Helen Kim, MD Director, HCMC Mother Baby Program and Hennepin Women’s Mental Health Program Department of Psychiatry Hennepin County Medical Center www.mnwomensprogram.org

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<ul><li>Slide 1</li></ul><p>Helen Kim, MD Director, HCMC Mother Baby Program and Hennepin Womens Mental Health Program Department of Psychiatry Hennepin County Medical Center www.mnwomensprogram.org helen.kim@hcmed.org Minding the mother and restoring natural rhythms to support the mother-baby relationship Slide 2 Outline I.Definitions: mind, mindsight, mentalizing II.What interferes with mindsight? III.Psychiatric illness as brain/mind disorders that include disruptions in energy and biological rhythms IV.The role of psychiatrists and medication V.Functional or integrative medicine as a lens to interpret mind/body symptoms Slide 3 Mission: To support families by strengthening the emotional health and parenting capacity of mothers Slide 4 Mission: To support families by strengthening the emotional health and parenting capacity MINDSIGHT of mothers Slide 5 MIND Slide 6 Definition of Mind by Daniel Siegel, MD Mind: an embodied and relational process that regulates the flow of energy and information. An emergent process that arises from energy and information flow within you and between you and others Slide 7 Mindsight the ability to reflect on the mind or mental states of oneself and others. emerges from within attachment relationships that foster such processes. essential in healthy relationships a learnable skill I am sad vs I feel sad Slide 8 Mindsight is a kind of focused attention that allows us to see the internal workings of our own minds. It helps us to be aware of our mental processes without being swept away by them, enables us to get ourselves off the autopilot of ingrained behaviors and habitual responses, and moves us beyond the reactive emotional loops we all have a tendency to get trapped in The focusing skills that are part of mindsight make it possible to see what is inside, to accept it, and in the accepting to let it go, and, finally, to transform it. Dan Siegel, MD Slide 9 Mindsight -- seeing the mind 1) Insight into oneself 2) Empathy for others 3) Integration within you and your nervous system and between you and others Intepersonal Neurobiology -- the study of mindsight Slide 10 Mentalize To be aware of mental states (desires, needs, feelings, reasons, beliefs) that drive reactions and behaviors of ourselves and others To feel and think about feeling at the same time A psychological skill that allows one to understand the internal state of oneself and another Occurs on intellectual/conscious level Occurs on a gut/intuitive level An old idea --- Descartes, Theory of Mind, Fonagy (mentalizing in the context of attachment relationship, Arietta Slade (mentalizing in context of parenting; reflective functioning) Slide 11 Mindsight - noun Mentalize - verb Nonjudmental curiosity, acceptance, compassion Mindfulness of the mind of self and others; Mind mindedness, reflective functioning, psychological mindedness Empathy for self and others Slide 12 Mentalizing as a Compass for Treatment Jon G. Allen, PhD, Efrain Bleiberg, MD, and Tobias Haslam-Hopwood, PsyD, The Menninger Clinic http://www.menningerclinic.com/education/clinical- resources/mentalizing Mentalizing as conceptual compass to help patients understand how staff approach treatment Shared understanding and shared goals as foundation for sense of were in this together Slide 13 Why is mentalizing important? Self-awareness: to reflect on and communicate our feelings/thoughts Self-agency: Understanding that behavior doesnt just happen but is based on mental states. I am responsible for my behavior Self-regulation: I feel angry vs I am angry I am not my feelings Relationships: feeling felt by another provides sense of connectedness/security; promotes understanding, intimacy Finding meaning from suffering and hope Resilience Mentalizing as a Compass for Treatment Jon G. Allen, Slide 14 Why is mindsight or mentalizing important? Responsibility Regulation Relationships Resilience Slide 15 "The