Mar 31

It was NOT the depression

by Dr. Micaela Wexler

As a psychiatrist who treats people with depression on a daily basis it is disheartening to see news story after news story referring to depression in relation to the Lufthansa Germanwings Airbus crash. The latest news story I’ve seen is one titled “Lufthansa’s Deadly Confession,” and it reveals that Lufthansa (gasp) knew Andreas Lubitz was depressed and continued training him.

People do NOT murder because of DEPRESSION. People do not do much of anything because of depression. That’s the problem with depression: it prevents people from taking actions, from accomplishing, from participating. People with depression are unable to do things they could previously do before a depressive episode. They lack interest, energy, concentration. People with depression do not suddenly get an urge to go out and do something evil that takes a great deal of skill and planning.

Perhaps there is confusion about what depression is. If so, then it is up to people like me, a psychiatrist who is intimately acquainted with depression, to educate about what depression is. The mnemonic device DIGSPACES (Depression, loss of Interest, Guilt, Sleep disturbance, Psychomotor agitation/retardation, Appetite changes, loss of Energy, Suicidal thoughts) is a helpful way to remember these key symptoms of Major Depressive Disorder. To be diagnosed, the person has to have had FIVE or more present over the previous two week period, and it has to reflect a change from the previous level of functioning.

Does any of this sound like someone is focused and energetic enough to go plan the murder of 149 people?

It is stigmatizing to the many people I see who courageously struggle with their depression to see the media continuing to relate this tragedy to depression. I am not saying Andreas Lubitz did not suffer from depression at some point. Evidence shows that he did, and that is very sad. What I am simply saying is that the depression is not why he did what he did. Yes, depressed people can be capable of evil things, they are capable of hurting others, of causing damage, of lying, stealing, just like anyone else. But, it isn’t the DEPRESSION that makes them do this. Their motivations would be the same as anyone else committing evil, violent acts.

It’s hard enough to get people who struggle with depression to get help. Let’s not make it worse by stigmatizing them. This will not only serve to further marginalize the mentally ill, but it will do nothing to get to the root of what really caused Andreas Lubitz to crash a plane full of innocent people. And, both of those situations hurt all of us.

Appointment information for Dr. Micaela Wexler: wexlerpsych.com

Nov 26

Comparing Ferguson to the OJ Simpson case

by Dr. Micaela Wexler

In the days since the tragic events in Ferguson Monday night, I have seen an appalling number of Facebook posts comparing the Michael Brown case to the OJ Simpson case. Judging by the wording of the posts, the posters consider themselves quite clever as they point out that “white people didn’t riot when OJ Simpson was acquitted.”

First, it is disappointing to see how quick people are to judge when they have not walked in another person’s shoes. I don’t know if Officer Wilson was right or wrong in what he did, I wasn’t there, it is not my place to judge him. It is also not my place to judge how a people responds to deep psychic pain. Second, to compare the Michael Brown case to the OJ Simpson case is irresponsibly ignorant. OJ’s acquittal says more about how we devalue women and over value celebrities then it says about race.

In addition, whether one agrees with what Officer Wilson did or not, what happened in Ferguson is a monumental tragedy. First, an 18 year old man lost his life after doing what I have witnessed countless teenage boys do: shoplifting and walking in the street. His body was left to bake in the hot sun for four hours before it was removed. This loss tore open a deep wound in that community.

What happened in Ferguson Monday night is a large scale of what I see every day as a psychiatrist: people who are so angry and wounded they give up and destroy themselves. That community committed a form of collective suicide. It is as morally repugnant for us to use these events as a form of entertainment as it would be to make an individual who died from suicide an object of derision.

Early diagnosis beneficial in AD
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Appointment information for Dr. Micaela Wexler: wexlerpsych.com

Oct 14

Talking to your teenager about Ebola

by Dr. Micaela Wexler
wexlerpsychiatryEbola

As the Ebola epidemic continues to grow in West Africa and begins to spread to other countries, it is natural for teenagers to become distressed. One teenager asked me yesterday, “Are we all going to die from this?” Even though I am a psychiatrist who treats teenagers daily, I did not have an immediate answer.

