Maya Adam:

Welcome to Health Compass. I'm your host, Maya Adam, director of Health Media Innovation at Stanford Medicine.

Victor Carrion:

It's not an all or non phenomenon, and you can be resilient in certain areas of your life and less resilient in others. You can be more resilient today than you were yesterday, so it is very dynamic. What we want to do is have youth practice the skills that they're developing when they're feeling certain amount of stress.

Maya Adam: 

Stress and resilience are enormously important factors that can make or break our mental health. And this topic is a growing concern for many of us, especially those of us with teenage and young adult children. Today we're talking about some key pieces of the mental health puzzle from diagnosis and management to emerging research that's planting new seeds of hope. My guests are Victor Carrion, the director of the Early Life Stress and Resilience Program who specializes in youth mental health. And Laura Roberts, chair of the Department of Psychiatry and Behavioral Sciences. I spoke with Victor First. Victor, thank you so much for joining us today.

Victor Carrion: 

Hi, Maya. It's so nice to be here. Thank you for the invite.

Maya Adam: 

Victor. As I was reading the beautiful interview that you did for the Stanford Medicine Magazine, something caught my eye. Can I read it to you?

Victor Carrion: 

Sure.

Maya Adam: 

You said trauma is the focus of my research, and I know as well as anyone how harmful trauma can be. How did you first see how harmful trauma can be in childhood?

Victor Carrion: 

I was working with youth and I was listening to their stories, but what hit me harder was how sometimes they were being, and their symptoms were being misinterpreted. So for example, many children that experience traumatic stress develop a certain hypervigilance and around stability. Their amygdala sometimes is firing really hard, and sometimes that was being misunderstood as hyperactivity. Children that experience trauma also sometimes appropriately so use dissociation as a defense mechanism. We all know about the fight or flight response to experiences that are threatening. However many times children cannot fight. They're too small and they cannot fly right? They are dependent. They cannot say, I'm just going to go away. So then they just freeze and they have dissociation as a normal defense mechanism. What happens is that sometimes this defense mechanism gets used a lot. You can create dissociative problems and disorders, but dissociation was also being misinterpreted as inattention.

And many of the children that I was seeing was being misdiagnosed as having attention deficit hyperactivity disorder. And as a consequence, they were also being not treated correctly. They were giving stimulants, which was not making their PTSD any better. Of course, the clinical scenarios are more complicated than that, and sometimes you have clinical pictures were both are present, A DHD and PTSD, and sometimes having a DHD puts you at risk. In this field, we have something called allostatic load, which in my team, we call the backpack that we all carry, which is the accumulation of stressors throughout life. And we are built in a way, and we'll talk about this, I think that we can manage carrying that backpack. But if you are 5, 6, 7 years old and your backpack is really heavy, you may fall backwards. I've become very concerned about how much we sometimes want to protect this generation from any stressor at all.

And I think that that has the problem that sometimes children do not develop problem solving mechanisms. They don't develop their own coping skills, they become less resourceful. And that first half of that inverted U-shaped curve is exactly about that. It's almost inoculating the body with amounts of stress like a vaccine where the individual can start developing an armamentarium of what's helpful to them or where they're good at, or where their support systems are, what their coping tools are, so that when that other big stressor comes, be it a pandemic or something else, they have a toolbox. They know where to extract resources from. Without that inoculation, without those little problems of daily living and having children confront them and attempt to solve them themselves, it is difficult for them to develop that.

I really don't like when people think that children are resilient by virtue of being children. There's nothing really in the scientific literature that supports that. In fact, we know the opposite is true, that they're more vulnerable. That's why we take care of them. If a group of children and a group of adults go through the same traumatic experience, let's say an earthquake, the rates of post-traumatic symptoms in the youth would be higher than in the adult. We have a treatment that we've developed for children that experience traumatic stress and develop functional impairment as a consequence that we call Cue Centered therapy. And we have a training program that's available online, part of it called Cue Centered Therapy Training Program. Part of this training, and part of this therapy is the construction of an actual toolbox for youth, where we teach them a certain number of tools and they decide if they're helpful for them or not.

