With May being Mental Health Month, we sat down with Neill Epperson, MD, professor and chair of the CU Department of Psychiatry, for a wide-ranging conversation about expanding mental health resources and services to the CU Anschutz Medical Campus and broader community in the midst of the COVID-19 pandemic, her new “Mind the Brain” podcast, the state of mental health in Colorado, and why the brain is so intriguing.
CU Anschutz Today: How is the COVID-19 pandemic impacting our mental health?
Neill Epperson, MD: Depression, anxiety, insomnia, post-traumatic stress and increased use of alcohol and other substances are already on the rise and will likely be the second wave of this pandemic. Clearly, individuals who have experienced these problems in the past as well as those who are newly in the process of recovering from a mental health or substance use condition are at high risk for illness relapse.
However, other groups are also at risk. Those on the frontlines who are most proximal to the threat of illness, loss of their own life as well as that of their patients, are at high risk though they may experience a delay in onset of symptoms. It is not uncommon for those closest to the trauma, whether a natural disaster, terrorist attack or pandemic, to be so engaged in managing the crisis that they do not process the impact on their mental and physical health until the crisis subsides.
How does your new podcast, “Mind the Brain: Mental Health in the Time of COVID-19,” address the mental health challenges we’re facing amid the pandemic?
When social distancing first began, we realized that this was going to be a very difficult time for everyone. Human beings are very social creatures. Positive social contact helps us to manage our anxieties, distress, and uncertainties. During the first weeks of the pandemic the focus was on resilience and coping strategies. We and others provided many resources and tools via online and other virtual formats to help individuals of all ages and situations “manage” the crisis.
While resilience is clearly important to weathering this unprecedented global threat, I became increasingly concerned that our singular focus on resilience, support and “coping” could backfire… resulting in increased stigma, diminishing an individuals’ willingness to seek formal mental health care. It is so easy to think that resilience means that we can “take it,” we can experience these tremendously adverse events and not experience insomnia, post-traumatic symptoms, depression or anxiety. In reality, resilience is far more complex. To admit that one is suffering takes tremendous strength. To overcome mental illness or a substance problem demonstrates true resilience.
Dr. Epperson recently launched the new podcast, “Mind the Brain”.
I was particularly concerned about my physician colleagues. We are trained to be team leaders, healers, to put our personal distress aside in order to provide the best care possible for our patients. While this is clearly part of our role, our mission, it can lead us to ignore our own needs for support and yes, psychological counseling and/or medications.
I created “Mind the Brain: Mental Health in the Time of COVID-19” with the CU Anschutz Office of Communications as a forum for us to discuss mental illness, substance misuse and addictions in addition to resilience. All of the data we have at this time, indicates that mental illness is going to be the second wave of this pandemic. While we may have a vaccine in the coming month to years, the psychological sequelae of this pandemic will live on. My goal is to make sure that people can benefit from help, do not suffer in silence out of shame, guilt or lack of access to care.
How are you and your team working to expand mental health resources and services to the CU Anschutz campus and broader community in the wake of the COVID-19 pandemic?
In addition to the terrific resources on our website COVID-19 Support, we created a warmline for individuals who need rapid access to emotional support. We also created virtual support groups for students, residents, staff and clinical faculty and non-clinical faculty. We engaged with our colleagues at the University of Colorado Hospital and Children’s Hospital Colorado to offer virtual “teams” support groups. More than 400 people have used these groups to process clinical events, family stress, uncertainty, feelings of guilt and grief and anxieties about so many aspects of this pandemic. We have now been asked by public and mental health authorities to extend these resources across the State providing us with the opportunity to help an increasing number of Coloradans.
What fascinates you most about the brain?
Pretty much everything! Who we are, how we view ourselves, our personalities – the processes that we refer to as “the mind” – all of these are essentially rooted in the central nervous system- neural chemicals interacting with each other within and between functional neural networks. Some people don't like that definition of personality or the mind, because it sounds relatively reductionist: like all we are is just all a bunch of neurochemicals in our brain communicating with each other. I'm comfortable with that.
We don’t judge how the heart works. We don't believe that the importance of the heart is diminished just because we understand that its function is to pump blood to the body. The importance of the brain is tantamount to how we function in the world today.
What is the relationship between mental health and physical health?
Mental health is about brain health. We can't separate brain health from the health of other organ systems.
There is a direct relationship between what happens in the central nervous system and other parts of the body. The brain controls many organ systems, and if your brain is not working well, then you can have illnesses in other parts of the body, and vice versa. If your heart is not working well – blood flow to the brain can be compromised – seriously impacting brain function, cognitive processes, and your mood. If you have an inflammatory problem, or cancer, or any number of other health conditions, the brain health can be adversely affected.
What's different about treating brain illnesses versus heart disease or a broken limb is that we ‘are’ our brain to some degree. How we think about things, what we find funny, serious or worrisome, and our response to our environment, is very much driven by the central nervous system. We may worry that our personalities will change, that we may be cognitively impaired after our treatment. So treatments that impact our brain can be very scary, striking at the very core of who we are.
