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Floating in the Bathtub of Medicine

Posted on 24 April 2015 by Erica Hoe (Meds 2016)

 

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Having recently finished my psychiatry rotation, I have become more attuned to the importance of mental health in our profession. It’s been estimated that rates of depression are about 15-30% higher in medical students and residents compared to the general population. Adopting a healthy lifestyle can help us to stay afloat in a profession that demands much of our sanity.

I picture myself as a rubber duck. I don’t physically resemble one, at least not usually, but I think it’s a good analogy. I am floating along, happily in the bathtub. I feel weightless. I meet a few bubbles here and there. All’s good.

Once in a while, though, I have patient encounters where I find myself not only empathizing with their struggles, but also bearing their burdens. In the end, it’s like a couple of small bubbles have been added on my back, and I must carry them around on my journey in the bathtub. I carry around these bubbles, and I sink a little lower down in the water. That would be fine, however, in addition to my patient bubbles, I also have “improve your hand-writing and stop losing pens” bubbles, “don’t lose your cool at the anti-vaccinators or the crying babies” bubbles and “smile-and-nod no matter what your preceptor says” bubbles, etc. All as to say, at some point, I have taken on too much. I am expecting myself to stay afloat, when I physically cannot. I have to make some sort of change, or I sink.

 

There are three ways I can help myself from sinking:

  1. Inflate myself with more air and act like a floatation device.
  2. Increase my surface area so I can hold more bubbles.
  3. Just let the bubbles roll right off my back.

 

Let’s start with #1: Inflate myself with air.

 

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This means, I’ll need to breathe more and increase my tidal volume. What better way to do that than through exercise?

A recent JAMA article and 2013 Cochrane review show that exercise causes a greater reduction in depression symptoms than placebo or other interventions like relaxation or meditation.1 Depression has also been found to be associated with lack of physical activity.2

Exercise may provide physiological effects such as increases in endorphin and monoamine levels, and reduction in cortisol levels.2 Exercise stimulates the growth of nerve cells and the release of brain-derived growth neurotrophic factor (BDNF), which is important for learning and memory.2,3 Exercise has the ability to improve executive function and increase neuroplasticity. In fact, neuroimaging studies show that there are changes to areas involved in higher-level cognitive functions such as the prefrontal cortex and hippocampus.3 This improvement allows for a sense of mastery, positive thoughts, and enhanced self-efficacy which all improve mood.3

Even a small amount of exercise appears to be helpful, as there is no indicated type, intensity or frequency that has been associated with alleviating depressive symptoms.2 There is even some small evidence to suggest that exercise may work as effectively as pharmacological or psychological therapy, however more studies are needed.2

Needless to say, do anything active, and your mood will be uplifted. You may even lower your risk for developing depression.4

 

#2: Increase my surface area.

 

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No, this does not mean I physically increase my surface area. Though it would be fun and delicious to binge on junk food, I actually want to increase the proportion of healthy foods that I eat. By eating the right proportion of foods, we gain the energy to power through the day. A good guide is to follow these 5 tips from the Dieticians of Canada5:

  1. Go for whole grains.
  2. Load up on veggies and fruit. Making a smoothie is a good way to get 2-3 servings at once.
  3. Have 2 cups of milk or fortified-soy beverage per day. The Vitamin D is not easily found in other foods.
  4. Choose lean meats or meat alternatives (chick peas, lentils, kidney beans).
  5. Limit saturated and trans fats. Healthier unsaturated fats are found in: avocados, nuts, seeds, oils (olive, flaxseed, nuts, canola)

More tips here: http://www.dietitians.ca/Downloads/Factsheets/5-Tips-for-Healthy-Eating.aspx

 

I was also recently made aware of the positive effects of Vitamin D on depression. A meta-analysis published in 2013, revealed that lower serum 25-OH Vitamin D3 levels were associated with a higher risk of depression.6 In fact, another recent study found that depressed older persons had significantly lower 25-OH and 1,25-(OH)2 Vitamin D3 levels compared with non-depressed counterparts.7 Another study found that lower levels of Vitamin D3 were associated with increased severity of depression and an increased risk for depression.Proposed mechanisms for this association include that vitamin D: 1) has receptors that are distributed in neural areas involved in emotional processing and affective disorders, 2) regulates serotonin synthesis, and 3) impacts the production of pro-inflammatory cytokines that influence mood by activating the stress response.9

Despite these findings, a meta-analysis published this year in March, looks at 9 randomized controlled trials and found that there was no significant reduction in depressive symptoms after Vitamin D supplementation.10 However, these authors do identify that perhaps the duration of follow-up was not yet long enough to determine any effect.10 And, even though Vitamin D was not shown to have a significant effect in those who are already depressed, lower levels are associated with depression, and thus supplementation may play a role in prevention. Given the low cost and limited issues with toxicity, it cannot hurt to take extra Vitamin D supplementation and to incorporate foods that contain Vitamin D into our diet.9 Perhaps this is also a perfect excuse to bask in the sunlight more often.

 

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The Family Medicine Practice Guidelines recommend 800-2000 units of Vitamin D per day in adults.12 The Canadian Cancer Society recommends 1000 units of supplementation to all adults who live in Canada, especially in the fall and winter months. The daily upper limit is 4000 units. Supplementation is contraindicated in hypercalcemia and hyperphosphatemia.12

In addition to taking big gulps of sunlight whenever you get the chance, there are some foods that have Vitamin D. These include: fish like salmon and tuna, liver, fortified milk or soy beverage, fortified orange juice, margarine, egg yolk.11 One glass of fortified milk or soy beverage has about 100 units of Vitamin D. Fish can range between 100-700 units.

