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May 05, 2022 The Suicide that Wasn’t

From the Lived Experience

Why do some suicides seem to happen so "fast?" That question underscores many of the complexities, nuances, and possible solutions for a growing health crisis. As a Black American, I am driven to write about this phenomenon through the lens of people like me. My Story Invisibility. Invisible problems. In reality, the progression to the final act was not fast. The problems had been there for years. Between 1992 and 2001 I published 10 books, traveled nationally, and went from adjunct instructor to tenure-track assistant professor. I did that all while having clinical depression. Society sees the outside. When we get the awards, we get pats on the back.  Having the class privilege of professional parents, I was socialized to "behave," so to most eyes, I was the good boy from a good family.  No one could see the insomnia. My upper middle class support network made sure that I always lived in reasonably safe neighborhoods. I had a car. I wore the right clothes. I could ‘adjust’ to something like inadequate sleep because I had years of grooming and training in how to navigate higher education spaces. At the age of 55, I was diagnosed with autism spectrum disorder, unspecified ADHD, and Generalized Anxiety Disorder. A lightbulb went off, I had been dealing with, adjusting to, and coping with these disorders my whole life, without knowing I had them. As with a smoker who seems to be just fine for many years, one day, the poison caught up. But for me, the mask was still there. Due to my social class position, a year in and out of outpatient and inpatient drug rehab and psychiatric treatment was deemed "a sabbatical." With the exception of a few people directly close to me, the world thought I was just away writing a book. The challenging pattern continued for years, until it didn't. A combination of recovery programs, a structured church environment, and counseling allowed me to stabilize. In recent years, I benefited from new tools and approaches due to the diagnoses. I am now in autism support groups. My employers get my Americans With Disabilities Act (ADA)  letter stating accommodations to be made, when necessary.  I adjust how I approach my  day and advocate for breaks--nervous system resets, whether it be at a picnic, shopping with family, Zoom meetings, or at the theater. Therein lies the point of this article. Somewhere near you, right now, there is a "well supported" person who is suffering. But like the smoker who can go on for years because he is strong otherwise, one day the system will collapse. What backup is there when that day comes? I like the coping mechanisms described in this article by Allyson Byers. They reduce the risk of that day ever arriving.   Many masks exist. Well meaning. Unintentional. But masks nonetheless. We all know these stories…a football player falls off of a roof at a drunken party and breaks several bones. But he had football going for him in the first place. He goes to sports rehab and is back on the field in several months. What did we miss? He has demonstrated self-medicating and self destructive behavior. He was in emotional pain long before that party. But everyone saw an "accident." They saw 20-something energy. They did not see the invisible, the well-hidden truths. When he became suicidal later, people were shocked. And of course, "he had such good grades." So here I am. The suicide that could have happened, but did not. At my lowest point, the people in my life showed me that I was still worth something. Crippling and fatal despair never grabbed a foothold. I was a lucky one. Suicide in Black Americans That reflection opens the door to examining the larger circumstances within my affinity group. Suicide is a tragic and complicated phenomenon the African American community. In 2017, the rate of suicide of Black people in California was less than half the rate of white people. Statistics like these long contributed to the account of the white phenomenon of suicide. Invisibility rears its ugly head once again.  This New York Times article helps to explain these numbers, challenges in interpretation and protective factors. And this recent article after some high profile black suicide losses highlights additional insights and misconceptions. For a long time suicide rates in the Black community were supposedly a lot lower than in the general public, according to a report to Congress from The Congressional Black Caucus Emergency Task Force on Black Youth Suicide and Mental Health, Chaired by Representative Bonnie Watson Coleman. These misconceptions are also detailed in the TIME article, What We Misunderstand About Suicide and Black Americans Further examination paints a much more dire and serious picture. The 2019 Congressional Black Caucus report says that death by suicide among Black youth is rising faster than any other racial group. Suicide ranked as the third leading cause of death in Black men from ages 15-24 and Black men are four times more likely to die by suicide than Black women. Overall, much can be learned from differing rates of suicide among groups. For example, “because of pervasive racism, Black Americans experience substantial stress, fewer opportunities for advancement and more threats to well-being,” writes Austin Frakt in the New York Times. “These negative experiences can degrade mental and physical health, as well as limit education, employment and income — all of which can increase suicide risk. Unemployment, which is higher for Black Americans than white Americans, is itself a source of stress.” Michael A. Lindsey of New York University worked on a study which showed that highschool suicide attempts for Whites  Latinos and Asians decreased from 1991 to 2017. However, in this time period the number of attempts by Blacks has increased substantially — by 73%. “Over the last decade, suicide rates in the United States have increased dramatically among racial and ethnic minorities, and Black Americans in particular," writes Rheeda Walker, professor of psychology and director of the University of Houston’s Culture, Risk and Resilience Lab. "Suicide deaths occur across the lifespan and have increased for Black youth, but the highest rate of death is among Black Americans aged 25-34 years of age.” Bullying, trauma and racial discrimination are clear risk factors for Black youth. However, research shows that those who attempt suicide are less likely to have been diagnosed with a mental illness, perhaps due to reduced access to mental health care. "What can I do?" many ask. Experts suggest parents should also start talking to children, as early as possible, about their feelings and how to process them. For further insights, watch more stories on the rise of Black youth suicide here: "A Different Cry."  As with other public health problems, such as drunk driving, we need to continue bringing these conversations into the public arena. Historically marginalized populations are especially vulnerable, but we have noticed a rise in African American suicides from middle class and wealthy families also. Unique experiences must be put at the front of the discussion. Awareness, education and support are the key. Moving Forward When I feel completely and utterly alone, I push myself to reach out. If I don’t feel like talking aloud, I use Facebook messenger, email, text, prayer, and even walking at night and talking to the stars. There is something about the expanse of the universe, be it through the world wide web or a brilliant night sky, that reminds me that I am worthwhile and part of something larger.  It reminds me that I’m not alone, and that I (and the choices that I make) matter to someone. This is comforting. I remember that when in a depressed state, I’m not in a position to make permanent decisions, especially when there’s no one there to offer perspective. When it feels impossible to focus on anything other than what makes me angry or sad, I find a distraction. My journey has taught me that no matter what the voice of depression says, I don’t have to believe it. When mental anguish seeks to overwhelm me, my combination of a stable church group; supportive friends; therapy; a family-focus; behavior modifications; support groups, taking in uplifting art, music and media; allowing myself to “not be productive” all the time; positive self-talk; intermittent fasting, and overall self-acceptance always finds me stronger than I thought I was, yesterday, or even a few minutes earlier. Finally, I forgive others and I forgive myself. The future is bright. If I can come this far, only greater things can lie ahead.  The author, who prefers to remain anonymous, is an Ivy League graduate and current university  instructor. He has published a dozen books and hundreds of articles. He has been happily married for 20 years and is the loving father of three daughters.

