Ramadan: Advising clinicians on safe fasting practices

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If you are a basketball fan who recently watched Portland Trail Blazers’ Enes Kanter play against the Warriors in the western NBA semi-finals, you may have heard about Ramadan fasting. But most Americans haven’t — and that includes clinicians.

“Even those clinicians who are aware of Ramadan often do not fully understand the nuances of fasting,” explains Rania Awaad, MD, a clinical assistant professor of psychiatry and behavioral sciences and the director of the Muslims and Mental Health Lab at Stanford. “For example, there is no oral intake from sunup to sundown of food, liquids and also medications. For clinicians who may be alarmed by this, it’s important to remember that fasting is globally practiced safely by adjusting the timing and dosing of medications and by following best practices like consuming enough fluids to rehydrate after the fast.”

Ramadan is the ninth month of the Islamic calendar, which is 11 days shorter than the solar year. This year in the U.S., it began on May 5 and ends on June 4. During Ramadan, many of the nearly two billion Muslims around the world fast during the sunlight hours as a means of expressing self-control, gratitude and compassion for those in need.

Several groups are exempted from this religious requirement — including pregnant women, children, the elderly and people who are acutely or chronically ill — but some fast anyway because of the spiritual significance, Awaad says.

“Ramadan is a very spiritual and communal month. So when clinicians immediately advise their patients not to fast, they may not realize they’re inadvertently isolating their patients from the broader community and support system,” Awaad says. She notes this is particularly important for patients with mental health disorders.

Awaad says she strongly advises clinicians to encourage their patients to seek a dual consultation with both a faith leader and medical professional at places like the Khalil Center, a professional counseling center specializing in Muslim mental health. Alternatively, patients observing Ramadan can consult both their faith leader and physician individually and help facilitate a consultation between both entities.

“Without a holistic treatment plan, patients are either fasting when they shouldn’t be — not taking their medications without telling their health care provider — or they are potentially not partaking in Ramadan when they can be,” Awaad says.

In a recent editorial in The Lancet Psychiatry, Awaad and her colleagues outline more clinical suggestions on the safety and advisability of Ramadan fasting that she hopes physicians will consider. For example, the editorial suggests that physicians working with patients with eating disorders should discuss the risks and benefits of fasting and consider close follow-up in this period and in the months following.

But the first step is knowing whether patients are Muslim. By co-teaching the “Culture and Religion in Psychiatry” class, Awaad says she helps Stanford psychiatry residents become comfortable asking about their patients’ religion, in the same way they are trained to ask other sensitive questions like sexual orientation.

“If we miss that our patient draws strength and support from their religion, then we miss the opportunity to support them holistically by incorporating their faith leader or faith community into their treatment plans,” Awaad explains. “The last Gallop poll revealed 87 percent of Americans believe in God, so it’s important to incorporate this into our patient care.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

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Genetic roots of psychiatric disorders clearer now thanks to improved techniques

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New technology and access to large databases are fundamentally changing how researchers investigate the genetic roots of psychiatric disorders.

“In the past, a lot of the conditions that people knew to be genetic were found to have a relatively simple genetic cause. For example, Huntington’s disease is caused by mutations in just one gene,” said Laramie Duncan, PhD, an assistant professor of psychiatry and behavioral sciences at Stanford. “But the situation is entirely different for psychiatric disorders, because there are literally thousands of genetic influences on every psychiatric disorder. That’s been one of the really exciting findings that’s come out of modern genetic studies.”

These findings are possible thanks to genome-wide association studies (GWAS), which test for millions of genetic variations across the genome to identify the genes involved in human disease.

Duncan is the lead author of a recent commentary in Neuropsychopharmacology that explains how GWAS studies have demonstrated the inadequacy of previous methods. The paper also highlights new genetics findings for mental health.

Before the newer technologies and databases were available, scientists could only analyze a handful of genetic variations. So they had to guess that a specific genetic variation (a candidate) was associated with a disorder — based on what was known about the underlying biology — and then test their hypothesis. The body of research that has emerged from GWAS studies, however, show that nearly all of these earlier “candidate study” results are incorrect for psychiatric disorders.

“There are actually so many genetic variations in the genome, it would have been almost impossible for people to guess correctly,” Duncan said. “It was a reasonable thing to do at the time. But we now have better technology that’s just as affordable as the old ways of doing things, so traditional candidate gene studies are no longer needed.”

