Dr. Dawn, The Suicide Prevention Pharmacist

Today I want to highlight another possible treatment option for depression – vagus nerve stimulation, or VNS.  The Mayo Clinic has a very good overview of VNS, which is my source of information and can be found here:  https://www.mayoclinic.org/tests-procedures/vagus-nerve-stimulation/about/pac-20384565

Vagus nerve stimulation is typically used for seizures and depression, but research is being done to determine if there is a benefit in other conditions.  And, while most vagus nerve stimulators are implanted, there are some noninvasive stimulators now available.  There are two vagus nerves – one on each side of the body, and they run from the brainstem through your neck and into the chest and abdomen.

When it comes to depression, vagus nerve stimulation has been used for treatment-resistant depression.  These are patients who have tried things like medications, counseling, and electroconvulsive therapy (ECT), and have still not experienced much or any relief.  From what I can see, it is not known how VNS works to treat depression, and the research is mixed on the benefits of using an implanatable VNS device in this population.  There may also be an issue with getting the procedure covered by insurance.  Overall, my interpretation is that this is currently a last ditch effort to try something when nothing else is working.  It may not be a great option, but it is an option when other traditional methods have failed. 

If someone is considering VNS for depression, it is important to remember that it will likely be an invasive procedure that comes with potential risks and side effects.  Some examples include infection, pain, difficulty swallowing, voice changes, and shortness of breath.  Although hopefully these are minimal, it is important to know risks, benefits, and potential side effects before the procedure.

What are your thoughts on VNS?  Does it seems worth trying if everything else has seemed a failure?  

Have you heard of the term “evidence based medicine”?  What exactly does that mean?  Is it important?  If so, why?

The term “evidence based medicine” is used in many settings, but definitions can vary.   Essentially the name pretty much gives away what it means.  Evidence based medicine is medicine that comes from some kind of research or study or observation.  Most practitioners believe that when they practice medicine, they should be using medications, techniques, procedures, etc. that have been proven to help.  Another important piece of evidence they like to use is safety, because obviously providers do not want to increase any pain or suffering for their patients. 

When it comes to evaluating all of the information, not all evidence is created equally.  Most practitioners will consider evidence from prospective randomized controlled clinical trials to be the “gold standard”, while retrospective and observational data are considered less credible.  However, over the years, a lot of questions have come into how research and study is done and reported.  When reporting results, a lot of bias can be presented, and sometimes there can be large conflicts of interest that might make things look better or worse than they really are. 

That being said, this makes trusting any information harder, but that is the main point I want to get across – all evidence, no matter where it comes from, should be questioned.  Sometimes prospective randomized controlled clinical trials are very beneficial, but sometimes observations found with just one patient can be beneficial too.  When facing depression, it’s important to think about what might work for you, from both a benefit and safety standpoint, regardless of where the information may be presented.  Ultimately, this is a discussion between you and your provider, but challenge your provider to consider all of the different types of evidence that may be out there.

While I was not going to originally discuss today’s topic, I feel like I need to share my opinion and process it while it seems to be on my mind.  Within the last week, it seems like I am constantly reminded that it is winter and being out can be scary and dangerous.  My understanding is that this comes from an urge to keep our fellow humans safe and protect life, but right now I am questioning how far that should go before we are terrified into doing nothing. 

Don’t get me wrong – I am just as susceptible to the fear of bad snowstorms and really cold temperatures, but on the other hand, haven’t we all been through these things before?  Did we not survive when we were less aware of these dangers and warnings?  Did we not prepare somewhat, but not go overboard with worry and fear?  I am all for safety and taking precautions, but I am not for scaring all of us into thinking we should stop living because of it.  I am also sitting here thinking, no wonder we have so much anxiety and depression in the world!  When something like cold temperatures becomes an overly dramatized life or death situation, how many other things have we overblown because of fear? 

There has to be a better way.  There has to be a better way of warning people about risks and discussing important precautions, but we need to stop short of the line that goes into scaring people unnecessarily.  What are we doing?  Why does it feel like everything has to be so dramatic?  Again, no wonder we see so much depression and anxiety in the world – there are way too many triggers out there that can play a role in its development.

What are your thoughts on fear?  Does it seem like a lot of things are way too dramatic in our world these days?  It is not really a fun topic, but it is important to understand that this could very well contribute to the depression and anxiety we see in others.

