Sleep Well, (or else, get to getting you some.)

The Biopsychosocial Model of Evaluation and Treatment in Psychiatry |  SpringerLink

The intricate tapestry of sleep intertwines with various aspects of life, reflecting its impact on physical health, emotional well-being, and interpersonal relationships. Let’s weave these threads together.

Here is the outline for tonight’s NAMI meeting:

  • **Understanding the Biopsychosocial Model:**
    • The importance of the biopsychosocial model in addressing sleep difficulties. By considering internal and external factors, embrace a holistic perspective.
  • **Importance of Biological Perspective:**
    • The recognition of sleep as a fundamental component of our biological identity – Sleep is not merely a restful activity but a vital process that shapes our emotional and behavioral well-being.
  • **Tools for Better Sleep Hygiene:**
    • Practical tips for better sleep hygiene serve as actionable tools to enhance the biological foundation of our mental health. From bedroom habits to daytime activities, these tools offer a roadmap for fostering healthy sleep.
  • **Daytime Alertness and Stimulating Medications:**
    • Underline the importance of daytime alertness, emphasizing the connection between wakefulness-promoting activities and overall mental well-being. The introduction of stimulating medications provides an additional layer for those facing challenges in staying alert.
  • **Personal Stories:**
    • The challenges of adopting better sleep hygiene are a human issue we all have, and our home system/culture paved the way we got here.
  • **Psychiatric Vital Sign: SLEEP:**
    • Underscore its diagnostic significance. This reframing encourages a proactive approach in assessing and addressing sleep-related concerns.
  • **Cultural and Emotional Complexities:**
    • There are cultural and emotional complexities tied to sleep, acknowledging that changes in sleep habits involve more than just physical adjustments. It’s a journey of self-discovery and adaptation.
  • **Advocacy for Sleep:**
    • The call to fight for one’s sleep urges individuals to prioritize their well-being. This advocacy is a powerful reminder that prioritizing sleep is an act of self-love and perseverance.
  • **Sacrifice for Well-Being:**
    • The essence of sacrifice for a healthier, more capable self. Prioritizing sleep is not a selfish act but an investment in personal and relational well-being.

In weaving these narratives together, the common thread is the recognition of sleep as a foundational pillar for overall health. Whether approached from a medical, psychological, or personal standpoint, the message remains clear: prioritize sleep for a richer, more vibrant life.

One of the many reasons I speak at these meetings is that it gets me thinking and writing more.  In brief, we’ll talk about, well, sleep!  (Smile.)

Keep on!

Psychiatric Hospitals and Homelessness

Hello “FriendtoYourself Community”!

Have you ever heard of a day hospital? In the psychiatric treatment options, the day hospital is a gem. Sometimes it is known as a “Partial Hospital Program”, or PHP. This hospitalization is called a “step down unit” as well and is classically where people go when they need more than typical outpatient care with either or both of a psychiatrist and a talk therapist, but they are not needing full inpatient care in a hospital where they stay overnight. In my community, one of our hospitals is working to develop a day hospital program.

I’ve been asked about my experience with patient’s of whom I’ve referred to psychiatric day hospitals. “They” want to know about the demographics of whom I send, why the patient’s go, and their outcomes. They have a concern that by providing day hospital care, it puts the community at risk for increasing homelessness. You can see the pavers span a distance before arriving at that conclusion but it is understandable if we walk. Fears are important. None of us are above them.

Oftentimes, patients on initial evaluation come to me in crisis because they wait. They prefer to try anything else before seeking help, even resorting to unconventional methods. There has to be something in their life that pushes them to the point of willingness to see a psychiatrist. They come to me when it’s either see me or go to a psychiatric inpatient hospital bed. They may not qualify for a 5150, (a legal hold when someone is danger to self, danger to others, or gravely disabled – unable to provide food, shelter, or clothing for themselves). Yet although they are not disabled, at that time in their illness, I may still not be the best match for their medical care.

Outpatient clinical psychiatry is for people not in crisis. If you’re having an emergency, you should not be in my office. My outpatient clinic is not equipped to deal with emergencies, aside from being able to call law enforcement. For those in a psychiatrically fragile condition, they need more. In outpatient clinics, there are fewer allowances for this.

So, it was with Anna. Seeing a psychiatrist was the very last thing she was willing to do to get better.

People like Anna come to me at a critical juncture in their life. It’s a choice between visiting me or heading to the emergency room.

Let me introduce you to her. Anna is a 38 year-old mother of three. She’s been married for 15 years and comes from a family who survived their own depressive mother and a father who excessively drank alcohol. Her mother parented in the ’70s and ’80s when there were not many options for her. Her mother had tricyclics and MAOI‘s until Prozac came out in 1987. It was a different world of understanding mental illness and being able to treat it. Anna and her three siblings grew up with a depressed mother and an alcoholic father. Depression is contagious. So, Anna grew up with a household of depressives. Not only is it impossible to live with depressives without getting depressed, but she also had the added burden of her genetic loading written into her DNA. She was at high risk of developing depression herself.