December 03, 2021 We Know So Much More Now…

From the Clinician AND From the Lived Experience

Last spring we posted about mind-body insights and tools for stress regulation that we learned from Dr. Kathleen Mackenzie at the Active Minds conference, and recently we had a chance to catch up with her directly.  Dr. Mackenzie's insights are especially powerful since they stem from a broad academic and clinical career, as well as personal life experiences with racial concerns and mental and physical health issues. Dr. Mackenzie's background motivated her to develop a scientific understanding of the factors that contribute to our overall functioning and wellbeing.  As outlined in her bio, Dr. Mackenzie has a background in clinical social work across various settings, academic contributions at Northeastern University, and certification in mental health integrative medicine. As she personally addressed her health 'through the help of alternative medicine and a lot of research, she realized that individual, social, and group dysfunction has a lot to do with a lack of knowledge about how what we do to our bodies and brains not only impacts our health and our lives, but it also impacts the people around us, including family, co-workers, community members, and future generations.' Much of what we are learning from Dr. Mackenzie is also included in this interview with the New Bedford Guide, where Dr. Mackenzie highlights her views on mental health, regulation, and mind-body concerns. She promotes a need for understanding ourselves and our lives in context, and highlights that help seeking is a good thing.  We invite you to listen as she talks mind-body connections: sleep as 'the number one thing,' the importance of setting body clocks and the dangers of electronics, and benefits of good nutrition, sunlight and fresh air, exercise, and other habits for mental health and wellbeing. Dr. Mackenzie also advocates for screening and awareness, and highlights that the average person experiences a delay of 8-10 years from symptom onset to mental health diagnosis, even as 50% of symptoms appear by age 14 and 75% by age 24. That is a lot of lost time and opportunity, especially when interventions can help change a life's course and rates of suicide in young people are increasing by 70 to 150%.  As a provider in a local school system she focuses on supporting regulation in her students, much of which can occur through schedules and healthy approaches to physical needs of sleep, exercise, diet, etc. Dr. Mackenzie hopes that telling her personal story and journey helps to make these considerations more approachable to parents and individuals who need support and information to overcome their fears and get needed help.  As she highlighted in this video from September 2020, we were already in a mental health crisis and Covid is only making things worse.

November 04, 2021 JKBF bestows second Biological Research Award at Suicide Summit

In October JKBF was pleased to partner with the International Academy of Suicide Research (IASR) and the American Foundation for Suicide Prevention (AFSP) in giving an award in support of an early career scientist who focuses on exploring biological contributors to suicide. At the virtual 2021 International Summit on Suicide Research we presented the second James Kirk Bernard Foundation Award for Excellence in the Biological Exploration of Suicide to Nikolj Høier in recognition of his presentation Association of Hospital-Diagnosed Sleep Disorders with Suicide: A Nationwide Cohort Study. This year we were excited to see a variety of candidate abstracts from young investigators exploring biological factors ranging from sleep, to traumatic brain injury, air pollution, and inflammatory markers. Selected from a pool of early career researchers presenting innovative biological studies, Mr. Høier was chosen for his work investigating a role for sleep disorders in suicide risk. Mr. Høier worked with an esteemed team at the Danish Research Institute for Suicide Prevention to explore the national registry data and found that higher suicide rates occurred in individuals suffering from narcolepsy and sleep apnea. Mr. Høier is a medical student at The University of Copenhagen and a Master of Science by Research in Psychiatry student at the University of Edinburgh. His main area of interest is in how sleep disturbance and disorders, as well as sleep medications, affect risk for suicide. We wish Mr. Høier success in his efforts and look forward to his future contributions in suicide prevention research. JKBF appreciates the collaboration with IASR and AFSP and the efforts of Gil Zalsman and Jill Harkavy-Friedman in the selection process and in making this award possible. Mr. Høier received an honorarium and will receive an award featuring a piece of Jamie's art, and we look forward to meeting him in person at a future scientific gathering.

From the Scientist:

Summary of Presentation “Association of Hospital-Diagnosed Sleep Disorders with Suicide: A Nationwide Cohort Study”

By Nikolaj Kjær Høier
In collaboration with an amazing group of senior researchers, including Trine Madsen, Adam Spira, Keith Hawton, Michael E. Benros, Merete Nordentoft, and Annette Erlangsen, I set out to study the possible link between sleep and suicide at DRISP – The Danish Research Institute for Suicide Prevention. Our effort was motivated by the fact that sleep disturbances and disorders have often been linked to suicide.1-3 However, the evidence has been restricted to data sources with certain limitations. Death by suicide is, fortunately, a rare event, but this implies that large sample sizes are needed to study this outcome. For this reason, our insights have been restricted to outcomes that are more frequent, such as suicide ideation or self-harm behavior.4,5 We thought that analyses of the national Danish registries with individual-level data on more than 6 million individuals who have lived in Denmark since the 1980s would be able to answer this question. Our aim was to examine, in a population-based cohort study, whether persons who had been diagnosed with a sleep disorder had a higher suicide rate than persons who had not been diagnosed with such a disorder. We were able to analyze this using the Danish national linkage data, which covers the entire population and combines a range of data, for instance socio-demographic information, hospital diagnoses, and data on causes of death. Spanning the period of 1980-2016, we investigated 7,362,727 individuals, age 15 or older, who lived in Denmark. Among these 35,483 were diagnosed with a sleep disorder in a hospital setting, predominantly narcolepsy and sleep apnea. Investigation of cause of death revealed that people who had been diagnosed with a sleep disorder were found to have higher rates of suicide than those not diagnosed. For males a 1.55 higher rate and for females 2.19 higher rate for suicide was noted, showing that the risk for suicide amongst those diagnosed is significantly higher than those not diagnosed. This association was confirmed when adjusting for relevant covariates, such as sex, socio-economic factors, previous history of mental disorders, and previous suicide attempts. We found that males and females suffering from narcolepsy had increased rates of suicide in adjusted analyses, and a link between sleep apnea and suicide risk was established for males. Our results indicated that the highest risk for suicide was seen within 6 months of sleep disorder diagnosis. It is important to emphasize that suicide is a rare event, and it was only 1.17% of those diagnosed with sleep disorders who died by suicide. Although the group of persons with sleep disorders has a higher risk of suicide, this does not mean that many of these people, in absolute numbers, will die by suicide. Suffering from sleep disorders can, however, be very distressing, dysregulating, and affect daily routines. Sleep disorders are also a symptom of mental disorders, which in turn are linked to higher rates of suicide. We also identified that those who were diagnosed with a mental disorder after their sleep disorder diagnosis had a high rate of suicide than those who were diagnosed with a mental disorder before their sleep disorder. This could suggest that when a sleep disorder is severe, it can lead to mental health problems and thus increase the risk of suicide. For this reason, it is important to ensure that the diagnostics of sleep disorders includes effective and attentive treatment, and an assessment of and ongoing attention to mental health. We cannot exclude that some of the persons with sleep disorders who died by suicide might have suffered from undiagnosed mental disorders. Our findings allude to the importance of conducting a thorough diagnostic assessment when people suffer from disturbed sleep over longer periods. Seemingly, our findings provide the first documentation for an association between narcolepsy and suicide risk. Being a chronic sleep disorder, narcolepsy is also an autoimmune disorder. It is caused by a lack of orexin-producing neurons, orexin being important in the systems that maintain our wakefulness. People suffering narcolepsy experience spontaneous sleep attacks which have a severe impact on daily life and put a limit on the person’s daily activities, for instance, driving a car or walking up and down a set of stairs. Individuals who are diagnosed with sleep apnea often suffer from other comorbidities, such as cardiovascular disorders and obesity. People with sleep apnea have a reduced uptake of oxygen during their sleep, which can induce hypoxia (oxygen deprivation) to the brain, with minor brain damage being one of the more severe potential consequences. The fact that as many as 3-6% of adults may suffer from sleep apnea underscores the need for a better understanding of how this disorder might be linked to suicide. It is likely that people with insomnia are most often treated in primary care at general practitioners. Therefore, our findings can only provide information on individuals who were so severely affected by a sleep disorder that they would end up being referred to hospital setting. Other sleep disorders that were less frequent were compiled in our analysis and a mixed group of sleep disorders comprised of disorders such as insomnia, nightmare, sleep walking and disturbed circadian rhythm were also found to have higher risk of suicide. However, seeing how this is a diagnosis group with a high degree of heterogeneity, it is hard to draw any precise conclusion from this finding. Having been diagnosed by a medical doctor specialized in sleep disorders is likely to have a higher clinical validity, which means that there may be sleep disturbances in others who died by suicide but were not diagnosed in hospital settings. Our findings point to a higher risk of suicide among persons with severe forms of sleep disorders. A better understanding of the neurobiological pathology of persons suffering from narcolepsy and sleep apnea might help elucidate the intricate relationship between sleep disorders and suicide.
  1. Liu RT, Steele SJ, Hamilton JL, et al. Sleep and suicide: A systematic review and meta-analysis of longitudinal studies. Clin Psychol Rev. 2020;81:101895.
  2. Porras-Segovia A, Perez-Rodriguez MM, Lopez-Esteban P, et al. Contribution of sleep deprivation to suicidal behaviour: A systematic review. Sleep Med Rev. 2019;44:37-47.
  3. Bernert RA, Joiner TE, Jr., Cukrowicz KC, Schmidt NB, Krakow B. Suicidality and sleep disturbances. Sleep. 2005;28(9):1135-1141.
  4. Harris LM, Huang X, Linthicum KP, Bryen CP, Ribeiro JD. Sleep disturbances as risk factors for suicidal thoughts and behaviours: a meta-analysis of longitudinal studies.
  5. Timkova V, Nagyova I, Reijneveld SA, et al. Suicidal ideation in patients with obstructive sleep apnoea and its relationship with disease severity, sleep-related problems and social support. J Health Psychol. 2020;25(10-11):1450-1461.

