September

Oi vey. September. Here again already.

September used to be my favorite month. When asked my favorite season I used to say fall. When asked my favorite time of year I used to answer with September, the month of my birth.

When Oscar died September 11, 2015, that all changed. How could it not?

This year over the deathday week I am taking my Lane kids to the Pacific Northwest, where their lives all began, to bury the ashes of their father, Nick.

Last year, on September 16th two Overland Park police officers knocked on my front door with the news that Nick had died. It was revealed the next day when I spoke with the detective assigned to his case, that he had died of suicide.

We believe he died on Oscar’s deathday, September 11.

It took the better part of six months for Nick’s family and I to decide what/ how to best honor his memory. At the end of April, we all finally came to an understanding that his memorial service needed to happen during the deathday week- it was my suggestion that we honor him on the deathday itself. Since then all of the arrangements have slowly been coming together.

We are attempting to frame this week not as “grief week” but instead as “healing week”. The Lane family is going to once again attempt to put the “fun” in “fun”eral…

I have felt myself pulling way way in over the past several weeks. It started at the first brush of cooling fall air on my skin during August. This round of grieving has once again made it clear who is with me and who is against me. That is an extremely simplified expression of what is a somewhat complicated human response, but it seems fitting to me. When someone tells you that “you are smarter than that” when it comes to having your grief hijack your emotions it seems fairly obvious that the person is not with you. Truly that last thing you need to hear when you are suddenly overcome with grief is that you should somehow “know better”.

Grief is a visceral response to an impossible change in your reality.

There is no thought involved whatsoever.

That experience has helped me, though, once again, to understand myself alongside my grief with a touch more clarity. This is truly something that I feel my way through. And I feel that I am becoming a little bit better all the time at navigating it.

I have been focusing on my self-care more than usual. The basics: exercise, eating nutritiously, sleep, prayer, meditation, bathing regularly. I have also started a new course of mental wellness products which are focused on balancing the Gut-Brain Axis. I think they are helping because instead of feeling completely emotionally spent with zero energy constantly (which is usually where I live this time of year- all the way through until after the New Year) I feel… okay.

Feeling okay is a miracle.

This year I am giving myself permission to enjoy Fall. It is worth a try.

 

Where Primary Care Nursing and Mental Health Nursing Meet; a labor of my deepest love

Here is the research paper that is the culmination of a course filled with so much deep, confusing emotion. I dedicate this to all of us that have lost loved ones to suicide. May we see the changes in our lifetime that it will take to save the lives of millions more who suffer from the worst antagonist: suicidality.

Abstract 

An area of concern in nursing practice is where primary care and mental illness meet.  Suicide is a disease process requiring an urgent and exponential increase in attention from all members of the community, and where primary care nurses can make a lifesaving impact through education and frequent follow up phone calls.  In 2016, 45,000 Americans died of suicide.  “Research indicates that during 2012-2014, an estimated annual average of 30 million mental health-related physician office visits were made by adults aged 18 and over” (Cherry).  Educating patients on best practices for a healthy lifestyle including mindfulness, diet and exercise has long been a primary treatment for chronic disease processes.  In patients with mental health related office visits, is education on healthy lifestyle including mindfulness, diet and exercise in combination with regular follow-up phone calls every other week from primary care nurses effective in decreasing symptoms of mental illness as indicated by lower patient health questionnaire 9 (PHQ-9) score, fewer office visits and emergency room visits over a 12-week period?  Research was reviewed from four articles found utilizing EBSCO-CINAHL Plus with Full-Text.  Four types of research studies including quantitative, qualitative, mixed method and meta-analysis were reviewed and analyzed. The quantitative and mixed method samples were obtained randomly.  The qualitative method sample was obtained purposively.  The meta-analysis was a review of six randomized controlled trials.  The quantitative and mixed methods articles utilized longitudinal data collection.  The qualitative study utilized cross-sectional data collection.  Sample sizes ranged from 5 patients to 696 patients.     

Introduction 

Nearly one in five adult Americans experience the effects of mental illness ranging from depression to suicidality.  Suicide is a disease process requiring an urgent and exponential increase in attention from all members of the community, and where primary care registered nurses can make a lifesaving impact through education and frequent follow up phone calls.  In 2016, 45,000 Americans died of suicide.  “Suicide is a leading cause of death in the US….Health care systems can provide high quality, ongoing care focused on patient safety and suicide prevention” (OADC).  Lack of mental healthcare resources places primary care clinic registered nurses in a position to fill the gap.  “Research indicates that during 2012– 2014, an estimated annual average of 30 million mental health-related physician office visits were made by adults aged 18 and over” (Cherry).  Treating mental illness as a chronic disease process is where the key to change lies.  Educating patients on best practices for a healthy lifestyle including mindfulness, diet and exercise has long been a primary treatment for chronic disease processes.  “In 2014, there were an estimated 885 million office-based physician visits in the United States” (Ashman).  This illustrates the tremendous opportunity for impact primary care registered nurses can make through patient education. 