And if they decide that they're helpful, then they put them in the toolbox. So we teach them things that are not surprising, that everybody has heard about things like deep breathing, for example, muscle relaxation, visual imaging exercises of mindfulness. Then they go, they practice those and they're invited to create their own. And if they're musicians, for example, and playing the guitar is something that relaxes them playing the guitar then goes into the toolbox if they want. And it is very interesting. There's an element of empowerment and self-efficacy here. That is key because the instruments that they develop themselves and that are unique to them and their personality and their style usually end up working better than anything else that we teach them. So the first step is to open the lines of communication. And I like to say open the lines of communication, because many times it doesn't mean that when we want to talk or when we are ready to talk, they are ready to talk, but they certainly need to know that we are available for when they are ready.

They can come to us and they can do that. So it helps to say, there are no secrets here. I noticed that sometimes you struggle with X, Y, and z. I would like to teach you some exercises and you can let me know if these work for you or not. And for some kids, some kids will sit there and say, okay, teach me. The majority of them would walk away and not pay attention to anything else that you have to say. But they may come back. They may come back and say, oh, when you talk about that, what were you trying to say? What do you want to teach me? So when it is about breathing, it is very important to let them know that there is a biological component of this where we're basically consuming and bringing more oxygen into our bodies, and that oxygen goes into hemoglobin and it goes through the blood into the muscle and helps that muscle relax and invite them to have that experience with you.

And I say with you, because modeling is very important. If we really want to teach them breathing, if we want to teach them mindfulness, if we want to teach them relaxation, if we want to teach them not to use their phone during dinner time, we have to do the same. We cannot ask them to do that and then model to them the opposite behavior. There are some reports that kids that become really addictive to the behavior of the using their telephone and engaging in social media constantly have an increase in anxiety and increasing depression. And that definitely seems to be happening. But we also have to remember that during the pandemic, social media and technology in general was very critical to maintain the social ties for some kids and also to even conduct their academics. So what do we have here? What we have is a tool and every tool, it can be used well, and also it can be misused.

So what I like to do is I tell parents about the use of a hammer, and when they brought a hammer for the first time to their house, they just didn't just hand their hammer to their 5-year-old and the 5-year-old spend the whole day hammering everything in sight. They told them what it was was for when to use it, how it helped. They demonstrated its use modeling again. And the same thing. The same thing with technologies, with the phone, with social media. Let's get the good out of it, and let's put some guidelines that work for our family so that they don't jeopardize our health. Everything that we do in access is negative, right? Sleeping, eating, talking, anything, really, everything has to be balanced. The same with the use of this technology. There are a lot of stressors, and the important thing is to recognize them and to talk about them and to develop the skills to manage the stress that they come with.

As I mentioned, children are not resilient by virtue of being children. They're actually more vulnerable. The fact that they have these experiences they're having, I would look at that as an opportunity to study how they're managing them and what skills can they develop to problem solve, for example, and take care of their own distress, usually by developing emotional maturity, developing cognitive flexibility. And the thing about resilience is that it's not an all or non phenomenon, and you can be resilient in certain areas of your life and less resilient in others. You can be resilient, more resilient today than you were yesterday. So it is very dynamic. What we want to do is have youth practice the skills that they're developing when they're feeling certain amount of stress. We'll talk about technology in a second, but because there's hope there. But my real hope comes from the fact that every year we admit a new medical school class, and many of those individuals will end up going into fields related to mental health,

And they come different from what previous generations brought there. They come with all of this experience we've been talking about today. So for them, that's baseline. They know they need to build from there. So it gives me hope to know that there's youth now interested in helping youth, and the way they're going to do that is plentiful. We then have to work. We cannot wait for them to come to us. It might be too late for them when they show to our clinics. So we have to go where they are. We have to go to schools, we have to go to community centers. We have to work in group. And so I'm very hopeful about work that is being done at schools and centers that are being built in communities where other individuals that may not necessarily be mental health professionals, but can be trained to give some type of interventions are accessible to do that.