I decided to do some research and share my findings and ideas on this blog.

First, be calm when talking to children of any age about Ebola. Don’t panic. Don’t give in to hysterics. If you harbor fears or conspiracy theories, share them with other ADULTS. There is no need to share ideas not founded in fact with teenagers.

Stick to established facts. After consulting the CDC web site, I not only had some answers, but I was reassured that it is very unlikely, maybe impossible that we are all going to die from Ebola.

Share with your teenager how Ebola is transmitted. According to the CDC web site, Ebola is transmitted through direct contact (through broken skin or mucous membranes in, for example, the eyes, nose, or mouth) with:
- blood or body fluids (including but not limited to urine, saliva, sweat, feces, vomit, breast milk, and semen) of a person who is sick with Ebola
- objects (like needles and syringes) that have been contaminated with the virus
infected animals

Ebola is not spread through the air or by water. In the United States, it is also not spread by contact with food. In West Africa, handling wild animals used for food also poses a risk for Ebola transmission. There is no evidence that mosquitos or other insects can transmit Ebola virus. Only mammals (for example, humans, bats, monkeys, and apes) have shown the ability to become infected with and spread Ebola virus.

Point out to teenagers their low risk for Ebola. People at highest risk are healthcare providers caring for patients with Ebola and close friends and family members of patients with Ebola. So, unless your teenager is a healthcare provider, her or his risk is almost non-existent.

Ebola Symptoms

Teenagers benefit from having concrete facts. It doesn’t hurt to teach your teenager the signs and symptoms of Ebola. Signs and symptoms include: fever, severe headache, muscle pain, weakness, diarrhea, vomiting, abdominal pain, unexplained bleeding or bruising.

Give your teenager a plan for coping with Ebola. I was happy to note that for non-healthcare workers, it is pretty easy to avoid acquiring Ebola. Practice personal hygiene, such as frequent hand washing. Avoid contact with bodily fluids, such as vomit or saliva, of people with signs of infection. Avoid travel to areas of the world, namely West Africa, with Ebola outbreaks. Avoid contact with bats, rodents and non-human primates known to carry the virus.

Ask your teenager to share her or his ideas of how the Ebola outbreak should be controlled. Remember, teenagers will soon be tomorrow’s leaders; let them know we value their ideas.

Finally, point out our healthcare system is one of the best in the world. Yes, tragically, the first person to be diagnosed with Ebola in this country has died and a nurse who cared for him has contracted Ebola. However, we have the capability to learn quickly and implement changes.

The same day a nurse caring for Thomas Duncan was diagnosed with Ebola, the University of Kansas began treating a patient who arrived with a high fever and had been working on a medical boat off the coast of West Africa. KU Medical Center immediately implemented CDC guidelines. The patient called the hospital and was met with staff wearing protective equipment. The patient was immediately isolated in an area of the hospital with its own ventilation system. The staff caring for the patient will not care for any other patients until Ebola is either ruled out, or the patient no longer requires treatment. (Update: initial tests are negative for Ebola.)

As with any crisis, it is important to remain calm, get the facts, and focus on scientifically backed methods to cope with the crisis. There are many other dangers which our teenagers face. For example, it is estimated that every year 2 million adolescents attempt suicide. Teenagers face a great number of risks which do not have easy solutions, such as hand-washing and avoiding vomit. Let’s keep things in perspective as we communicate with our teenagers, and let’s not let hysteria distract us from their very real needs.

Dr. Micaela Wexler provides child, adolescent and adult pscyhiatric services in Kansas City.

Please visit Wexler Family Psychiatry to schedule an appointment.

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Appointment information for Dr. Micaela Wexler: wexlerpsych.com

Aug 13

Paul Fleiss, MD, September 8, 1933 – July 19, 2014

By Dr. Micaela Wexler
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In 1997, I was the young mother of two daughters, an infant and a toddler. I was an unemployed playwright, with no marketable skills. I was married to a working actor who struggled to support our family so that I could be home with our daughters instead of working menial jobs. Central in this decision was our fervent wish that I breast feed our daughters “on demand.”