Most current nursing research revolves around the role of the psychiatric mental health nurse practitioner instead of the role of the office-based ambulatory care registered nurse.  The gap between primary care nursing and mental health nursing would be further closed if there was one electronic medical record (EMR) to unite all EMRs.  This would also assist the registered nurse as case manager, which is the role supported as most effective in integrating primary healthcare and mental healthcare in current research.  Mental health patients are being lost in the United States healthcare system because registered nurses are not involved in patient care at the primary care level to the degree that they could be and should be. 

The role of registered nurse in bridging the gap between what is considered classic disease management processes such as diabetes mellitus and hypertension, and mental health processes such as depression and anxiety, when it has been studied, shows repeatedly that patients respond with comfort and ease to the registered nurses at their primary care physician’s practices which increases their success in treating the symptoms of their disease processes.  Registered nurses are an extremely important key to a patient’s care.  No other healthcare team member treats patients as an entire human being the way registered nurses are trained to do.  Registered nurses address not only a patient’s physical symptoms, but also a patient’s mental, emotional, spiritual and environmental symptoms, as well.  Because of this, registered nurses are poised at an excellent vantage point to understand a patient’s complete care needs, which makes them especially qualified to intervene on multiple levels to ensure a patient is receiving needed therapies to maximize quality and quantity of life.   

Methods 

Research was reviewed from four articles found utilizing the Cumulative Index of Nursing and Allied Health Literature (CINAHL) through EBSCOhost.  Limitations set for the searches included utilizing EBSCO-CINAHL Plus with Full-Text as well as setting search parameters for the past five years only and searching keywords which included nursing education, nursing, depression, mental health, suicide, machine learning, mindfulness and primary care. All articles were published in the English language. All articles were reviewed and analyzed utilizing Avila University’s Nursing Department Literature Review Protocol for each of four types of research studies including quantitative, qualitative, mixed method and meta-analysis. The quantitative and mixed method samples were obtained randomly. The qualitative method sample was obtained purposively. The meta-analysis was a review of six randomized controlled trials. The quantitative and mixed methods articles utilized longitudinal data collection. The qualitative study utilized cross-sectional data collection. The sample sizes ranged from 5 patients to 696 patients.  

Results 

The first article reviewed was a quantitative study, “Collaborative nurse-led self-management support for primary care patients with anxiety depressive or somatic symptoms: Cluster-randomised controlled trial (findings of the SMADS study)” authored by Thomas Zimmerman, Egina Puschmann, Hendrik van den Bussche, Birgitt Wiese, Annette Ernst, Sarah Porzelt, Anne Daubmann and Martin Scherer.  This study was published in 2016 and took place in Hamburg, Germany in twenty general practitioners’ practices with a total of 220 patient participants.  The patients that participated in the study were chosen by, “a biometrician (AD), not involved in field work” (Zimmerman, Puschmann, van den Bussche, Wiese, Ernst, Porzelt, Daubmann, Scherer).  The sample was obtained utilizing certain eligibility criteria including “a) age: 18-65 years old, b) literacy (German), c) fully able to give consent, d) sufficient auditory and visual capabilities, e) currently not in psychotherapeutic treatment, f) Patient Health Questionnaire (PHQ) scoring 5 points or higher” (Zimmerman, et al.).  Patients were divided 1:1 to either participate in nurse-led care or routine care.  Nurse-led care involved case management and counselling techniques to encourage patients to lead their care plan through self-management.  By the end of the study patients who were in the nurse-led intervention group reported increased self-efficacy as measured by several different scales, including the General self-efficacy scale (GSE scale), PHQ, EQ-5D quality of life and the Freiburg questionnaire of coping with illness (FQCI).  Data collection was longitudinal.  The main barrier to implementing this type of intervention across the board in Germany is lack of economic resources and lack of education of healthcare professionals related to what a registered nurse is capable of in the primary care setting. 

The second article reviewed was a qualitative study, “Feasibility of training practice nurses to deliver a psychosocial intervention within a collaborative care framework for people with depression and long-term conditions” authored by Lisa A. D. Webster, David Ekers and Carolyn A. Chew-Graham.  This study was published in 2016 and took place in the North of England with ten clinicians—five general practitioners (GPs), three practice nurses (PNs), one health assistant and one mental health specialist and five patients (four of which completed the interview).  “Recruitment of clinicians…was by personal invitation from the research team to those participating practices who took part in the service development project.  The invitation was made after two months of working within the collaborative care framework in order to explore the implementation of the intervention within the practice” (Webster, Ekers, Chew-Graham).  The recruitment of patients to participate was also by invitation, which was sent about two months after the patients had received the intervention with an offer for a “love to shop voucher” (Webster, et al) for those willing to give their time for an interview.  Demographics of the patient sample were predominately female diabetics with some form of arthritis or back pain in addition to being depressed.  Demographics of the clinician sample were also predominately female.  Practice sizes ranged from 4,402—25,386.  Data collection was cross-sectional and was completed utilizing semi-structured interviews which were face-to-face for clinicians and via phone for patients.  The results of this study also support the integration of mental health services in the primary care setting, but with one important caveat: tending appropriately to the mental healthcare of the registered nurses who are the leaders in providing and coordinating that level of patient care. 

