I Sing Wild Songs Of Adventure.

Where do you belong?

STRESS-
Small Hassles, Big Stress: Why the Little Things Get to Us.
Don’t underestimate how everyday hassles create stress and wear you down.
Reviewed by Davia Sills

KEY POINTS-
Major life events can have significant consequences, yet the gnawing of persistent minor irritations may be more prevalent and harmful.
Failing to recognize and address small, accumulating aggravations can lead to serious emotional, social, and physical problems.
Experiencing stressful issues is inevitable; our responses and the resources we rely on for assistance are key to protecting our health.

In Jonathan Swift’s 18th-century novel Gulliver's Travels, shipwrecked sea captain Gulliver collapses on the shores of Lilliput—the land of tiny people. He awakens to find himself completely immobilized; though he is a giant by comparison, the Lilliputians have bound him with thousands of minuscule ties. The story illustrates how something tiny, when multiplied, can topple even a giant.

By analogy, in our everyday life, we encounter many minor aggravations: the Lilliputian hassles. We are all aware of the stories of people who overcome mind-boggling injuries, medical illnesses, or severe financial and other life obstacles. These narratives are undoubtedly inspirational, yet, while instructive about the power of resiliency, there is the other side of the story: Little things can (and do) get to us.

Lilliputian hassles: Tiny aggravations are stressful.
Because the everyday hassles are small, we may underestimate their effect. At face value, these common, everyday irritations might not seem like they should impact us: the toddler who throws a fit at the grocery store line, waiting forever on hold to address a cable bill, the significant other who forgets to stop at the store and buy milk, the elderly parent who forgets to charge their cellphone, the mandatory online work training that you can’t link onto, and so on. Waiting on hold is not the same as “big-ticket stressors," such as getting fired, divorced, or losing a loved one. Therefore, it may seem trivial and irrelevant to our mental health.

We underestimate the impact of daily hassles on our emotional health because—unlike major life events—they are common occurrences. Although we have more than enough psychological resources to deal with a single tiny stressor, Lilliputian hassles, when multiplied, can emotionally overwhelm and immobilize us. Daily hassles can and do cause stress.

Daily hassles can negatively impact emotional health.
The impact of daily hassles on emotional health is not negligible. Psychological research has repeatedly demonstrated that daily hassles are stressful, particularly when they create negative emotions. Over 30 years ago, psychologists began to recognize how major life events—the death of a parent, spouse, or child, loss of employment, or a significant health issue—create psychological distress. The research then turned to the impact of daily hassles that also predicted emotional distress—and, in some studies, with an even stronger effect than the impact of major life events.

When not managed, daily hassles can stress our bodies. They can lead to poor habits (overeating, drinking too much, not exercising) that can compromise our physical health. When an event is perceived as stressful, even these seemingly trivial stressors over time may trigger the release of cortisol and other hormones (as in through the hypothalamic-pituitary-adrenal axis). A daily and relentless dose of negative emotions, which are reactive to hassles, can erode one’s sense of well-being.

Manage daily hassles as they occur to avoid emotional exhaustion.
Each daily hassle by itself is manageable. It is the buildup that is emotionally exhausting. The pathway out of emotional exhaustion and inertia may be finding ways to neutralize the effect of everyday hassles as they occur. Psychologists have found that reducing the negative focus of the stressor through cognitive reframing—deliberately pivoting toward the positive—can reduce the subjective distress that can accompany minor irritating events.

Neutralizing the impact of the hassle requires recognizing the event as a stressor and identifying its impact in the moment. As an example, you have been either on hold or switched from one customer service representative to another in dealing with a credit card charge issue. You may be thinking, “I’m feeling really irritated waiting so long on hold.”

Neutralizing the impact requires that you actively re-brand (cognitively reframe) the experience: “I feel glad that I am getting this overcharge finally taken care of.” Follow up with rewarding yourself with an “uplift” or a positive experience, such as treating yourself after the task is over to something you enjoy: a latte at your favorite coffee shop, listening to a song that lifts you up, or going for a brisk walk.

Free yourself from being a prisoner of stress.
Everyday hassles are stressful, and the impact of that stress is not inconsequential. We get to an emotionally depleted state when we don’t recognize the emotional consequences of the Lilliputian hassles. The cumulative impact of hassles is that they can create negative emotions: worry, irritability, anger, and unhappiness. These emotions can wear on a sense of control over one’s life, enhance a feeling of lack of competence in the ability to manage our lives, and, in turn, foster helplessness.

Gulliver—a giant, by comparison—became a prisoner to the tiny denizens of Lilliput. Our psychological resources are like Gulliver—gigantic in comparison to a daily Lilliputian annoyance. Recognizing at the moment that the annoyance is tiny and neutralizing the Lilliputian hassle is a pathway out of being immobilized by a thousand little daily irritations. In other words, it is freeing yourself from becoming a prisoner of stress.

ADDICTION-
This Underutilized Addiction Medication Can Save Lives.
Restrictions on buprenorphine have been removed, but broader access is needed.
Reviewed by Tyler Woods

KEY POINTS-
Buprenorphine is a safe, evidence-based medication for opioid use disorder that can control drug cravings and prevent overdose deaths.
Despite its safety profile, buprenorphine is under-prescribed, due to a lack of medical provider training, as well as stigma.
The federal government recently lifted a regulatory burden on buprenorphine, but patients still need to advocate for access the medication.
More than 100,000 people are dying of drug overdoses each year in America, driven chiefly by opioids.