We had a pediatrician at the time who had not been supportive of me breast feeding my first daughter while pregnant with my second daughter. I had attempted to educate this pediatrician with research articles showing there was no harm in breast feeding while pregnant, but this had led to an acrimonious debate in her office during which she warned me my daughter could be removed from my home if I did not stop “harming her.”
I was aware that as a dark skinned minority woman without a college degree, I could not afford to fight with a pediatrician, that this could very well lead to my losing custody of my daughter. In my hormonal state, I began to have nightmares that I was sent to prison and my daughter soon forgot who I was.

I didn’t stop breast feeding. My husband and I simply lied to our pediatrician. We also lied to our obstetrician. I continued to breast feed throughout my pregnancy and then, when my second daughter was born, I started to “tandem feed,” all the time concealing my breast feeding practice from the person, who after my husband and me, was most responsible for my daughters’ health.

I shared all of this one day with my writing group. During the lively discussion that ensued, I was told about a pediatrician who was a champion of breast feeding, including tandem feeding. He was active in La Leche League, and did not turn anyone away, regardless of their ability to pay. His name was Dr. Paul Fleiss.
At that point in my life, I was still shy and timid. One of the women present surmised that I didn’t have the courage to call him, so she went to the phone and called him herself. It was late evening, but Dr. Fleiss answered his phone and listened as she told him my entire story. She got off the phone and told me I had an appointment the next day. When she gave me directions, I realized I had been walking by the cozy craftsman house he used for his practice the entire time I had been a mom.

During my initial appointment, Dr. Fleiss asked me questions in his soft voice, and as I gave my history of my daughters, he praised me, telling me what a great mother I was. He gently examined both my daughters, letting my toddler play with his stethoscope and place her finger on the end of the ophthalmoscope.
He was impressed I had found research articles about breast feeding while pregnant. He invited me to the La Leche League meeting held every other week in his office. He also invited me to join him and other people from the neighborhood in a morning hike in Griffith Park they took every morning at dawn. “Bring the babies,” he said. “They’ll love it. We’ll help you with them.”

Thus began a friendship that lasted until Paul died July 19, which happens to be my birthday. Paul became a friend, mentor and father figure to me.
I began hiking with the group, and developed several close friendships with other hikers. During one of our hikes, Paul shared that he did volunteer work in the Latino community, and could always use a fluent Spanish speaker. I accompanied him on one of these excursions, and my professional life began to take form.

For reasons that are no longer important I was not raised with the stability nor was I taught the skills one needs to pursue a career of any magnitude. During our many hikes I shared with Paul the story of my childhood and he took it upon himself to fill the paternal void in my life. He gave me advice as we climbed the hill in Griffith Park. He supported me in all my endeavors with the same enthusiasm he had for breastfeeding and pediatrics. Paul brought a group of friends to see each of the productions of my three plays.

One day I shared with him my desire to become a doctor, and my fears that I was too old. Whereas many well meaning friends advised me to consider nursing or physician assistant school, Paul never once said a discouraging or negative word about my desire to become a doctor. He gave me nothing but support in every way possible. He assured me that I was not too old, and then he said, “It’s better to be a good doctor for five years than a bad doctor for 20.” He gave me advice on where to take my pre-med classes, and how to make my resume more competitive. He allowed me to shadow him for countless hours in his office. He regaled me with stories about women who had become physicians after having children.

When I received my medical school acceptance letter, Paul was overflowing with pride. He then suggested a way for me to afford medical school: applying for the National Health Service Corp (NHSC) scholarship, a program that pays the entire cost of medical school (tuition plus a monthly stipend) in exchange for four years of service in a primary care specialty in an underserved community. “You’re exactly what they’re looking for,” he said.

During medical school, I did one of my pediatric rotations in his office. He risked our friendship for the greater good of pushing me hard as a medical student. He never passed up an opportunity to share one of his pearls of wisdom. A constant refrain was “always listen to your patient. If you listen long enough and carefully enough, the answer will come to you. The patient will tell you what you need to know.”