The third article reviewed was a mixed methods study authored by Brenda Reiss-Brennan, “Mental health integration: Normalizing team care.”  This study was published in 2014 and focuses on nine primary care clinics of Intermountain Healthcare in Salt Lake City, Utah.  Three clinics from each phase of mental health integration were included: potential, adoption and routinized.  Even though this study utilized a mixed methods approach, it is primarily a qualitative study.  The sample included both clinicians and patients.  Fifty clinical staff were selected for balance among team members including physicians, clinic managers, nurse care managers, mental health specialists and medical support staff.  Patients were randomly selected who had received care for depression from their primary care provider (PCP) in the previous twelve months, for a total of 59.  This study tested the effectiveness based on objective and subjective criteria of mental health integration (MHI) which is “a team-based approach where complementary roles include the patient and family and are operationalized at the clinic improving both physician and staff communication” (Reiss-Brennan).  MHI is a standardized approach to incorporating mental healthcare into the primary care setting.  The data collected was longitudinal and was collected via self-report, observation and interview.  Again, the data collected, which included a decrease in emergency department visits and patient-reported decrease in mental illness symptomatology, as well as positive provider reported reactions to MHI, support implementation of mental healthcare via the primary care setting. 

The fourth and final article analyzed was a meta-analysis authored by Kathleen Barrett and Yu-Ping Chang, “Behavioral interventions targeting chronic pain, depression, and substance use disorder in primary care.”  The study was published in 2016 and reviewed a total of six articles with a total of 696 participants.  Four electronic databases were searched including CINAHL, Medline, PsycInfo and Google scholar.  Key words included in the search were as follows: chronic pain, depression, depressive disorders, behavioral interventions and primary care.  Limitations set on the search included articles published during the years 1995 to 2015, available in English, original randomized controlled trials (RCT), adult population and studies that contained a behavioral health intervention.  Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used.  The patients in the study had an average age of 45, with 316 men and 380 women.  Three of the six studies were conducted in the United States, two in Australia and one in England.  All study participants had at least two of the three diagnoses (depression, chronic pain and substance used disorder) during the time of the study.  Two of the six studies were conducted strictly in primary care.  The results of this meta-analysis showed, again, that integrating behavioral healthcare in the primary care setting had a positive impact on patient care through decreased mental illness symptomatology. 

Discussion 

The changes that need to happen to better serve our country’s mental health patient population revolve around nurse-led mental health integration of primary care.  The resources it would take to influence the people who could make this change are tremendous.  The changes that need to be made to standardize mental health integration have already been successfully implemented by Intermountain Healthcare in Salt Lake City, Utah.  To make these changes across the country there will need to be a change in healthcare law.  This begins with one EMR that acts as an umbrella for all EMRs.  There needs to be a way for each of the many pieces of the care puzzle to fit together so that each piece of a patient’s records from different providers can be viewed by each of the team members on the patient’s care team.  This would also allow application of machine learning algorithms to accurately predict suicidality in patients.  In some cases, before the patient is aware of the imminent danger facing them.  “In an effort to contribute to the development of one such method, we applied machine learning (ML) to electronic health record (EHR) data.  Our major findings included the following: (a) This method produced more accurate prediction of suicide attempts than traditional methods, with notable lead time (up to 2 years) prior to attempts; (b) model performance steadily improved as the suicide attempt became more imminent; (c)model performance was similar for single and repeat attempters; and (d) predictor importance within algorithms shifted over time” (Walsh, Ribeiro, Franklin). 

The changes that are needed are possible, but only with the help of big money to lobby lawmakers in the community on a local, state and federal level.  To find funding for this type of initiative nurses would need to contact major non-profit organizations that study mental illness such as the American Foundation for Suicide Prevention (AFSP), the National Alliance for Mental Illness (NAMI) and perhaps the countless of other small non-profits started by parents, family members and friends of those who have died of suicide.  Bringing these voices together as one voice would provide the power needed to move legislation.  This is the tip of the iceberg and would eventually lead to a massive healthcare system reformation.  The first step, though, is to have one medical record that unites them all.  Ideally this medical record would be fluid enough to communicate with most of the EMRs already in existence.  

So many lives are lost every day to suicide.  If the resources were in place to address mental illness where it meets primary care, it is certain that the number of sons, daughters, husbands, wives, ex-husbands, ex-wives, mothers, fathers, brothers, sisters, cousins, aunts, uncles, friends, neighbors and other community members that we lose to suicide would drastically decrease.  The evidence uncovered in this research review supports this without a shadow of a doubt.  “Most patients with behavioral health needs use the primary care office as their main source of care, and given the nation’s shortage or behavioral health providers, this may be the only setting in which behavioral health problems can be broadly recognized and treated” (Crowley, Kirschner).  Bottom line is there is a huge need for nurses in primary care who are able and willing to implement changes once they are legislated either as part of health care law or part of their health care entity’s updated care standards at the place where primary care nursing and mental health nursing meet.   