Medications can prevent opioid overdoses by blocking the effects of deadly drugs while also controlling cravings to use those drugs. Yet, they are vastly underutilized. Less than one-third of people in need of medications for opioid use disorder (OUD) receive them.

One of the evidence-based medications for OUD is buprenorphine. Approved by the FDA in 2002, until recently it could only be prescribed by providers who took a special course and applied for a waiver, known as an X-waiver. At the end of last year, the federal government lifted this regulatory burden. It remains to be seen whether this change will save lives.

The two other FDA-approved medications for OUD, methadone and naltrexone, have more limited use. Methadone cannot be written as a prescription for OUD but rather must be dispensed by a federally certified clinic. Naltrexone is available as a prescription but is less effective than buprenorphine or methadone.

People in need of OUD treatment should seek treatment settings that offer medications, in particular, buprenorphine.

How Does Buprenorphine Work?
Buprenorphine is a partial opioid. It attaches to opioid receptors in the brain, just as heroin, fentanyl, and other full opioids do—but relative to other opioids, buprenorphine activates those receptors weakly. Think of a lackluster opening act when you go to see a show—it’s enough to keep you in your seat, but it’s not the main performance.

Buprenorphine can control cravings to use other opioids, but as long it is dosed properly, it does not cause intoxication or suppress breathing, which is the mechanism of opioid overdose. Now, imagine if that bland opening act refused to leave the stage, keeping the main act stuck behind the curtain. That is how buprenorphine prevents overdoses: it clings more tightly to the opioid receptors than full opioids do. When people use other opioids while on buprenorphine, they do not get high or stop breathing.

Why Is Buprenorphine Underutilized?
For most of history, addiction was stigmatized as a moral failing. It was not until 1997 that the National Institute on Drug Abuse introduced the concept of addiction as a brain disease, and not until 2012 that a landmark report connected the growing issue of untreated addiction to a dearth of medical training. Even today, many drug treatment programs consider recovery to mean abstention from use of all opioids; they do not consider a person who is taking buprenorphine to have achieved recovery.

The recently revoked X-waiver also posed a barrier; fewer than 100,000 clinicians in the country had one as of January 2021. Given the irony that no such waiver was required to prescribe the oxycodone, Percocet, and other full opioids that delivered us an epidemic in the first place, the X-ing of the X-waiver is a cause for celebration.

Yet it is premature to declare victory in the struggle for broad access to buprenorphine. One study that assisted clinicians in obtaining an X-waiver, including providing the requisite training course, found that the majority did not use the waiver. Medical training curricula have a gaping hole when it comes to addiction, one which a single course cannot fill.

Starting buprenorphine can be tricky. If initiated too soon after the last use of a full opioid, it will displace that full opioid from its receptor in the brain, precipitating a sickness known as withdrawal. Sometimes described as “leaking from every orifice,” withdrawal involves watery eyes, a runny nose, vomiting, diarrhea, and more. Imagine if the boring opener pushed the headliner off the stage mid-act—the audience would be pretty miserable. On the other hand, if the main act suddenly left mid-performance, the opener could step in to fill the time, cheering everyone up. Similarly, once a person with opioid dependence is already experiencing significant withdrawal, buprenorphine can soothe the symptoms.

How Can These Barriers Be Overcome?
With appropriate education, patients can start buprenorphine at home without precipitating withdrawal. Inpatient and residential facilities can observe patients until they have reached the appropriate stage of opioid withdrawal for buprenorphine to alleviate rather than exacerbate their symptoms.

Many rehab facilities do this already—only to stop buprenorphine once the withdrawal has resolved. They may claim that at this point the patient has completed “detoxification,” or “detox,” but the use of these terms can perpetuate the stigma that a person who uses drugs needs to be “cleaned” in some way. Moreover, addiction is a chronic medical condition that warrants treatment with maintenance medications, just as, for instance, diabetes management may require long-term use of insulin. Limiting the use of medications to the withdrawal phase disregards clinical reality and undermines recovery.

Rehab facilities bear a special responsibility to not only start buprenorphine but also to link patients to a community prescriber who will continue the medication after discharge. Buprenorphine can control the cravings to use drugs that are triggered by the stressors of returning to the real world after rehab. Moreover, while sequestered at rehab, people lose their tolerance to opioids. With their bodies no longer accustomed to using the amount of street drugs that they used before, they are especially vulnerable to a fatal overdose—which can be prevented with buprenorphine.

How Can People With OUD Access Buprenorphine Treatment?
If a patient with OUD is safe in their current home environment, they can start buprenorphine while remaining in the community. You can find outpatient buprenorphine prescribers here.

If you or your loved one is seeking inpatient or residential treatment for OUD, inquire about each facility’s policy on buprenorphine. This means asking not only whether they provide short-term buprenorphine for withdrawal management (or “detox”) but also whether they support long-term use, including providing a bridge prescription to last until patients establish with an outpatient prescriber.

By asserting a right to evidence-based treatment, patients and their loved ones can erode the stigma against medications that has clung to the addiction treatment world for far too long.

The End of Sex?
How technology will change the way we have children.
Reviewed by Tyler Woods

KEY POINTS-
Few people realize just how powerful embryo selection will become in the near future.
Over the past two decades, the human genome has been decoded, and genetic testing has become ubiquitous.
We will still have sex. And we will still have children. But the link between the two will grow more tenuous.

Sex is fun because people who found it boring died without descendants.

But the link between having sex and having kids has been severed since the sexual revolution of the late 1960s. Cheap contraception allowed women to decide when to have children. Social norms also changed—abortion became easier to access in case contraception failed.