My second year of residency took me out of Los Angeles to Kansas City in 2007. The excitement of starting a new life was tempered by leaving Paul. Not only was I leaving an amazing pediatrician for my children, but I was leaving my mentor, father figure and close friend. Paul softened this blow by suggesting that I fly to Los Angeles with my daughters for their annual physicals. “Many people do it,” he said. For the first three years, that’s exactly what I did, and each time we saw him, he treated us as if we had never left.

My NHSC service obligation took me to a small town in Southwest Missouri where I was the only psychiatrist providing outpatient care. I also staffed the inpatient unit. The hours were long, and it was challenging to find coverage so I could take time off. My last trip to Los Angeles to see Paul was in 2011, for a short, impromptu weekend. Despite the short notice, Paul made time to see me. We went on a hike, and I had two of my three meals in town with him. I shared with Paul the challenge I faced in rural Missouri: the patients had come to expect doctors to write them multiple prescriptions for controlled substances. This expectation was especially high when patients saw a psychiatrist. My visit with Paul strengthened my resolve to “listen carefully to the patients,” and not just give out multiple medications.

My job in Southwest Missouri became more demanding as the months passed. The poverty there is brutal; the incidence of substance abuse is staggering. I was physically attacked on several occasions for various reasons: my dark skin, my refusal to dole out narcotics, my reluctance to place patients on disability until all avenues had been exhausted, and on two occasions, when parents became convinced I was the one who had called child protective services.
In the summer of 2012, I called Paul. “I can’t go on,” I told him. “I’m not going to make it through my contract.” We discussed the enormous financial penalties I would face if I didn’t complete the contract: 3 times what it had cost to attend medical school plus 18 percent accrued interest.

“I’m going to have to move to Mexico,” I concluded.

“That’s a wonderful idea!” Paul said. “my son went to school in Mexico. He loved it. You could teach in the medical school.” Always the dreamer, his mind was always brimming with possibilities. His reaction was perfect, it lifted my burden, giving me the freedom to think of other possibilities myself. I began to indulge my desire to treat children with developmental challenges, which became my plan to pursue a child and adolescent fellowship after completing my contract.

That plan fueled me for the rest of my service obligation. In September 2013, I got in touch with Paul to wish him a (late) happy birthday. When I expressed my fears that I would not be accepted into the program, he promised me he would hire me to do child psychiatry in his office. “In my eyes, you’re already a child psychiatrist.”

A month later I was accepted into the fellowship program at KU Medical Center, to start immediately upon completion of my NHSC service. I completed my service July 18, at midnight. Paul died the next day. My mentor and friend saw me through to the end.

There have been many moments since Paul died that I have been overcome with grief. It’s hard to believe I will never hike up the hill at Griffith Park with him, that I will never “talk shop” with him about my work with children. It’s difficult to accept that his seemingly endless energy really has stopped. To me, he will always be that thin man hiking next to me, his mind sparkling with ideas, showering me with flakes of hope and possibility. I get through these sad moments by taking comfort in the many gifts he gave me. Each time I think about Paul, I remember to “listen to the patient, and the answer will come to you.”

Dr. Micaela Wexler provides child, adolescent and adult pscyhiatric services in Kansas City.

Please visit Wexler Family Psychiatry to schedule an appointment.

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Appointment information for Dr. Micaela Wexler: wexlerpsych.com

Jul 17

My rural medicine adventure

By Dr. Micaela Wexler

Tomorrow my four year adventure in rural medicine will come to an end. It will be bittersweet. I will complete my four year service obligation for the National Health Service Corps (NHSC). The NHSC is a federal program that provides scholarships and loans to physicians and nurse practitioners willing to provide primary medical care to under served communities. I was in their most competitive program, the Scholar Program for Physicians: the NHSC paid for me to attend medical school in exchange for providing psychiatric care to a community on a “critical need” list.