References 

Ashman, J. J., Rui, P., & Okeyode, T., (2017). Characteristics of office-based physician visits 2014. National Center for Health Statistics Data Brief (no 292). Hyattsville, MD. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db292.htm 

Barrett, K., & Chang, Y. (2016). Behavioral interventions targeting chronic pain, depression, and substance use disorder in primary care. Journal of Nursing Scholarship,48(4), 345-353. doi:10.1111/jnu.12213 

Cherry, D., Albert, M., & McCaig, L. F., (2018). Mental health-related physician office visits by adults aged 18 and over: United States, 2012–2014. National Center for Health Statistics Data Brief (no 311). Hyattsville, MD. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db311.htm 

Crowley, R. A., & Kirschner, N., (2015). The integration of care for mental health, substance abuse, and other behavioral health conditions into primary care: Executive summary of an American college of physicians position paper. Annals of Internal Medicine,163(4), 298. doi:10.7326/m15-0510 

National Center for Health Statistics., (2016). Depression. Retrieved from https://www.cdc.gov/nchs/fastats/depression.html 

Office of the Associate Director for Communications., (2018). Vital Signs: Suicide rising across the US, more than a mental health concern. Retrieved from https://www.cdc.gov/vitalsigns/suicide/index.html 

Reiss-Brennan, B., (2014). Mental health integration: Normalizing team care. Journal of Primary Care & Community Health, 5(1), 55-60. doi:10.11/2150131913508983 

Walsh, C. G., Ribeiro, J. D., & Franklin, J. C., (2017). Predicting risk of suicide attempts over time through machine learning. Clinical Psychological Science,5(3), 457-469. doi:10.1177/2167702617691560 

Webster, L. A. D., Ekers, D., & Chew-Graham, C. A. (2016). Feasibility of training practice nurses to deliver a psychosocial intervention within a collaborative care framework for people with depression and long-term conditions. BMC Nursing,15(1). doi:10.1186/s12912-016-0190-2 

Zimmermann, T., Puschmann, E., Bussche, H. V., Wiese, B., Ernst, A., Porzelt, S., Daubmann, A., Scherer, M. (2016). Collaborative nurse-led self-management support for primary care patients with anxiety, depressive or somatic symptoms: Cluster-randomised controlled trial (findings of the SMADS study). International Journal of Nursing Studies,63, 101-111. doi:10.1016/j.ijnurstu.2016.08.007 

 

 

 

Nick

This season is hard for me. My oldest son Oscar’s deathday is September 11, 2015. This year I was working hard through it. I posted about how much better I felt this year and how much hope I had for my new nursing position as a triage nurse in a primary care clinic. And I made it through Oscar’s deathday and the week surrounding it and I did okay. The most okay I have done since the year he died.

I was beginning to start thinking about the rest of the holiday season and how Nick (my ex-husband and the father of my oldest three– Oscar, Pierce and Vivian) and I would work out some sort of new parenting schedule in court soon that would be focused on the kids’ safety. How good it would be to have that settled and with hope that Nick was doing the work to get clean again and be a healthy example to the kids. That is all I ever wanted from Nick, truly, was for him to get clean and sober.

Instead, on Sunday, September 16th, in the late afternoon, two police officers knocked on my front door. I picked up my little Shih Tzu, Andy, and answered the door. I invited them inside and they stepped in gratefully as it was one of the last of our hot days here in KC, but when they saw my daughter, Vivian, sitting on the living room sofa they said maybe it would be best to speak outside. My heart dropped. We went out front and they told me that one of Nick’s neighbors had called for a wellness check and Nick was found in his apartment deceased. All of the physical ways that I had responded to Oscar’s death happened. My knees got weak, my stomach immediately tied itself up into knots and I had to sit. I sat on the front step and the tears came. I knew deep down what had happened. Nick died of suicide on Oscar’s deathday. And that is what the investigation has revealed thus far. Swirling horrid nightmare.

Over the next several days, when I had to face this gaping hole in my family’s life with zero grace from the world around me (no bereavement leave for an ex-spouse– not even when you have underage children that were fathered by that ex-spouse), a shining light has been shone on what I have been doing since Oscar died. I have been doing what I know how to do as a scientist (that is the core of what a nurse is): researching to make sense of the way my oldest son had died. And I have learned so so much about mental illness and suicide. I have come to a place of solace and understanding related to suicide.

Now that Nick has died of suicide I need to be able to put it in a box and walk away from it. I need to be able to have days where it doesn’t come up in conversation, especially about and with patients. So I made an extremely careful, well-thought out and thoroughly discussed with my nuclear family members decision to go home to the operating room. I crave the feeling of family and support that I have in the operating room, as well as the standard of care that goes along with caring for surgical patients. The first month that I was away from the OR in primary care I dreamed about the OR nearly every night! Luckily for me my OR family needs me as much as I need them and so I will be starting at Menorah again on October 22nd. My last day in primary care was yesterday. Even though I cannot afford financially to take the next week off from work I absolutely need the time to regain my sense of balance and my own mental health. I won’t do anybody any good if I push myself so far that I cannot work because I have a mental breakdown.

School has been a real struggle since Nick died. I have been heavy into researching where primary care and mental healthcare meet and the results are humbling. I need to put it all together in a research paper over the next couple of days and I am not going to lie, I am procrastinating it. Thinking about suicide and mental illness and how it tears people’s lives apart and away from them and how simple it would be to fix the problem makes me kind of queasy. The disconnect is that the change starts with one electronic medical record (EMR) that is like an umbrella over all of the varying different electronic medical records currently in existence. This umbrella EMR would translate each patient’s multiple medical records into one place where clinicians could view all of the symptoms and interventions that the patient has experienced. This would also allow the application of machine learning algorithms to predict suicidality in patients and allow for early intervention, in some cases before patients might even understand themselves the danger they are in. Such a simple change, but a change that will only happen with roots in change to healthcare law. That feels like moving a mountain to me.