Whatever you think of these developments, contraception and abortion have led many people see sex as an activity we do for pleasure (or for bonding between couples), and having kids as an active choice to create a life.

Not long after the pill enabled the sexual revolution, a new technology emerged that allowed gay and infertile couples, as well as single people, to have children: in vitro fertilization. IVF is a simple medical procedure that extracts eggs from women and combines them with sperm from men to create embryos. Couples can then decide which of the embryos to implant.

While IVF was considered controversial at first, as soon as it proved viable in England and the U.S., attitudes quickly changed from skepticism to acceptance. In Japan, for example, about 5 percent of all births now come from IVF. In Denmark, the number is 10 percent, though that is partly because Denmark is a popular destination for women seeking sperm donors and fertility treatments.

Since couples using IVF usually produce several embryos, and sometimes dozens, it is commonplace to use a simple genetic test to determine whether any of those embryos have “aneuploidy.” Aneuploidy occurs when an embryo has too few or too many chromosomes. The most common version of aneuploidy results in Down syndrome, and it is no surprise that couples will generally pick an embryo without chromosomal abnormalities when given the choice.

Polygenic prediction
Over the past two decades, the human genome has been decoded, and genetic testing has become ubiquitous. People get genetic tests to reveal their ancestry, to predict disease susceptibility, or to find out who the biological father of a child is in contested cases.

But a new kind of genetic testing has entered the fertility clinic. Preimplantation Genetic Testing (PGT) can now be done not only for aneuploidy, or for monogenic traits such as Tay-Sachs disease; it can also be done for polygenic traits which involve many genetic variants, each of which has a small effect. Most of the traits we care about—ranging from height and weight, to cancer or schizophrenia—are highly polygenic.

A few companies already offer polygenic risk scores that predict the likelihood that an embryo will develop a specific disease like diabetes. It is inevitable that some will apply these tests in ways that enable couples to select for aesthetic and cognitive traits. The more embryos couples can produce, the greater genetic variability there will be from which couples can choose. Mate choice will constrain the possibilities, but more embryos means more options.

It is important to distinguish embryo selection using polygenic risk scores from gene editing. Selecting one embryo from a set of embryos is as old as IVF. It can be done at random, or it can be guided using polygenic scores. Embryo selection using polygenic scores is very different from gene editing since it involves selecting among whole embryos.

Gene editing is still too dangerous to use on embryos, since it frequently produces off-target mutations that can have harmful effects on a developing fetus. It is possible that at some point in the future, CRISPR, the most common genetic editing techinique, will be used to “spell check” the genome, and maybe even rewrite it in fundamental ways, but we are a long way from that possibility. Few people realize, however, just how powerful embryo selection will become in the near future.

In vitro gametogenesis
IVF will become more potent as our understanding of genetics improves. And IVF will likely become more common as people around the world delay reproduction longer. Having children later raises the chances of infertility, but it also increases the risks to children since older parents pass along more de novo mutations. This means more couples will either need to use IVF to have children, or will use IVF electively in order to minimize disease risks to the children they have.

Polygenic risk scores will become more accurate as the data from genome-wide association studies accumulates. But the game-changer right around the corner is in vitro gametogenesis (IVG). IVG allows scientists to take an adult cell, such as blood or skin cell, and turn it into a pluripotent stem cell (the kind that can become any cell, including a sperm or egg cell).

When IVG becomes a reality for people (it’s already been done for animals), menopause and mutation accumulation will become less important, and couples will be able to create many embryos from which to select without the need for IVF. This means that the genetic variety of a couple’s embryos will be large enough that two short people could select a tall child, or two people at high risk of diabetes or schizophrenia will likely be able to select an embryo at low risk for both.

We will still have sex. And we will still have children. But the link between the two will grow more tenuous. The prospect of artificial wombs is likely to increase this gap even more. An obvious risk is that both sex and babies will be thought of in more instrumental and less romantic terms. An obvious benefit is that our children will have lower risks of disease.

In a series of forthcoming posts I’ll tackle some of the moral questions raised by these new technologies. I also hope to explore how these technologies will alter the way we live.

How Did You Experience the Divorce?
Focusing on the subjective rather than the objective experience of a life event.
Reviewed by Davia Sills

KEY POINTS-
People differ in how they perceive major life events, such as marriage or divorce.
The perception of a life event can be measured according to nine characteristics, including its valence and predictability.
The perception of a life event can change over time, offering the possibility for people to actively work on their perception.
The perception of the life event, rather than its occurrence, may explain how people change in their personality after a life event.
Major life events
People experience various life events across their lifespans, such as marriage, the birth of a child, and divorce. Lay beliefs about how such life events change personality are common. But interestingly, research suggests that life events change our personality only to a small extent, if at all (see my previous blog post).

But is it really the case that life events have little to do with our personality? Or, rather, is it the case that research still has to find the right ways to assess how life events do, in fact, change personality? The most recent body of research would suggest that the latter is the case: We have to develop the right methods to assess personality change in response to life events.

Imagine the following scenario: Laura has recently divorced her husband; their marriage has been full of conflict, tension, and dissatisfaction. Laura’s friend Emma also divorced her husband, but their marriage had been one with closeness, affection, and fulfillment—until the very last months. In Laura’s case, both decided to divorce, while in Emma’s case, her husband started the divorce.