I decided to pursue medicine after my two oldest daughters were born, and without the NHSC, I would not have been financially able to attend medical school. I was thrilled to discover that my area of interest, psychiatry, was on the list of required specialties. The financial support from the NHSC felt like a luxury: they paid my medical school tuition and fees up front along with a monthly stipend. This made medical school extremely enjoyable for me. I didn’t have the shadow of mounting student loans looming over me, which made me almost giddy as I immersed myself in anatomy, pathophysiology and clinical rotations. It wasn’t until I was in residency, exposed to critically underserved populations that I began to consider the rigorous job options that awaited me.

At the beginning of my last year of residency, I learned that psychiatrists in my cycle of service would be required to serve in remote rural communities. This had a profound impact on my family. There were absolutely no rural communities which had a Jewish community. My best option was to be placed in a community one and a half hours from a Jewish community. I chose Southwest Missouri, 85 miles away from where my children would be living. This meant I would be living alone as I completed my service obligation.
This turned out to much more difficult than I ever imagined. When I arrived, I was convinced the commute would be easy, that this would be no different than when I did my rotations during medical school in Los Angeles and regularly did 3 hour round trip commutes due to traffic. Well, it’s a completely different story when you’re the only provider and 20 to 30 people need your care on a given day. You can forget about making that commute. And, when you do make that commute, be prepared for something worse than traffic: no other cars at all. No one to help you if you hit a deer or get a flat tire, or, worse, you fall asleep and fly off the road. All of those things happened to me at least once.

When I arrived in my community, I assumed I would pursue multiple hobbies with all my “spare time.” I had hopes of making a quilt, joining the gardening club, riding with the local cycling group. Well, again, that huge patient load made all of that impossible. I never even had time to go inside the quilting store, something that still makes me sad. I rode my bicycle alone in the pre-dawn hours.

I spent many days when the only people I had conversations with were my patients and the nursing staff. I ate most of my meals alone, while I completed charts. I engaged in stress eating, which caused me to gain weight.
While I did manage to visit my children at least twice a week for the entire four years, I did miss quite a few parent teacher conferences, school performances, and even a couple of birthdays.

So, why am I not absolutely ecstatic that my service is over? The patients. I was able to start an outpatient psychiatry clinic from scratch, and provided face to face care to people of all ages. I provided inpatient care to patients from all over the state who typically arrived in a state of crisis. I never had even one hour when I felt I was useless or superfluous. I learned about the brutality of rural poverty and the devastating effect it has on children and adolescents. This knowledge focused my efforts in a profoundly meaningful manner.

My work in the clinic afforded me the opportunity to treat entire families: children, parents, grandparents, and in a couple of cases, great grandparents. I acquired deep knowledge of their hopes and struggles, of the fierce family loyalty which survived substance abuse, incarceration, chronic unemployment and severe mental illness. I witnessed the miracle of children growing and thriving despite their many obstacles.

I fell in love with my patients. I will never stop being inspired by their admirable struggles to overcome the challenges of mental illness. Their hope and optimism in the face of considerable adversity will inform my practice of medicine from this time forward.

Apr 28

Talk to your kids about sex . . . and love

By Dr. Micaela Wexler
This is an important topic parents have a hard time discussing with their children. Too often I find that my adolescent patients have never had an in depth discussion about sexuality with their parents. In the best case scenarios, they have been told about pregnancy and STDs, but usually sex has been presented as a forbidden activity, in an atmosphere of discomfort and embarrassment. There is rarely any discussion about relationships, intimacy, sexual expression, body image, masturbation and acceptable behavior. Parents seem to be oblivious to the fact that according to the Guttmacher Institute, 46% of teenagers age 14-19 report having had sex at least once.

Failing to talk to your teenager about sexuality puts him or her at grave risk for a variety of dangers ranging from the obvious – pregnancy – to others that are less obvious but potentially more life threatening, like depression and relationship abuse. Depression is the greatest risk factor for teenage suicide. Romantic break ups are a common trigger for depression in teenagers. Teenagers most at risk for depression following a relationship break up are those who have limited support and poor coping skills. Parental support is a potent protection against teen dating violence.