Today I want to touch on a questionnaire that you may have heard of or taken before – the PHQ-9, also known as the Patient Health Questionaire-9 item.  This questionnaire can be used to help determine the presence of depression, as the questions are based on the diagnostic criteria for depression.  The PHQ-9 is used widely in many types of health settings, and can be a quick and easy way to assess for depression in many individuals. 

The questions ask about what you have experienced in the last 2 weeks, and the questions ask about your eating, sleeping, energy, concentration, feelings, and interest in regular activities, among a few other items.  Responses can vary from not at all, to several days, to more than half of the days, to almost all of the days in the last 2 weeks.  The higher the score on the PHQ-9 indicates a greater need for follow-up and/or treatment, which could include repeating the PHQ-9, getting counseling, starting medications, or immediately seeking treatment.  A shorter version of the PHQ-9, known as the PHQ-2, is also used in the healthcare setting for an even quicker assessment for depression.

Although I assume you will not see the PHQ-9 or PHQ-2 in every health care setting, what is exciting to me is that I feel like I am hearing and seeing more of it.  Like all of the other forms you have to fill out at a provider’s office, the PHQ-9 or 2 is becoming a standard part of the paperwork, and that is important.  To me, this is a way to normalize mental illness and make it no different than any other illness.

What are your thoughts?  Have you seen the PHQ-9 or 2 before?  Have you taken it?  Do you feel it is important to have as part of the regular paperwork for any office visit?  My hope is that we continue to see the screening for depression increase.

In previous posts, I have mentioned an organization called AFSP, which stands for the American Foundation for Suicide Prevention.  At the beginning of 2019, they have launched a national campaign called Project 2025, and today I want to talk about what is involved.

A more detailed description of Project 2025 can be found here: https://project2025.afsp.org/  Essentially, the aim of Project 2025 is to reduce the annual suicide rate in the United States by 20% by 2025.  In order to meet this aim, AFSP has identified four critical areas of focus: firearms, the healthcare system, emergency departments, and corrections systems. 

According to AFSP, over half of all suicides are by firearms, so it seems obvious as to why they are focusing on them.  And, while I haven’t read a lot of the details, it does not appear to be about gun control or laws, but rather about educating the firearms community about spotting suicide risks and how they can save lives.  Healthcare systems and emergency departments are related in that both areas can do a better job of screening, asking about, talking about, and dealing with suicide risks.  Finally, suicide is the leading cause of death in jails, so screening and changing attitudes about suicide prevention in corrections systems is important.

Although suicide is not a glamorous or fun topic, I am so glad that the AFSP has created this nationwide project.  In a perfect world, the number of suicides would be 0, but until we reach that day this is a step in the right direction.  I applaud the AFSP for their efforts and look forward to seeing this goal become a reality.

How about you?  Do you support Project 2025?  Does it seem like an attainable goal?  Does it seem like it is not enough, and a bigger goal could be created?  Regardless of how you feel about it, I hope you spread the word about this important project.

With my background in pharmacy, I spend a lot of time thinking about medications.  In my experience, we typically seem more concerned with adding or keeping medications, not taking them away.  Today I want to touch on deprescribing, which involves ways to potentially reduce or remove the number of medications that are being used by an individual.

When I think about it, deprescribing is very important.  How many people end up on a medication and continue to take it for years when they may no longer need it?  Maybe someone takes a medication that gives them certain side effects, and they start taking another medication to treat the side effects.  Is the medication worth the side effects if you have to use another medication to treat them?  Or, if the medication is beneficial, could the dose be lowered to minimize the side effects and maintain a benefit?  Perhaps the medication does not seem to cause any noticeable or bothersome side effects, but it doesn’t seem to provide any benefit either.  Is there any reason to continue a medication if it doesn’t seem to be helping?  These are all questions that reflect the need to consider deprescribing.

Of course, there are potential risks with deprescribing, and it is something that should be considered and undertaken with a health care provider.  Many medications should not be stopped cold turkey, and many would be safer if they are tapered off over time.  And, since every individual has a different medication regimen, deprescribing is going to look different for everybody, and some people may not be candidates for deprescribing at all. 