A divorce is not a divorce.
It is to be expected that Laura experiences her divorce differently than Emma. While Laura might even feel some relief that the tensions are over, Emma might struggle with the unexpected divorce. If researchers studied how Laura and Emma changed in their personalities in response to their divorces, they would likely observe different patterns of change: Laura might increase in emotional stability and self-esteem, while Emma would decrease in emotional stability and self-esteem.

In other words, there would be no reason to expect that both would change in similar ways to their divorce. This, however, is how the effects of life events on personality change have been studied so far. For good reasons: Most study designs only included information about whether a person experienced a life event like a divorce, but no further parameters of the life event were assessed.

How individuals perceive events
The recognition that the same type of life event—marriage, childbirth, divorce—may be perceived differently by different people led researchers to develop new instruments to assess life events. For example, Luhmann and colleagues (2021) developed a taxonomy of nine characteristics for how life events can be perceived. Specifically, life events can be rated regarding their (1) valence, (2) impact, (3) predictability, (4) challenge, (5) emotional significance, (6) change in worldviews, (7) change in social status, (8) external control, and (9) extraordinariness.

Based on these characteristics, we can now describe the divorce experiences of Laura and Emma with much more precision. For example, these divorce experiences would differ in their predictability (more predictable for Laura, less predictable for Emma), external control (more external control for Laura, less external control for Emma), and emotional significance (fewer feelings in Laura, stronger feelings in Emma).

How subjective experiences predict personality change
It is likely that the individual experiences of the life event, rather than its pure occurrence, can explain how people react to the life event. As noted above, the higher predictability, larger degree of external control, and lower emotional significance could explain why Laura would show a more positive development in personality characteristics like emotional stability, life satisfaction, or self-esteem than Emma. But again, these observations would be trends, and specific people could still show different trajectories in both the short term and the long term: for instance depending on their initial level of emotional stability, their life circumstances (e.g., financial situation), or their social support. We now see how complicated it is to study the effects of life events on personality change.

Individual perceptions may change over time
What makes the study of life events even more complicated (and interesting at the same time) is that individual perceptions of life events may change over time. Maybe you can recall your own experiences, in which you had a different perception immediately after the event than you had one week, one month, or one year later? Indeed, our perceptions of life events are dynamic, and some perceptions are even more dynamic than others.

For example, Haehner et al. (2021) studied the stability and change of perceived event characteristics across five assessments in one year. Overall, they found that individual differences in perceived characteristics were relatively stable over time (less stable than Big Five personality traits but more stable than affect). This means that Laura, who perceived her divorce as more predictable than Emma, would perceive her divorce also as more predictable than Emma's one year later.

At the same time, the findings indicated that the perceived change in world views increased over time, while the perceived extraordinariness of the life event decreased over time. Both developmental patterns may suggest functional reactions in response to the life event, including more distance to the life event. However, a limitation of this body of research is that perceived event characteristics have mainly been assessed among young adults. Perceptions of life events may change depending on the developmental life period of an individual, so more research in this area is needed.

What to take from the findings?
Life events are important in the lives of most people. However, people differ in how they perceive the very same type of life event, and these differences can be measured according to nine characteristics, such as the predictability or emotional significance of a life event. These different perceptions may explain why previous research could not observe consistent patterns of how a life event (i.e., a divorce) is associated with personality change. Thus, better knowledge will be gained when aiming at understanding how and why people perceive a life event and how these perceptions generate changes in personality.

Moreover, perceived event characteristics are not perfectly stable over time, leaving room for actively changing the perception. For example, if the perceived emotional significance of a life event is associated with more negative personality change, prevention and intervention programs may be developed to actively work on this event perception. Together, this helps to generate a better understanding of the impact that life events have for our lives.

Same but different
Even before research can provide this knowledge, we can use the findings for our own lives: We can acknowledge that different people perceive the very same type of life event in different ways. On the one hand, this helps us to understand why we do not perceive a presumably positive life event (e.g., marriage) positively and a presumably negative life event (e.g., divorce) negatively. Thus, we may develop a more understanding attitude toward ourselves. On the other hand, we can develop a more understanding attitude toward other people who have experienced a life event that we would perceive differently than the other person did. Together, this may generate more empathy for us and others.

DEPRESSION-
How My Depression Revealed My New North Star.
A Personal Perspective: Failing to identify my own severe depression.
Reviewed by Lybi Ma

It was a humbling experience, but one I feel is important to share: Although I am a 20-year veteran of psychiatry and the chair of a major department in the field, for months I failed to identify my own severe depression and resisted getting treatment, causing myself pain and harm.

How could this happen? Well, doctors are clearly not immune from the proverbial saying that the shoemaker goes barefoot. But I have concluded that there is more: our society must shut down the stigmatization of mental illness.

I feel I'm called to tell my story, in hopes of helping others muster the strength and courage to seek the help they need. So here it is.

A few years ago, I became the chair of Behavioral Medicine and Psychiatry at West Virginia University’s Rockefeller Neuroscience Institute. We have over 200 employees, a psychiatric hospital, and a residency training program. I was new at this, and nobody put me through a ”chair school” to learn it. But it’s not uncommon that people who demonstrate some degree of confidence, trustworthiness, and perhaps competence receive authority. So far, so good.

I began to experience insecurity about the new job. I compared myself to others – the “compare and despair” phenomenon. That leads to what’s known as imposter syndrome – the feeling that any day somebody might realize you’re the wrong person, just pretending to be what others wanted you to be. I think this is more common than often realized, and it affects people in different ways. Some can become horrible bosses. I became more vulnerable.

