In an effort to make science and healthcare information accessible, Carbon Health has partnered with Rob Swanda, PhD to answer questions about mental health, from actual people (via Dr. Swanda’s Twitter and newsletter followers). Dr. Swanda is joined by Dr. Sarah Borish, a clinical psychologist and a director of mental health at Carbon Health, to speak about the mental health related questions below, and many more in the full-length video discussion found near the bottom of this post.
Dr. Swanda: “How does somebody go about setting up an appointment to start checking on their own mental health?”
Dr. Borish: “It can be really daunting to initiate this process. The best place to start is with a visit to a primary care provider. In many cases a primary care provider is the most likely person to prescribe an antidepressant. They may also have some good referral sources in your insurance network, so when in doubt start with your primary care provider. But, there are other places you can also look. A simple search on Psychology Today can provide a list of therapists in your area and it's usually pretty up to date as to whether someone is accepting patients or not. It can be really frustrating to call a lot of providers and then have them just say 'no I'm not accepting', so that's a great place to start. You can also try reaching out to your insurance company for a list of providers, and when in doubt there's a ton of great online mental health providers today that really are increasing accessibility across the country.”
Dr. Swanda: “How does mental health overall play into your full health picture?”
Dr. Borish: “I think we're increasingly aware as a society that there's this clear overlap between our mental and physical health. When we feel good in one way we generally feel better and the other, and vice versa. A couple of key things that I like to think about in assessing the relationship between mental health and physical health are things like your overall sleep health. So, we need sleep to feel good physically and it turns out sleep is a really big factor in your overall mental health. The same is true for healthy eating. So, these are factors that are actually part of the diagnostic criteria for many mental health disorders, and are well understood to contribute to your overall physical health.”
Dr. Swanda: “We had a ton of questions that came in from individuals who were asking about how SSRIs work? I think a lot of them had heard of SSRIs for the treatment of depression or other mental health illnesses, so could you just give a description of how those SSRIs work and why they work?”
Dr. Borish: “SSRIs are a class of medications this stands for Selective Serotonin Re-uptake Inhibitors, and there are similar medications like SNRIs and all of these medications are based on a hypothesis called the 'monoamine hypothesis' for depression, which basically states that the basis of depression is lower levels of serotonin, norepinephrine, and dopamine in the central nervous system. So, a medication like an SSRI or an SNRI works by increasing the amount of free-floating neurotransmitter in the postsynaptic space. So in that space between one neuron and the other these medications work to increase how much serotonin, norepinephrine, or dopamine one might find. I will say that the hypothesis is a little bit under scrutiny today. It's sort of been the belief for many decades that this monoamine hypothesis explains depression, and we're increasingly suspicious of that hypothesis. I would say that being said, we do still know that for many people these medications work and they work quite well. It just doesn't quite fit-in as neatly into our understanding as it used to fit into that understanding.”
Dr. Swanda: “You brought up neurotransmitters and I'm just curious, are those also part of other conditions that are involved in mental health such as anxiety?”
Dr. Borish: “We definitely have neurotransmitter involvement in many of our mental health conditions. A great one to think about is anxiety. In anxiety we're looking specifically at a neurotransmitter called GABA, it's sort of the calming neurotransmitter, so at higher levels of GABA we think of feeling calmer and quieter and more at peace. With anxiety we would expect to see the opposite of that, not quite enough of GABA. And, it's not just our neurotransmitters, there's also a hormonal component to this. I think we talked about the HPA axis in previous conversations looking at Long-Covid and the dysregulation of the HPA access. Something like that, it turns out, is involved in anxiety. When we have higher levels of cortisol and a long-standing exposure to cortisol throughout your body, that can lead to anxiety.”
Dr. Swanda: “Are there any biomarkers or research that's ongoing for molecules that could be detected for certain mental health conditions?”