September 09, 2021 Applying Biology to Build Resilience

This post presents an overview of the Community Resiliency Model (CRM), a resource for building skills in advance of a challenge or crisis, developed by the Trauma Resource Institute. While some people make a suicide attempt without much warning, an estimated 12 million adults in the US each year contemplate suicide or experience chronic suicidal ideation. And we all experience stress, loss, and various levels of trauma at some point in our lives. Tools such as safety plans have been developed to help reduce suicidal behaviors in those known to be at risk. Research shows that attention to lifestyle concerns such as adequate sleep, a balanced diet, exercise, and avoidance of substances may have positive mental health effects, in part by helping to regulate the nervous system. The CRM is an approach that approaches stress modulation as a way to build resilience. While application of the CRM has not been studied in suicide, there is evidence of effect in anxiety, depression and PTSD and testimonial of its effects on her resilience from Jen Housholder.

by Ashleigh Zaker, MSW
Many of us face life challenges that affect our ability to respond to stressful situations in a healthy manner. Research on resilience, our ability to withstand and recover from hardship, highlights the importance of developing positive emotions and expanding coping resources for those who are suffering. The Community Resiliency Model (CRM) is a set of biologically-based wellness tools that helps us stay connected to self and work to stabilize our nervous system. Practicing these skills increases a person’s ability to effectively respond to adversity. Elaine Miller-Karas, a key developer of CRM states, “The Community Resiliency Model encourages individuals to learn how to discern the differences between sensations of distress and well-being.   This can provide hope as one learns to focus on sensations of wellbeing and that contributes to a greater sense of resiliency in mind, body and spirit." Eric Kussin, founder of We’re All a Little “Crazy” and the #SameHere movement, describes this process using the metaphor of fire safety. Almost all of us have experienced a fire drill and rehearsed emergency evacuation procedures. It is unlikely that we will experience such an emergency, but this preparatory measure mitigates danger and increases the likelihood that, in such an event, things will run smoothly. This works because we NEVER know for certain where the risks are or when they might happen. In the same way, rehearsing go-to calming methods can help to make these practices habitual and increases an individual’s access to helpful tools in challenging and upsetting situations. This is important when considering the function of the nervous system, which is to support and facilitate homeostasis, or balance, within our bodies. One responsibility of the nervous system is sensory and emotion regulation wherein external information is received and a response to that information is generated. Sometimes perceived ‘threats’ can be destabilizing.  Our nervous system is designed for survival.  Trauma and stress can impact our biology and thus can impact our mental health, increasing distorted thoughts and irrational beliefs about ourselves and our environment contributing to suicidal ideation and behavior.   Adolescents are particularly vulnerable to the impact of the nervous system on mental health due to the process of brain development. A key element of the nervous system, the prefrontal cortex responsible for cognitive control (including impulse inhibition, cognitive flexibility, and emotion regulation) does not mature until age 25. As a result, adolescent brains rely more heavily on the amygdala, a unit of the central nervous system that drives our fight or flight response and can elicit defense behavior. The social, developmental, and nervous system vulnerabilities of this stage of life makes bringing awareness of risks, teaching calming and coping methods, and being available to talk through safety plans with youth even more important. Life experiences, traumas, and other environmental factors affect everyone’s mental health in varying degrees, and in some may represent suicide risk factors. Suicidal thoughts can and do happen to many of us, for some on a chronic basis, and for others without warning in response to a ‘perfect storm’ or  distressing situation. It is important to recognize these thoughts of self-harm are a result of powerful emotions. No matter how upset you may feel, having skills to re-regulate and a plan to follow can be comforting and promote safety. As a set of biologically-based wellness tools, the Community Resiliency Model (CRM) compliments the JFBK mission of bringing awareness of bio-environmental factors in suicide prevention. The primary focus of the CRM model is to provide necessary skills needed to re-set the natural balance of the nervous system. This is a biological process that is triggered when our bodies release energy created by toxic stress, sometimes associated with traumatic events, community level injustices, pandemics, and sometimes it can simply be the impact of everyday stress that is often dismissed or underestimated. Biological responses to trauma are triggered by anything that leads to physical or emotional pain, suffering, or distress. This natural rhythm of our nervous system, and the interruptions that occur, is referred to by the CRM as our “Resilience Zone”.  Feelings of anxiety, restlessness, or tension, indicate being in the “High Zone,” and depressive feelings such as exhaustion, disconnection, and hopelessness, the “Low Zone.” These feelings are our bodies way of communicating that our nervous system is out of rhythm. We no longer feel like our best self. Applying the skills outlined in the CRM (tracking, grounding, HELP NOW!, resourcing, shift and stay, and gesturing) can help to interpret and reduce the impact of stress. Learning to recognize and utilize this process does not happen overnight and takes practice. It involves building resiliency by working through tools that address adverse circumstances and emotional and physical pain. The good news is that a person’s resiliency is not fixed. Resiliency is skill that can be cultivated over time, using lifestyle choices to help modulate the nervous system and CRM tools to replace distorted thoughts and behaviors with healthier, more productive responses. The CRM model may be a helpful source for individual learning and for supporting those around you. The Trauma Resource Institute  offers trainings and curriculum for teachers, families, and business. Additionally, the iChill app is available as a free resource that outlines the skills discussed in the article. Ashleigh Zaker, MSW, is passionate about holistic approaches to quality-of-life improvement and understands the importance of balanced and practical applications in restorative care. She is currently a doctoral student at Colorado State University and focuses her research on the physiological and psychological benefits of the human-animal bond.     Reviewed 9/21 by Elaine Miller-Karas, MSW, LCSW, Co-Founder and Director of Innovation of the Trauma Resource Institute and author of the book, Building Resiliency to Trauma, the Trauma and Community Resiliency Models (2015).