whole idea of thinking about thinking is that we learn about ourselves through being understood by other people. Babies learn about their feelings by having their feelings understood by someone else." ~ David Wallin David Wallin Slide 16 Slide 17 What interferes with mentalizing? Strong emotions: shame, anger, fear ---&gt; flight/fight/freeze Defense strategies: repression, denial, avoidance, suppression Apathy/indifference: I dont care whats in my mind or yours Psychiatric illness: depression, anxiety, substance use, mania, psychosis Slide 18 Psychiatric illness as disruptions in biological rhythms and energy Maternal depression or anxiety inhibit mindsight and/or the ability to mentalize disrupt biological rhythms and energy Stabilizing a mothers biological rhythms is essential before she can synchronize with her babys rhythms. Parents as brain scientists or curators of the mind: Compassionate stance Non-judgmental curiosity Awe and wonder Slide 19 Depression is the number one complication of childbirth (Wisner, NEJM 2001) Perinatal Depression: 10% in general population 25% in high risk groups Perinatal Anxiety: 7-10% Gestational Diabetes: 5% pregnancies Slide 20 Kessler RC, et al. J Affect Disorders 1993;29:85-96 Women have 1.5-2.5 x rate of depression vs. men Lifetime prevalence: 21.3% women and 12.7% men Slide 21 Psychosis Slide 22 50% of women with PPD have depressive symptoms during pregnancy Slide 23 Risks of Untreated Depression/Anxiety Poor self care, nutrition, and prenatal compliance. Increased smoking, alcohol, drugs Increased ob/neonatal complications, such as preterm delivery Increased attachment and behavioral problems More pediatric visits for behavioral problems and injuries Slide 24 Maternal Depression and Risk to Early Parenting Children 0-3 years old are most vulnerable to risks of maternal depression due to rapid brain development and sole reliance on caregiver Slide 25 Childrens Defense Fund of Minnesota. (2011). Zero to Three Research to Policy: Maternal Depression and Early Childhood. www.cdf-mn.org Maternal Depression and Risk to Children Slide 26 Total annual cost of not treating 1 mother with depression = $22,647 Cost of not treating the mother = $7,211 Cost attributable to a child born to a depressed mother = $15,323 Cost of untreated maternal depression for mother and baby Wilder Research, Oct 2010 Slide 27 Slide 28 Slide 29 Slide 30 Waiting until behavior is a problem is not early detection/early intervention Psychiatric illness -- disorders of the brain/mind that can manifest in behavior changes* Mind behind the behavior as the target Early intervention starts prenatally and with parents/children Brain/Mind Science vs Behavioral Health *Thomas Insel, MD, NIMH http://www.ted.com/talks/thomas_insel_toward_a_new_understanding_of_mental_illness Slide 31 Slide 32 Are psychiatrists just prescribers and behavioral health providers? You need to see a psychiatrist = You need meds Slide 33 Slide 34 Slide 35 STRESS Slide 36 STRESS affects mind/body and ability to mentalize Difficulty sleeping Headaches, body or joint aches Poor energy Poor concentration Altered appetite Digestion problems Heart problems High blood pressure Irritability/anger/depression Slide 37 Stress, Depression and Anxiety through a Functional Medicine lens Slide 38 Slide 39 Personalized medicine that deals with primary prevention and underlying causes instead of symptoms for serious chronic disease. Based on these principles: -Biochemical individuality - Patient-centered medicine -- "patient care" vs "disease care - Web-like interconnections of physiological factors - Health as a positive vitality not merely the absence of disease What is Functional Medicine? www.functionalmedicine.org Slide 40 Slide 41 1)Hormone and neurotransmitter imbalances 2)Energy, mitochondria, and oxidative stress 3)Detoxification imbalances 4)Immune and inflammation imbalances 5)Gut and digestive health 6)Mind-body dysrhythms Some clinical imbalances underlying chronic medical conditions: Slide 42 Chronic Inflammation: the common final pathway to chronic disease Slide 43 Slide 44 Is depression an inflammatory