Healthcare

GPs have a role in providing mental health treatments and should bear in mind that talking therapies have as good if not better levels of success than pharmacological approaches and they have no side effects. Efficacy without side efficacy! What’s more there is no possibility of physiological dependency and therefore no withdrawal syndrome.

For talking therapy to be effective both the practitioner and the patient need to be in the moment. But what does that mean? It can mean that your mind, body and soul are in harmony, that your full attention is in a specific place and time i.e. in the therapy space.

This can be formalised explicitly – as in Acceptance and Commitment Therapy, or implicitly – as in Solution Based Brief Therapy.

Either way, you should not be sitting in the therapy space whilst thinking about having a coffee with a friend or what you will eat for dinner. Another way of describing it is getting rid of your internal dialogue. If a stray thought pops up, and they will, then let it go and then refocus your attention back to that therapy space.

Solution focussed therapy does not dwell on the past, but rather works from a premise that the future is negotiable. Solution Focus is not so much a set of therapeutic steps as a way of communicating with the patient and letting them open their own eyes to their own functional solution to their problem. Knowing the problem or engaging in analysis is quite unimportant.

So, what is the process?

Well, it begins by asking the patient.

Actually ask the patient how they want to live their lives, don’t tell them how to do it. Admonishment as therapy is so twentieth century!

Ask your patients what is better since they last saw you. Ask them what their “exceptions” were that show their suffering is not entirely constant. Ask them if they can be complimented on anything. Was there anything that the patient handled that was challenging, that they coped with when others would have crumbled. These complements are reflections on the resilience, coping and values of the patient. Ask them what their hopes are for the session you have with them that day.

Self-knowledge

Sun Tzu said “If you know the enemy and know yourself, you need not fear the result of a hundred battles. If you know yourself but not the enemy, for every victory gained you will also suffer a defeat. If you know neither the enemy nor yourself, you will succumb in every battle.” Sometimes therapy can feel like a battle of wills, but it should not be seen thus. Rather it can be a space wherein both the patient and the therapist achieve an in depth understanding of the patient’s strengths and weaknesses, their ideas concerns and expectations and their concept of purpose. With this understanding the levers of change can be engaged. The patient needs to see where their own levers are, so they can use them to effect meaningful change. The therapist is not trying to win but trying to coach the patient to develop their own self efficacy, their own hope and ultimately to win their own battle.

A useful question to ask in this context is “what are they good at”? what would a significant other/close friend/child/colleague say they were good at? Third party perspectives can be more powerful in unlocking this truth, and it can sometimes be useful to ask this question about someone whom the patient fears or does not like. With this question we get an idea of the connections the patient may have with other people and question provides an opportunity for the patient to consider themselves within the context of a family, a tribe and society.

The miracle question

The miracle question is also a useful tool to unlocking the potential for change. IT is a question designed to evoke a detailed vision of their desired future.
The question might be phrased as follows.

“So, you go to bed tonight and you don’t know it happened, but during the night a miracle happened and all the things that brought you here today just dissolved. What would be the first clue that the miracle had happened? What would someone else see hear or feel? What would they see you do?

It is important to drill down, get detail, about what their desired future would look like on day one.
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Follow up questions might include the following.

What would you do differently?
What would you still do?

And the line of questioning could then be brought back to bear on the present by asking such questions as “Could you do something different now, as if the miracle had happened? Would you be prepared to try?”

Having a dream, a hope, and noticing that the problem is not there all the time (exceptions caused by a degree of agency) works towards them determining the small steps required to get big results.

Dead men’s goals

When considering solution focussed therapy and change management it is important to recognise and avoid dead men’s goals. An example could be “to not drink”. These goals are so called because the dead don’t drink. Rather, it is more engaging and beneficial to use the instead” question. An example might be “So what would you do instead of drinking?”. And an answer might be “I’d spend more time playing with my kids.”

The power of the right question ta the right time delivered in the right context should not be underestimated.

The image below represents a starting point on the journey a therapist takes with a patient towards successful change management and recovery.

Watch our show on topic on MedHeads

On Lifestyle Matters Saveena and I chatted about the hormonal regulation of the fed and fasted state.

When we eat we ingest carbohydrates, proteins and fats, these are broken down by the digestive system into glucose, amino acids and triglycerides. These substances are then absorbed by the body. Therefore, In the fed state our bodies are full of sugar that needs to go somewhere. Insulin is secreted by the pancreas in response to two signals. Firstly the presence of food in the gastrointestinal tract triggers the gut to secrete incretin hormones (GIP and GLP-1) which in turn triggers the pancreas to secrete insulin. Secondly the presence of glucose in the blood stream also stimulates the pancreas to secrete insulin.