July 21, 2021 My Journey With My Mental Health and How I Deal, Part Two: Diet

In her second piece for From the Lived Experience our contributing writer discusses the impact of diet, which affects our brain and mental health just as it does our physical health--as JKBF has outlined here

By Guest Contributor, Christine Bushrow
I grew up eating predominantly healthy, comforting, home-cooked meals with my family. My mom's Italian heritage influenced most of the meals she cooked; there was plenty of lasagna, ravioli, spaghetti, and "stuffed shells." She'd also make delicious, creamy casseroles and frittatas. Despite being a vegetarian for most of her life, she cooked all kinds of meat for us and let us decide whether we wanted to partake or not. She never tried to influence our decision based on her preference. My dad is also an excellent cook, but most of my memories growing up of his cooking revolved around the grill. He's the reigning "grill master" and is rightfully proud. Not a single summer weekend passed without grilling cheeseburgers, steaks, and hotdogs on the back deck, with a side of watermelon, chips, and salad. Another fun tradition I remember fondly is ordering pizza every Friday night and eating in the living room - it was a huge deal to eat away from the kitchen table! - while watching a movie as a family. When I went away to college, I pretty much ate whatever I pleased, whenever I pleased. I had a lot of fun destroying my health with dorm cafeteria food, 7-11 burritos, frozen Bagel Bites, Hostess cupcakes, and soda.  It didn't get much better when I returned from college and moved into my first "adult" apartment. I had a roommate, but we lived parallel lives and didn't interact much, so I focused on myself at mealtimes. For example, I didn't see the point in grocery shopping since I didn't know how to cook for one, so I'd stop by any fast food drive-thru on my lunch breaks and after work each day.  After a few years of living that way, I was feeling pretty horrible mentally and physically. I had brain fog, daily stomach pain, headaches, and absolutely no energy. Plus, my skin started breaking out badly. All of this, on top of my existing anxiety and depression, felt unbearable. I knew I needed to make a change but had no clue how. One day while scrolling online, I came across the term "veganism" and was immediately intrigued. A parade of healthy, happy, glowing people flooded my screen as they excitedly explained how veganism had positively changed their lives and their health. I wanted to feel like that, too.  The changes I made started small. First, I cut out red meat, then all meat, and noticed a massive difference in how I felt. After that, I ate many processed vegetarian foods and slowly learned how to adjust my vegetable portion sizes to be more substantial rather than small side dishes.  About a year later, I made the ethical connection to animals, cut out eggs and dairy, and began eating more whole foods than processed foods. Not only did my self-esteem improve as my actions matched my morals, but this was also when the most significant shift in my health occurred. My skin cleared up, I felt light on my feet, I had more energy, my seasonal allergies disappeared, and my brain fog slowly cleared. I engaged in more physical activity with this newfound energy, not because I had to, but because it felt great to move my body! My yoga practice intensified, I hiked and kayaked often, and I discovered a new passion: walking. Christine Bushrow is a passionate freelance mental health writer and mental health advocate. When she's not writing, you can find her reading, spending time with loved ones, practicing yoga, and exploring the outdoors in a constant state of wonder. www.christinebushrow.com  

April 12, 2021 Insomnia, Sleep Medicines, and Suicide – it’s complicated!

To further our understanding of the role of sleep disturbance in suicidal behaviors, below we present a sleep researcher’s explanation of a recent study addressing insomnia, sleep medications, and suicide. The researcher, Andrew Tubbs, and his collaborators from the University of Arizona have just published data that indicate the particular type of sleep medicine may not be as big of a factor in suicide risk as the underlying sleep disturbance itself.  In this From the Scientist piece below Andrew summarizes his findings for us.  Moreover, Andrew and his colleagues were kind enough to provide JKBF with additional insight into the landscape of insomnia/suicide research and open questions at this time. We learned that while there is an established correlation between suicide and insomnia, we don't actually know the cause of this association. Possibilities might include that suicidal ideation and distress promote insomnia, or that individuals with insomnia develop suicidal ideation because of a lack of sleep, or that the usefulness of medications for insomnia is insufficient or variable across individuals or over time. From a research standpoint, insomnia itself has not been shown to increase the risk of suicide. Rather, the number of suicidal thoughts and behaviors tends to be higher in individuals with insomnia, which means insomnia is most accurately described as a suicide risk marker, not a suicide risk factor. Research has also shown that sleep medications might offer a very valuable approach to treating short-term sleep difficulties arising from acute emotional trauma, and yet offer only marginal sleep induction/maintenance benefits after several weeks of use. Medicine is more an art than a science, and how we use sleep medicines matters. Furthermore, as this recent advice from the British Medical Journal outlines, there is support for a role for Cognitive Behavioral Therapy as a primary (first line) treatment modality due to effectiveness and safety. A primary hurdle for establishing insomnia as a cause would be a longitudinal study showing that insomnia precedes suicidal thoughts or behaviors. While the field has some long-term data supporting this using sleep as a predictor of suicidal ideation or attempts a year or more later, prospective exploration of whether “incident insomnia” (e.g. acute sleeplessness as a result of a disruptive event) leads to suicidal thinking/behavior weeks or days later still needs to be done. More convincing evidence would be a study that explored whether treatment of insomnia reduces the incidence or likelihood of suicidal ideation/attempts. To date, there are only two randomized clinical trials of insomnia treatment to reduce suicidality: one showed reduced ideation in those with severe insomnia when sleep medication was paired with SSRIs, and a pilot trial of brief behavioral therapy showed effect in primary care patients. Clinical trials like this are hard to conduct, expensive, and require large samples and long-term follow up. In sum, more studies need to be done to determine causality as well as the potential for treatment of sleep as an intervention for suicidal behaviors and JKBF supports a call for this line of research. As Franklin et al have established, 50 years of research and the currently accepted risk factors are still insufficient in predicting suicidal behaviors --  having deeper knowledge of a role for chronic or acute insomnia or sleep disturbance might provide meaningful improvements for those assessing, treating, and experiencing suicidal thoughts and behaviors.