And that includes parents education to parents on issues of mental health. Having podcasts like this one, congratulations very much for doing this because it's spreading the word, getting the information out for people to know, when should I be concerned? When should I be wary? Oh, when I see functional impairment, not necessarily when I see anxiety, because we are all anxious individuals, all anxious beings. So little things that people can learn can help them take care better of themselves and of our kids. So going to where kids are working with others and using technology, using technology in a positive way, in a way in which with oversight, with accountability, we can really develop instruments to assess individuals and even treat, or at least partially treat individuals while let's say they are on a wait list and waiting for a long period of time. And you were asking me, oh, but what do you exactly teach them?

And Pure Edge, which are our partners, are a very good resource for this, pure Edge inc.org. Dot org. They actually have a lot of exercises that we've developed together called Brain Breaks and invite students to take these brain breaks. And it's all through the teachers actually. It's all through training the teachers so that the teachers can bring it to the classroom. But these are accessible, they're free. Anyone can use them. You don't have to be a teacher. If you're a parent, you can go to pureed inc.org and learn some of these brain skills. They're available in Spanish because they've been working with me for a long time, so they know I'm doing work in Puerto Rico in Spain, so we have them available for Latin America populations as well, and mainlands Spanish speakers and other languages as well. So it's a great resource, and that's just one example of many resources that are out there.

The American Academy of Child and Adolescent Psychiatry, acap acap.org has a section called Facts for Families. That's also very helpful. First, we take our own pulse, right? And first, we make sure that we are maximizing what we can do to have good health, to be able to take care the best we can of our family. Kids get very worried and kids get very preoccupied when they don't see their parents healthy, and it's not totally selfless. It's part of evolution. They know they're dependent on this individuals, and they better be competent and they better be safe, and they better be secure. And that's what they want to hear. They want to get that message. They want to get that message that we have the capacity to maintain them safe, to maintain them secure. This is particularly important when something tragic happens in the community, and kids get very upset to let them know that that's my role. That's why I'm here. I'm here to keep you safe. So first, take care of yourself. Second, send that message. Third, that invitation to communication. It is more difficult during the teenage years because unfortunately, one of the reactions that teenagers have is this withdrawal and isolation. But if they know that the door is open for them, then they'll come and talk when they're ready.

Maya Adam:

Yeah, that's fascinating. So we really have to look after ourselves first, make sure we are solid, that signals solidity and stability to the child, and then watch for obviously any functional problems, any struggling in the children as well.

Victor Carrion: 

Yes, and the rule of thumb there that I mentioned earlier, I think, is we want to look for how they're functioning. We can all be depressed at times. We can all be anxious at times. We're all humans. It's part of our humanity to be sometimes preoccupied, to be sometimes a little obsessive. But how do we know it's a problem? And how do we know when it needs treatment, but how do we know it's a problem? And how do we know when it needs treatment? It is when it affects our function. So we need to look at how they're doing in school or how they're doing at work. We need to look at how they're doing in their relationships with their family, with their friends, and what level of distress are they experiencing. If none of those areas are affected, they can be as obsessive as they want.

Maya Adam: 

Thank you for making the time to share your wisdom with us, and I look forward to continuing the conversation in the future.

Victor Carrion:

Thank you so much.

Maya Adam: 

Hearing from Victor about how he approaches mental health in young people was really interesting for me, especially because I have three teenagers myself. I also reached out to Laura Roberts, who chairs the Department of Psychiatry and Behavioral Sciences to ask her about the state of mental health globally, how the pandemic impacted our mental health and the latest treatments that are giving many people hope. Here's what she had to say. Laura, thank you so much for being with us today.

Laura Roberts: 

Thank you. It's really a pleasure to be with you,

Maya Adam: 

Laura, before we start talking about the state of the world's mental health, I always love to ask our guests to tell us a little bit about your backstory, what brought you to medicine, and specifically what led you into the field of mental health?