In high school, Anna met her first and last boyfriend, Dave, and she thought he was everything; religion, hope, and fresh backed cake. They went to college together, moving in their freshman year and dropping out when she got pregnant. They had an active life before pregnancy, going out all the time and having common interests. They were best friends. It was the happiest time of her life. Then, when the babies came, life became more difficult. Dave started using drugs and alcohol, and they hadn’t had sex in eight months. They were not connected, and Anna found herself really loving her kids but not liking them. She could hardly stand listening to them cry. Their needs, as expressed through their angry voices, pulled on her viscerally. She felt like she was losing her mind.

Now, her children were irritable, and in this next generation, the contagion of Anna’s depression spread through the family. You can trace, now, three generations have suffered because the biological was never treated. The psychological and the sociological followed and also became misaligned.

When Anna first came to me, I was actually happy because she was entirely treatable and had huge resources that she hadn’t yet accessed. I knew Anna had this coming, and I was happy because she was totally treatable. My heart also broke to see something that was so treatable savage three generations.

Even so, I knew that the outpatient clinic was not the best treatment for Anna because, in outpatient clinics, the services we offer people in crisis are not the best for them. Anna was in crisis. She was having morbid thoughts that life wasn’t worth living. Her whole family had become emotionally ill in the context of the contagion of her depression. And she felt like she was losing hope. This was a higher level of care than what I could offer in the clinic.

In an outpatient clinic, I don’t generally see people more frequently than every three to six weeks. Anna needed to be seen much more frequently, especially in the short term while her medications were established and had time to take effect. She needed intensive therapy, more than what outpatient therapy could offer and intensive enough so that it could actually reroute the way her automatic thoughts traveled in her brain. She needed intensive dialectical behavioral therapy that helped when something triggered her mind, and the electrical conduction traveled across her neurons; then it actually chose a better pathway.

When a patient like Anna comes to see me, I refer them to the outpatient program, a higher level of care than what I can generally offer as an outpatient clinician. You can see the reverse of this as well. When a patient stabilizes from an inpatient psychiatric hospitalization, then they should be referred to an outpatient hospital program rather than to my clinic. This outpatient hospital program in this scenario is called a “step-down program”, one that allows them to continue the healing with intensive and close follow-up; (generally 5 days a week for 4-12 weeks). We call this a step-down program or a step-up program, depending on which direction the patient is coming from.

I’m happy to report that Anna went into the outpatient hospital. After nine weeks of intensive psychotherapy with weekly physician monitoring of her medication, medication adjustments, having a nurse available to her five days a week, having an individual psychotherapist assigned to her, as well as attending groups every day, I am so happy to say that Anna is back in our community. She’s back at home with her kids, and stable on medication. Her illness, her biology is healed, and now her family is starting to heal.

In fact, Anna is able to work again. She is a certified ultrasound technician, and she’s now helping to support her family. She and her husband are healing together; he is now in treatment as well for his alcoholism and no longer uses drugs to escape. And you can see how close it was for Anna to lose everything. She almost lost her family; she almost lost her capacity to be gainfully employed and contribute to her community. She almost lost her marriage; she almost lost everything that she considered worth living for. Now she has it back. It’s humbling, and now I see her in the clinic every 4 to 8 weeks depending on her needs. Sometimes we go 12 weeks because she’s stable. I always know when somebody’s stable because they really don’t want to see me that often.

And every time I see her, I really wish I could see her more often. It’s the bummer of being an outpatient psychiatrist.

Self-Care Tip: Go get medical care for emotions and behaviors that aren’t working out before they escalate. Sooner is better! And if you don’t, just go as soon as you are ready. Just get in. Keep on!

Question: Have you every gone to a day hospital? What is your opinion of having these in your community? Speak! We need to hear you.

Seasonal Recommendations

Different ways that holidays affect Mental Health

Fall is here!

In Southern California we have a glossed version of this and not the classic effect. But what we do have, includes this. Every morning when I wake up and open our bedroom door to the great outside, the fall “air” bursts in, hits my amygdala and a slurry of happy neurotransmitters perfuses throughout in a language I don’t have the best words for. I “smell”? or sense? or something, the air, and it says, “Fall is here.” So lovely and wonderful.

The problem in psychiatry, of what these changes do to our biology, come from the body rhythms. Some of us lose the sun to Jack Frost’s government. Some struggle with the time change. And the holidays have their own weighted steel tipped boots that kick up at any of us within kicking distance. Relationships struggle.

Here is a quick list of Fall simple treatment options I just thought you might like:

1.) How to Have A Stress-Reducing Conversation, from the research of Drs. John and Julie Gottman.
2.) UV lamp to help with the seasonal influence on mood and circadian rhythm, with a 10,000-lux intensity with full-spectrum light bulbs.
Also get 10-20 minutes in the morning and in evening before sunset of what sunlight you can.
3.) 10-20minutes of exercise every morning routinely, getting your heart rate up, thereby helping especially with mood, anxiety, and circadian rhythm. Of course you can do more but for many, this is a reasonable bite off of life’s apple. Consider just starting with a video from online that will even do 5min of core, and so forth.

