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Mental Health in the Seven Domains of Women's Health
Today in the studio, we have two of the stars of the "Bundle Of Hers", an award-winning podcast here from the University of Utah called the "Bundle Of Hers". So we have Margaux and Harjit today in the studio. Both are psychiatry residents here at University of Utah Health, and I'm Kirtly Jones and we want to talk about mental health. So we've talked a little bit about the seven domains and is mental health in the seven domains? Is it physical health or is it emotional health or is it both? Go for it.
Margaux: I love that you asked this question. I have felt like mental health and physical health are innately connected, and we react physically to our emotional being and vice versa. And so I think you cannot exclude them and historically they have been siloed in the medical system.
Harjit: Yeah, I think for me, it's similar to what Margaux said. I think that they aren't things that are exclusive, but rather inclusive. They work together. You both get an emotional reaction to, and also a physical reaction to, and I think that's one of the reasons why I was so interested in the field of psychiatry.
Normalize Prioritizing Mental Wellness
I remember reading, about 15, 20 years ago, an incredible article, very short article in New England Journal, a really fancy journal and talked about the physical consequences of stress. Now we always thought when I went to medical school that stress causing physical problems was kind of woo-woo. You know, it was kind of granola girls and hippies thought that and this was a really profound issue. Physical, emotional stress or stress as perceived, however it might be actually leads to permanent changes in the way our bodies process our stress hormones and our immune system.
It knocked me off my socks because I guess I knew that. I really knew that, but to have someone do the biology, the neurobiology, the endocrinology was great, but we need more because sadness, loneliness, anxiety, depression, you know, it's rampant. It's a big deal.
Margaux: And I think the stigma around it, especially when I am working in the adolescent clinics is a lot less and kids, they have way better language to talk about their mental health than I remember having in middle school and high school. And so I'm very encouraged by that, but at the same time, now that they're empowered with language, I think we're really uncovering the depths and the reality of mental health and depression and anxiety in our adolescent population.
Dr. Jones: So you think that it's the language that we've offered up or there's been more available to adolescents rather than we've created a generation of a phone addicted, anxiety provoked social media addicts. So do you think it's that we finally gave them the language to talk about it and that's not that those of us who were boomers created a world that was so anxiety provoking that we wrecked the next generation? I'm a boomer. I'm a boomer. I admit it, I'm a boomer.
Margaux: I don't think we fully have all the data, you know, to like make that correlation. I would say social media contributes. I don't even think we know or fully understand to what extent. I do think the language uncovers a lot of things that may have existed prior that we didn't know about. And because the stigma was to not talk about mental health, unless you were, until you were in crisis, we may not have fully understood. And some people can endure with subacute depression and anxiety, and just think that that's normal because they've never been able to talk to others or have a language and develop that way. So I think that's an interesting point. I don't know or have the data. What do you think, Harjit?
Harjit: Yeah, I think that is a complicated question. I think that there's maybe a combination of both. I think one that it doesn't feel like such a taboo. Like I have depression or I have anxiety. So people talk about it more. We find that there're more people that suffer from that.
But I also think there's this huge factor of the way that our cultural norms in our society are progressing towards. I definitely think social media has a factor in it. I definitely think technology has a factor in it. I definitely think there's a combination of things that are happening. And like Margaux said, there's not concrete data, but you can pick up on themes and clues, you know, growing up here and like looking at the way society works. I think that that definitely is contributing.
But I also agree that now because people talk about it more, you'll see more cases because now there's the words in language. You'll see a lot. But before in older generations, I'm sure it existed. It's just people didn't want to talk about it.
I would argue that you can give two, three and four-year-olds and I'm not the only one who's arguing. Some very famous neuroscientists are saying that we can teach two, three and four-year-olds emotional intelligence. And we've talked on "The Scope" about the RULER project, which is from Princeton, I think, and it can be used at any level.
- Recognize that you're feeling something.
- Understand a little bit you, why you're feeling it.
- Label it. You have to have the words to label it.
- Express it to people. This is what I'm feeling and this is maybe why.
- Regulate it. So you can teach kids the words.
When someone's feeling as a parent, you can take your two-year-old and say, "Oh, I can see you're feeling sad," or "This makes you mad." Or we could actually, as new parents come up with those little words on the fridgerator, with all the different emotional labels that you give kids. So they've got words for how they feel and then mirror with them. When you see them behaving a certain way that looks like a certain emotional state, give them the word for it, help them understand it, help them express it in words, and then help them regulate it. I think we are all going to be living with emotional states, how we come to some understanding that this is normal, or this is not normal and I need help. That's a complicated thing.