Duncan said she began questioning the candidate gene studies as a graduate student. As she studied the scientific literature, she noticed a pattern in the data that suggested the results were wrong. “The larger studies tended to have null results and the very small studies tended to have positive results. And the only reason you’d see that pattern is if there was strong publication bias,” said Duncan. “Namely, positive results were published even if the study was small, and null results were only published when the study was very large.”

In contrast, the findings from the GWAS studies become more and more precise as the sample size increases, she explained, which demonstrates their reliability.

Using GWAS, researchers now know that thousands of variations distributed across the genome likely contribute to any given mental disorder. By using the statistical power gleaned from giant databases such as the UK Biobank or the Million Veterans Program, they have learned that most of these variations aren’t even in the regions of the gene’s DNA that code for proteins, where scientists expected them to be. For example, only 1.1 percent of schizophrenia risk variants are in these coding regions.

“What’s so interesting about the modern genetic findings is that they are revealing entirely new clues about the underlying biology of psychiatric disorders,” Duncan said. “And this opens up lots of new avenues for treatment development.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Tips for discussing suicide on social media — A guide for youth

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There are pros and cons to social media discussions of suicide. Social media can spread helpful knowledge and support, but it can also quickly disseminate harmful messaging and misinformation that puts vulnerable youth at risk.

New U.S. guidelines, called #chatsafe: A Young Person’s Guide for Communicating Safely Online About Suicides, aim to address this problem by offering evidence-based advice on how to constructively interact online about this difficult topic. The guidelines include specific language recommendations.

Vicki Harrison, MSW, the program director for the Stanford Center for Youth Mental Health and Wellbeing, discussed this new online education tool — developed in collaboration with a youth advisory panel — in a recent Healthier, Happy Lives Blog post.

“My hope is that these guidelines will create awareness about the fact that the way people talk about suicide actually matters an awful lot and doing so safely can potentially save lives. Yet we haven’t, up to this point, offered young people a lot of guidance for how to engage in constructive interactions about this difficult topic,” Harrison said in the blog post. “Hopefully, these guidelines will demystify the issue somewhat and offer practical suggestions that youth can easily apply in their daily interactions.”

A few main takeaways from the guidelines are below:

Before you post anything online about suicide

Remember that posts can go viral and they will never be completely erased. If you do post about suicide, carefully choose the language you use. For example, avoid words that describe suicide as criminal, sinful, selfish, brave, romantic or a solution to problems.

Also, monitor the comments for unsafe content like bullying, images or graphic descriptions of suicide methods, suicide pacts or goodbye notes. And include a link to prevention resources, like suicide help centers on social media platforms. From the guidelines:

“Indicate suicide is preventable, help is available, treatment can be successful, and that recovery is possible.”

Sharing your own thoughts, feelings or experience with suicidal behavior online

If you’re experiencing suicidal thoughts or feelings, try to reach out to a trusted adult, friend or professional mental health service before posting online. If you are feeling unsafe, call 911.

In general, think before you post: What do you hope to achieve by sharing your experience? How will sharing make you feel? Who will see your post and how will it affect them?

If you do post, share your experience in a safe and helpful way without graphic references, and consider including a trigger warning at the beginning to warn readers about potentially upsetting content.

Communicating about someone you know who is affected by suicidal thoughts, feelings or behaviors

If you’re concerned about someone, ask permission before posting or sharing content about them if possible. If someone you know has died by suicide, be sensitive to the feelings of their grieving family members and friends who might see your post. Also, avoid posting or sharing posts about celebrity suicides, because too much exposure to the suicide of well-known public figures can lead to copycat suicides.

Responding to someone who may be suicidal

Before you respond to someone who has indicated they may be at risk of suicide, check in with yourself: How are you feeling? Do you understand the role and limitations of the support you can provide?

If you do respond, always respond in private without judgement, assumptions or interruptions. Ask them directly if they are thinking of suicide. Acknowledge their feelings and let them know exactly why you are worried about them. Show that you care. And encourage them to seek professional help.

Memorial websites, pages and closed groups to honor the deceased

Setting up a page or group to remember someone who has died can be a good way to share stories and support, but it also raises concerns about copycat suicides. So make sure the memorial page or group is safe for others — by monitoring comments for harmful or unsafe content, quickly dealing with unsupportive comments and responding personally to participants in distress. Also outline the rules for participation.