We also know that the environment that you grew up in – whether you suffered poverty and maltreatment, or were lucky enough to have a very supportive, loving and well-resourced childhood – can have an enduring effect on the brain. When treating central nervous system disorders like psychiatric or substance use conditions, it is important to consider these early life events. These events can impact how a person responds to both psychotherapies and pharmacotherapies.
Why can it be difficult for people to know if they need to seek mental health support?
What sometimes makes it difficult for people to know that they need to seek mental health care is that emotions are normal. Stress is normal. We all experience happiness, sadness, fear, anxiety, and stress. That difference between having emotions and having those emotions impact your functioning is a very difficult boundary to be able to distinguish.
It's tough for folks to know, "When do these emotions become problematic? How do I know when they're severe enough, or I feel sad enough long enough? Is my anxiety now reaching the point of panic? Does my anxiety get in the way of my going to work or going out and having fun with my friends?"
For people who think they may need mental health support, why is it often difficult for them to seek help?
Unfortunately, in 2020, stigma about mental health conditions is still rampant. It’s one of the reasons people don't seek care. They think, "I’m feeling a little sad, but I'll just get over it.” The idea of talking about their issues can be very scary. And a lot of people don't really know what happens when you go and talk to a psychiatrist or a psychologist.
‘That difference between having emotions and having
those emotions impact your functioning is a very
difficult boundary to be able to distinguish.’
What I tell people is that if you feel there's any question that you're not functioning as well as you would like to, then seeking help is the right way to go.
Why do you think stigma around mental health support is still so persistent?
One of the reasons I think stigma exists, but it's only one, is that people don't recognize that we actually have really good treatments for mental illness. People can get better. Many mental health conditions are actually curable.
Years ago, before we had really wonderful and effective treatments for cancer, cancer was highly stigmatized. I think that there is a direct benefit from knowing that what is bothering you – the condition that you're experiencing – actually has a name and is treatable. It's something that we have to make people aware of so that they understand it's true for psychiatric conditions as well as it is now true for cancer conditions.
How can we decrease the stigmatization of mental health conditions and the act of seeking treatment and support?
It will help decrease stigma the more we educate people about how common mental illness is. Fifty percent of people in the United States and worldwide are going to suffer with a mental health condition of some sort in their lifetime. In Colorado, one out of five individuals will have a mental health condition this year alone. How can you stigmatize something that is so common and affects so many people?
There is an immense need here in Colorado for mental health services. Unfortunately, we have about 25 counties where there is no practicing psychiatrist or psychologist, and that's just unacceptable. Even in counties where we do have psychiatrists, psychologists, and social workers, there are not enough to meet the mental health needs of that particular population or region. We have to do a better job of thinking strategically about how to get mental health services out to these other regions in the state.
What is the biggest difference in behavioral health research and treatment today, versus when you started working in this field?
When I first started my training in psychiatry in the 1990s, we had relatively few medications. Prozac was just released to the market. We had very few evidence-based psychotherapies to treat various psychiatric conditions, like post traumatic stress disorder, social anxiety, phobias, and OCD. We have these treatments now, and they are effective. We have much more information about the specific profile of the individual, the kinds of symptoms they experience, and how to modify our treatments to target those particular patient profiles.
Why did you choose to focus the majority of your clinical and research work on women’s mental health?
I chose to study women, because at the time women were often left out of research – not just in psychiatric research, but in medical research in general. Though women are increasingly included in research today, many investigators still do not examine outcomes by sex or gender. As a result, we know less about women than men in terms of how they respond to medications, and the kinds of treatment we should offer them.
We also know that hormones have a dramatic impact on brain health. Women undergo dramatic hormonal fluctuations every month when they have a menstrual cycle. I observed women in my practice developing depression, anxiety, psychosis, insomnia, and many different types of behavioral health conditions during these periods of hormonal fluctuation. I became fascinated by the profound effect hormones have on the brain.
From left, Drs. Nanette Santoro, Neill Epperson and Judy
Regensteiner map out the intersection of the primary issues
of focus for the Center for Women’s Health Research.
Regensteiner is director and co-founder of the CWHR.
I am also fascinated by hormones because people don't mind talking about hormones. People might feel stigmatized if they talk about mental health, but talking about hormones is cool. You become the most popular person at the party when you tell people that you study hormone effects on the brain. People, particularly women, are curious about how hormones change the way they feel, think, and believe.
Where has your research and clinical work into the effect of hormones on the brain taken you?
Roughly one out of 10 women who have just given birth will experience depression or what we refer to as postpartum depression. They often feel that they're a bad mother, and they question why this is happening to them at a time when they're supposed to be so happy.