Overall, I think deprescribing should be considered every time there is a visit with a health care provider.  Like others things in life, less can be more, and it is important to consider what medications are truly needed.  And, by talking about deprescribing, I am not saying that we get rid of all medications.  Many medications can be helpful and have a place in treatment, but in my opinion they are not always the only answer.  Regardless, I encourage everyone to consider having a discussion with their provider about reducing or removing some of the medications that may no longer be needed.

Perhaps you have heard of peer support before, but for me it has been a somewhat vague term.  Today, I want to explore what peer support is and how it works.  There are many websites available that describe peer support, but today’s information is coming from the following webpage: http://www.mentalhealthamerica.net/conditions/what-peer

In general, a peer is someone that we can identify with in some way (such as someone your age or someone who speaks the same language as you).  In mental health, a peer is typically used to refer to someone who shares the experience of living with a mental illness and/or substance use disorder.  Peer support is the process of giving and receiving encouragement and assistance to reach recovery.  Peer supporters can offer emotional support, share knowledge, teach skills, provide assistance, and connect people with resources.  In mental health, peers offer their unique lived experience with their conditions to provide support focused on advocacy, education, and mentoring.

Peers can facilitate education and support groups and work as a bridge linking people to services as they transition from health care facilities or jails into the community.  Peers also can act as role models, mentors, coaches and advocates.  As you can see, there are many ways that peers can help others and many opportunities for peer support in the community.  Peer support is a another possible option for those facing a mental illness, and I hope this is yet another piece that is considered when thinking about treatment and recovery. 

How about you?  What do you think about peer support?  Is it something you have been a part of or tried?  It is something you have considered?  Based on what little I have read, it seems that peer support will continue to grow and help more and more people, and that is exciting news to share.

Today I want to point out another resource that is available for another group of people – college students.  It is called “Starting the Conversation: College and Your Mental Health”, and it can be downloaded for free on NAMI’s website at https://nami.org/collegeguide.  NAMI worked with the JED Foundation to create this guide.  The JED Foundation is a national nonprofit that helps protect the emotional health of teens and young adults.  The JED Foundation also works on suicide prevention in these age groups.

The guidebook is almost 30 pages long, but it can easily be reviewed if you don’t want to read every word.  Topics covered include talking about mental health with others, managing stress, common signs of a mental health condition, campus resources for mental health, substance use, mental health care on campus, health information and privacy laws, and general mental health resources. 

Like the caregiving resource mentioned in my previous post, I think it is great to have a guide like this available.  I assume a lot of college students would appreciate having help in knowing what they can do if a mental health issue affects them or someone they know.  I also think it is important that we let college students know that it is ok to talk about their mental health and any struggles they may be having.  Everyone needs to know they can get support, and although it might be hard for college students to ask for help, I feel that the more college students hear about it the more they will be willing to get assistance when they need it.

How about you?  What are your thoughts on this guide?  Does it give you some helpful information?  Is it missing important pieces that would be helpful for you to know?  I hope you will take some time to download and review the guide to see if it can be helpful to you or someone you know.

Today I want to point out a resource that is available for caregivers.  It is called the “Circle of Care Guidebook”, and it can be downloaded for free on NAMI’s website at https://www.nami.org/About-NAMI/Publications-Reports/Guides/Circle-of-Care-Guidebook.  NAMI worked with the National Alliance for Caregiving to create this guide.

The guidebook is a little over 50 pages long, but it has many different sections, so you can pick and choose what is important to you if you don’t want to read the entire guide.  It is important to note that the guide is for family, friends, or others who care for an adult with a mental health condition.  Topics covered include finding a compatible provider, communicating with health care workers, making sure you have an accurate diagnosis, discharge planning from a facility, dealing with health insurance, looking into community services that may be available, working with the criminal justice system, planning ahead for the future, confidentiality and involving the family, and self-care. 

Personally, I think it is great to have a guide like this available.  I assume a lot of caregivers would appreciate having help in navigating their roles and responsibilities.  As a lot of us have come to realize, understanding the healthcare system and insurance can be challenging, even if you are not faced with a mental health condition.  And, from what I have seen over the last few years, there is more emphasis being placed on the well-being of caregivers, and I think that is very important.  Everyone needs to be cared for, whether it is by others or by themselves. 

How about you?  What are your thoughts on this guide?  Does it give you some helpful information?  Is it missing important pieces that would be helpful for you to know?  I hope you will take some time to download and review the guide to see if it can be helpful to you or someone you know.