Happy Holidays!

Keep on!

PGY-3 Medical Student Lecture

Hello Friends!

I thought you might enjoy the outline of a lecture I’m giving Tomorrow to CUSM (California University School of Medicine) 3rd year medical students. It’s one lecture intended to cover mood spectrum and anxiety spectrum disorders.


Here’s the outline:

  • **Psychiatry as a Type 2 Error Problem:**

Type II Error Explained, Plus Example & vs. Type I Error – Investopedia

In psychiatry, assume people are much worse than they look until proven otherwise. Unlike other medical fields where you prove the existence of an illness, in psychiatry, you want to rule out disorders, not rule them in.

  • **Monitoring and Recognizing Depression in Yourself:** Monitor our own selves for subtle signs of depression. Depression often manifests in small changes like sleep disturbances or increased irritability. It’s essential to catch it early, as depression can have profound physiological effects, akin to a bear chasing the body constantly.
  • **Depression as a Physiological Issue:** Depression is not merely a result of stress or external factors—it’s primarily a physiological issue. Treating mild depression proactively is crucial, as it not only impacts the individual but can also affect the entire family due to its viral nature.
  • **Seeing People as Brains, Not Just Individuals:** Shift the perspective from viewing patients as individuals with stories to understanding them as brains in need of healing. By focusing on the brain’s physiological state, it becomes possible to reduce suffering more effectively.
  • **Combining Physiology and Coping Skills:** Physiological aspects, address them first and then integrating coping skills. Changing habits takes time, but when combined with improved physiology, it becomes a potent approach for reducing the impact of depression.
  • **Environmental Influence:** The temporal impact of environment but stress that the viral influence of depression can be severe. Living with someone experiencing depression can affect the entire family, emphasizing the need for proactive and aggressive treatment.
  • **Genetics and Heritability:** Genetic loading and heritability, understanding family history and genetics is crucial in psychiatric assessment.

I want to give each of these students four years of psychiatry residency, just so they can grasp some of this. I don’t know how to get it to the community. Depression is biological. Physiological. It is dramatically under diagnosed. It is largely responsible for treatment nonadherence in any area of medicine. And it destroys our own lives.

I remember when I was a Psychiatry graduate of 6 years, when the word sounded through our community. Dr. Schultz’s, our beloved residency director, the one who had joked around with me, who had worked so hard to eliminate my imposter syndrome and who gave me a sense of being among my people, he shot himself. In our clinic’s corner bathroom, between seeing patients, he used his own gun.

I am still grieving him. He was a mentor. He was a friend.

But more than his impact on my life, he was a father of a preteen son, and was survived by many beloved family.

I’m sure you, readers, have your own stories. Maybe even against your own person. Please share them here. We need your story. Somehow, our community, our practitioners, our own medical graduates, don’t understand. Depression ruins us. And treatment can heal.

Keep on!

Where to trust

Sometimes, ok quite often, we feel misunderstood by others and unclear of our paths going forward. We are not alone, dear readers, in this.

This is what Taylor swift says,

“How did I go from growin’ up to breaking down?
And I wake up (Wake up) in the middle of the night
It’s like I can feel time movin’

How can a person know everything at eighteen
But nothing at twenty-two?

And will you still want me
When I’m nothing new?”

I’m thankful for her voice in this.

I am nothing new and my personal value has to be on aught else besides novelty. Nor can it safely be placed in my behaviors and emotions.

It is our life duty to discover where to put our trust. In our own capacity? In identity? Or where? We are vulnerable to our biology one could say. But we are able to trust something someone somewhere. And whether it is fortunate or unfortunate, I can’t hand you trust like a baton.

You got this though.

Sending you readers all my affection. Thank you for joining me in this life journey of being a Friend to Yourself.

Keep on!

Being in the trenches is not the Pathology

The trenches are not the pathology.

Image from page 553 of “The Journal of nervous and mental disease” (1874)

The stressors, the triggers, the many things that go very wrong every fraction of a second in our lives—these are not the pathology. These are normal. These are what we all have.

The pathology is being alone.

Don’t hang out in the morass of bad-alonen. Be in community. Push for that in your life. It may not come “naturally.” Community is part of self-care.

Keep on!

$400 million and the cost of life

My reaction when I heard this was about the money. I thought, “Why not put that money toward mental health?” And I proceeded to look up related costs and details that wrapped around me like strings, making me dance. My emotions got involved. But if you know me, you’re thinking, “When aren’t they!?” Smile.

I continued to reflect and landed on, the value of our lives. How rotten does someone need to be before they should end it? How horrible should their tally of mistakes, and even volitional wrongs, quantify? And then I get caught in the eddy of political thought about law and the impact on community and so forth. And that is just not where I want to go either.

There has to be more than a bank account of talents, good deeds, beauty, popularity, and all the accoutrements that marks us. Life, your life, matters. That’s the truth of all of it. The world is better with you in it.