Insulin is the main storage hormone in the body and as such acts to “bring in the harvest. It has three main actions. Therefore, it limits the sugar high that occurs after eating.

It stimulates the liver to convert glucose to starch (also known as glycogen). Secondly it acts to trigger the conversion of amino acids to proteins, and thirdly it stimulates fat cells to convert free fatty acids into fat, a process known as lipogenesis.

When the liver’s glycogen stores are saturated then insulin directs excess glucose towards the production of fat, hence insulin is known as the “fat hormone”.

After a couple of hours, the glucose rush abates, and our glucose levels drop. We then enter the fasting state. At this point a different hormone comes into play. Glucagon, also secreted by the pancreas, is released in response to a low blood glucose and stimulates the liver to convert its glycogen stores back into glucose. This then maintains the body’s constant level of glucose in the fasted state. The liver however has a limited supply of glycogen that can be broken down into glucose. When glycogen stores run out another hormone, growth hormone, acts to trigger fat cells to release their stored energy in the form of glycerol (which can be converted into glucose) and free fatty acids, which can be used as an alternative energy store.

Growth hormone also acts to stimulate protein synthesis, which provides a survival benefit. When we are in a prolonged fasting state growth hormone causes our bodies to preferentially burn fat and preserve muscle, allowing our ancestors to hunt and gather, and allowing us to drive and go shopping.

Therefore, it can be seen the both the highs and lows of glucose as we progress between the fed and fasted state are tightly regulated by the opposing actions of insulin in the fed state and glucagon and growth hormone in the fasting state.

Appetite is also regulated hormonally. Our empty stomachs secrete a hunger hormone, ghrelin which stimulates us to eat. After eating ghrelin secretion reduces. Food then stimulates insulin secretion, which in turn causes our fat cells to secrete leptin which acts to trigger our brains into thinking we are full. Therefore, appetite and glucose is closely regulated by the interaction of hormone sin our body. In obesity however, leptin secretion is increased, but despite the higher levels of leptin circulating in our bodies the leptin signalling is blunted, the body does not recognise the “I am full” message. This lack of satiety messaging, despite higher-than-normal levels of leptin, is known as leptin resistance, one of the hormonal hallmarks of obesity.

View the show on MedHeads

On Lifestyle Matters show this week

COLTE – how to entrain your sleep wake cycle.

This week I chatted with Dr Saveena about the factor that help regulate our sleep wake cycle.

Our natural sleep-wake cycle is more than 24 hours. So, we need to constantly entrain our sleep-wake cycle to the natural day night cycle that does last 24 hours. We do this by use of zeitgebers which are environmental time cues. The most significant zeitgeber is light.

Daylight, and particularly blue light which has a wavelength of approximately 480 nm has an activating effect. It suppresses melatonin secretion; it increases cortisol secretion and activates our sympathetic nervous system causing an increased heart rate and blood pressure. These effects are all beneficial in the morning when we need to get up and face the challenges of the day. Prior to the advent of industrial lighting, the evening, associated with dim light allowed the secretion of melatonin which then caused drowsiness and prepared us for sleep. This interaction between external light and darkness therefore kept our sleep wake cycle entrained to the 24-hour day.

However, with the advent of industrial lighting we are exposed to light, including blue light, well into the evening which can have the effect of causing inappropriate activation and interfere with melatonin secretion and the onset of sleep. Lack of exposure to daylight can also have an adverse effect on sleep by rendering the body more sensitive to even low levels of evening light further impairing the natural sleep wake cycle. Therefore, we need adequate exposure to daytime light and night-time darkness to sleep well.

Light however is not the only factor that can affect our sleep. If we look at the COLTE mnemonic C stands for carbohydrates. When we ingest carbohydrates, the insulin rise also stimulates intracellular storage of amino acids, all except tryptophan. Therefore, in the presence of a high carbohydrate load the relative concentration of tryptophan increases. Tryptophan is then metabolised to serotonin and melatonin which as we know contribute to sleep.

This effect occurs maximally four hours after ingestion of carbohydrates so we should be eating our last meal of the day four hours before out anticipated sleep time.