From the Scientist:

Summary of "Prescription medications for insomnia are associated with suicidal thoughts and behaviors in two nationally representative samples"

By Andrew Tubbs, BSC
Research has shown that individuals with insomnia are at a higher risk of suicidal thinking, suicidal actions, and dying by suicide. Our study in the Journal of Clinical Sleep Medicine is attempting to address this correlation, and specifically to help tease apart the relationship between insomnia medication and suicidal ideation. In the United States, an estimated 3 percent of adults receive a prescription medication for insomnia, which means this is a fairly common problem. However, the medications used for insomnia are associated with suicidal thoughts and behaviors; in one study, individuals using a Z-drug (Ambien, Lunesta, or Sonata) were 2- to 3-fold more likely to report suicidal thinking than those not using a Z-drug. The trouble is that these studies cannot establish causality – we cannot prove that Z-drugs cause suicidal thinking. In fact, one way to read the finding above is that individuals whose insomnia is so bad that they went to the doctor to get a medication to sleep are more likely to think about suicide. Thus, the issue may not be the medication, but rather the underlying severity of the insomnia. Interestingly, a study of healthcare data from South Korea found that among individuals with depression, the risk of a suicide attempt peaked just prior to starting a prescription for insomnia, and that the risk decreased thereafter. This seems to support the idea that the severity of insomnia, not the medication itself, is responsible for suicidal thinking and attempts. If this is the case, and medication is just a proxy for insomnia severity, then this association should be consistent across medications used for insomnia, even if they work in different ways. Z-drugs, benzodiazepines, and the antidepressant trazodone are all used for insomnia, but they do not all work in the exact same way. Thus, our study compared how Z-drugs, benzodiazepines, and trazodone were related to suicidal thoughts and behaviors using 2 nationally representative datasets. While all 3 medication groups were linked to more suicidal thinking and suicide attempts, the strength of these associations did not differ across medications; they all had roughly the same connection with suicidality. We believe these findings support our hypothesis that underlying insomnia, not use of a prescription sedative, increases risk for suicidality.

December 06, 2020 Sleepless in Pennsylvania

The ebbs and flows of days, seasons, and life cycles all play into the functioning of our bodies and our minds. This From the Lived Experience story from Elise shares her journey with bipolar disorder, and reminds that issues of sleep and hormones can factor into our mental health. Seeking help and understanding all of these issues together was important for Elise's journey.

By contributing writer, Elise Seyfried
I was diagnosed with bipolar disorder in May of 2006. The summer before, I had put my 16-year-old daughter Rose on a plane to Thailand, where she would spend a year as an exchange student. A few weeks later, we welcomed a student of the same age from Switzerland. My two oldest sons were away at college, but I still had a houseful; in addition to our teenage guest there was my husband Steve, ninth grader Patrick, fifth grader Julie, and my 80-year-old mom. I’d been managing my very full life (including my job as Spiritual Formation Director at our church) for years. It never occurred to me that I was anywhere near a breaking point. Shortly after Rose left, my sleep habits suddenly changed. I found I needed only a few hours a night, and felt unusually energetic and sharp the rest of the time. My productivity at church and at home soared, and I began experiencing the euphoria I would come to love so much. Life was beautiful, even if I often snapped at my family. Life was exhilarating, even if I was constantly cursing a blue streak. Life was incredible, even when I was maxing out our credit cards on impulse purchases. I swept my compulsive nastiness and very frequent mall trips under the rug, preferring to concentrate on the up side of things—I could now be productive 20 hours a day! Who needed sleep anyway? And, mostly, I’d never felt more intense happiness. Periodically I would have crying jags that would last most of a day, but for the most part my mood remained elevated. As the year went on, my mother’s Alzheimer’s disease worsened. Though I had always been extremely close to Mom, now I couldn’t bring myself to notice, or care, that she was failing—I was too wrapped up in my “fantastic” self. I proposed more and more grandiose activities (who plans to take 40 teenagers to Alaska for a mission trip? Me!) and I started dropping some of the many, many balls I had in the air. Finally, one day over tea, a good friend bluntly told me she thought I needed to talk to a therapist. While the suggestion was infuriating, I did call someone that night. By then my “highs” were much more frightening than delightful, and it was a huge relief to see someone, and get a diagnosis at last. It took two doctors, four changes of medication, and many months of talk therapy, to turn things around. Even then, it was one step forward and two back. That Alaska mission trip happened in July, while I was still on the wrong meds and reacting badly to the 18 hours of sunlight there each day. That novel I’d wanted to write? I wrote it in October—and it took only eight days, with a mere two hours of sleep per night. It wasn’t until the beginning of 2007 that I really felt OK again. During one session, my doctor asked me if I’d ever had another time in my life when I’d felt like this. Initially I didn’t think so. But then my senior year of high school came back to me--the agitation, the restlessness, the compulsive behavior. Always an excellent student, I stopped turning in assignments and focused solely on my love life. Steve and I got engaged on my graduation day, when I was still just 17. At the time I thought it was hopelessly romantic. Now I know how risky and impulsive that decision was (though we are lucky enough to have reached 43 years of happy marriage). Why would I have been sick at 17, and then fine until my late forties? My psychiatrist explained the possible connection of hormones and the surfacing of mental illness. In my late teens, conditions were ripe for my bipolar disorder to appear for the first time. Then, during my childbearing years, every symptom subsided. Menopause seemed to be a significant factor in bringing them all roaring back—and my sleeplessness only intensified my issues. [caption id="attachment_2053" align="alignleft" width="300"] This is My Brave Cast[/caption] Now, 13 years since my last mood swing, I can look back without feeling sad and embarrassed. I can look ahead, daring to hope that I will never experience bipolar mania again. I take my medication religiously, and try hard to get enough sleep--I am even napping. I now advocate for others with mental illness through my writing, producing shows for the incredible organization This is My Brave, and leading a support group. Life may not be ecstatic, but it’s good. And that’s enough for me. I am so grateful to the family and friends who stuck by me when I was at my worst. I’m determined never to put them through another time like that if at all possible. But if I do notice symptoms returning, I know now not to ignore them. That is my message for others who are struggling: please don’t wait until things are totally out of control to reach out. And above all, don’t feel ashamed or alone. There are millions of us living with mental illness, and the stigma is lessening. Be kind to yourself. Get some rest. And get help if you need it. Your life is worth saving.

September 09, 2020 A Case Study in the Importance of Integrative Care to Mental and Physical Health and Wellbeing