My patient, Ronald, came twelve years ago with a severe depression. He wasn’t interested in anything. He had 39years of successful employment in the entertainment business and used to love it. He just didn’t care. He wanted to retire and even just die. We jostled his medications and the right ones fell into place. Now he cares.

Ronald is now interested. Interest led him to purpose and that now gives him a greater sense of the value of his own life.

My patient, Evelyn, also in treatment for many years, has struggled more finding her treatment response. Sometimes she is “there” with her mental health, and sometimes she is not. Often she hates herself. She relives years of horrible sexual, physical, emotional abuse during the worst of it; thoughts intruding without invitation. She loses her freedom to choose her own thoughts. She wants to die then. Other times, she sees her value. It is a “life-er”, this battle for the mind and body and spirit. Today, Evelyn doesn’t want to die but still she isn’t doing well. Life has swung again and got a kidney punch in. She can barely breath.

The community at large must say, “Evelyn, you think you are ugly and rotten inside but it is a false perception” of an over-watered cactus, putrid smelling. Even so, that’s not the point. The point isn’t how good or bad we are. The point isn’t performance. There’s waaaayyy more than that which marks us for life.

400-million dollars. How many should suicide a year to justify the expense? If we could, we would pay for a net around each one of those who have lost their tether. But regardless, we must know, each of us, “No matter what condition you are in, the world is better with you in it than without you.”

Self care Tip: Step away from the edge and know you have value no matter what condition you are in.

Questions: Have you ever thought about not wanting to live? Why are you still alive?

Keep on!

Biology for self care

Man lost 2 kids to drugs, Wife to divorce and her addictions, terribly depressed and anxious with his own morbid thoughts.
After finding the right medication treatment, he is able to grieve better because his biology is better.
Everything in his life is still the same except his biology. His biology is not. His biology is well.

That is self care.

Keep on.

Lyft Rides and what happens after Death

Lyft rides are blowing my mind. They’re becoming the stage for some of the best dialogue of my day. Really cool people driving these rides. 

Today’s post is a bit of a hodgepodge, as conversations usually are.

My driver, call him Brandon, was a 20-something married man, who considers starting a family. We talked about using these days, before kids come to push push, to grow. Because life trajectory changes to a perpendicular when kids come and that life trajectory you are on for the many years before they come will be gone gone. Growing “now” is a privilege that changes shape after kids. 

Also start each day having a worship with your spouse before even getting out of bed. Make that a habit that will cross over, in part because it is routine. The behavior has pressed into your basal ganglia and is now automatic. Then it won’t take energy when energy has become such a guarded commodity. It can save your marriage. Parenting inevitably changes your togetherness-flow, your common ground. What was once likable about you from your “other life,” diminishes by the force of where all our energy bank ends up getting spent on. As we age out, we have to keep working on having shared experiences and interests. Kids are a distillation to what we have in common and hones our energies toward their needs. The interests of the partner can rank down. It’s not rejection. It’s accounting. Be proactive about maintaining intimacy and connection with your partner.

Brandon then shot in the dark with his next question; “What happens after you die”? This is such a wonderful topic. I go to the Bible. And without getting into a Bible-verse-battle, I’ll just give the big picture and we can do a study any time any of you like. It is a topic of huge hope and super calming. 

When we die, we sleep. Our spirit, or breath or soul as it is called, goes back to God who gave it to us and He holds it while we sleep. Then when Jesus returns, he wakes us up and everyone who is asleep in Him will greet him along with everyone who is still alive, together. There is nothing that we are doing in between death and God’s coming other than sleep. God’s character is so loving. If we were going straight to heaven, it’d be pretty tough watching the immense suffering of all our loved ones on earth that is still going on. That’d be a terrible burden. He spares us.

It’s important to note that the beliefs about the afterlife can vary widely among different religions and individuals. My beliefs are not meant to be a disregard of them. I don’t know everything! I really don’t even know a lot, when you look at this by volume. lol! And I know what I do see as truth will morph into a more complete view by God’s grace. There are so many dimensions and paradigms that my basic biology can’t grasp. And isn’t that wonderful. How boring otherwise! Eternity is a long “time” and who wants it if it is an eternity of what I see. Ultimately, beliefs about the afterlife are a deeply personal matter, and it’s up to each individual to explore and come to their own conclusions.

Brandon asked, are you a pastor or something? Laugh. Nope. I’m a psychiatrist. I just am a psychiatrist who reads the Bible. Whoever you are. The Bible helps us walk our walk, together with each other and with God. And the only thing that lasts is love. Nothing else we gather will survive us. But He/She who holds our spirit, holds our love too until we wake up again and we will recognize who we are in relation to each other and to Him/Her. 

Self care Tip: Set up patterns in life that connect you to each other and to God. Keep on!

Question: How do you connect with the people you love when the connection frays?

You Matter

Dad died and the concept, “This world is not my home”, started growing exponentially. The difficulty I’ve been running into is talking about eternity without disregarding our ongoing human experience. 