Nick’s death has made it clear to me that I need to take care of myself and get back to living for me. Whatever that means. Right now that means focusing on my children and our health. When our family celebrates Nick’s life it will be in the summer, at the family plot at the cemetery on Sand Hill in Washington state. The weather will be beautiful, we will release butterflies and listen to Death Cab for Cutie’s song “St. Peter’s Cathedral” (Nick always told me he wanted that played at his funeral) and maybe share a meal together at Pat’s Little Red Barn. We will focus on hope and love and what it takes to make healthy choices in order to lead our lives away from the darkness that consumes our family members all too easily and causes them to die of suicide.

Rest in peace, Nick.

3 years

At this time three years ago I was reeling with the new reality that my oldest son, my sweet beautiful prince, was dead.  His time of death was pronounced at 0523 this morning three years ago.  There is so much about that time I cannot remember.  My friend, Sara, who is also a bereaved mama saw all of the spirit coincidences that were happening all around me all the time and she told me I should write it all down because I wouldn’t remember if I didn’t.  There was no space for writing.  At that time the only things I could tolerate were the work it took to keep my house running and coloring.

Occasionally I’d have the extra capacity to read a little bit and after I got through a couple of short grief-centered, other-side-centered books I turned to fiction, which is so rare for me.  I have a preference for non-fiction, always with my nose in some kind of self-help book, especially since I got clean in 2012.  This was different.  So different.  My brain could not tolerate real.  I had just gotten the ultimate and unwanted dose of real.  I even thought I couldn’t be a registered nurse anymore for awhile.  I channeled that energy into returning to school, where I am now almost finished with my BSN.  The series I managed to get myself lost in right after Oscar died is called Abarat.  I’ve been thinking eventually I will revisit those books.  Perhaps when I finally finish school…

I remember there was always some sort of amazing and seemingly not possible coincidence happening right after Oscar died.  I think he was manipulating things from the other side to help us adjust to his death.  I still feel him all the time with me, guiding me, an unseen friend.  Everything from a penny from heaven with my birth year on it that seemed to appear out of nowhere when I was taking Vivian roller skating on Sunday to my nursing career.

Today I have found a niche in nursing far far away from the operating room, which is where I spent the better part of ten years.  I loved surgery, but when Oscar died and I wasn’t sure I could even continue being a nurse I knew I needed to change.  Recently I began working in a primary care physician office.  It feels like the absolute right fit.  The physician I work for is like minded and extremely supportive of my work in suicide awareness, prevention and loss support.  Today I am diligently working to make a difference for patients with mental illness through education and support, as only a nurse can.  It is a very special niche and one that I am hoping to expand.  The class I am taking this semester is evidence based practice for nurses, and of course, true to form, I am researching how nurses can make a difference at the place where primary care and mental health meet.  This is such an important focus.  For so many reasons.

So today, three years after my oldest son Oscar’s death I have hope.  My mantra is, “I am healing and I bring love and the energy of love to every shadow.”  All for Oscar.  I miss you, I love you, there will never be enough of you, my sweet sassy first born son.

 

poem

yearning to hear his voice

smell his skin

touch his face, his shoulder, his hair

look into his beautiful eyes

his eyes like rare jewels with a spark of knowing

always with a hint of mischief

i want to say the words one more time

so he can hear them

oscar i love you

you are my life, my soul, everything that is good about me

my reason for living

my first baby

you have taught me everything about life that is worth knowing

please don’t go

please stay

but it is too late for all of that

he is already gone

he has already left

the pain i feel cannot be defined by words

every single moment i feel his absence

whether waking or sleeping

i feel his absence

my life is now defined by the death of my oldest child

his death from a disease shrouded in taboo

and not understood

largely because it makes people uncomfortable to speak the words

pediatric suicide

The World Before and The World After

I was living in a world full of hope, happiness and love before Oscar died. I believed that so long as I kept putting my recovery first, which included all of the time that I was spending on myself to go to meetings, play music and exercise, that I was setting an example for Oscar that would somehow rub off on him. Somehow it would inspire him to recover from his depression. Before Oscar died I lived in a world that avoided conversations about suicide. I lived in a world that denied the reality of mental illness. A world that believed mental illness was a choice.

The world I lived in was like a beautiful, fragrant garden. An early morning garden where the leaves and petals of the plants and flowers are still covered in a soft, filmy dew. A garden full of bright colors and rare blossoms. The warm morning sun slowly melting away the chill of the night before. Steam, like fog, slowly creeping into the brightening sky.