By Susan Parmelee, LCSW
As social workers we have a guiding tenet: “Start where the client is.”  In practical terms, this means that if my client is not housed, does not have access to food, or is physically ailing, there is no chance of working on higher level needs through mental health therapy. Addressing the needs of the whole person is my job as a social worker - to make sure all parts are considered and integrated. To illustrate the importance of integrated care as outlined in my previous blog, I present this case study. Please note that for privacy reasons, names have been changed.  Jennifer Jennifer’s mother called me to request an appointment, telling me, “Jennifer will not get out of the bed in the morning, she has missed the last 5 days of school, and she tells me she just cannot go to school right now.”  I had an opening that day, so I asked Jennifer’s mom to bring her in. Mother insisted on meeting with us, not able to leave Jennifer’s side. Mother told me she is a single parent, having split with Jennifer’s father when Jennifer was 4 years old. Jennifer would not look me in the eye. Mother went on to dominate the conversation, telling me Jennifer had been diagnosed with Mononucleosis four months prior and had missed three weeks of school. Jennifer made up all her work over winter break and returned to school for the Spring term.  Mother noted that Jennifer, normally a very upbeat and happy young person, had broken up with her boyfriend about a month ago and stated that she felt “he was not a good influence on my daughter.” She began missing one or two school days a week and then last week stopped going to school all together. Mother claimed the doctor said Jennifer was over the mono and Mother believed the vitamin regimen she put her on should make her feel good. I gave Mother instructions to take her back to her pediatrician for a blood panel workup and suggested asking about adding Vitamin D to her vitamin regimen.  I eventually succeeded in persuading Mother to allow Jennifer and me to spend some time alone. I did my best to increase Jennifer’s comfort level in sharing her experiences with me and gathered more information. Jennifer opened up quickly, telling me how sad she was about the break-up, how her mother dominated her life, and how she was looking forward to applying to and leaving for college in 18 months. She broke down and told me she was worried that she would never be able to catch up on her Junior year school work, which would jeopardize her future. I helped Jennifer understand that her health needed to come first right now, and the rest would follow. I noted that she was very pale, not unusual since she had not left the house in several weeks. We discussed trying to take walks outside, improving sleep hygiene, and trying to get back to school for a part of the day. Before they left I shared with  Mother that Jennifer was very pale and could possibly be anemic, making the blood work even more important to rule out or to uncover physical reasons for her shift in mood and behavior.  Although Jennifer did turn out to have anemia, the recovery from this clinically significant depressive episode did not spontaneously resolve as her iron levels improved. Addressing the anemia was an important component of her disease management, along with weekly mental health therapy, and the use of a low dose antidepressant. Jennifer completed her Junior year and was prepared to apply for college. We continued to work on the tension building between Mother and Jennifer, seemingly driven by her imminent departure for college and Mother’s need to overprotect her child.  As is usually the case, I never consulted with Jennifer’s pediatrician, relying on Mother and client to relay important information. Notably, a significant piece of her clinical presentation was a result of her illness and subsequent anemia, layered upon the hormonal and developmental changes of her age and the stresses unique to her life. Unaddressed, the anemia would have hindered her recovery and potentially caused other health issues. Could there be a better way to integrate the care of our youth, to consider the health of the whole person,  that possibly is more efficient and effective?  Could integrated care prevent or reduce poor outcomes, including death by suicide?  I would argue yes, more communication between healthcare and mental health providers could help save lives and reduce self-harm among young people Susan Parmelee, LCSW is a board member of the James Kirk Bernard Foundation and the founder and Executive Director of the Wellness & Prevention Center (WPC), a nonprofit mental health clinic in South Orange County, California. WPC's mission is to help youth and families lead healthy lives. The WPC provides easy to access clinical services on secondary school campuses and educates the community about the diseases of addiction and mental health. 

August 25, 2020 Mental Health and Physical Health – We Need to Advocate for Integrative Care Models

By Susan Parmelee, LCSW
As a Licensed Clinical Social Worker specializing in mental health services for youth ages 12-25 years old, I spend a lot of time talking to youth and colleagues about mental health and how we can prevent suicide. Suicide remains one of the most difficult challenges in our work due to the complicated interaction of many factors. As a nation, we continue to lose young people at increasingly staggering rates to death by suicide, and rates of hospitalization for self-harm and attempted suicide are also of concern.  Suicide is Complex and Multi-factorial The perfect storm that leads to a death by suicide usually includes environmental, societal, biological, and emotional components. However, at the trainings and meetings I sit in to “lower the stigma,” get to “zero suicide,” and increase access to mental health services, very few physical healthcare providers are in the room. If they are present, those medical doctors often look to the mental health providers for the answers and approaches.  I received my degree in Clinical Social Work in the early 2000s. In my program we learned the importance of referring youth and adults with symptoms of mental health diseases to their primary care provider to rule out certain medical conditions that could be evaluated through a comprehensive lab work order and physical exam. As the rule out article describes, ‘common examples are sleep and thyroid dis­orders; deficiencies of vitamin D, folate, and B12; Parkinson’s disease; and anti-N-methyl-d-aspartate receptor autoimmune encephalitis.’
Additionally, a careful evaluation of substance use is critical to a correct diagnosis and then appropriate treatment, as many substances (both prescribed and illegal) and withdrawal scenarios can trigger psychosis, agitation, and other mental health symptoms. In youth, conditions such as Attention Deficit Disorder and Autism Spectrum Disorder can be diagnosed by pediatricians and referred for evaluation, and some of these neurological symptoms can mimic, co-occur, and/or trigger the diseases of mental health.  I supervise graduate student social work interns, so I have asked them what they are now taught as medical rule outs. Their list is more comprehensive, as research has allowed for an increase in knowledge about human physiology and how this affects neurological and social-emotional functioning. Of note, these students now learn about how the gut biome may be a culprit in the diseases of anxiety and depression.  Beyond the bloodwork that I suggest to have primary care docs check in every new referral - thyroid function, vitamin D, and iron levels - there is now extensive research on lipid levels in blood and associated symptoms of anxiety and depression and suicide risk. While we do not yet have clinical guidelines and there are questions about causality, this appears to be an important link and a reminder to consider diet and nutrition.  In fact, I was taught, as were my graduate students, to carefully evaluate sleep, exercise, and diet as part of each psycho-social evaluation.  Addressing these areas and providing referrals to nutritionists, helping people become more active, and coaching people on sleep hygiene can effectively reduce mental health symptoms. Exploring these modifiable behaviors and working to encourage healthier habits is a preferred approach and should be tried prior to a referral to a psychiatrist for a medication.  The exception is when the client is in the midst of a psychosocial crisis, then referrals for more intensive services may be required, particularly if the client is at risk of harming themselves or others.  What is the role of Primary Care Medicine? Returning to my original comment, I do not truly know how primary care doctors are trained to address their patients’ mental health. However, in the important work that I participate in to lower rates of suicide and self-harm, medical doctors are not sitting at the table. I spent some time looking into how their professional societies suggest addressing suicide and the diseases of mental health. 
The American Academy of Pediatrics (AAP) developed a periodicity screening that guides pediatricians in behavioral health development from an early age and stresses the importance of prevention of and recovery from adverse childhood experiences. In 2018, the AAP added guidelines for screening depression in teens that should start when a child turns 12 years old, using a standardized form that the AAP adopted. This policy was in response to findings by the AAP prevention committee which stated, “The report reveals that half of teenagers with depression are not diagnosed in the pediatric primary care setting before reaching adulthood, resulting in two-thirds going without needed treatment. Even in cases in which adolescent depression is diagnosed, about half of teenagers still go without appropriate intervention.” The guidelines stress the need for pediatricians to develop a treatment plan that includes educating the teen and their parents about treatment options, referrals to outside services, safety planning with emergency measures clearly taught, and ongoing management. The guidelines note the difficulty in finding enough time in a patient visit to screen and provide the appropriate management of the results. The AAP guideline’s authors note that they are optimistic about the prevalence of pediatricians who incorporate these screenings, yet note that many pediatricians have not adopted these measures.  In my practice, I do not typically talk with the outside pediatricians who care for my clients. Managed care requirements make it very difficult for pediatricians to have time to consult with other health care providers. Healthcare in the United States is fragmented and managed care leaves little time for professional consults outside of a healthcare network. Additionally, there is a shortage of mental health care professionals who treat youth across the globe. In the US, many suggest increasing the responsibility of the pediatrician and the primary care doctor in caring for our mental health. They note, in particular, that nearly three-quarters of mental health disorders have childhood onset and there is evidence that challenges such as anxiety and depression can be prevented or ameliorated through early intervention.  Fostering Collaborative Approaches I would lobby for public funding for the education of mental health social workers and mental health nurse practitioners to fill this gap in practitioners. Additionally, insurance companies should allow psychiatrists to bill for longer intensive visits. Prescribing psychotropic medications is an art form, much different from prescribing an antibiotic and watching an infection clear up. There are no clear markers that a medication is working, and many can do harm. Furthermore, most pediatricians who prescribe antidepressants and anti-anxiety medications report no formal training in use of these medications.  For depression and anxiety, as well as many other psychiatric diseases, the optimum treatment includes a medical exam to rule out physiological symptoms, sleep disorders, nutritional concerns, and possible side effects from other medications.  The medical evaluation may be concurrent to the therapist assessment and formulation of a treatment plan.  If the therapist and the primary care doctor see the need, a referral to a psychiatrist for medication may be the next step.  The most successful outcomes with medications also employ continued counseling or behavioral therapy using evidenced-based treatments targeted to the diagnosis and symptoms. In my experience, clients often drop out of therapy when medications are working, sometimes leading to adverse outcomes when the medications are no longer effective or sufficient. Fully understanding the individual's challenges and circumstances before prescribing psychotropic medication is essential.  The optimum combination is a team approach where the psychiatrist and therapist consult regularly and establish mutual goals with the client. A promising model is embedding mental health professionals in the pediatric setting for ease of referral and consultation between professionals and a focus on treating the whole person. A hurdle to this model is the lack of parity in insurance reimbursement for mental health care and resistance by insurance companies to provide ongoing mental health care to keep these conditions from escalating. However, this model has been adopted in Health Resource & Service Centers and Health Center Programs (which predominantly serve adults with public health insurance or no insurance) using integrated behavioral health programs. These centers report a reduction in costs for chronic illness management, lowered stigma about the diseases of mental health and addiction, as well as the benefit of data sets for research and knowledge-sharing across federally funded healthcare programs and to the general public. Enhancing resources, costs savings, and better treatment for each individual seems like something we should all support. Susan Parmelee, LCSW is a board member of the James Kirk Bernard Foundation and the founder and Executive Director of the Wellness & Prevention Center (WPC), a nonprofit mental health clinic in South Orange County, California. WPC's mission is to help youth and families lead healthy lives. The WPC provides easy to access clinical services on secondary school campuses and educates the community about the diseases of addiction and mental health. 