Finanical Elements of Mental Health and the Rise in Rates of Suicide
Particularly, actually, in young people, meaning the 20 to 30-year-olds. But in fact, the biggest jump has been in men and women in their 50s and 60s. And so it's a complicated issue as I think about how to help people. Well, I'm going to take a little tack here and talk about AA. It turns out that the Cochrane Collaboration, which looks at the evidence that shows something works or not found that AA is actually better than cognitive behavioral therapy, Alcoholics Anonymous for helping people stay sober and stay sober for longer.
And I was thinking about MA. I mean, there is something about getting together with people, being with people who can sympathize with each other, and it's free. All walks of life suffer from mental illness, but people who have the largest burden are in the lowest socioeconomic strata and they can't necessarily afford what it costs to get mental health.
The New England Journal has now started an editorial series, a case series on social health where social health interacts adversely with physical health, people's healthcare. And it's almost always financial. It's when they run out of money, when the kid at home doesn't have any care, when that they can't bring their dog in because they don't, you know, the hospital doesn't let them or they can't pay for their care anymore.
So financial resilience allows people the kind of care that might help them deal with mental illness, but people who aren't financially stable or their illnesses made them initially unstable leaves them in our country with really no safety net.
Margaux: I think it's another sign that our system is broken and not caring for people that contribute or could contribute to society. And it's injust to me to know that if you have money, you can afford the treatments and continue on your life the way it was maybe before you had this disorder. And if you don't have access, then you're on the street essentially. And I don't think that's fair that money should dictate who gets treated and who doesn't.
The thing that blew me away in psychiatry was noticing that the physicians had to do "one-to-one." So where the attending who's taking care of the patient on an inpatient unit has to call another provider who's never met the patient at the insurance company and basically defend for their right to be in the hospital. And I've never seen that.
If a person had pneumonia and they lived in Wyoming and it was snowing, we'd keep them for an extra day. No questions asked. But if a second that person was feeling a little bit better that day, the insurance is on the phone saying, "Hey, your patient's no longer suicidal. We're not going to pay for them anymore." And that . . .
Dr. Jones: They would go out to live on the streets when it's snowing.
Margaux: Yeah, and that blew my mind away.
Harjit: I think the difficult part there is the value is not being placed on these mental health conditions because the people that are impacted by these mental health conditions, because the psychological and social factors are generally the ones that also don't have the power. They're already marginalized communities. So it's just a perpetual cycle of not getting things fixed.
Dr. Jones: A third view of this is there are people with chronic conditions. Let's say it's kidney failure, or it's a cancer, or it's something that's really awful and their insurance company only pays for X amount and the family which is supportive, has gone through every resource they have. We see this with kids who are addicts. The parents have put them into expensive rehabs three times and now they have no more money. Or someone only gets nine visits a year with the mental health professional. And if you have a chronic illness, nine is not enough.
So even well-meaning families that have some money, they're middle-class and they're working, all of their savings, their retirement can go into paying for, it might be rehab, or it might be for a hospitalization that only pays for one day and somebody needs three months. These are really difficult things for families and families can run out of money in a hurry when they have a kid who needs a lot of financial support and insurance companies under I think, under support mental illness.
Harjit: I think it comes back to that value that's placed on it. And also when we think of health in general, when someone has pneumonia, you can see it on a chest X-ray, you know? It's a lot of having trust in providers to know that they know what they're doing, which I think often people want proof. We live in a kind of a world, like, prove it to me kind of thing. I remember growing up with that, like prove this to me, prove it to me.
Margaux: Or it's like, "Picture or it didn't happen." Like if you can't picture it didn't happen, yeah.
Harjit: Yeah, exactly. So I think that things are more complicated than that and it's complex. That's why you talk about the seven domains of women's health. Things aren't just a one dimensional picture. And I think that's what's difficult for a lot of the people that do have the power to place that value.
Group Therapy for Mental Illness
But there's something about being surrounded by your peers. And this is what you guys have done in "Bundle Of Hers," is making this group of women who can talk about what you're going through. What do you think about this in your practice about group therapy, whether it's supervised or not, women love to talk to each other. And this is, we're talking about seven domains of women's health and we're women, all women in the studio today. What do you think about group therapy for mental illness?