I matter. 

Human suffering matters. This includes missed opportunities. Things we wish we were. I wish I was a fabulous musician. And athlete. And I wish I could look at my wardrobe and know which clothes I should just toss out. We have eternity to grow our many facets. I’ll have a better wardrobe. We are not allowed to grow so many of these facets in this world and that’s important, but it matters that we have grown the ones we have, the ones we have fought for. It matters that we have dug in the dirt and been soiled by traumas too horrible to speak of. It matters when we summit and when we slide. 

Jesus came to the globe, gestating in womb, walked Jerusalem and Samaria, 100% human, not living as God even though He never stopped being God. He gets us. He gets the trauma and the great sensation of realizing hard earned hopes and what comes after that. And then He wove our human conscious awareness into an awakening of our eternal selves. 

This matters. 

We are more than this. “I see you. You’ve got a lot coming.” There is movement in this. There is an exercise of presence, along with the exercise of growth and hope and future. 

There is nothing lonelier than a summit without a sense of going on and toward. Listen to Freddie Mercury, 

“You can have everything in the world and still be the loneliest man. And that is the most bitter type of loneliness.” “Success has brought me world idolization and millions of pounds. But it’s prevented me from having the one thing we all need – a loving.”

A summit without connection is isolation. There is no movement. So how do we talk about this hope and future without dismissing our now? I remember my brother on his unspeakable pain of no longer living with his children, when I opened my big mouth and said something like, “I’m so glad we have a forever. A space without edges when we will not be separated. When we get to do all the things we weren’t allowed to do in this life.” And he turned to me and said, without aggression but rather immense sadness, “This feels like a threat.”

My brother was responding from humanity and I was moving right past it into a place of disconnected unrealized otherness. And whizzing past someone, like the Road Runner, can be catastrophic to them. I suppose he felt like I was dismissing his current, ongoing place in the world and indeed. That was threatening.

I see my dad watching football in the electric recliner. The Sunday paper is in his hands. He’s making unconscious glottal noises that sound like something cooking on the stove. Mom is thrumming through the house like a lawnmower, always moving. Always working. Always serving. I see my dad in the garden picking white sapote. “Get me that one over there, Sana. See. It’s still good.” And the sapote dissolves in my mouth as sweetly and as fast as this memory does. Dad has persimmons in his pockets and I’m trundling beside him, chattering and heard. He heard me.

It matters. 

And I know I will see Dad again and not be separated and that matters too. Prepping for his 82nd birthday party when his friends would come one more time to our home, Dad tells me to sing, “that song,” for his funeral. “The only Thing I want is to be with Jesus. Just to see him smile and say, ‘Well done.’” And my attention shifted from Dad here with me to Dad apart for a time, asleep in the care of Jesus. We will greet Him together and there will be no more tears and no more saying goodby. 

I never got to sing that for his funeral and I guess this is sort of an apology too. It was the worst. All I did was blubber!

Frank tells me about his son dying 10 years ago.  I asked him how to avoid inking like this, marking up one experience by talking about another. He says to ask more relational questions about his son. Get the survivor to focus on the things that they should be focusing on. I like that. It’s going toward the pain rather than away from it. So can we go toward the pain while describing our future? Frank recalls when his son died he had a pair of gloves in his briefcase he had intended to give to a lady who sold papers on the street and had cold hands all the time. “He was me but so much better in so many areas.”

Rev. 21 Verses 1 to 4

He will dwell with them, and they shall be his people, and God himself will be with them; he will wipe away every tear from their eyes, and death shall be no more, neither shall there be mourning nor crying nor pain any more, for the former things have passed away.

Dad died three years ago, Good Friday. The earth has not felt the same under my feet since then and I’m glad of it. Because it is one more way that speaks, “You matter.” And I’m am able to gain movement into the weaving of our future.

Self Care Tip: Find a way to integrate our future beyond this life with the significance and value of our present experiences and relationships. You matter!

Question: How do you bring your present suffering along with hope? Speak.

The End of Evil

I remember I was wearing my blue polyester-blend maternity outfit; a shirt that tented over my son, who was growing inside at the time, and pants that hid a band of elastic the size of Texas. I remember the kitchen florescents, whilst getting breakfast ready for my daughters. We had slept over at my parent’s home because my my mom was out of town.

Dad had been, “going through it,” during those years. He was suffering the progressive sequela of Guillain-Barre syndrome, feeling like his extremities were aflame, burning all the time, plus a long list of other stacking medical conditions. He was trying to survive the losses. These, along with their respective medication therapies, clouded his consciousness and he was not a good driver. That morning when in the kitchen getting ready for our day, Dad showed up, somehow dressed and ready to go to work as well. The business he worked for at the time provided a driver, but that day, he either wanted to drive himself or the driver wasn’t available. I remember the keys in his hand.

About ten minutes later, our neighbors called us. “Sana, I just passed some emergency response vehicles parked by a car that looked like your dad’s. I think he got in an accident.”