Then Covid hit in March of 2020, and we didn’t know what this would do. Would we harm patients by bringing them in? Would staff be harmed by coming into work? Would we bring this virus back to our families? There was so much fear and uncertainty, and as the department head, I felt responsible for people's lives.

I threw myself into my job, working 12-hour days, while my community support shut down. My church had been an especially important community for me, for connection and spirituality. Looking back, being cut off from it was a big hit against my wholeness, and even who I was as a human being.

When I talk about this now with other doctors, we realize that we can be horrible about recognizing illness in ourselves. I did recognize that I was stressed, waking up in the middle of the night with panic attacks, but felt it was just stress from job anxiety. For all my training, despite all the teaching I’d done, I couldn’t recognize that I was in a state of clinical depression.

I think what saved me was some caring friends and colleagues who began to note that I wasn’t looking so good and to tell me that I don’t seem like myself. I reached out to my mentor, who is a psychiatrist at the University of Hawaii, and he walked me through some questions:

Are you losing weight? Yeah, I’ve lost about 15 pounds in the last two months.

Are you sleeping? I sleep about two hours a night.

Are you enjoying anything anymore? No, I can't stand anything and don't enjoy the things that I used to. I feel like every day is drudgery and that it’s a chore to get out of bed.

Are you feeling like you don’t want to live anymore? Yeah, I think about suicide every day, and I wish I were dead.

And then he said it: “Jim, you're depressed.”

I imagine readers will ask themselves how it can be that experts cannot diagnose themselves. My explanation is that like everyone else we put up defense mechanisms to just get through the day. All people have strong egos and we don't want to admit that we are weak – that something powerful could interfere with who we are. We are slaves to a mystique that we are masters of our domain. In short, emotions are stronger than intellect at times.

Even after I acknowledged I was in a depression, it took me weeks to finally get treatment for it, because of pride. I thought should be able to handle this myself. And while I had prescribed thousands of antidepressants over the years, I was unwilling to take one myself or to see a therapist.

Finally, I broke down and agreed to treatment directed by my mentor. He started meeting with me weekly to check in. I started exercising, which I had not done in a long time. I started an antidepressant. I saw a counselor who helped me understand what was happening within my body and my brain.

It was all stuff I knew, but I needed to hear it from another professional – where I could be the patient as opposed to the educator. It is akin to a medical doctor who comes in for a physical – you need to leave your own stethoscope at the door.

Over about a month I began to feel more energetic. I started feeling better, standing up straight, regaining weight, sleeping better, and thinking less about dying. The whole ordeal lasted about five months. It could have been shorter.

My experience is probably typical. What can we do better?
I think part of the issue is that our culture enforces competition and if we show signs of weakness and vulnerability that puts us at a disadvantage versus others in what is seen as a zero-sum game. As a society at large, we can do better in that area. This is not good for society, or individual wellness.

We could also use a renewed emphasis on human connection. The fact that I had friends who cared about me enough to warn me was invaluable. I knew they had my back and could go into a position of safety, to confront what I didn't want to confront.

We need to better educate the public that depression is something that certainly can be managed, and it can go away. Even chronic mental illnesses like schizophrenia may not go away but we have the tools to help people thrive. For all of us, the three hardest words to say are “I need help.” That’s especially so with mental illness. We need to arrive at the point where it's as natural and supported to reach out to get help for your mental illness as it is for your hypertension, diabetes, or cancer.

Mainly, though, we need to genuinely fight the stigmatization of mental illness and of everybody who suffers from it. No one is spared from such issues – including those in powerful positions, like CEOs or principals or judges, or politicians. As it is, there will be barriers that will keep them from getting help. The stigma of mental illness should not be one of those barriers.

In my case, part of my fear had been whether my career would suffer. In West Virginia, as in many states, the medical license renewal form asks whether you’ve been treated for a mental illness. I wanted to be ethical, so I wrote yes – but really, why is that question there? It's discriminatory against people who suffer from mental illness. Better, as some states do, to ask whether the doctor is undergoing anything that would impair the ability to practice medicine.

I'm sorry I went through this. I never want to go through it again. But in a way, I’m grateful that I did. It has given me a new dimension of understanding what people go through when they're in the depths of despair. Once you get out of it you've got space to reflect on the bigger picture. But when you're in the middle of it, it's just darkness.

I want people to know that there’s no reason to wallow in that darkness and that they need not be alone. That is the North Star for me now.

KETAMINE-
Update on Ketamine via Telemedicine Delivery.
A breakthrough treatment for depression or a risky precedent? Here’s the latest.
Reviewed by Tyler Woods

In 2020, the federal government changed the rules to make it easier for providers to treat patients via telemedicine. One rule change allowed providers to prescribe controlled substances like ketamine without first seeing the patient in person.

The thinking was that, because the pandemic was raging, it was too dangerous for people to go to doctor’s offices for visits and to get their prescriptions.

Since that time, the number of people receiving ketamine via telemedicine has soared. The reason is clear. Several studies, as well as anecdotal evidence, in the last few years have shown ketamine to be highly effective for some people with treatment-resistant depression (TRD). It is also showing efficacy for bipolar disorder, PTSD, and certain other mental illnesses.

But depression seems to be the sweet spot. Many who have been suffering from debilitating TRD for years, and who have tried other medications with no success, are finally seeing their symptoms improve with ketamine. Some see a dramatic improvement over a period of days or even hours.

Another positive development? Ketamine obtained in this way—it usually gets sent in the mail in lozenge or tablet form when the prescription is filled—often costs far less than when a person receives the medication in person at a clinic.