Margaux: I think you've hit on a very important point, which is isolation can be one of the key driving factors for mental health disorders. And I think that's part of the reason social media plays a factor too, is it can be very isolating. And I think one of the reasons why AA works like you were saying is the community aspect coming together face to face, being vulnerable in a shared community is very important.
And I think like Harjit was saying a lot of our society is moving towards a very individualistic approach. And I think that's isolating a lot of people and sort of driving, maybe these rise in suicide rates or increase in mental health disorders being diagnosed.
But I do agree that the access to mental health care is not good. And even in the way we practice in our system from a psychiatry standpoint is a one-on-one interview. But patients who are admitted do go through group therapy. And I think that a lot of the patients really from what I've observed benefited from that, especially on the adolescent side, they seem to really connect with those who are going through similar experience. And I think that's very helpful for them.
Harjit: I will say again, my naive thoughts because I'm just starting this career and I think there'll be a lot of things that I will grow in and understand. If you go back to, let's go back to kind of like the starting of civilization, right? A lot of people worked in groups and tribes and like hunted together and like were together, right? And I think as people were meant to be that way, that's why we have the "Bundle Of Hers," where we vent to each other if something's stressing us out or we hang out with our friends, we socialize, women get together and talk, you know, things like that. And I think, again, there's a lot of gendered issues as well because it's more acceptable for women to get together and talk than men, right? So there's . . .
Dr. Jones: We're working on that here at "The Scope." We're working on it.
Harjit: Yes. So there's a lot of complex things that are going into it, but yes, I do feel like there's large value in group therapy and I think that it is something that is already known. That's why it's existing in a lot of mental health spaces. And I think like Margaux said we're kind of born to be together as people. So it's really, the isolation is kind of that big theme that's being hit on really changes the way that we function.
Dr. Jones: Right. I believe that profoundly. We have this big frontal lobe, not so that we can make rockets that go to the moon, but that we can assess the social situation that we're in. And we have language so that we can connect in ways that are powerful. So they did actually some very, I think, critical work in Africa, where there was a fair amount of post-traumatic stress among refugee populations and people who were under financial stress and under war situations. And they trained women in the village to be mental health workers and these were women who had no other skills necessarily, except they were seen as being emotional leaders in the village. And those women started doing group therapy in their villages.
They found that the rates of depression and anxiety dropped in those villages where they had mental health workers, who were just people seen as having a touch of wisdom or a touch of empathy or a touch of believability, get women, again, we're talking about women here, but get women together. And it works when we get together with people we trust and we grow to love and you need a constant dose.
So people who do AA, they keep going, they just keep going to meetings. It's not like, "Oh, I feel better." They know that they've got to keep going because mental illness is often a relapsing disease. And I know that having a safe place and having an income and having a family that's supportive are all ameliorating factors for people with schizophrenia.
Flaws in the Healthcare System When it Comes to Mental Health
But the natural course of this devastating disease and bipolar disorder is that it pushes people away from their support and they end up on the streets. And it's the saddest thing to me. It's the saddest thing to me to see homeless men and women whose brains just don't work at all. And they don't feel safe around people and they're cold. I mean, it's just gets to me like nothing else, because these are biological diseases we barely understand. And the consequences to families, it just wrecks families to have their sibling, their kid alone on the street.
Harjit: I think there's a huge issue in the structural systems that exist in this country when it comes to mental health. I think because it's barely being recognized as important and necessary is kind of where we are start to see kind of movements pushed in that direction. But because of that lack, I think that's why we're in the position we are today.
And I also think a lot about when I am doing an assessment, basically we get all the data, we figure it out, we figure out what disease a person has and then we make a plan for that. And a lot of the assessment when it comes to psychiatric illnesses has three domains, right? There's the biological, there's a psychological and there's a social aspect and they work very strongly together.
Margaux: Yeah, I agree with Harjit just said and the reality is our healthcare fails. Our system fails these people, and I think one of the hardest things going into residency, is not going to be the time, but having to discharge those people who have no resources back to the street . . .
Dr. Jones: Like that would just break my heart.
Margaux: . . . with only like two weeks' worth of medications, knowing full well that they will not be able to probably afford or have access to that medication, to therapy or to continue. And so we are very much part of this cycle that is broken. So I think like Harjit said, it is a little bit encouraging that now it is less taboo. It is more recognized that it is a big issue in our society. And so there's very slowly coming to be legislation and changes into insurance to write these things, but it's, it needs to happen faster.