And I knew. I knew. Dad had crashed.

There was one road that came from my parents, leading to three more roads, that fed into the west, north, and east. Thinking I had a one in three chance of finding him, I went driving. Somehow I came upon firetrucks. They were driving loudly, and again, “I knew,” they were going to Dad. I followed them Eastward.

Dad had hit a tree and his car split in the center. He was being removed at the time from the front half. The second piece was a distance behind. I remember his face, knowing, “This is Dad,” even though I couldn’t recognize him. There was so much blood.

People had gathered, watching my dad being pulled out of his wreck. One of the officers asked me to go back to my car. It made me upset, and now that I look back, I don’t know why I wanted to get to my dad. Did I think I could save him? For some reason, even fully aware that I was trained in psychiatry, (not emergency medicine mind you,) and as a thirty-eight week pregnant beast, I think I did.

This was the second life threatening event I went through at the end of my third trimester in two of my pregnancies. The first was when my niece died. That’s another story. But in both of them, although utterly helpless, I thought I could save my family.

You know the answer to that though. You know. You know what my viscera did not. I couldn’t save anyone. My niece died, and my dad suffered more and more, chronically ill with a step-wise decline, until he also finally died two years ago.

You have survived your own life threatening events, or other sufferings, that has made you think of being a savior. We all have. And although we can’t be her or him for ourselves or others, it’s always been true. We do need a savior.

Today for, “Sabbath School”, I’m speaking on the topic, “The End of Evil.” While studying this morning, I remembered driving up to Dad. His car split in half. I was running, two hundred and three pounds of me. Holding my huge front side, I remember calling him, “Dad! Dad!” Thinking, “He’ll answer me. Call him one more time.”

And that, Folks, is what trauma looks like. Trauma from an emotional standpoint and from a physical, i.e., he just got his face bashed in, standpoint.

I’m not going to write more about trauma today, nor about needing a savior. I’m really just starting a thread.

I have to go study more. But what is your story and what do you think?

Sincerely, and Waiting to Hear From You,

Your own, Dr. Q.

Keep on!

Do I have to stay on medication?

Medication treatment duration is a multi-threaded rug.

Some ask about the effect “wisdom and growth” has on their need for ongoing medication versus growing out of the need for medication therapy. It is normal logic to think that we should behave better and feel better when we know better. This leads many to wonder if it’s time to come off of medication therapy.

Let’s work on this by considering these variables.

  1. Coping skills. 

Coping skills are how we deal with stressors. When something happens to us, like getting yelled at, honked at when driving, or suffering a loss like a break up – our automatic thoughts and actions may be kind or unkind to ourselves. They may serve us well or may not. Coping skills can be intentionally grown, such as through dialectical behavioral therapy, and/or may require medical treatment. Coping skills regress with mental illness. But there are therapies that will improve them, helping our resilience, and helping us choose to continue vs. taper down medications.

  1. Recurrence.

Has the patient had multiple episodes. Multiple episodes of mental illness will signal differently, as compared to a single episode, in regards to risk of relapse.

  1. Genetic loading. 

What’s the family history of mental illness? Genetic loading. Genetic loading. Genetic loading. It tells the story of our biological risks. 

  1. Risks and Benefits.

Weighing the disabling impact the disease processes have on a patient’s life against the risks of medications. Consider the psychic suffering. We suffer and the suffering is real. Compare this to what we don’t like about taking medication. Weigh it and find your balance. Medication may be too “costly” to continue.

  1. Impact of disease process on future brain health. 

Mental illnesses in general are progressive, and the medication therapies not only treat the current symptoms but also are prophylactic (preventative and protective) against further brain insult. The brain now, if mental illness goes on, will be a different brain in ten years. We are fighting for that person too when we fight mental illness. Our future selves.

  1. Full treatment response.

Even though the patient has been on medication for a long time, what is the current condition of the diseases and the treatment response? Is the patient fully treated? Symptom free? Or does the patient have ongoing symptomatology even if improved from prior to treatment? For example, if the patient’s depression has resolved but they still have symptoms of anxiety then they are at a higher overall risk if medications are stopped. Being better may not be good enough. Or it might.

Self-Care Tip: Staying on medication can be discomfiting but take a turn with your treatment provider to consider.

Question: What is being on medication like for you? Tell us your story if you stopped it or if you chose to stay on it.

Involuntary Movement and Medications

Tardive Dyskinesia Awareness Week was May 1-7, 2022.”

This comes at a good time for me as well. Last week I was just working with a patient, “Joe”, who was suffering with an “involuntary movement.” Joe had taken an antipsychotic as an augmenting agent for his treatment resistant depression and had a brilliant response… as far as his depression-disease went. Within one week of treatment, his jaw-breaker-depression started to dissolve small pieces away. He was astounded. 