So far, so good. However.
The risks of ketamine via telemedicine delivery
There are several serious downsides to this development. For one, when ketamine is taken chronically in high doses (which can happen when it’s taken at home in an unsupervised manner), it can cause severe bladder damage. In some cases, the damage requires surgical reconstruction of the bladder.

Ketamine can also be highly addictive for some individuals, and you can overdose on it. It can also dramatically raise heart rate and blood pressure when you take it, and it’s risky for those who live with certain kinds of psychiatric illnesses.

Maybe the biggest downside of all is that there is virtually no data on the long-term health effects of taking ketamine daily or every other day, as many who get it delivered via telemedicine do. (Many people receive their monthly dose of lozenges or tablets, take more of the medication each day than is prescribed, and run out early.)

Compare that lack of oversight to ketamine’s FDA-approved nasal spray form, called esketamine or Spravato. This is normally taken in a controlled clinical setting only once or twice a week for a set number of weeks under medical supervision.

Given all these upsides and downsides, what’s the best way forward with ketamine? Let’s start with the basics.

What is ketamine?
A synthetic substance, ketamine (pronounced “KEH-ta-meen”) was developed in the early 1960s as an anesthesia treatment to keep people from feeling pain from injury or during surgery. It’s still used today and is especially common in veterinary hospitals.

Classified as an anesthetic, ketamine causes feelings of dissociation and sedation in higher doses. It gained notoriety in the 90s as a club drug—people inject it, snort it, or add it to marijuana or cigarettes. Nicknames include "K," "Special K," and "Super K." Ketamine has also shown benefits in pain management for both chronic pain and acute pain in emergency room settings.

When taken to combat depression and other mental illnesses, ketamine can produce hallucinatory effects, visual and sensory distortions, out-of-body experiences, and euphoria or a “buzzed” state. Often, a ketamine “trip” lasts about two hours, though occasional side effects, such as unconsciousness and high blood pressure can be severe.

Many ketamine patients say that their sessions with the drug can act as a reset button for the brain. The drug allows them to detach from themselves, and many report profoundly pleasant thoughts and visualizations. Afterward, your daily problems can feel less oppressive, and the improved mood can last for weeks or longer.

A few cautionary words on telemedicine as a delivery method
As an addiction treatment clinician, I am wary of working remotely with patients, prescribing medications to them via telemedicine, and monitoring their progress and recoveries via videoconference. Why? Because it’s harder to do all those things remotely than if you’re seeing someone in person and can assess body language, attitude, hygiene, and other behaviors. It’s also easier for patients and providers to abuse the “virtual” delivery system.

So yes, in a perfect world where quality in-person care was available to everyone, that delivery method would win every time. But that’s not the reality. To extend our health and medical reach to those who otherwise wouldn’t access it, telehealth is vital, and it’s here to stay. On balance, that’s a great thing.

Telemedicine and ketamine
Here’s my take: Telehealth-based care (usually via video) works well for physical ailments like strep, skin rashes, or sinus infections. But things get more difficult with mental health because there are fewer physical symptoms to guide you. It gets dicier still when the medication that is prescribed for the illness is itself risky, as is the case with ketamine, because it’s harder to monitor remotely.

That said, the answer isn’t to shut down this delivery method for ketamine. Rather, we need to create regulations and safeguards that allow for the medication to be prescribed and monitored by a certified provider in a safe manner.

With that goal in mind, I offer the following.
4 recommendations on ketamine
Put clear, enforceable rules around that first visit with the provider. If the government doesn’t require a return to an in-person visit before prescribing controlled substances like ketamine, that first virtual visit must be comprehensive, recorded, and trackable by an oversight body. I hear all the time that these initial visits are as short as 30 minutes, and I can say with certainty that it is impossible to do a thorough mental health assessment with a patient in that amount of time.
Require certification of all providers and companies that offer ketamine via telemedicine delivery. This is how it works now with clinics that offer in-person FDA-approved Spravato nasal spray. Similar regulations need to be in place for the new providers offering ketamine via telemedicine.

Require addiction screening for all patients. Because ketamine can be addictive, providers and patients are playing with fire if patients aren’t thoroughly screened (this takes more than 30 minutes!) for addiction use past or present. This needs to happen, no exceptions. My recommendation is that a patient must be sober from drugs or alcohol for at least six months, if not a year, before a ketamine prescription is considered.
Make it mandatory that providers do frequent video checkups with their patients who take ketamine. This oversight is vital. Providers need to see how the patient is doing in order to make dosage adjustments. Video chats also allow for visual evidence to be shared, for example, the provider can ask to see a patient’s remaining dosages.

Key advice for patients
Always advocate for yourself, and remain vigilant about fraudulent or suspicious activity by your provider.

Remember, providers are not infallible. They sometimes make mistakes in judgment—or worse. There’s money to be made in this new-frontier area of medicine at the moment, which means you’re always going to get some bad characters involved.

If something smells fishy about the way medications are being prescribed by your provider, ask about it. Push back. Ask direct questions. Make inquiries. Do your due diligence. Google your provider to check on their credentials.

Bottom line: Be careful. Hold your provider to the highest possible standard. This is your (or a loved one’s) mental health we’re talking about, and there’s nothing more important than that.

RELATIONSHIPS-
5 Things You Should Do Every Single Day.
An evolutionary perspective on everyday living.
Reviewed by Tyler Woods

KEY POINTS-
Life is full of choices. And it is often difficult to know what choices to make.
An evolutionary perspective on everyday human life can help shape healthy choices and actions in all life domains.
Based on work in evolutionary psychology, here are five actions that we can take every day to help us thrive.