July 21, 2020 Diet Matters: The Food-Mood Connection

by Alison Brown, MSc

“Let thy food be thy medicine and thy medicine be thy food” - Hippocrates, 400 BC

We are generally aware that our diets affect our physical health—after all, “you are what you eat” is a fairly common idiom. However, it’s interesting that 2000+ years passed before the mental health field focused on one of Hippocrates’ great insights: food is medicine for our entire bodies, including the ever-important human brain.
Increasing evidence suggests that what you eat affects your mental health—in more ways than one. While more research needs to be done, several studies have found that eating a diet of whole, unprocessed foods may decrease your risk of depression and suicide, and a diet made up of refined carbohydrates, simple sugars, and processed meats can increase that risk. Diet may offer an additional modifiable tool in an integrative approach to mental health. Scientists and clinicians have launched the relatively new field of nutritional psychiatry, where research builds a case that focusing on nutrients for the brain and a strategic diet can help to avoid, and even substantially improve, symptoms of depression, anxiety, and other conditions. Reinforcing the concept of mind-body connections, diet affects how your brain and body function to keep your mind healthy. In fact, researchers from the International Society for Nutritional Psychiatry Research claimed in an opinion piece in Lancet Psychiatry that, “the emerging and compelling evidence for nutrition as a crucial factor in the high prevalence and incidence of mental disorders suggests that diet is as important to psychiatry as it is to cardiology, endocrinology, and gastroenterology.” Can your diet protect you from depression and suicide? Mediterranean-style diets, popular in addressing many physical health conditions, have received increasing attention in the nutritional psychiatry field. As mentioned in the Harvard Health Blog, one study that surveyed dietary patterns suggested that the risk of depression is lower in those who follow ‘healthy’ dietary patterns rich in fruits, vegetables and fish, as compared to those consuming a diet rich in processed meat, chocolates, sweetened desserts, fried food, refined cereals and high-fat dairy products.
Furthermore, a meta-analysis of observational research surveying dietary patterns showed that consumption of whole, unprocessed foods was associated with less depression and that Western-style diets increased depression risks. The authors called for further studies and clinical trials to confirm and build upon these findings. Crucial evidence that changing your diet can support your mental health comes from the SMILES trial, the first intervention study to test the therapeutic effect of food on the development of major depressive episodes. In this controlled study, adults with major depressive disorder reported significant improvements to their mood after following a Mediterranean-style diet for 12 weeks. Participants were asked to add 12 key food groups to their diets: whole grains, vegetables, fruit, legumes, low-fat and unsweetened dairy foods, raw and unsalted nuts, fish, lean red meats, chicken, eggs, and olive oil. In addition, they were asked to reduce their consumption of sweets, refined cereals, fried food, fast food, processed meats, and sugary drinks. In comparison with the control group, improvements were also shown in secondary measures of anxiety. The researchers pointed out that weight loss did not occur, and surmised that diet-induced changes in inflammation, oxidative stress, brain plasticity, or the microbiome might be influential factors. Another trial recently found that young adults who followed a Mediterranean-style diet for only three weeks reported significant improvement in depressive symptoms and lower levels of anxiety and stress. Those who had a greater intake in fruits and vegetables showed the greatest improvement in depressive symptoms. These authors refer to diet as a modifiable risk factor for depression, meaning that it is something you can changethat reduces risk. In meta-analysis of clinical trials published just last year, researchers reviewed 16 studies of dietary interventions and their effects on symptoms of depression and anxiety. They found that improving diet by increasing vegetable and fiber intake and decreasing consumption of fast food and sugar shows promise in providing a measurable benefit on depression and, to a lesser extent and more so in women, anxiety, and suggested a need for more research into mechanisms and approaches for dietary interventions. As for diet’s relationship to suicide (beyond the overlaps with depression), there is some evidence that deficiencies of certain nutrients can influence suicidal behavior, but as of yet, there are no controlled studies assessing dietary interventions. This paper highlights nutritional features associated with depression and suicide and suggests that there are certain nutrients (fatty acids, vitamin C, zinc, magnesium, vitamin B12 and folic acid) that support key cellular functions and may have therapeutic benefits for depression and suicidal behaviors. Researchers have made a case that a deficiency of Vitamin D can affect suicide risk. One study found that low Vitamin D levels in the blood samples of US service members were associated with an increased risk for suicide. In an investigation of patients with a recent suicide attempt, researchers found that as many as 90% of the patients who had made a suicide attempt had low levels of Vitamin D, and 60% had a clear deficiency as well as elevated markers of inflammation. A recent study of adolescents who had made suicide attempts revealed Vitamin D deficiency, and the authors suggested that those treating adolescents test for Vitamin D levels, as there is some support that treatment may reduce risk.
Fatty acid levels have also received some attention. A study of young Chinese males found that low levels of the omega 3 fatty acid EPA represented a risk factor for suicide attempts. Another study of US service members who died by suicide found that low levels of the omega 3 fatty acid DHA were a strong predictor of suicide, and service men with the lowest levels of DHA were 62% more likely to die by suicide. Dr. Arthur Ryan (who received the first James Kirk Bernard Foundation Award for Excellence in the Biological Exploration of Suicide) presented evidence to a conference from his study which found that individuals who later died by suicide were more likely to have particular combinations of fatty acid profiles. It’s important to note that these studies cannot confirm that these nutrient deficiencies were caused by diet alone, as metabolism, genetics, and lifestyle may affect any individual’s results. However, sometimes nutritional imbalances can be supplemented or improved with diet, especially critical nutrients such as DHA and EPA that cannot be made by our bodies. How does your diet regulate mental health? There appear to be three mechanisms by which diet affects mental wellness. First, your diet provides your brain with nutrients, such as fatty acids and B vitamins, that it needs to grow, function, and generate new connections. Dozens of neurotransmitters affect brain function and mood, and many of the nutrients needed to make them come from your diet. Of note, serotonin is a major regulator of mood, appetite, pain, circadian cycles, and digestion and is so important in mental health that boosting it is the target of anti-depressant medications such as SSRIs. Dopamine regulates pleasure, energy, mood, focus, and sleep and norepinephrine is involved in learning, mood, and forming new brain cells. One lesser-known nutrient for brain growth is brain-derived neurotropic factor, or BDNF, which increases plasticity and primes your brain for learning, good moods, and clear thinking. In fact, increased BDNF levels are associated with effective treatment of clinical depression. Another means by which diet