Dr. Jones: And I think that people, once they have the diagnosis of something like bipolar disease or schizophrenia can usually get on, many of them can get on Medicare, meaning they have a lifetime disability as much as anybody who has a renal transplant or is on dialysis. It's just, it's more deadly. They're more likely to die in 10 years than someone who's got kidney failure. It's just that we just make it hard to access things. You have to have a good brain to be able to get on the bus and find a bus pass to get to someplace that might be able to help you.
And I'm thrilled that one of our homeless clinics, one of our clinics that takes care of homeless people has a mobile van that goes to the homeless shelters and that we've created shelters where people don't get kicked out at eight o'clock in the morning and have to line up at night to see if they might get a place to stay. Oh, it's just, it's so hard. And you are going to be seeing teenagers when these awful diseases present.
Margaux: Yeah, and I think that also plays deeply into the social situation as well. A, being able to recognize and have access to getting your child the care that they need or feeling trust in the system to begin with, and then having some sort of understanding of what the physician is telling you because the word "schizophrenia" has been so tainted by Hollywood, I would say, that most people have this idea that schizophrenia is like a split personality disorder. I think that sentiment is very much still held by the general public.
And so there is a lot of misinformation about mental health and even when a family hears the word schizophrenia, it is so fear inducing. And I think we really need to have honest conversations with our patients about like what it means, the truth of that disorder and not just assume that everyone knows what schizophrenia is. That was my experience with one family and how terrified they were to get that diagnosis for their child.
Going back to what you were saying about the women in the village or AA, I don't think those groups would be as successful if they were led by people who did not have the same experience as the people they were talking to or creating community around. So for example, if I, as a white person went to that village in Africa and tried to host that group, I don't think it would be as successful.
And so I think that really feeds for the need of people with diverse backgrounds and experiences, whether that's mental health or within the criminal justice system and giving those people opportunities to come in and be these leaders to create community and make change that way. And I think we have to think differently about the way we're doing things and building community.
Harjit: I 100% agree with Margaux on that point, because I think that's another reason why I'm very motivated to go into psychiatry as a woman of color. It's something that I haven't seen often. And I think that me having my experiences and background will hopefully in some way, allow me to see things differently and treat my patients differently just as Margaux with her experiences, will be able to treat her patients differently. And I think that's the reason why we are very big advocates of pushing diversity in medicine, making sure that every field is diverse, but that's difficult because I think another issue going back to like homelessness is there's certain racial identities, certain sexual identities, such certain gendered identities that are more impacted than others.
I think that we always try to see things separately. Like this is healthcare, this is politics, this is education, but they're all intertwined and you really can't separate those.
Characteristics of Good Mental Health
I will say that my struggles with mental, with my brain state or mental health had to do when I was in my late teens through my 30s and as a woman who always had irregular periods, I did not know. I knew I would be troubled with episodes of feeling, you know, I'm down and lonely, I'm going to eat some worms. This is a great little nursery rhyme about being sad and lonely. And then my period would come. And I didn't really know before I went to medical school, there was such a thing as PMS. And because my cycles weren't regular, I couldn't always predict that was going to happen. But eventually I realized there were some biological determinants of how I felt about myself and my place in the world.
And as a woman, that's not something that men necessarily appreciate, but I appreciated it more and more. When I would feel that way, I would say, this is temporary. I'm going to go out for a walk, and no, I'm not going to eat chips and chocolate, which would be my first thing, because that just makes me feel worse. And the second thing, which is, again, uniquely a woman is that by the time I was in my 30s and early 40s, I had some skills, had some powerful skills because there'd been some bad stuff that happened, but I was not ready to be a mother. So it's very interesting that you look at the brain of women who are pregnant and their brains are being rewired in many ways. Almost the way adolescents are.
Dr. Jones: And so the seven domains are interwoven into this tapestry of what makes us be who we are. So what would be the characteristics of someone who had wellbeing, who had good mental health?
Harjit: So basically I think first we focus on the individual, right? Every individual has an identity. They have several identities and they form that throughout their life. Especially when they're teenagers, that's kind of like when they're really figuring out who are they, what do they like? What do they want to be? But that keeps on going on forever. Once they figure that out, they live in a world with people. Now, if those people don't support that, it gets really hard because you're having to sacrifice who you are. And I think that complicates issues. So I think that's a really huge part of mental health. Is that knowing, being able to formulate your identity and being supported with that through the communities you're a part of.
Now that is thinking about like depression, anxiety, etc. But again, there's also the biological component, right? Some people might be born like, you know, quote unquote, born with . . . have a biological reason why they have a pathology. So then it makes it a little complicated.