After Oscar died the world instantly plunged into darkness. While my eyes were adjusting to the lack of light I had to use my hands to feel my way in this new place. I would slowly reach forward, shyly testing my new boundaries. The pain no matter where I placed my hand, or how gingerly I attempted to discover the new terrain was shocking. All sides of this new world pressed in on me, causing the greatest pain I have ever felt. The world that was once bright and full of hope was now small, black and lifeless.  Suffering was my new companion. As I slowly, so slowly, learned to integrate this new sensory stimuli my vision began to see another world. As my brain began to make sense out of this new stimulus my understanding of life without Oscar grew.

The world I live in now, two years since Oscar died, is gray. There are moments of joy and happiness. Pierce, Vivian and Phoenix’s smiles always bring light. I have learned how to carry the weight of my grief. I can see the garden again, it is just colorless now. The fragrance of the sweet blossoms has gone. It is shrouded in a gray haze.

I see things that I didn’t see before. Life is now defined by death. My extreme ignorance regarding mental illness has been replaced with the keen wisdom of lived experience and a clinical understanding grown from hours of research. Mental illness is not a choice. Suicide is a disease process that affects certain regions of the brain, particularly the prefrontal cortex and the anterior cingulate cortex. Suicide has it’s own cluster of diagnosable symptoms.

Also in this new world, one where Oscar is dead, I have a new sense of the other side. I feel Oscar on the other side. I feel his spirit self. His angel self. He has been making himself known to me through dreams and impossible coincidences since the moment of his death, when he crossed from this plane of existence into the other. The first time that Oscar hugged me in a dream after he died I felt an incredible comfort, like an itch was being scratched that I could not reach no matter how hard I tried. Within that dream, after that dream hug, Oscar said to me, “Mom, keep yourself open to me and I will be able to keep doing the work that needs to be done.” And so I do, and so I will.

In this brave new world without a living, breathing Oscar I will keep having the conversation that no one wants to have, the one about pediatric suicide.

Depression and Suicide as Chronic Inflammatory Disease Processes and the Effect of the Standard American Diet versus the Mediterranean Dietary Pattern for Treatment

Depression and suicide are very personal for me. On September 11, 2015, my oldest son, Oscar, died of pediatric suicide after being diagnosed with depression in April of the same year. He was 15 years old when he died. We had followed the widely accepted formula of therapy (weekly even) and antidepressant medication to no avail. In the months following his death I was devastated and confused, yet motivated to find answers. The language commonly used when people talk about others who die of suicide didn’t sit well with me, I felt myself revolting at a cellular level every time I heard someone try to comfort me by saying that “he had a choice”. I had seen how hard he had tried to live. I had seen how he had treated his little brother and sister so kindly and with such concern and compassion, I would often refer to him as “my little mother hen”. He was always so concerned about everyone around him and their safety and well being. And as I started to research depression and suicide more deeply, both scholarly articles and the lived experiences of other suicide loss survivors and suicide attempt survivors, I became more and more convinced that he didn’t have a choice, that suicide is a disease process not understood.  

Earlier this year I read an article online that approached depression and suicide as a chronic inflammatory disease process and I was fascinated! I felt a complete eureka moment and decided to buy the cookbook mentioned in the article, Anti-Inflammatory Eating for a Happy, Healthy Brain by Michelle Babb, MS, RD, CD. I felt a difference in not just my mental health, but in my body as well, after implementing the suggestions and recipes in the cookbook on a limited basis (my family has been slow to adjust to and embrace the new lifestyle recommended by this cookbook). Research repeatedly states variances of: “The Western dietary pattern…has been associated with higher cardiovascular disease (CVD) risk and worse levels of biomarkers of endothelial dysfunction and inflammation. Moreover, physiological and biological links between CVD, inflammation and depressive disorders have been repeatedly suggested. Therefore, it is plausible that some mechanisms implicated in the genesis of CVD could be also shared by depression.” (Sánchez-Villegas, Almudena, et al.) Moreover, the standard American diet (SAD), is, indeed, making us not just sad, it is making us suicidal. The SAD is known for high amounts of inflammatory producing ingredients, namely refined sugar, saturated fat, sodium and processed grains, i.e. easy to eat processed foods. And who can blame us when it is cheaper and easier to go through the drive through at a fast food restaurant than it is to grocery shop and cook at home? One of the characteristics of our Western culture is the desire for instant gratification and nothing is as quick and easy as the SAD. The SAD provides us empty calories which are low in antioxidants because it is a dietary pattern that lacks fresh fruits and vegetables. The result is inflamed brains that are depressed and suicidal. “In one study, researchers discovered an association between oxidative stress and suicide attempts. Those who had attempted suicide had significantly higher levels of oxidative metabolites in their blood as well as lower antioxidant levels.” (Babb, Michelle) A very recent study utilizing positron emission tomography (PET) shows a positive correlation between markers for inflammation and depression with suicidal ideation. “…we have replicated the first PET findings of increased translocator protein (TSPO) availability…in the anterior cingulate cortex (ACC) of medication-free patients in a major depressive episode (MDE). Our findings add support for the presence of a neuroinflammatory process in major depressive disorder (MDD) and for TSPO as a therapeutic target. Trials of anti-inflammatory agents in MDD have indicated that they might be most effective in a subset of individuals with heightened inflammation, suggesting that a more targeted ‘personalized’ strategy might be a successful approach to treating depression.” (Holmes, Sophie E., et al.) It seems obvious that our diets affect our brains.