It is never too early to talk to your child about sex. Ideally, the “sex” talk should begin at birth. Use correct words for genitalia when changing diapers or giving your child a bath. Make positive statements about their body (and yours) throughout their childhood. Early childhood is when boundaries should be taught, that their private parts are their own and no one else should touch them. The same is true about other people’s private parts. Introduce the physiological aspects of sexuality in the elementary school years, with anatomy lessons, including the different processes that occur, such as hormonal and physical changes, pregnancy and orgasms.

I recommend that birth control and STD protection issues be brought up during elementary school years, even if you are a strong believer in abstinence before marriage. Hearing about both birth control and abstinence at the same time does not lead to children engaging in sexual activity earlier. Parents should remember that children hear alternative, even conflicting views about many topics in their lives. Presenting children with choices teaches them decision making skills.

Children are being exposed to sexual topics outside of the home at an earlier age, and they will be safer if they have heard about them from you. In addition, talking about birth control and STDs helps children open up about other sexuality related topics; they are less shy about sharing what they have been exposed to at school and in the media. Don’t be afraid of letting them know the meanings of words they hear, ie blow jobs, fuck, cunt, etc. These are valuable opportunities for parents to express their views on acceptable sexual behavior.

Explore your own thoughts and feelings about sexuality. If you are uncomfortable discussing the topic of sexuality, try to figure out why. Are you unhappy with your own sex life? Are you disappointed with the level of satisfaction you are achieving? Maybe you have a history of domestic abuse or childhood sexual abuse. Were you taught negative views about sexual expression during your own childhood? Or, perhaps you are mourning the loss of a relationship. Getting in touch with your own emotional feelings regarding your sexuality will help you address the emotional impact sexual expression has on your teenager.

Studies show that most parents do not discuss the emotional aspects of sexuality with their teenagers. They do not discuss intimacy, relationship conflicts and violence in relationships. Teenagers are left to navigate the confusing world of dating, relationship building, sexual expression without any skills and with no one to turn to when problems occur. Whether they are engaging in sexual activity or not, teenagers experience very strong emotions when it comes to relationships. Due to their raging hormones, every aspect of the relationship is magnified. This is a dangerous time to withdraw parental support.

Once you have talked to your child about all the concrete aspects of sexuality, you have set the groundwork to talk about the complex emotional issues surrounding sexual expression. It is important to approach the topic in a non- judgmental and non-threatening manner. Open the discussion by asking if their friends are in relationships. Rather than focusing on sex, focus on issues like trust, mutual respect, friendship and honesty. Guide your teenager through a relationship conflict. Be on the lookout for signs of teenage violence. Do not trivialize their feelings. Teach your teenagers that their sexuality is a gift that should be treasured, and that it should never be used to hurt them.