Truth be told, I get astounded too, when my patients show these kinds of “Whaaat?!” responses. Although it is less than before, still too often (20-60%), patients work hard on getting treatment responses that remain elusive. Too often, I watch someone’s life step down from one loss to another due to their disease process, like a slinky. They start taking days off from work, then weeks off. Their most beloved relationships plunk, plunk, less and less connected. They stop getting out of bed much. And so forth. These are not just words. Brain disease is real. Whether it is depression or psychosis, anxiety or dementia, and more, it’s not any less medical than a deadly cancer. 

But when patients like this, with whom we have determinedly worked toward healing, all the while, together, watching their life losses… well it is grievous.  And miracles, such as Joe experienced, astounds us. 

About a month later, I started to notice that his mouth was moving without his conscious intention. His lips jerked together, like a “purse string” pulled on them. This is one of many early symptoms of dopamine blockade that might happen with antipsychotics. For Joe, it resolved easily by decreasing the dosage of his medication. He was reluctant to do this, considering the benefits he enjoyed with the medication. Thankfully, however, his benefits remained even with the lower dose.

Joe had been experiencing “acute dyskinesia.” If Joe had stayed on his antipsychotic agent over time, or one could say “tardive,” and at the higher dosage, the involuntary movement might have worsened and become more difficult to get rid of. Involuntary movements are also more often experienced in the elderly population and from older classes of antipsychotics, but they still can happen in the newer ones. 

These secondary movement disorders are grouped under the name “extrapyramidal side effects,” (or EPS,) of which tardive dyskinesia is one. And in case you were wondering more about its cause, it is described in PubMed: “The mechanism of EPS is thought to be due to the antagonistic binding of dopaminergic D2 receptors within the mesolimbic and mesocortical pathways of the brain. However, the antidopaminergic action in the caudate nucleus and other basal ganglia may also contribute significantly to the occurrence of EPS.”

For reference, NAMI also has a clean, well described, web-page on tardive dyskinesia worth reading for more details. It doesn’t include all the names of the newer agents which can be hard to keep up with. These “second generation antipsychotics” are frequently increasing in number as our medication options through research increase.

Understand that TD is a movement disorder. Not all movement disorders are caused by medication and deserve a medical work-up. It may or may not be reversible and the risks and benefits of treatment need to be evaluated progressively, over time.

Keep noisy. Keep talking. Keep asking. Keep on!

Questions: Would you please tell us about your involuntary movements if you’ve experienced them? Or seen someone with them?

In the mean-time, Waiting for Treatment Response

A crowd of Neuro-receptors fill our brain like a high school mosh pit. It’s noisy and possibly dangerous up there. It’s hard to focus. The negative thoughts are drumming. Medical treatment for depression is the Arthur Murray instructor to our brain-dance. And it takes time.  

When we take medication, the neurotransmitters targeted in our brain have to respond to the neuro-messengers that are the medication. Some receptors downregulate, i.e., decrease in number or activity. Other receptors likewise, upregulate. Again, this takes time. For example, fluoxetine, or Prozac, which came on the market in the late 80’s, is one of our most familiar antidepressants. When we start the medication, (and please don’t call them drugs because no one is panhandling for fluoxetine… Nor are we taking fluoxetine to get a high, but rather to treat a medical illness)… 

When we start fluoxetine, it can take 3-6weeks to start experiencing the benefits. Furthermore, during the first few weeks it is common to feel worse before we feel better. Worse anxiety, worse depression, this is because the receptors are learning a better dance. And it takes time to learn. And learning in this case feels worse before it feels better. 

You ask, what do we do until the medication takes effect? Marvelous consideration. Because here we are, asking for help, and our psychiatrist gives us something that makes it worse. Ummm. 

In the first couple weeks, which can feel like forever, perspective being what it is, a cloudy lens, feeling worse is described by the health of our brain. The brain, from which all emotions, behaviors, and sense of reality come from, takes time to heal.

We come to the psychiatrist by the hair of our chinny chin chin, almost dead inside. We waited, of course, to make the appointment. Waited for our courage to catch up with our disease. And then we waited for an appointment to open up three months later, seemingly forgotten at the train station scanning the crowd for kindness and help to come. And then? Then we receive treatment that takes another month to start, to start I say, not finish, the healing it promised, (a promise that values at about 50-60% of the time to come through. That’s the statistic for fluoxetine to be effective for each of us with our first trial of depression treatment. Thereafter, the likelihood of responding to fluoxetine diminishes after each trial.) 

This is the lighting on the stage for your question, “What do we do in the meantime?” We survive?

It’s too easy to come up with behavioral solutions that if they were to work, they would have already done so during that waiting – ex: 2 months of worsening mood, 2 months to call the psychiatrist, 3 months to get in for your appointment, 1 month for the medication to start working = 8 months. 

You’re not a dummy. But we’ve been advised as if we were by our community. “Feel better.” “Snap out of it.” “Pull yourself together.” “Be strong.” It’s not like you didn’t think of these on your own and were waiting for someone wiser to tell you to get on with life. But, If you are able to, please do get on with it. Go exercise. Sleep better. Eat better. Look at the world with hope.