What most people do not realize is that pregnancy is like one big hormonal gymnastics. Women go from experiencing really high hormone levels during pregnancy to, within 24 hours after delivery, having those hormone levels plummet to their socks. That is a major adjustment for the brain. This concept is foreign to most people. They think, "It's a major adjustment for my body to deliver this baby,” but they don't think about the fact that it's a major adjustment for their brain.
Can you talk about the important breakthrough your team made regarding pregnancy and the brain?
One of the major breakthroughs in the Department of Psychiatry this past year was the finding that choline, which is a nutrient in various foods, is critical to fetal brain development. We know that the in utero environment is one of the most important times in an individual's life. People think of birth as the start of life, but conception and what happens to the developing fetal brain during pregnancy is also critical for that individual's risk or resilience to mental health or mental illness later in life.
If a woman has low levels of choline during pregnancy, this can have an adverse effect on the fetus' neural development. Our researchers found that if you treat women with choline, you can decrease the negative effects of depression, anxiety, infection, and marijuana use during pregnancy on fetal brain development.
This is such an important finding that the American Medical Association has put forth guidelines recommending that women have a certain level of choline intake during pregnancy.
Given the fact that about 15 percent of women will experience depression during pregnancy, about a third of women are using cannabis at the time of conception – at least here in Colorado – and about 50 percent of women will have some kind of an infection during pregnancy, increasing choline levels during pregnancy could protect not only this generation from the adverse health effects of these maternal physical and psychological states, but generations to come.
How does being part of the CU Anschutz Medical Campus help you further your research into the brain and translate your findings into effective treatments?
One of the most exciting aspects of being a psychiatrist today and conducting research in neuroscience here on the CU Anschutz Medical Campus is that we have a number of state-of-the-art tools and techniques that allow us to access and understand how the brain is working far more than we ever have before.
For example, through deep-brain stimulation, we can put a probe in a very specific area of the brain to treat severe Obsessive Compulsive Disorder, or OCD. We can use brain imaging to visualize what happens when we give medications to patients, and to understand how early life adversity has an enduring impact on the way the brain functions when a person is performing a cognitive task. We can see the brain regions that are critical for those particular tasks.
We can measure neurochemistry in the brain, and how those neurochemicals interact with each other. This was unthinkable 20 years ago.
What have you learned from your research and clinical work about how early life experiences affect aging?
Early life experience can have an enduring impact on risk and resilience for depression, anxiety, cognitive outcomes, and even cognitive aging. On average, women today live a third of their lives in a post-menopausal state. We know that estrogen has a profound, positive effect on many aspects of brain function. To live a third of your life in a low- estrogen state was unheard of 100 years ago, when life expectancy for a woman meant she was likely to die around the time of menopause. For some women, living without estradiol is going to cause a problem. These are the people that I treat, and these are the people that I study. I want to understand ‘Why them and not someone else?’
One of the things we discovered is that early life adversity can have an impact on someone's risk for depression or cognitive changes when they go through menopause. Using functional brain imaging and novel neuroimaging techniques, we’ve seen that for people who have adverse childhood experiences, their brain actually functions differently when they try to do a complex cognitive task than somebody who didn't undergo those experiences. These cognitive changes can make it difficult for women to balance their home life, work life, and all the tasks they have to do.
As a psychiatrist, I can't go back and change what happened to one of my patients when they were a child, but if I give that post-menopausal woman estrogen, we may actually reverse the effects of those adverse childhood experiences.
What are your goals for the Department of Psychiatry and the communities you serve?
My goal for the Department of Psychiatry is that we are a top-five department in the nation. That means we're doing cutting-edge research that is impactful and changes peoples' lives. My goal for the state of Colorado is that we enable all Coloradans to live without mental illness and to enjoy the most fulfilling lives possible.
Our motto for the Department of Psychiatry is “Brain health for all, for life.” We believe every Coloradan should have access to state of the art evidence-based mental health care. We say "for life" because psychiatry and mental health are critical for a good life, and it’s reflective of our belief that one has to think about the whole lifespan of the patient when one considers the treatment of mental health conditions.
What keeps you up at night?
I try to get a good night sleep, because I believe sleep is important for mental health, but what keeps me up at night is knowing that there are people suffering needlessly from mental health conditions, either because they don't know that they're suffering from a clinical depression or anxiety disorder, they're afraid to seek treatment, or they feel stigmatized. When they do seek treatment, they find it challenging to find a provider they can afford. Those issues are very upsetting and very concerning. I know that we can do better. We must do better.
What do you find most gratifying about your work?
As a psychiatrist, you’re often working with someone who comes to your office in tremendous psychological pain. That psychological pain actually can be experienced physically. When you can bring hope to that individual and then over the course of several weeks to months get them back to what they consider their normal state, it is exceptionally rewarding. You can see that pain falling away from them.
There is still much to learn, but the brain is not a black box anymore. It is complex, but let's face it: this is the organ that is at the seat of who we are. Don't we hope it's complex?