Feb 02

Children of addicts deserve our protection

PhilipSeymourHoffmanBy Dr. Micaela Wexler

As has become common, we were spared no details as yet another beautiful mind was stolen from us by addiction, this time heroin. Given Philip Seymour Hoffman’s frank honesty about his struggles with substance abuse in his youth and his recent relapse, I would like to think he would want the circumstances surrounding his death to serve as a warning to all of us, especially young people.
So what are we to make of this tragedy, and the message inherent behind these graphic disclosures? Are we to focus our anger at the media, for violating his privacy and that of his family? True, his three children deserve protection at this difficult time. But, like all other children with parents who struggle with addiction, they are at heightened risk of future struggles with addictions themselves, and why not protect them, and other young people, by gathering our resources to fight this horrible disease?
We do not, as yet, have a cure for this disease. A person in recovery is like a person in remission form cancer. The threat of a recurrence of their disease lurks over his or shoulder permanently. Our best hope lies in prevention, followed by treatments that have been proven to work.
Prevention must start with targeting the children of addicts. Since it is not always possible to know who they are, given the stigma surrounding addiction, we must target all children by educating them as well as ourselves. Research shows that the best prevention lies in identifying risk factors, and tailoring interventions to strengthen specific protective factors. Risk factors in childhood for eventual addiction include early childhood aggression, genetic predisposition, lack of parental supervision and substance abuse.
Early aggression can be addressed by teaching conflict resolution and addressing the anxiety that triggers this behavior. Genetic predisposition could be addressed by teaching adult addicts how to educate and protect their children. Lack of parental supervision can be addressed by increasing community support of families, as well as educating parents. Find out WHY parental support is lacking, and how that child can be supported.
Substance abuse in children is sadly widespread and oftentimes ignored. There is good research showing that exposure is a common trigger for initiation of drug use. Children are exposed to tobacco advertising from the time they are toddlers standing next to their parents at the convenience store. We advertise alcohol on television. And, now with the increased legalization of marihuana, pot advertising campaigns have introduced a new avenue of exposure. In our zeal to do legalize pot, we have, once again, disregarded the needs of our most vulnerable people. A child with multiple risk factors doesn’t really stand a chance when talk of pot use is on the evening news, all over social media and on the radio.
Substance abuse must be addressed promptly and with compassion. A strong parent-child bond has been shown to be the best prognostic factor; however parents’ high level of anxiety when confronted with their child’s substance abuse often interferes with this parent-child bond. We must support, rather than shun, parents when they are faced with this crisis. We must advocate for positive interventions when children are caught with drugs at school rather than punitive measures, such as suspension.
Adults struggling with addiction are often denied treatments that have been shown to work. A good example is the use of Suboxone in the treatment of opioid addiction, which has been shown to be life-saving. This treatment is sadly very underutilized due to the critical shortage of Suboxone providers. The training required to prescribe Suboxone is not a routine part of medical training. Currently, a physician is only allowed to have 100 patients on Suboxone at any given time. Both these factors contribute to the severe shortage of Suboxone prescribers.
We must increase the availability of this and other successful treatments, and we must do away with the many myths surrounding addiction. For example, let us do away with the idea that addicts are “choosing” their drugs over their families or jobs. This will only happen when we, as a society, accept that this is a disease, and then mobilize our resources the way we have behind diseases like breast cancer and multiple sclerosis.
Philip Seymour Hoffman left behind three children who join countless others who have been orphaned by drug addiction. All of them cry for our protection. Let us use the tragedy of his death to make their world, and ours, safer from addiction.

Dr. Micaela Wexler also blogs on child psychiatry topics at kidpsychdoc.com.

Jan 09

Spirituality is good for the brain!

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by Dr. Micaela Wexler

Turns out that religion and spirituality are good for the brain! A strong connection to spirituality actually makes the brain tissue itself stronger.

For years, psychiatrists have known that religion and spirituality protect against depression. Studies have shown up to a 90% decreased risk of depression in people who had a strong religious or spiritual connection.

A study published in the American Journal of Psychiatry in 2011 showed that having strong religious or spiritual beliefs prevented a recurrence of depression. In this study, led by Lisa Miller, Ph.D., an associate professor of psychology and education at Columbia University Teachers College, assessed the influence that a strong connection to religion or spirituality had on the mental health of 114 adult children of both depressed parents and non-depressed parents. The study found that those who reported a high personal attachment to religion or spirituality had only a one fourth risk of experiencing depression as those who did not.

WexlerSpritualBrainReligion and spirituality also protected those with a family history of depression. For people whose parents had depression, a strong attachment to religion or spirituality reduced their risk of experiencing depression to just one tenth.

It turns out that a connection to religion or spirituality actually affects brain tissue.

In a new study, published in JAMA Psychiatry, a strong attachment with religion or spirituality was associated with thicker cortices in multiple brain regions. Thicker brain cortices are associated with decreased risk of developing depression. Depression has been found to cause the brain cortices to thin. The theory is that if they are thicker to begin with, they are less likely to thin to a level that causes depression.

WexlerPrayDepressionAwayYou don’t need organized religion. The same studies showed no correlation between frequency of attendance and protection against depression. Nor did they find any particular denomination offered increased protection. In other words, it was the connection to spirituality or religion that offered protection rather than level of participation in an organized religion. What this means for you is that to protect yourself against depression, you just have to find your own spiritual path. So pray your depression away in whatever manner suits you. Your brain will thank you.