Dr. Borish: “Yeah, this is such an important area for the future of mental health. When we look at the way we diagnose mental health conditions right now it's really a checklist. So, we're walking through a list of symptoms and we're kind of seeing what someone has and what they don't have and it can be a little bit subjective and it also leads to people walking out of their doctor's office with three or four different diagnoses, when probably what's happening is really one underlying syndrome but that's the way our checklist system works right now. So, there's a lot of movement toward trying to find some biomarkers. There's a couple of cool spaces here. One of them is that there's an indication that some of our inflammatory responses, some of our immune hyperactivity, could be associated with depression or with anxiety. There are certain biomarkers that they're looking for in blood tests there. We're also looking at some neuroanatomical changes among people with depression, anxiety, or other related conditions and so we can look at functional neural imaging, like an FMRI, and start to see changes in someone's what we call the dorsolateral prefrontal cortex, so kind of up toward the front (of the brain). Other changes might be seen inside of the anterior cingulate, the amygdala, the hippocampus, all of these areas are starting to show some difference among people with depression and anxiety. And then another really cool space in the biomarker world is looking at different gut biomes. It turns out you've got a nervous system in your digestive tract that can be a really early warning sign actually for depression and anxiety. Very early science there, but cool stuff is coming out.”
Dr. Swanda: “Is there also some type of genetics that are in play related to our mental health?”
Dr. Borish: “Yeah, absolutely. Certainly when I'm meeting with a patient I'm really trying to understand their genetic history. So, do they have a family history of any of these conditions? It sort of leads to this idea of a genetic vulnerability. It's not that just because your mom has depression you're gonna have depression, but it increases potentially your level of wearability. We're not just looking at genetics though of course. We're also thinking about genetics and the context of psychosocial stressors and coping strategies that you might have. So, it's genetic but it's genetic with a lot of other contextual factors at play.”
Dr. Swanda: “There are some natural disasters that have been ongoing in the U.S., but also around the world, and some community members wondered how that played into maybe triggering some mental health conditions or bringing back some mental health conditions that somebody may be suffering from?
Dr. Borish: “In the immediate response to some kind of trauma, a natural disaster, your body goes into the fight-or-flight mode, which again comes back to this HPA axis that keeps coming up in conversations. Your body responds to stress by going into fight or flight, which is exactly what it's supposed to do and it only really becomes a problem when it's chronic, when it doesn't quite reset back to that baseline. On the one hand when you're constantly exposed to trauma, you look at some of the things happening around the globe such as global conflict, you never really get the chance to reset, so it stays up. And then there are other times where perhaps it's a hurricane or there's a natural disaster and your body reacts and then it just doesn't quite reset itself back to baseline in the aftermath, and that's where we start looking at sort of clinical syndromes. So, in the immediate aftermath of a trauma we might see someone having an acute stress reaction which looks like intrusive memories, avoiding things that are triggering, negative emotions, problems experiencing positive emotions and this can rise to a clinical level, but we would expect almost anyone in the aftermath of a trauma to have some negative symptoms. If those don't reset over the course of about a month that's when we start looking at something like PTSD, or post-traumatic stress disorder, and that's this more chronic ongoing response to a trauma. And, it's basically fight or flight that your body just never quite snaps out of, staying in that highly elevated state long past the point where your body was designed to be in that elevated state and hopefully long past the point where it actually was in that acute traumatic situation, but not always though.”
Dr. Swada: “And, what has the (Covid-19) pandemic done to mental health services overall, both in a positive way but also maybe in a not so positive way?”
Dr. Borish: “Well let's start with the not so positive, which is that the rates of mental health conditions globally have spiked up pretty significantly since the pandemic. It's really become much more common than we've seen in the past and what that means is that there are fewer providers available and more people in need of clinicians mental health care, and so that has been a real challenge and it's something that as a field but also as a country and as a global community we're going to have to figure out how best to address that. On the other hand, I will say both personally, anecdotally, but also there's some data that back this up, the general understanding of the importance of mental health - a recognition that mental health matters as much as physical health - that has really become more ingrained in our culture in a way that I hadn't seen before the pandemic. People are comfortable talking about mental health in a way that most people or many people were not before the pandemic. It's become a thing that we talk about, we can acknowledge, and so even though there's a shortage of providers and many more people in need of services we're talking about the fact that that need exists, which is really a great step in the right direction.”
Check out the full conversation posted on October 19, 2022.
Rob Swanda, PhD is an mRNA biochemist and science communicator who obtained his PhD from Cornell University in 2021. Follow Rob Swanda, PhD on Twitter: @ScientistSwanda
Dr. Sarah Borish is a clinical psychologist and mental health director at Carbon Health.