O stands for osmolality. Osmolality refers to the salt and water content of body fluids. During early sleep blood vessels dilate which reduces blood pressure and allows heat to escape from the core to the peripheries. High salt content or relative dehydration impairs the dilation of blood vessels and therefore impairs the reduction of blood pressure and the core body temperature that need to occur in early sleep.

T stands for temperature. AS discussed above early sleep requires a reduction of core body temperature and an increase in peripheral temperature. Therefore, we need to be mindful of the ambient bedroom temperature and we may benefit from wearing bed socks to keep our peripheries warm to facilitate early sleep.

E stands for exercise. Exercise activates our adrenaline and cortisol, hormones which activate us. Therefore, we should exercise in the early morning preferably outdoors to catch the morning light. Exercise in the late afternoon may also be beneficial in promoting unbroken sleep. Exercise prior to attempting sleep however is not advisable. All that adrenaline and cortisol surging through our bodies will just keep us awake.
So, we can see that COLTE (carbohydrates, osmolality, light, temperature and exercise) relate to the factors that can influence how well we sleep at night. An understanding of how to manipulate these factors is an essential component of the lifestyle medicine interventions that we can offer for people with sleeping difficulties.

In this episode of Lifestyle Matters Dr Ferghal and I discuss the benefits of exercise both in primary and secondary prevention of cardiometabolic diseases, heart disease and maintaining a robust immune system.

Some statistics from Diabetes Australia and Australian Institute of Health and Welfare show that:
• In Australia, 1 person develops diabetes every 5 minutes
• An average of 2 people die from heart disease every hour
• 23 Australians die from a stroke every day.

High blood pressure is a well-known risk factor for both, heart disease and stroke. There are studies to show that a modest weight loss of 2kg in a 6-month period can reduce diastolic blood pressure by 2.7mm mercury and systolic by 3.7mm mercury.

This occurs via a variety of mechanisms including the production of free radicals and growth factors that can promote cell signalling and remodelling of our blood vessels. This in turn will reduce the resistance of our blood vessels, thus reducing the risk of high blood pressure.

When we exercise, our heart consumes more oxygen. If exercise is done regularly, one of the changes that occur is the reduction of resistance to blood flow. This is because our blood vessels have adapted to the repeated shearing forces. This in turn improves our cardiorespiratory fitness. For example, the breathlessness a standard sedentary person experiences when walking up 2 flights of stairs at a fast pace would reduce over time if she/he were to engage in regular exercise.

Cardiac rehabilitation (i.e. a tailored exercise program under supervision) after a heart attack can also reduce the rate of recurrence and further hospitalisations. Commencing with aerobic training for a few weeks followed by strength training under guidance is the best way forward in this regard to minimise any risks and enhance one’s cardiorespiratory fitness.

The Diabetes Prevention Program was a study designed to explore if we can reduce the incidence of developing diabetes by way of lifestyle intervention in those diagnosed with Impaired Glucose Tolerance / Pre-Diabetes. All that was required was a 7 % weight loss and 150 min per week of exercise such as brisk walking. The results were astounding – the lifestyle group had a 27% greater reduction in diabetes compared to the cohort that took Metformin (a medication used to treat diabetes)

Some of the ways exercise helps this is by reducing insulin resistance and triglycerides, weight loss and changing our body composition i.e. increasing muscle mass thereby increasing our basal metabolic rate.

Many are worried to exercise after a stroke for a variety of reasons. But really, exercise has been shown to be just as effective as blood thinners in reducing mortality after having a stroke. Starting slow and building up will be the best way forward, with the support of a rehabilitation physiotherapist or exercise physiologist. Cardio workouts are important to improve our heart and lung function and reserve, stretch and flexibility helps reduce spasticity and improve mobility. Tai Chi; for example can improve coordination, balance and cognition and lastly, resistance training can potentially improve muscle strength. Any or all of these exercises can help improve our mood and social connectivity as we would potentially engage with other people and even join a gym.

When it comes to exercise and our immune system, striking the right balance is important. Exercise has an interesting effect on our immune system. Regular moderate intensity help boost our immune function to ward off a plethora of infections by increasing the function of our T cell lymphocytes and natural killer cells amongst others. On the other hand, prolonged intensive exercises (for example; military training) have been thought to depress our immune system. However, there are many other factors such as stress or lack of sleep that could contribute hence this is slightly controversial at this stage. Following the recommended guidelines and not greatly exceeding it; i.e. no more than 420mins / week should keep us safe.