Margaux: I would say that I feel like sometimes there's this misconception that with the push for like, you know, like #wellness, like we should be well all the time, but I think it's important to recognize that our emotions naturally flux up and down and it is natural and normal to feel sad and down. And that is part of being a well-rounded human being is experiencing the whole spectrum of emotions. And I think allowing yourself to be comfortable sitting with those "negative emotions" is building sort of an emotional fitness and gears you towards wellness.
And I think like you're talking about the seven domains is represented in this circle and it very much is a circle and a cycle and we should be comfortable riding that cycle. And for me, that's a fundamental part of wellness. Of course it's easier said than done because we're socialized to hide or stuff away those negative emotions because they're seen as weak or whatnot. But I think the more we can talk about like, "Hey, I'm feeling down today, I'm feeling . . . " and I think we've been really good. And I really appreciate having my group of friends in the "Bundle of Hers" is to be honest and be like, I'm feeling depressed today and just like have a space and a community to come around.
So I think for me, number one, that is a key identity of wellness is emotions are fluid and you don't always have to feel happy.
Harjit: A lot of stuff just builds on top of each other, like Margaux said, you can't do this work in like a week or two weeks. It takes months and months and years and years and something we have to continuously work on. And you also said it was like a relapsing thing. I think that I also recognize that emotional intelligence is knowing that kind of the behaviors that you take and the actions that, or the outcomes that come out of it, they still impact you in the future and being okay with that. And also understanding that and managing that in the best way possible is kind of like the big thing that I think helps build that strength and resiliency. I think we all have it in us to be strong people and I think a lot of people are. I think it's just something that we also need to recognize that it's a continuous process as well.
It's Okay to Cry
I think that spiritual health profoundly underlies some of the tools for which we can develop our sense of wellbeing. I am not a religious person. I don't hang my hat or my coat or my sweater on any religious principles. But I do feel like I am part of something bigger. And when I'm not feeling at my best, doing something for somebody else, being part of something bigger than myself, and I've been lucky to have a career in which that was a focus, that was more powerful than anything for me. For people who have a spiritual practice, whatever it might be, I would say, if you ask what my religion was, I'd say I'm a biologist because the biological world gives me a profound spiritual platform from which to feel awe and wonder.
But if you have something that's bigger than you, that you can spend some time with, so it's easy to get there. So working on your mental health, this is something that I think you have to do every day. And if you establish those practices, whatever they might be for you to be part of something bigger at such that it comes easier.
Dr. Jones: But as empathetic individuals, as that you've found yourselves to be, and you've exposed your empathy and your podcast, the "Bundle Of Hers," you will be every day bumping up against people who are having the worst days or years or life. How are you not going to cry every schizophrenic that you see that lives on the street? How are you going to make yourself get through that? I couldn't.
Margaux: I think it's okay to cry. It shows humanistic. I mean it shows humanism and it is sad. So why shouldn't we cry? Why should we hide that?
Dr. Jones: Is that what good psychiatrists do?
Harjit: I mean, what's a good . . .
Margaux: I mean, yes, you have to have some composure in front of your patient, but I wouldn't say that I would go back and not cry if I felt sad. But part of that motivation is if that is happening and it has frequently feeling so overwhelmed by the situation is that I am entering into this as a part of the system. I cannot function when something is broken. And so taking steps to fix it, to legislate, to advocate for change in legislation, to advocate for those patients is the way that I am going to combat it and not just sit idly by and cry. I'm still going to cry. I'm a big crier.
Dr. Jones: I wasn't a big crier, I'll tell you as a kid. So this is another one thing that got totally unplugged.
Margaux: I think first of all, I think physicians, it's totally appropriate to tear up if your patient is especially like with kids who have had histories of abuse and they're telling you that, it is sad and we should cry if that's what your emotion is telling you. And I think that helps us connect.
Harjit: I think for me, it's having that bigger understanding that I'm doing this for something. And I think that though, every patient I hear I'm listening to their story and I'm feeling connected to them. And like Margaux said, sometimes there'll be, you know, I will cry. Maybe it'll be after every patient, but it just reminds me that there's so much to do and that's what I need to focus on. That what will be the best for my patient so they can be healthy individuals so we can build healthy communities, so we can have healthy societies and so we can have a healthy world. I think it's like that. Every person counts. Often in people don't believe that every person counts, but I believe that and that's what keeps me going every day.
Resilience in hard times
Have the heart to see it through
To feel and give love