Dec 10

When you call a girl a slut

By Dr. Micaela Wexler
When I say “girl,” I am talking about females who have not yet reached adulthood. Girls start being subjected to this abuse starting at the age of 10, if not earlier. By “slut,” I am not just referring to the actual word, but also to any language that shames a girl for expressing her sexuality. And, when I say “you,” I am limiting myself to the adults in girls’ lives who do this who are supposed to be supporting and nurturing these girls: parents, step parents, parents’ girlfriends, aunts, older sisters, teachers, neighbors.

This behavior is so wide spread that a word defining this behavior is now part of our lexicon: slut-shaming. Slut-shaming is defined as “publicly or privately insulting a woman because she expressed her sexuality in a way that does not conform with patriarchal expectations for women.” As a child psychiatrist, I hear slut-shaming several times a day. And, sadly, it is usually women who engage in this behavior. Examples I have heard include:

- a teacher I spoke to about a bullying incident said, of the 12 year old in question, “excuse my language, but if she didn’t dress like a slut . . . ”
- a woman, speaking about her stepdaughter: “she is 15, and she’s already a slut”
- another stepmother, speaking of her husband’s 14 year old daughter, “she goes prancing out the door with skirts up to here, make up that makes her look cheap, to hang out with a bunch of kids to do who-knows-what. I don’t like that sort of behavior around my 12 year old son. You should see how he looks at her. I wish she would just go away.”
- a woman whose boyfriend has a 16 year old: “instead of making her babysit (their one year old), he let her go out with her friends. All she does is go out and screw everyone she sees.”

The implications behind this slut-shaming behavior is that these girls are unworthy of our love, support and protection. In each of these examples, the girls’ behavior was being used as a rationale for not considering her needs. In the first example, the teacher is absolving herself of any responsibility for protecting a 12 year old girl because of how she DRESSES. The other examples all involve stepchildren. So, not only do the girls in question have to suffer the calamity of their parents’ divorce, but they now have a new slut-shaming person in their lives.

In every single example, the needs of the girls are completely ignored. The 14 year old girl mentioned above is entitled to safety in her own home regardless of how she dresses. The 12 year old son would benefit from being taught to respect females rather than watching the behavior that is undoubtedly being demonstrated. If it really is true that the 16 year old is “screwing everyone she sees,” that is a tragedy, not an opportunity for derision.

As a child psychiatrist, I have to think that the women in these slut-shaming examples, and others like them, do not truly wish these girls harm. The teacher chose a helping profession and has dedicated several years to serving middle school children. All the mothers in these examples are incredibly nurturing to their own children.

So, why do you do this? One reason, in my opinion, is that you are truly overwhelmed by the daunting task of shepherding girls through these turbulent years. Raising teenagers, both boys and girls, has become very complicated. Families face constant intrusion from the world at large, through the media, social media, as well as from economic pressures that expose families to risky situations. Many of you are the products of a society that gave you negative images and limited opportunities. You live in a world that offers your family very little support.

I have to believe, also, that you are unaware of the damage this behavior causes. Slut-shaming causes deep, long lasting damage to a girl’s self perception. When girls are slut-shamed by the adults in their lives, they are shunned, isolated, left to navigate the dangerous waters of the teenage world alone, without protection, information and support. This places boys at risk, as well. Slut shaming leaves boys without any meaningful tools they can use in communicating with girls. They are being asked to view potential friends and romantic partners in a negative, one dimensional fashion which ignores who they are as people.

When we make negative comments about how a girl dresses, we are are objectifying that girl, and teaching her, and her male peers, that her value is based on how she looks. Whenever we slut-shame, we make it harder for these girls to defend themselves against rape, child molestation and relationship abuse. We also make it difficult for these girls to develop a healthy sexual identity. Some girls react by exaggerating this behavior. Other girls react by shutting down their sexual side, acquiring negative attitudes about their sexual feelings.
By slut-shaming, you are adding to the turbulence all teenagers face. Since I know that this is not at all your intention, I ask, for the sake of all teenagers, that you examine this behavior and why you engage in it. Next time you get the urge to do this, instead find out what the girl’s behavior means about how she feels as a person. Reach out to her and help her navigate the treacherous waters she and all teenagers find themselves in.

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