This week on Lifestyle Matters I chatted with Saveena about the basics of exercise. This episode is the first of a series of shows in which we plan to explore all aspects of exercise and how it applies to health and wellbeing.

Exercise can be classified as: aerobic, resistance, balance, and flexibility.

Aerobic exercise can be thought of as fitness training, and can include activities such as brisk walking, jogging, cycling, or rowing. These are all types of activity that may you puffed out.

The Australian Government department of health advises the following activity guidelines for adults between 18 and 64.

Adults should be active most days, preferably every day.
Each week, adults should do either:

• 2.5 to 5 hours of moderate intensity physical activity – such as a brisk walk, golf, mowing the lawn or swimming

• 1.25 to 2.5 hours of vigorous intensity physical activity – such as jogging, aerobics, fast cycling, soccer, or netball

• An equivalent combination of moderate and vigorous activities.

In addition, Department of Health guidelines state the following regarding resistance training.

Include muscle-strengthening activities as part of your daily physical activity on at least 2 days each week. This can be:

• Push-ups

• Pull-ups

• Squats or lunges

• Lifting weights

• Household tasks that involve lifting, carrying, or digging.

Both balance and stretching activities should performed at least twice a week, especially by older Australians above the age of 65.

Flexibility activities

Activities that focus on your flexibility help you move more easily, and can include:

• Tai chi

• Bowls (indoor and outdoor)

• Mopping or vacuuming

• Stretching exercises

• Yoga

• Dancing

Balancing activities

Activities that help improve your balance can prevent falls and injuries, and can include:

• Side leg raises

• Half squats

• Heel raises.

We also chat about the perils of being sedentary. Sitting increases all-cause mortality and has been found to be, independent of exercise, a risk factor for obesity, metabolic syndrome, cardiovascular disease, and type 2 diabetes mellitus.

Television viewing has been found to increase all-cause mortality even in those getting seven hours of exercise per week. Interrupting sitting with light to moderate intensity walking every 20 mins reduces blood glucose and insulin levels in obese patients.

On MedHeads

I chat with DR Andrew Rees about a particularly challenging case of a military veteran in his fifties who ahs been a victim of both a traumatic abusive childhood and combat trauma.

He suffers from chronic pain secondary to degenerative disease of both knees and spine (rather than combat trauma) and is dependent on high dose opioids (oxycontin 40 mg bd) and various benzodiazepines. He also suffers form PTS. In terms of his lifestyle, he is obese, he smokes twenty to thirty cigarettes per day. He lives with a partner and has a child from a previous relationship.

We discussed firstly what his needs might be according to the “SPEW CRAFT” mnemonic.
Sustenance – there do not seem to be any unmet needs in this domain
Protection.
His PTSD may indicate an unmet psychological need for protection.
Engagement with meaningful activities.
He does not engage in any meaningful activities; he has no hobbies or interests and self isolates for most of the time.
Wisdom – He may not know how to seek help, or for that matter that help is available
Creativity – there do not seem to be any unmet needs in this domain
Rest – He does not work, and as mentioned above he does not engage in any meaningful activities, but this does not mean he has rest. He does not have rest from psychological restlessness, and his diurnal rhythms are disturbed.
Freedom – He feels trapped and isolated and is not sure who his tribe is. There is a reluctance to engage with the local RSL for fear of exacerbating his PTSD.
Transcendence or Legacy.
He has no idea of his identity or his personal worth.

Starting from this apparently hopeless situation Dr Rees has been able to engage with this patient and help this patient grow by simply asking the right questions.

What does he hope for in life?
This man’s quest for his purpose in life led him to realize that he wanted to re-establish his relationship with his daughter.
What is he good at, what would his spouse think he is good at, what would his daughter think he is good at?
He identified that his strengths included reliability, conscientiousness, and a sense of duty.

After understanding the answers to these questions then comes the miracle question.
“If all your problems magically disappeared overnight, what would it look like for you, what would it feel like for you and what would be the first sign that someone else would notice?”
In this case the answer was that he would smoke less, take less medication, and do more exercise.

The miracle question has unlocked in this patient the potential for deprescribing and a healthier lifestyle. Finding his purpose in life has shifted his focus from being dependent on medication and has unlocked his desire to be medication free, to enjoy mental clarity and to engage with his family.

Archimedes once said that with a big enough lever he could move the earth. Dr Rees has shown us a similarly profound effect: that with the right question we can unlock a willingness for change and a desire for a drug-free life.