Laura Roberts: 

Oh, well, thank you so much for asking. I was the daughter of a surgeon and a nurse, so the last thing I was going to do was go into medicine, but I started working with emotionally disturbed children at a school, residential school for emotionally disturbed children, basically just as a job when I was in college and in graduate school, and having the insights that I drew from my medical background of my family, and I saw how the children were cared for in this residential school. It made me a very fierce advocate for children with mental health issues, the need to clarify if there are underlying medical or biological issues that are the basis of some of their mental health issues. And I ended up going into medicine, going into psychiatry, and then child psychiatry, and then have had this wonderful privilege of leading in my field for now many years.

Maya Adam: 

Wonderful. Yeah. I guess we all are committed as youngsters not to follow in the paths of our parents, and then we find that we turn into them at some point. Right. It's really true. It's Laura. In recent years, it seems like we're hearing more and more about the importance of mental health, and at the same time we're in the midst of a global mental health crisis. Can you tell us a little bit about what's driving that crisis?

Laura Roberts: 

Sure. First, I want to thank you for asking the question that way, because I do think there's more thoughtfulness about the importance of mental health and resilience and wellbeing, and that's kind of the silver lining of this current situation. But objectively, there really is more of a worldwide problem around mental health, and particularly since the pandemic. So just a few facts. There are about a billion people in the world living with a significant mental health condition that would meet criteria for a formal mental health diagnosis. So not merely distress as important as that is, but really symptoms and signs that significantly affect the ability to live your life and to work and to take care of your family and yourself. There is an increase in these conditions. More women than men are affected throughout the world, and about half of the adolescents in the United States now qualify for meeting criteria for mental disorder.

So it's a very significant issue. Now. For many years, the years of life lost to disability, that's kind of a full term in epidemiology, the years of life lost to disability, it's been, mental disorders have been the number two contributor throughout the world for a very long time, for decades. But with the pandemic, there are certain conditions that have just become much, much more prevalent. So there's been a 25% increase in anxiety disorders throughout the world, a little bit more than that, about 28% increase in depression related disorders throughout the world post pandemic. And as I say now, about a billion people are living with very significant mental health concerns. Another thing besides the pandemic is, well, I guess it is directly related to the pandemic, is we've lost so many people throughout the world to covid and Covid related conditions. There are about 7 million confirmed deaths due directly to Covid and more than 27 million people who died throughout the world from related conditions to Covid.

So they call those excess deaths. Every one of those 27 million people had someone who loved them, and often entire families were grieving and really feeling the loss of those individuals, really the tragic loss of those individuals. So there's the direct impact of the distress. There's the grief that goes with it. And now including climate change, there are so many displaced people throughout the world, so about one in 70 people throughout the entire world has been forcibly displaced either through war or the impact of climate change. So if you just kind of put that all together, you've got people who are grieving, people who've been displaced and have lost the familiar home that they've been in. You already had baseline issues around mental health, and then the distress of the pandemic and all of its implications of increased depression, anxiety. And then you've got an aging world. So the world is growing older. That's wonderful. People in many countries where there was really a shortened lifespan now are leading full lives. But it means that by 2050, we'll have double the number of people who are over age 60, who have 2 billion people who are in later life. And we know that people who are aging have more mental health and cognitive kinds of issues. So it's a reality. It's an objective reality that we've got more mental health burden and that trend is going to continue.

Maya Adam: 

And Laura, is there a place in the future for digital health technologies like ai?

Laura Roberts:

Yeah, and in fact, that's where there's just tremendous promise. Not only are there digital strategies that make access easier, there's evidence based delivery of care through digital strategies, including new approaches with ai. So it might be text message, asynchronous text messaging that helps support mental health. We've already talked about how you can have in real time a very easy access to a mental health provider through digital strategies. And then we're doing a lot to scale up using digital health supports to try and bring evidence-based mental health care across the world. The other exciting thing I've never seen in all these years that I've been in psychiatry right now, we have these transformational new approaches. So in the past, there was maybe different kinds of medication that would make a difference, and there were different kinds of psychotherapies that would make a difference and really tailored psychotherapies.