If you're old enough to read this, then you already know that life is hard. People often look to publications such as Psychology Today to help provide guidance across all spheres of living. With this in mind, here I present a list of five simple actions that, if performed regularly, can help you thrive in all aspects of life.

From an evolutionary perspective, the human mind did not evolve for modern, large-scale, industrialized conditions—conditions in which we all have cell phones at the ready and can literally communicate our ideas with the entire world with the push of a button. From an evolutionary perspective, we evolved in small-scale societies surrounded by nature. Under the conditions that shaped our evolution, all communication was face-to-face and most interactions were with either family members or individuals with whom we had long-standing social relations.

From the perspective of positive evolutionary psychology, we can use our understanding of evolution and human behavior to help us make healthy choices and to build habits that, based on our evolved psychology, can help us thrive across all spheres of life.

1. Treat others with forgiveness and grace.
Based on work on the evolutionary psychology of moral emotions (c.f., De Jesus et al., 2021), we evolved in small-scale societies, surrounded by the same individuals over and over again. Our minds evolved to exist in such contexts. In such a world, treating others in a way that is selfish and disrespectful would have had adverse effects for oneself in the long run.

Maybe each day you should make a point to forgive someone in your world for some prior transgression or go out of your way to show someone grace and respect. Our ancestors who did this sort of thing stayed in the good graces of others. Such actions clearly played a role in helping our ancestors stay connected with (and supported by) others.

2. Experience love every day.
Based on all kinds of data, love is a real emotion that evolved to help keep people closely connected with important others (e.g., with romantic partners who also often served as co-parents; see Fisher, 1993). Famously, Maslow (1943) prioritized love as one of the core human needs.

Express love toward someone in your world each and every day. Loving, thoughtful acts (even as simple as ordering that special someone cream cheese and bagels when their fridge is empty) can go a long way to making that special someone feel valued and appreciated. And you'll both benefit from this kind of outcome in the long run.

3. Get out into nature.
Wilson (1984) famously talked about biophilia, and how humans, like all organisms, evolved to experience nature, in all its grandeur, each and every day. Regardless of the weather, I'd say make sure to get outside each day. This may be an epic hike up Mount Washington in New Hampshire, under intense conditions with 100+ mile per hour winds, or it may be as simple as a nice walk to the mailbox on a beautiful sunny day. Wherever you are geographically or physically, we evolved to have that kind of experience regularly.

4. Do something altruistic.
Based on all kinds of work in evolutionary behavioral science, humans evolved a broad array of prosocial acts. And it feels good to help others, partly as a result (see Wilson, 2007). Help someone with a project. Pick something up at the store and surprise someone in your life. Donate to a charitable cause that matters to you. Message an old friend and tell them that you are just thinking of them.

Prosocial acts of any size can have positive effects and they cost almost nothing. Rarely do people regret having engaged in altruistic acts; this fact seems built into our evolution.

5. Create something and share it with someone you care about.
Humans are a deeply creative ape (see Miller, 2000). In fact, creativity seems to be a core part of our evolved psychology. Writing poetry, painting, creating music, etc.—these activities all evolved to help us share and to demonstrate features of our internal psychology to others. And it is fun!

Even if it as simple as writing a 25-word poem for someone you care about, I'd advise to create something every day—and share the product with someone you love. Given how deeply creativity is embedded in our evolved psychology, you won't be sorry.

Bottom Line
Life is hard. The evolutionary perspective on the human condition can help us make it better. Understanding our evolved psychology can help us to thrive in so many ways.

I hope that this list of five simple kinds of actions that we can do each and every day helps provide something of a guide in terms of how to live the good life.

Want to be your best self and live your best life? Pay attention to the work of evolutionary science; you won't regret it.

MINDFULNESS-
Activating Hope, Truth, and Better Conversations.
Three practices to lead us out of the malaise and redefine our conversations.
Reviewed by Ekua Hagan

KEY POINTS-
People can shift how they observe the onslaught of misinformation and mistruths by adopting an insightful bird’s-eye view, or meta-perspective.
Society's reliance on science, facts, and expertise is critically important.
Shifting from conflict avoidance to the art of dialogue rebuilds conversational skills and allows for more respectful conversations.
Over the last six years, whenever conversations with friends and family moved into politics, the mood quickly spiraled into frustration and hopelessness. The country’s political malaise has divided us and frozen us into inaction. And today, while the expelling of two black representatives out of the Tennessee congressional chamber is discouraging, it is also possible that the anti-woke mob so fearful of change is sparking awakened reactions.

I put my faith and hope in three practices that can lead us out of the malaise and powerfully shift our perspective so we can embrace the truth and redefine and refine our conversations.

First, we can shift the way we observe the onslaught of misinformation and mistruths. By understanding the greater evolutionary context from which humans emerged, we can adopt a mindset with a higher meta-perspective—a zooming-out, or an insightful bird’s-eye view.

The second practice is remembering how critically important our reliance on science, facts, and expertise is. Misinformation, ignorance, and nihilistic rhetoric erode public trust and confidence. Better conversations are not possible until we understand the valuable role facts, expertise, institutions, and public trust play; that is if our desire is to create sustainable democratic societies.

The third practice is rebuilding our conversational skills, shifting from conflict avoidance around difficult topics to the art of dialogue, where tolerance and open minds are the heart of collaborative and creative conversations, and wise decisions flow from those respectful conversations.