An anti-inflammatory diet is basically the Mediterranean Diet Pattern (MDP), and so that has become the lens through which I frame educating my loved ones about the changes we are making to our diet. The Mediterranean Dietary Pattern (MDP) emphasizes the consumption of vegetables, fruit and nuts, cereal, legumes, and fish. Because of this the MDP has a healthy monounsaturated- to saturated fatty acids ratio of 1:2. “The MDP is associated with better glucose metabolism, reductions in blood pressure, and protection against abdominal obesity, the metabolic syndrome, and higher high density lipoprotein cholesterol levels.” (Sánchez-Villegas, Almudena, et al.) The importance of omega-3 fatty acids for protection against inflammation is profound. Omega-3 fatty acids are polyunsaturated fatty acids (PUFA). In Western countries over the past one-hundred years our intake of omega-3 fatty acids has declined significantly. Currently, our intake of omega-6 fatty acids (which are found in abundance in processed foods and vegetable oils) is twenty times that of our average omega-3 intake. “Given that approximately 20% of the dry weight of the brain is made up of PUFA and that one out of every three fatty acids in the central nervous system (CNS) are PUFA, the importance of these fats cannot be argued. Considering that highly-consumed vegetable oils have significant omega-6 to omega-3 ratios, it is quite plausible that, for some individuals, inadequate intake of omega-3 fatty acids may have neuropsychiatric consequences. While far from robust at this time, emerging research suggests that omega-3 fatty acids may be of therapeutic value in the treatment of depression.” (Logan, Alan C.) This is more evidence that we are on the right track to changing our mental health by changing our diets.

Further research is needed to verifiably correlate the SAD with TSPO in the human brain to diagnose suicide. This is my main focus of interest considering my personal experience as a suicide loss survivor. Once TSPO has been isolated and identified in brains of those with suicide reliably, forward progress can be made in researching specific modulations to those individuals’ diets and the effect of the MDP on what we expect to see as a decrease in TSPO, and therefore, a decrease in the symptoms of suicide. I think it is important to focus on TSPO since it is possible to isolate that particular protein and visualize it via a PET scan. It is important to choose one diagnostic criteria and utilize it until a standard of care can be established with the evidence provided by repeated clinical applications. 

Another point that needs to be addressed is education. When we are constantly bombarded by mass advertising campaigns showering us with all of the latest techniques in marketing it is impossible to resist grabbing that soda, hamburger, or candy. This is why a massive public health education campaign must be developed to combat the modern advertising efforts of major corporations who are more interested in their bottom line than the health of the general public. These efforts will change the conversations we are having about depression and suicide. It has never been more clear to me that depression and suicide are chronic inflammatory disease processes. How exciting that we have the opportunity to treat these diseases of chronic inflammation with simple dietary changes! By choosing vegetables, fruit and nuts, cereal, legumes, and fish we are choosing a happy, healthy brain.  

My favorite cookbook is Anti-Inflammatory Eating for a Happy, Healthy Brain by Michelle Babb, MS, RD, CD. One of my favorite things about this cookbook is that the author wrote it with the symptoms of depression in mind and how they would affect a person as they are attempting to make such a massive change in their life. She did this by rating each one of the recipes in the cookbook on a difficulty meter of one to five. Most of the recipes in the cookbook are on the low end of the difficulty meter, which puts a large number of different recipes at your disposal right away. One of my favorite recipes from this cookbook is Southwestern Burrito Bowl  (Difficulty Meter of 2). It has quinoa and black beans as the main protein ingredients, baby kale (or spinach), fire-roasted peppers (which I was able to purchase at Costco!), frozen corn, green chiles, pico de gallo, shelled pumpkin seeds, and an avocado.

Another reason I love this cookbook is because she gives you a complete guide in the first pages of the book on not just why an anti-inflammatory diet is important to brain health, but how it works to change your brain. She discusses the benefits, uses and also storage tips of each of the ingredients she suggests for your pantry. And then to top it off she offers three different menu plans with shopping lists, each for a full week of happy, healthy eating!!  The following recipe is easy, incorporates fairly common ingredients, and it tastes great. What do you have to lose by trying it?

References

Babb, Michelle. Anti-Inflammatory eating for a happy, healthy brain: 75 recipes for improving depression, anxiety, and memory loss. Sasquatch Books, 2016.

Holmes, Sophie E., et al. “Elevated Translocator Protein in Anterior Cingulate in Major Depression and a Role for Inflammation in Suicidal Thinking: A Positron Emission Tomography Study.” Biological Psychiatry, 2017, doi:10.1016/j.biopsych.2017.08.005.

Logan, Alan C. “Omega-3 fatty acids and major depression: A primer for the mental health professional.” Lipids in Health and Disease, Biomed Central, 9 Nov. 2004, lipidworld.biomedcentral.com/articles/10.1186/1476-511X-3-25.

Sánchez-Villegas, Almudena, et al. “Fast-Food and Commercial Baked Goods Consumption and the Risk of Depression.” Public Health Nutrition, vol. 15, no. 3, 2012, pp. 424–432., doi:10.1017/S1368980011001856.