For the rest of us with melancholia, ie. major depression, the choice left us when we lost brain health. Similar to the alcoholic choosing not to drink, choosing to feel well isn’t a choice. When the medical illness recovers, we gain our freedom to choose those things back. 

During these “8 months” there are some things that can be done however. 

Go to a psychiatric partial hospital program, (“PHP”).  This is a day hospital where you attend for about 6 hours, 5 days a week, for about 4-9 weeks. It’s incredibly supportive. But more than that, PHP teaches dialectical behavioral therapy, (“DBT”), a type of therapy that has been shown to make changes at a cellular level. There are changes to our automatic thoughts, so that when something triggers us, our pre conscious response is more friendly to “Me.”  It’s not a “stick-shift”, but rather increasingly automatic. The key is to work toward brain health. 

Others will collaborate with their psychiatrist to augment fluoxetine, or whichever antidepressant of choice, with another medication that can help pop you out of depression sooner. These treatments are not generally long lasting and don’t treat the underlying illness. Rather they treat the symptoms here and now. Some examples used include stimulants or thyroid replacement therapy. 

In the end, be in a community of support – be it PHP,  outpatient therapy, or NAMI

Support is the shell to our drippy egg, while we wait for our medical treatments to take effect. 

Question: Have your efforts in treatment worked out? What’s your story?

Self Care Tip: Don’t give up! Pursue treatment. Your illness is treatable. But in the meantime… be in a community of support. Keep on!

Medication: The Good, the Bad and the Ugly

Sometimes, we feel sideways.

Between the loss of control mental illness makes us feel and the quandary of how to go about getting better and staying better.

You’re all welcome to join us tonight for NAMI (National Alliance on Mental Illness). We are discussing this. 🙂

Topic: “Medication: The Good, The Bad, The Ugly”

Time: Jan 19, 2022 06:00 PM Pacific Time (US and Canada)

Join Zoom Meeting:

These meetings (NAMI Temecula Valley Mental Health Speaker Series) occur on the Third Wednesday of every month, 6pm-8pm

Please download and import the following iCalendar (.ics) files to your calendar system.


Whether we see you there tonight or not, hope you are doing very well in this new year, 2022.

Keep on!
Your Own,

Dr. Q

Meet Torie and Our New Podcast!


My name is Torie and I am a new co-host of Friend to Yourself Podcast.

Dr. Quijada and I are thrilled to be launching this podcast, and we’re so excited for you guys to see what we have planned.

Before continuing, here is some of this and that to get to know me.

I was born and raised in Southern California. I am the oldest of three girls, and studying for a psychobiology major with a minor in nutritional sciences. Mental health advocacy is my passion, especially in multicultural communities where mental health and illnesses are stigmatized, and in Eating Disorders recovery.

I absolutely love going to Padres games. But even more so, I am obsessed with my new English Bulldog, Keilani. On the weekends, you can find me and Keilani at the beach or local coffee shop. 

Both Dr. Quijada and I have been working hard to create content for our subscribers. Our podcast will focus on self-care as practiced in daily life struggles and wins, eating disorder recovery, and mental health from a biological perspective.

We’re getting some final things settled and our first episode should be out very soon! Please suggest or ask anything. We would love to hear you.

To stay updated, follow us on Instagram @friendtoyourself  & don’t forget to share with your friends and family!



More on Dying

Tonight my husband cast this up on our monitor/TV. “This was my colleague.”

A couple who worked in palliative care used social media to share their experiences after one of them received a terminal diagnosis. It was later featured on The NewYorker.

Watching with him the face of dying threw me back to watching my Dad. The way they both, Kathy Brandt and my dad, smiled up with tight faces, skin pulled over bones. So much love there. Dad would smile and I heard him say in it, “I love you Sana. Will you still love me while I die?” There is an insecurity I imagine in that process of saying goodbye.

Then when Kathy Brandt apologized to her audience for her condition. Her “weakness” was something to say sorry about. We also apologize for our weaknesses; for things we had nothing to do with other than that we are the carrier of some biology gone bad – major depressive disorder, cancer, alopecia… Name it. It will take you a while to cover all the things that we apologize for that describe our humanity more than they describe our fault.

Maybe we apologize rather, not in shame, but in empathy toward our listeners. There is a consideration of what our defect imposes on them. That could be. But I wonder what would happen if we didn’t apologize. Instead, allow the others to let our flawed selves just hang out there in the space between us, bringing them into a greater awareness of what we are going through. “Hello. There is no brush off here. Rather come be in my suffering and we will commune. You and me.”

There was no mention of God, what happens after death, or the meaning of life. I don’t know what they believed. They seemed like they just wanted to share the basic experience, the breathing, (…my dad rattled again in my mind when I heard that,) the changing face and body, the personality coming through, the relationships affected and so forth. This gives us space to be there with them, without doctrines setting up lines and corners we have to navigate. Not so bad. I appreciate them.

Speak: Let us know what you think of this documentary. Give us your adjectives. What notes does it hit for you; the resonance you hear and where you find your community. Speak!

Selfcare tip: Allow yourself not to apologize.