A Meta-Perspective
In the book Spiral Dynamics, Don Edward Beck and Christopher Cowan present a model of human development based on the theories of Clare W. Graves. Beck and Cowan discuss the evolution of our brains, systems, cultures, and behaviors. Their work provides a perspective of our ancestors’ revolutionary journey, a progressive march of human consciousness.

The complex and contentious evolutionary journey—from the cognitive revolution 70,000 years ago to the agricultural revolution about 11,000 years ago, to the scientific revolution 500 years ago, to our current biotechnical revolution—is marked by transformational progressions of conscious beings at the physical, psychological, cultural, societal, and governmental levels.

Each reformation birthed new ideas, morals, and social and governing systems, where ideas about right and wrong were forged, religious wars fought, and nations rose and fell. Each upward push of human consciousness created hostile, reactionary forces. Forces fearfully clinging to the known, rejecting the unknown, and sounding alarms of Armageddon: “Life will never be the same!”

Progress continued in the last century as liberal democracies evolved to promote citizen participation, including diverse racial, economic, religious, and ethnic groups. Within this brief time, much progress has been made (lots more to do) toward rejecting racism, embracing marriage equality, lifting voting restrictions, and, most recently, reconsidering gender stereotypes. As in the past, these reformations have set off strong adverse and fearful reactions.

A meta-perspective reminds us that life is a package deal. Biological, psychological, and sociological change, coupled with activism, are the engines of progress. And with progress comes resistance. Awakening to the upward march of progress and the danger of resistance informs the way we act. Accepting life’s complexity and pluralistic nature requires individuals, communities, and governments to take actions that enhance the arc of progress and to stay the course of building a better, more tolerant, and expansive future. The arc of history demonstrates that being awake is far superior to being asleep at the wheel.

Re-engaging Reality
Unscrupulous forces have hijacked the internet and social media platforms. They disregard facts, data, science, and expertise, making virtually every story, opinion, or pronouncement equally relevant. Podcasts, punditry, and conspiracy theories are no substitutes for trustworthy and knowledgeable expertise. When I was diagnosed with leukemia years ago, I wanted the best minds and most experienced docs by my side. There’s simply no excuse for rejecting expertise and experience.

While our understanding of the truth might vary, depending on our religion or spiritual beliefs, our shared democratic society relies on facts and common sense rooted in experience and documentable observations. Throughout history, when the truth and freedom of speech were eroded, societies and governments fell into the hands of chaotic authoritarianism.

What is a society without a solid foundation of factual information? On the surface, facts and truth may seem obvious, but when doubt is weaponized, our conversations have no solid ground to stand on. There’s no such thing as alternative facts. Ignorance and blind servitude are no excuse. We have an individual responsibility to educate ourselves. Current systems need to be improved to hold social media companies, cable news outlets, politicians, and institutions accountable. Perhaps, the dominion case against Fox News (entertainment) can lead the way.

Individuals, communities, and politicians must re-engage with reality and re-embrace science, expertise, and the authority of institutions. Trust is the foundation of democracy, and rebuilding it requires expertise, honesty, and reliability. It also requires each of us to make wise choices about what voices and opinions we listen to.

More Tolerant, Respectful Conversations
In contentious conversations, we accept our stories and opinions as the truth, fearfully clenching prejudices like racism, bigotry, and misogyny. This stance creates immovable conversations. With our hearts and minds closed, we become prey to untruths and conspiracies—a pattern of protecting rather than questioning our attachment to our beliefs.

David Bohm, a theoretical physicist and philosopher of the mind who is intensely interested in the unfolding of society, developed a process called the Bohm Dialogue. His dialogue offers a radical guide for transforming confrontational and adversarial debates into conversations of deconstruction and synthesis.

Bohm's process asks individuals to loosen the grip of their firmly held stories/opinions and deconstruct their roots, which consist of four archetypal: desires, concerns, power issues, and standards. Revealing and exploring these elements in conversation is the heart of collaboration. Any effort to deconstruct the hold our opinions have on us is like entering a conversation with a closed fist ready for battle fist vs. an open hand willing to be wrong, to have all the answers, and learn from others.

Desires
In conversations, our desires lurk in the background of our minds. We must be more aware of how desires shape our opinions and judgments. They can be a significant blind spot, locking us in unproductive conversations.

Concerns
In working with others and facing challenging issues, we all have concerns about what might happen. You may be worried about what might go wrong, or you might not want tomorrow to end like today. Our unconscious concerns are emotionally triggering and stressful.

Power Issues
In conversations, the question of authority is ubiquitous. Whether you’re a leader, colleague, teacher, parent, or friend, issues of power and control are always playing out, consciously and unconsciously.

Standards
Our standards play an outsized role in our conversations. Our opinions, judgments, preferences, and prejudices are driven by the standards, morals, and scruples we’ve consciously or unconsciously adopted through our families and culture of what is right or wrong, good or bad, pretty or ugly, wise or stupid.

In dialogue, as we share the thinking behind our opinions without others critiquing, a space for listening opens up. As we absorb other perspectives, our minds and hearts can change through synthesis. And as ideas are shared and compared, collaboration shifts into creativity. In a creative conversation, fresh, previously spoken ideas and solutions bubble up, as if by magic.

All three practices ask a lot of us. These are not easy tasks, but given the current situation, we have no choice but to muster up the energy to keep marching forward.

With the upcoming 2024 election heating up and fearful anti-change reactions on full display, we can all affect the outcome by aligning our actions with the evolutionary march upward. We can also hold politicians, social media platforms, and the press accountable by insisting on facts, trusting expertise, and practicing collaborative and creative conversations.