Sánchez-Villegas, Almudena, et al. “Association of the Mediterranean Dietary Pattern With the Incidence of Depression.” Archives of General Psychiatry, vol. 66, no. 10, Jan. 2009, p. 1090., doi:10.1001/archgenpsychiatry.2009.129.

Halloween, Signs from the Other Side and an Exciting New Study, “Machine learning of neural representations of suicide and emotion concepts identifies suicidal youth”

Holidays really suck when you are a bereaved mother.  My ability to “buy in” and fully participate with the general public, let alone my own family, is differing levels of non-existent.

The year that Oscar died I was unable to carve pumpkins.  Halloween was our favorite holiday.  I remember when Oscar was really little how we would plan his costumes for weeks.  He was Spiderman, Frodo from the Lord of the Rings, he was Link from Zelda. Each costume with it’s own special story.  The last year he dressed up for Halloween he created the character “Sir Edward of Hoppington”, he was almost 13 at the time.

This year, the second year into life without Oscar, and the third Halloween since he died, I tried so hard to do little things for myself starting at the end of August to make this fall season less terrible.  I bought pumpkin spice soap and pumpkin spice lotion because aromatherapy is very helpful for me.  I didn’t pre-judge what I was going to feel.  I started with a new therapist.  I pushed myself to get out into the garden by planting a memorial garden with my family on Oscar’s deathday.  And even though last year I was able to buy pumpkins and carve them with my other children this year I could not even look at pumpkins.  No.  I pushed myself past them every time I was at the store.  Even now I feel the little swirl of grief inside my chest as I think about pumpkins.  Such is grief.  Of course, I apologized abundantly to my daughter, who is 9.  She understands, or she says she does.  “It is just too hard,” I tell her.  And she nods her head yes and rubs my arm and gives me her sweet little hugs.  She replies with, “It’s okay mama.”  Oh the life of a bereaved mother.

Oscar sends me little messages from the other side on a regular basis and yesterday morning, Halloween morning, he sent me a new study.  I woke up to find an alert on my twitter feed about a new study that was just published in Nature Human Behaviour. (https://www.nature.com/articles/s41562-017-0234-y?platform=hootsuite) I took a glance at the article, “Machine learning of neural representations of suicide and emotion concepts identifies suicidal youth” and I immediately felt a rush of curiosity.  I could not wait to read more.  This study is so incredibly exciting because it uses functional MRI to actually look at and identify definitively the brains of youth with suicidal ideation!!!  Of course we need to recreate results using larger study groups, and do all the good things we do in science to prove things over and over in order to declare truth, but oh my goodness, what a huge leap forward!!  They even had a brief story covering this new study on NPR yesterday morning!

I started reading the study in full this morning, All Saints Day.  As I was taking it in the tears rolling down my cheeks, I felt not like a little glimmer of hope, but like a full ray of sunshiney, warm, bright hope was parting the clouds for all of us suicide loss survivors. Hope that with a test like this to determine suicidality biologically, instead of relying on self-report, that we can save more lives.  If only Oscar had been able to sit for an fMRI so we could know exactly his risk for suicide… he was such a brilliant mind, he knew how to play the system.  It was impossible to tell if he was teenage angsty or truly suicidal. With this, we would have known beyond a shadow of a doubt and we could have treated him differently, more aggressively, for his suicidality.  I am excited to see this diagnostic tool be studied more.  Deepest gratitude to the clinicians behind this ground breaking study who recognized the need for a biological indicator to identify suicidal youth.

Oscar

My name is Jessica Lane, but everybody calls me Jes.  I am a mother, a recovering addict, an operating room nurse and a bereaved mother.  My oldest son, Oscar, died of pediatric suicide when he was 15 years old.  I found his lifeless body the morning of September 11, 2015.  It was a Friday.  The Friday that changed everything.  Time is not the same for me anymore.  Life is not the same.  Neither is death.

Shortly after Oscar died it became very very clear to me that suicide is not a choice. Suicide is a disease process that we don’t understand.  Oscar’s death motivates me to understand and educate others about what I learn related to suicide, death, grief, and mental health.

Since Oscar died I have been researching suicide.  At first I could only look at grief support groups for suicide loss.  The Alliance of Hope for Suicide Loss Survivors was my first home after Oscar died.  I have participated in local suicide grief support groups.  I have returned to school to finish my Bachelor’s of Science in Nursing.  All of my research projects are through the lens of suicide loss.  One of my favorite grief activities was participating in Megan Devine’s writing course this past spring.  She inspires me in so many different ways.

Nothing was ever easy about Oscar.  He was always challenging, he questioned everything.  He was gifted and he had transitional disorder.  He was diagnosed as depressed at the beginning of May the year that he died.  His first words were, “why” and “wow”.  He was always manipulating his world, building with Legos, building model aircraft online, folding paper into origami or airplanes, and he was a puzzle master.  He had an incredible spatial awareness and relationship with his environment that was genius.  His depression was existential and was refractory to standard treatment: medication and talk therapy.

I will write when I can and share my research regularly.  In fact, I will be posting my final paper for my nutrition class shortly titled “Depression and Suicide as Chronic Inflammatory Disease Processes”.

This blog is for the love of Oscar and all kids like him; dead too soon of a disease that is not understood.