Individuals in crisis can receive help from the Santa Clara County Suicide & Crisis Hotline at (855) 278-4204. Help is also available from anywhere in the United States via Crisis Text Line (text HOME to 741741) or the National Suicide Prevention Lifeline at (800) 273-8255. All three services are free, confidential and available 24 hours a day, seven days a week.

This is a resposting of my Scope blog story, courtesy of Stanford School of Medicine.

Can AI improve access to mental health care? Possibly, Stanford psychologist says

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“Hey Siri, am I depressed?” When I posed this question to my iPhone, Siri’s reply was “I can’t really say, Jennifer.” But someday, software programs like Siri or Alexa may be able to talk to patients about their mental health symptoms to assist human therapists.

To learn more, I spoke with Adam Miner, PsyD, an instructor and co-director of Stanford’s Virtual Reality-Immersive Technology Clinic, who is working to improve conversational AI to recognize and respond to health issues.

What do you do as an AI psychologist?

“AI psychology isn’t a new specialty yet, but I do see it as a growing interdisciplinary need. I work to improve mental health access and quality through safe and effective artificial intelligence. I use methods from social science and computer science to answer questions about AI and vulnerable groups who may benefit or be harmed.”

How did you become interested in this field?

“During my training as a clinical psychologist, I had patients who waited years to tell anyone about their problems for many different reasons. I believe the role of a clinician isn’t to blame people who don’t come into the hospital. Instead, we should look for opportunities to provide care when people are ready and willing to ask for it, even if that is through machines.

I was reading research from different fields like communication and computer science and I was struck by the idea that people may confide intimate feelings to computers and be impacted by how computers respond. I started testing different digital assistants, like Siri, to see how they responded to sensitive health questions. The potential for good outcomes — as well as bad — quickly came into focus.”

Why is technology needed to assess the mental health of patients?

“We have a mental health crisis and existing barriers to care — like social stigma, cost and treatment access. Technology, specifically AI, has been called on to help. The big hope is that AI-based systems, unlike human clinicians, would never get tired, be available wherever and whenever the patient needs and know more than any human could ever know.

However, we need to avoid inflated expectations. There are real risks around privacy, ineffective care and worsening disparities for vulnerable populations. There’s a lot of excitement, but also a gap in knowledge. We don’t yet fully understand all the complexities of human–AI interactions.

People may not feel judged when they talk to a machine the same way they do when they talk to a human — the conversation may feel more private. But it may in fact be more public because information could be shared in unexpected ways or with unintended parties, such as advertisers or insurance companies.”

What are you hoping to accomplish with AI?

“If successful, AI could help improve access in three key ways. First, it could reach people who aren’t accessing traditional, clinic-based care for financial, geographic or other reasons like social anxiety. Second, it could help create a ‘learning healthcare system’ in which patient data is used to improve evidence-based care and clinician training.

Lastly, I have an ethical duty to practice culturally sensitive care as a licensed clinical psychologist. But a patient might use a word to describe anxiety that I don’t know and I might miss the symptom. AI, if designed well, could recognize cultural idioms of distress or speak multiple languages better than I ever will. But AI isn’t magic. We’ll need to thoughtfully design and train AI to do well with different genders, ethnicities, races and ages to prevent further marginalizing vulnerable groups.

If AI could help with diagnostic assessments, it might allow people to access care who otherwise wouldn’t. This may help avoid downstream health emergencies like suicide.”

How long until AI is used in the clinic?

“I hesitate to give any timeline, as AI can mean so many different things. But a few key challenges need to be addressed before wide deployment, including the privacy issues, the impact of AI-mediated communications on clinician-patient relationships and the inclusion of cultural respect.

The clinician–patient relationship is often overlooked when imagining a future with AI. We know from research that people can feel an emotional connection to health-focused conversational AI. What we don’t know is whether this will strengthen or weaken the patient-clinician relationship, which is central to both patient care and a clinician’s sense of self. If patients lose trust in mental health providers, it will cause real and lasting harm.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Myths and facts: Stanford psychiatrist discusses schizophrenia

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Inaccurate stereotypes and erroneous beliefs abound concerning schizophrenia. Stanford psychiatrist Jacob Ballon, MD, dispelled a few of these myths in a recent article in Everyday Health. Here are the takeaways and a bit of basic info regarding the disease:

  • There is an underlying, complex genetic component to schizophrenia that is not understood well enough to provide a diagnosis or guide treatment. Ballon said about 10 percent of the disease risk can be attributed to genetics.
  • Schizophrenics do not have multiple personalities — that is called dissociative identity disorder.
  • Most cases of schizophrenia develop between adolescence and age 30; children rarely develop schizophrenia.
  • People with schizophrenia as a group are not more prone to violent behavior. Although there is an association between violence and schizophrenia, the additional risk is largely due to substance abuse.
  • People with schizophrenia have a significantly higher risk of suicide and depression.
  • People with schizophrenia can have delusions and hallucinations. A delusion is a belief and a hallucination is a sensory experience, like a vision. Delusions can include persecutory delusions of feeling watched or followed, thoughts of feeling contaminated or delusions of grandeur. If you are with someone with schizophrenia, keep in mind that the delusion or hallucination is very real to them.
  • Movement can be affected and people with schizophrenia may have difficulty speaking or struggling to pay attention or remember things. Their decision-making may also be compromised.
  • Although there is no cure for schizophrenia, there are effective treatments, including psychotherapy and medications.
  • Starting treatment soon after the disease develops is thought to be the most beneficial.

“There are a number of people who are treated for schizophrenia and are doing quite well,” said Ballon in the article. He added, “If people are able to participate in psychotherapy, they can better extend the value of the medication and also apply some helpful principles to actual experiences in their life. I want people to get help and support with school and employment because I believe they’ll be able to get back on an upward trajectory much more quickly if they get help at an early stage.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Translating horror into justice: Stanford mental health physician advocates for human rights

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Photo taken in Fiji courtesy of Daryn Reicherter

It may seem obvious that the trauma of genocide, mass killings, rape and torture will cause mental health issues in the victims. But courts require evidence. So the Human Rights in Trauma Mental Health Program at Stanford provides the evidence needed in such judicial processes.

The program is an interdisciplinary collaboration between the WSD Handa Center for Human Rights and International Justice, Stanford Law School and Stanford University School of Medicine. I recently spoke with Daryn Reicherter, MD, a Stanford psychiatrist and the director of the program.

How did you become a human rights advocate?

“I was clinically treating survivors of human rights violations at refugee clinics and the center for survivors of torture. So I became familiar with treating issues like depression and post-traumatic stress disorder. And the very obvious cause of the mental health issues I was seeing was political trauma and torture — basically human rights violations.

Another major catalyst was working with the bigger network that supports these patients, particularly human rights attorneys. I’ve remained involved with the clinical part, the rehabilitation of victims of human rights violations. As doctors, my colleagues and I are starting with patients who already have terrible outcomes because of what happened to them. The attorneys are starting with how to get people access to mental health resources, or how to stop a crime from ever happening or how to hold a human rights violator accountable in a court. I started recognizing that the person in front of me has a larger problem that affects more people. So I started collaborating on how to use the science of psychology to make changes in human rights.

What kinds of traumas does the program handle?

“Our program has worked on a whole bunch of different projects, spanning from mass rapes in the Central African Republic to torture in Somalia. We’ve even worked on preventing California from putting men in solitary confinement for longer than 10 years.”

What is your role?

“We consult with attorneys who are trying to use the science of mental health to demonstrate a point about human rights violations. Our final product is usually a written report about an individual or situation, which is used by the attorneys in court. And we’re often asked to testify to clarify things in the report.

For instance, we write expert reports demonstrating that individuals have post-traumatic stress disorder from torture, which is likely to help them win asylum in immigration courts around the world.  And if there are many asylum claims that outline human rights violations happening in a country, we put together a report that is delivered to programs concerned with human rights violations and that ultimately may help create sanctions against the country that’s committing the violations.”

What is it like to work in international courts?

“I’ve testified at the  International Criminal Court on two occasions. In U.S. courts, lawyers argue in front of judges. In international courts, it’s really a dialogue between attorneys, judges and experts. And that’s very exciting.

Being an expert witness for something that’s so clear cut is actually quite simple. For instance, I testified in an egregious child rape case in the Fiji High Court. I presented evidence showing the man that raped his daughter over 300 times caused a lot of damage to her psychology, including the likelihood of her suffering from PTSD, depression, regular nightmares and other mental issues. The man got a life sentence, which had never happened before. And the attorney also used our report and my testimony in the Fiji Supreme Court, which extended the possible sentence for child rape. That’s exactly how our program hopes to work with attorneys and courts, in the U.S. and internationally.”