may affect mental health is by regulating inflammation, a factor of interest in many chronic health conditions, both physical and mental. Inflammation can lead to distress signals in the brain that influence anxiety and depression. Studies have shown that people with major depression have higher levels of some inflammatory markers, including C-reactive protein. Inflammation is also associated with symptoms of suicidal behavior like aggression, hopelessness, and hostility, and of increasing interest in the suicide research field. While the exact mechanisms that link inflammation, and especially neuroinflammation, to suicide are not yet firmly established, there are multiple theories currently being researched. The third mechanism by which diet may affect mental health is through your gut health. The gastrointestinal tract contains millions of nerve cells that send signals back and forth to the brain, so if your gut is feeling unwell, your cognition and mood can be affected too. Key to gut health and gaining increasing attention in both physical and mental health conditions, the microbiome is important for the production of neurotransmitters such as GABA and serotonin. While we think of serotonin as elemental to thought and emotions, and it’s important (and interesting!) to consider that 90% of serotonin is produced in the gut. Microbiome biodiversity is essential to gut health, and one study found that bacterial richness and diversity (influenced by what you eat!) was associated with decreased severity of depression and anxiety. What should we be eating? While consuming a diet including more whole, unprocessed food will likely also benefit your physical health, mental wellness is the target of these suggestions. That said, many chronic diseases raise the risk of suicide and psychological conditions, so what’s good for the body can be good for the mind. Of course, always consult your doctor before deciding which diet is right for you. Additionally, there’s a large body of research and an increasing number of experts on the food-mood connection, so we’ll just be highlighting a few recommendations here. The message is that what you eat can affect how you feel, so you may want to consider diet when thinking about mental health. Seafood is especially important—according to the CDC, the majority of Americans fall short of the recommended amount of fish in their diet (the USDA recommends two servings of seafood per week). Meat from seafood, including fish, shellfish, and mollusks, is the most concentrated source of the important omega 3s DHA and EPA, and diets high in these omega 3s are associated with reduced  depression, obesity, cancer, and heart disease. This study showed that men with low seafood consumption were much more likely to be severely depressed. Along with the omega 3s, fish is full of other great mood-boosting nutrients like iodine, magnesium, vitamin D, and zinc.
As the Mediterranean-style diet has been the most extensively researched, many nutritional psychiatrists recommend following this or a similar meal plan, as popular press is starting to report. Dr. Lisa Masconi, the director of the Women’s Brain Initiative at the Weill Cornell Medical Center, said in a New York Times article, “imaging studies show that the brains of people who follow a Mediterranean-style diet typically look younger, have larger volumes, and are more metabolically active than people who eat a more typical Western diet.” While following a traditional diet is a worthy goal, many experts agree that there’s no one food or one diet that is optimal for mental wellness. Instead, focusing on upping your intake of whole, unprocessed fruits, vegetables, fish, and meats and cutting out refined carbohydrates and sugar can make a difference. Dr. Drew Ramsey, an assistant clinical professor of psychiatry at Columbia University and a leading expert in the nutritional psychiatry field, champions these top mood-boosting foods: wild salmon and shrimp, cherry tomatoes and watermelon, chile peppers, beets, and garlic. Dr. Ramsey has helpful tips and tricks to eating your way towards a healthy and happy brain in his book, The Happiness Diet, and in his TEDx talks, linked here and hereWhat shouldn’t we be eating? First and foremost, one of the most important dietary changes to improve your mental health is to significantly reduce sugar consumption. In the past 200 years, we’ve increased our sugar intake by 3,000 percent, resulting in various metabolic changes. Alarmingly, one investigation shows that countries with the highest intake of sugar per capita are the countries with the highest rates of depression. Sugar is one of the primary driving forces behind the obesity epidemic, and obesity-related diseases, such as diabetes, heart disease, and cancer, have much higher rates of depression. Not surprisingly, studies show that excessive consumption of energy drinks and sugary beverages increases the risk of depression and suicide ideation. Diets high in sugar decrease the amount of circulating BDNF, which is important for your brain to grow and make new connections. High blood sugar can also shrink the hippocampus and amygdala, affecting brain areas essential to regulating mood, memory, anxiety, and cognition. Modern processed foods also wreak havoc on our mental health. Many nutrients that contribute to a happy brain have been stripped from our food supply, and in some cases, replaced with chemicals that may impair brain functioning. For example, to increase the shelf-life of flour, the naturally-occurring fiber is removed and replaced with chemical bleach. Vegetable oils (corn, soybean, sunflower) are particularly damaging, since they have high levels of pro-inflammatory omega 6 fats, in contrast to anti-inflammatory omega 3 fats found in fish. High levels of omega 6 fats and trans fats have been linked to an increased risk of depression. Preliminary evidence shows that meat intake may have an association with depression, while one review suggests that grass-fed and grass-finished meats have a healthier nutritional profile of fats and antioxidants. Factory farmed cows, chickens, and even fish are usually fed diets of corn and soybeans which reduces the amount of mood-boosting omega 3s in their meat. The less-than-ideal conditions that the animals live in also increase their stress hormones, which lowers their concentration of B vitamins, zinc, and vitamins A, E and C. Furthermore, higher consumption of meats cured with added nitrates, such as hot dogs and beef jerky, has been associated with episodes of mania. You Feel What You Eat Experts in nutritional psychiatry, as well as medical doctors, are increasingly aware that what you eat truly affects how you feel. As Dr. Felice Jacka, president of the International Society for Nutritional Psychiatry Research, said in a twitter video, “we now have a very large and consistent evidence base… to say that the quality of your diet is linked to your risk of depression in particular.” The growing field of nutritional psychiatry reinforces the idea that mental health isn’t all in your head, but rather a part of a complex biological and psychological system that does not function in isolation.  And while experts agree that there is consistent and compelling evidence that diet affects mental wellbeing, diet is not a silver bullet for treating mental health concerns or preventing suicide.  That said, healthy whole food coupled with professional support, as well as physical activity, carefully delivered  medication (when needed), adequate sleep, exposure to nature, social connectedness and a commitment to a balanced lifestyle can combine to help you feel your best each and every day. Alison Brown, MSc., is a freelance writer with a background in cognitive science and evolutionary and comparative psychology.      Reviewed 7/20 by Jian Zhang, MD, DrPH, MSc, Professor in the Department of Biostatistics, Epidemiology, and Environmental Health Sciences of Jiann-Ping Hsu College of Public Health at Georgia Southern University