And then you found that if you put medication and psychotherapy together, you would have unbelievably good outcomes for people with living with mental health issues. But now there's kind of these new approaches to brain circuitry stimulating and targeting very specific places in brain circuitry for really significant health issues like obsessive compulsive disorder or treatment resistant depression, different kinds of PTSD. And so we're seeing conditions that really were lifelong burdensome conditions, very disabling conditions, having cures or remission, and a lot of that work is happening in our department. It's just an incredibly exciting time. So we've got evidence-based strategies, we're scaling and bringing them to more communities. We've got transformational new approaches that are probably cures or creating periods of remission. It's really an exciting time in the field.

Maya Adam: 

Wow. I read in the Stanford Medicine magazine that you're a huge proponent of facilitating collaboration between bench scientists and clinicians. Why is that important? And can you maybe start with the definition of the different roles for people who might not be in the medical world?

Laura Roberts: 

Yeah, yeah. No. So they call it translational neuroscience, which sounds very kind of fancy, and it is really fancy actually. The techniques they use and the methods they use and the kind of intelligence that goes into is incredible. But really the simple idea is can we learn something that's fundamental about how the brain itself works and then using that knowledge come up with something that's just different and that kind of a new way of thinking about mental health disorders. So a great example around translational neuroscience is we understand that yes, there are cells and there are neurotransmitters. So medications have been working with cells and bundles of cells and neurotransmitters for many years and have really brought a lot of benefit through those things. So we knew that the brain is made up of cells. We knew that basic knowledge of the brain and neurotransmitters allows us to develop with medications that can make a difference.

The other thing we know is that these cells, as I said earlier, organize in these different bundles and come up with circuits and tracks in the brain, and that the functions of the brain are managed by these kind of bundles of cells or tracks of cells. The dysfunction of the brain often is managed that same way. And so by targeting areas of dysfunction in these circuits or bundles of cells and being very precise in where we target them, we can try to turn off dysfunction or augment good function in the brain. So that's where these stimulation approaches are really helpful. So we know that certain kinds of functions like fight or flight, really old evolutionary things, impulse control, are managed in certain areas of the brain. So by stimulating those areas of the brain, we can really turn up healthy function, return down dysfunction. So a lot of these new circuit based regulation strategies I mentioned earlier around OCD for example, or trauma depression, those are managed by these circuits in the brain, and there's just a lot of sophistication now around how to target and stimulate certain areas to reduce symptoms and improve function.

Maya Adam: 

Let me ask you this, you do so much for other people each and every day, and you have for so many years. What do you do to look after yourself?

Laura Roberts: 

I think for me personally, the sense of purpose, I've obviously talked about that a lot. I love taking care of and supporting other people. I get so much joy and so much sustenance personally from seeing other people do their best work and feeling like somehow find blocking and tackling or behind the scenes even helping them in some way. It's just infinitely joyful for me. It does a lot for me. I think I work with wonderful people, so seeing how, I don't know how they manage the hardships of life, especially with their patients and learning from them. I'm constantly learning from my colleagues and all that they do and try to apply what I can. I feel a lot of love for people and people who are in my family and in my life, and so I feel very grateful for that. So taking care of relationships and having friendships. Friendships are incredibly important, and I think it's something that people sacrifice a lot. So I think nurturing those friendships is extremely important.

Maya Adam:

Wonderful. Well, we wish you the best of luck and we will continue to follow your work, and thank you so much for making the time to meet with me today and speak with everyone.

Laura Roberts: 

That's great. Yeah. Thank you.

Maya Adam: 

Thank you. I learned a lot from my conversation with Dr. Laura Roberts today. She talked about the importance of naming and understanding where our feelings are coming from. She talked about the importance of some basic lifestyle behaviors, like getting enough sleep, eating well, and moving. She talked specifically about yoga and how effective that can be for basically building our reservoir of resilience. She also talked about the need to seek help when we need help, and the power of helping others. I think that's something that's extremely underrated. We feel better when we help others. What a wonderful takeaway message. Thank you for listening. If you like what you heard today and you want to keep up with Stanford Medicine's Health Compass podcast, you can find more episodes on the Stanford Medicine YouTube channel, or wherever you find your favorite podcasts. See you next time. Thank you.