How do you personally cope with this work?

“I’m passionate about doing clinical treatment, but I actually find it to be more emotionally challenging than my advocacy work. It’s more difficult to work with somebody who’s been through this kind of human rights violations than to write a detailed report, go into a court of law and present the facts.

And in court, I sometimes see justice. I see reparations given for mental health. I see someone winning asylum because they really ought to, and now they have access to mental health treatments. So for me the program is the morale booster.

Of course, I still need self-care. I can recall five or 10 stories that in an instant can bring tears to my eyes. And I’ve heard some stories I wish I could un-hear, but that’s the reality. If I’m able to translate that pain and grief into something that’s advantageous for that person or situation, wow, that’s power. And overall, I find our program to be very light, not dark.”

What are your future goals?

“We don’t want to be limited to cases with data published in psychiatry journals, but our program doesn’t have the manpower to collect all the data needed for court cases. So we’re developing validated screening tools from the Diagnostics and Statistical Manual of Mental Disorders that shouldn’t require an expert for data collection.

For example, if our attorney colleagues can ask a five-point questionnaire to see if someone has the hallmark symptoms of PTSD, then we can interpret the data. I think that’s the next big thing for our program, in addition to continuing and expanding our cases.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Medical students turn to peer-support groups for assistance: A Q&A

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School can be overwhelming, especially medical school. But Stanford Medicine offers many different forms of mental health support, including a peer-to-peer support program for medical students called Ears 4 Peers. To learn more, I spoke with Dina Wang-Kraus, MD, a Stanford psychiatry and behavioral sciences resident and co-founder of the program.

What inspired you to start the Ears 4 Peers program?

“In 2012, I was a first-year medical student and I was noticing that a significant number of my classmates were experiencing compassion fatigue and burnout. We were encouraged to reach out to the counseling and psychology services but there was some hesitancy, either from busy schedules or anxieties surrounding stigma. So, Norma Villalon, MD, and I decided to found a peer-to-peer support program. I started a similar program in college at Johns Hopkins, called A Place to Talk.

The hope was to have near-peers — those who were just walking in your shoes — provide support. Our goal was to bridge the distance students often feel when in a competitive, challenging situation. We may have been adults in our mid-twenties to forties, but we were only in the infancy of our training.

Rebecca Smith-Coggins, MD, is our faculty adviser and leader. From day one, she’s believed in our cause.”

What are some issues the program addresses?

“We receive calls regarding issues like academic stress, interpersonal relationship conflicts, imposter syndrome, intimate partner violence, Stanford Duck syndrome and suicidal thoughts. We also receive calls from students feeling lonely, disconnected and homesick, especially around finals, holidays and medical board exams. And some students call hoping to be referred for additional support.”

How are Ears 4 Peers mentors selected and trained?

“Ears 4 Peers mentors are nominated by their peers or self-nominated. They complete an application to tell us more about themselves, what draws them to this type of work and what they hope to gain from the experience.

We’re very lucky to have the support of Alejandro Martinez, PhD, the Associate Dean of Students for the Stanford undergraduate campus. He and his team designed a curriculum specifically for Stanford School of Medicine.”

What role do you play in the program now?

“As a resident, I’ve transitioned out of being an official Ears 4 Peers mentor but I continue to remain actively involved in near-peer mentoring for medical students. Two years ago as an intern in psychiatry, I worked with Jessi Gold, MD, to inaugurate Stanford’s  Medical Student Reflection Groups. Each group is made up of four to 10 medical students who commit to joining for six to 12 months. We meet every other week, and groups are facilitated by psychiatry residents trained in group therapy and psychotherapy. As resident physicians, we remain near-peers; however, we’re able to facilitate a different kind of support and personal growth given our psychiatry training.

Stanford students are welcome to reach out to me at sdwangkraus@stanford.edu to learn more.”

What advise can you give medical students and residents?

“I recall medical school to be an exhilarating time, but it also felt like I was drinking from Niagara Falls, one cup at a time. There were times when I felt overwhelmed and even burnt out.

We see a lot of beauty and humility in medicine, but there are also times when we see a lot of tragedy and suffering. Having peer-support, knowing that I was not alone, was empowering and liberating — and it continues to be.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.