed with negative feelings about their children, and forget that the American spirit has traditionally celebrated individuality, and that many of our great leaders have been defiant by nature. It is the defiant, non-conformist that changes the world for the better.
As a child psychiatrist, my first advice is to take a deep breath. Remember, you are your child’s number one advocate, but in order to act as one, you have to be calm.
The next thing is to ask yourself, is this really true? Who did you get the diagnoses from? The teacher? A doctor? A therapist? A psychiatrist? What was it based on? How long has the person giving the assessment known your child? What was the assessment based on? If your child responds to limits on his or her behavior with extreme anger, chances are the diagnoses is true. Other more subtle clues include: arguing with adults, constantly getting in trouble at school, being easily annoyed, trouble keeping friends, losing her temper over trivial things, being spiteful or vengeful. If you are in doubt, get a second opinion from a mental health provider with experience treating children. Make sure your child is also evaluated for other disorders, like depression, anxiety, attention deficit hyperactivity disorder and post traumatic stress disorder.
If you feel that the diagnoses is true, it is time to do an inventory. First, start with yourself. Do you have problems with your temper? What were you like as a child? Do you have difficulty keeping friends? Do you have difficulty sleeping, relaxing? Do you feel depressed, anxious? Are you having a conflict with an important person in your life (significant other, best friend, sibling, parent, co-worker, boss)? These are all things that can affect your relationship with your child, as well as contribute to his or her behavior. Children are very sensitive, and react to even the smallest stress in their environment. If you find that you are anxious or depressed, getting treatment for yourself from a psychiatrist will go a long way in helping you cope with and heal your child.
How do you feel about your child? Does your child feel loved and accepted by you? Or, does your child feel you are disappointed in their behavior? It is normal to feel overwhelmed by these children, and to get caught up in the trap of responding to their behavior with negative feedback. Examine your reactions to your child: are they mostly positive or negative? Do you find yourself reacting to the behavior? Do you mostly feel frustrated or angry? If you discover during your inventory that this has happened to you, then know that this will be a good place to start and change things.
Next, take an inventory of the family. Who are the people in the family that your child relates to the best? The worst? Is there someone your child is finding especially challenging to cope with? Have there been many changes in the family structure or living structure? Who does your child feel supported by? Is there someone in his or her life who the child feels acceptance, gratitude, and love from? Is there someone in the family who requires a great deal of attention, or has special needs?
Look at the physical structure of your child’s life. What is the diet they are on? Do they have a diet rich in fruits, vegetables, nuts (for those not allergic)? Is there a routine in the home? Do you have a regular “alone” time with your child, a time when the child can expect NOT to be disciplined? Is there a sleep routine? Does your child have a “safe space” in the house, a place he or she can go to de-escalate? Does the family eat at least one daily meal together?
Taking this inventory will be time-consuming, but it will help you get started on a positive road toward healing your child. More importantly, it will put you in the position to advocate for your child in a positive manner. It is very likely you will need support in taking this inventory. Be sure you turn to people who have a positive attitude toward children, and your child in particular. If you find the need to turn to professional help, find practitioners who have experience treating children. And, remember, your child is a complex, interesting human being who has much to contribute to your family.