For a full list of foods and number of units associated with serving size visit: http://www.dietitians.ca/Downloads/Factsheets/Food-Sources-of-Vitamin-D

 

#3: Let the bubbles roll off.

 

sleepbaby

Finally, what better way to shake it off, than to sleep it off. A meta-analysis of 21 studies showed that non-depressed people with insomnia have a two-fold chance of developing depression compared to people with no sleep difficulties.13 Treating symptoms of insomnia may help to prevent subsequent development of mood dysfunction.13

I mean, just look at that baby.

In order to get good sleep, it’s important to practice good sleep hygiene. This includes not doing any stimulating activities 1 hour before bedtime: no exercise, no big meals, and no TV-watching or use of electronics. Limiting fluid intake before bed can help to decrease the occurrence of nocturia. It’s also really important to decrease caffeine intake especially later in the day.

Going to bed at the same time every night, and waking up at the same time every morning can help, too. Yes, even on weekends. Avoid naps if you can, they throw off your sleeping schedule.

The best way to wind down before sleep is with a good book. Not a reader? Then find another activity to help you relax, whether it’s meditation or listening to music. The worst thing is to think about all your worries before bed. Forget them, or write them down an hour before you decide to sleep. Then, let your body know it’s time to shut down, and let all your problems roll away.

 

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And that’s it, the three ways I’m going to stay afloat in medicine – exercise, healthy eating, and sleep.

  1. Any little bit of exercise counts.
  2. Eat more healthy foods and get enough Vitamin D.
  3. Follow good sleep hygiene.

I think it’s a simple enough concept; sometimes it’s just hard to do. But when I don’t prioritize these things, I sink deeper into the bathtub of medicine and I gradually neglect my own mental health.

After all, if we don’t take care of ourselves, how can we manage to take care of others? And so, today I’ll be going for a run in the sunshine, whipping up a smoothie, and rewarding myself with a plentiful night of sleep. Every minute counts.

 

So, what will you do to stay afloat?

 

References

  1. Cooney G, Dwan K, Mead G. Exercise for Depression. JAMA. 2014. 311(23):2432-2433. <http://jama.jamanetwork.com.proxy1.lib.uwo.ca/article.aspx?articleID=1881295>
  2. Cooney G, Dwan K, Greig C, Lawlor D, Rimer J, Waugh F, McMurdo M, Mead G. Exercise for Depression. Cochrane Database of Systematic Reviews. 2013. <http://onlinelibrary.wiley.com.proxy1.lib.uwo.ca/doi/10.1002/14651858.CD004366.pub6/full>
  3. Erickson KI, Gildengers AG, Butters MA. Physical activity and brain plasticity in late adulthood. Dialogues in Clinical Neuroscience. 2013;15(1):99-108. <http://www-ncbi-nlm-nih-gov.proxy1.lib.uwo.ca/pmc/articles/PMC3622473/>
  4. Mammen G, Faulkner G. Physical Activity and the Prevention of Depression: A Systematic Review of Prospective Studies. American Journal of Preventative Medicine. 2013. 45 (5): 649-657. <http://www.sciencedirect.com.proxy1.lib.uwo.ca/science/article/pii/S0749379713004510>
  5. 5 Tips for Health Eating. Dietitians of Canada. <http://www.dietitians.ca/Downloads/Factsheets/5-Tips-for-Healthy-Eating.aspx>
  6. Ju SY, Lee YJ, Jeong SN. Serum 25-hydroxyvitamin D levels and the risk of depression: a systematic review and meta-analysis. J Nutr Health Aging. 2013. 17(5): 447-455. <http://www.ncbi.nlm.nih.gov/pubmed/23636546>
  7. Voshaar R, Derks W, Comijs H, Schoevers R, Borst M, Marijnissen R. Antidepressants differentially related to 1,25-OH2 vitamin D3 and 25-OH vitamin D3 in late-life depression. Translational Psychiatry. 2014. <http://www.nature.com/tp/journal/v4/n4/full/tp201414a.html>
  8. Milaneschi Y, Hoogendijk W, Lips P, Heijboer AC, Schoevers R, van Hemert AM, Beekman ATF, Smith JH, and Penninx B. The association between low vitamin D and depressive disorders. Molecular Psychiatry. 2014. 19: 444-451. <http://www.nature.com.proxy1.lib.uwo.ca/mp/journal/v19/n4/full/mp201336a.html>
  9. Kerr D, Zava D, Piper W, Saturn S, Frei B, Combart A. Associations between vitamin D levels and depressive symptoms in healthy young adult women. Psychiatry Research. 2015. In press. <http://www.sciencedirect.com.proxy1.lib.uwo.ca/science/article/pii/S0165178115001080>
  10. Gwoda U, Mutowow M, Smith B, Wluka A, Renzaho A. Vitamin D supplementation to reduce depression in adults: Meta-analysis of randomized controlled trials. Nutrition. 31 (3):421-429. <http://www.sciencedirect.com.proxy1.lib.uwo.ca/science/article/pii/S0899900714004857>
  11. Food Sources of Vitamin D. Dieticians of Canada. <http://www.dietitians.ca/Downloads/Factsheets/Food-Sources-of-Vitamin-D>
  12. Guideline for Vitamin D testing and supplementation in adults. Toward Optimized Practice. 2012. <http://www.topalbertadoctors.org/uploads/102912_Bzds37w2W3fC57Vz_92317.pdf>
  13. Baglioni C, Battagliese G, Feige B, Spiegelhalder K, Nissen C, Voderholzer U, Lombardo C, Rieman D. Insomnia as a predictor of depression: A meta-analytic evaluation of longitudinal epidemiological studies. Journal of Affective Disorders. 2011. 135(1-3): 10-19. <http://www.sciencedirect.com.proxy1.lib.uwo.ca/science/article/pii/S0165032711000292>

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