condition? Acute inflammatory response necessary for trauma or infection Overactive immune or inflammatory response harmful: autoimmune disorders, RA, IBS, asthma, allergies, MS, celiac, thyroid Chronic inflammation drives some chronic diseases: heart disease, obesity, diabetes, and depression Pro-inflammatory cytokines cause physical and psychological symptoms (malaise, low mood, low energy, sleep disturbance) called sickness behavior which resembles depression Neurotransmitter-focused theories of depression have been limited Depressions connections to inflammation and immune dysregulation offer other treatment options Psychoneuroimmunology: the study of the CNS and immune system Slide 45 What causes chronic inflammation? Stress Toxins SAD diet Lack of exercise Hidden allergens/infections Slide 46 What do you need to thrive? Safety Sleep Healthy Foods/Healthy Digestion Light, water, air Movement Love, community, connection Purpose Slide 47 Slide 48 Sleep Slide 49 SLEEP Average sleep in 1900 --- 9 hours Study of 669 middle-aged adults found people sleep much less than they should, and even less than they think. (Am J Epi, 2006) White women 6.7 hrs/night White men 6.1 hrs/night Black women 5.9 hrs/night Black men 5.1 hrs/night Poor sleep less than wealthy. Slide 50 National Sleep Foundation Sleep in America Poll 2003: % reportingSlide 51 Slide 52 Sleep deprivation: the costs Inhibits mentalizing (mind-blindedness) Irritability Poor concentration Increased inflammation Makes you fat Increased risk of accidents Slide 53 Healthy Nutrition and Digestion Slide 54 Slide 55 Standard American Diet (SAD) High sugar High processed food -- think Twinkies nutrient poor, high calorie High in animal fats High in unhealthy fats: saturated, hydrogenated Low in fiber Low in complex carbohydrates Low in plant-based foods Slide 56 Food Rules by Michael Pollan 1) What should I eat? -- Eat food 2) What kind of food should I eat? -- Mostly plants 3) How should I eat? -- Not too much NAD: Real food, fresh fruits and vegetables, lean protein, moderate amounts of healthy fat, adequate fiber Standard American Diet to New American Diet: From SAD to NAD Slide 57 Slide 58 Healthy Digestion Bacterial balance: Healthy gut has 3 pounds of good bacteria that digest your food, help regulate hormones, excrete toxins. Immune system protected by thin layer that lines the gut. If barrier damaged, can set off immune and and inflammatory reactions Slide 59 Enteric nervous system 100 million neurons line the gut (more than the spinal cord) Butterflies, pit in your stomach, gut feeling 95% of the bodys serotonin is in the gut Irritable bowel syndrome Bidirectional connection between gut and brain (pit in your stomach can be result or cause of anxiety) Neurogastroenterology Gut = the second brain Slide 60 What sabotages healthy digestion? SAD diet Overuse of medications (NSAIDS, antibiotics, H2 blockers) &gt; 200 over-the-counter (OTC) remedies for digestive disorders (GERD, irritable bowel, bloating, heartburn, ulcers) Chronic low-grade infections or gut imbalances with overgrowth of bacteria in the small intestine, yeast overgrowth, parasites Toxins Digestive enzyme dysfunction such as from acid blocking meds or zinc deficiency. Stress -- alters the gut nervous system, contributes to leaky gut and changing the normal bacterial flora in the gut. Slide 61 Slide 62 Stabilizing a mother s biological rhythms to help her synchronize with her baby s rhythms. Slide 63 Mind-Body Strategies Relax: breathing, yoga, meditation, prayer Sleep Address the stressors Gut health: Pollans Food Rules Get moving! Purposeful, meaningful activity Tend and Befriend Community Slide 64 Imagine with the patient the hoped for outcome of appointment Encourage a family member to accompany the patient Send a note with your patient --- concise and specific (e.g. help with restoring sleep) State what you are working on in therapy, such as We are working on mindsight or We are working on mentalizing and define what those terms are. State your understanding of the priorities: Safety Sleep/wake and daily routines Urgent needs/concerns Regulation, relationships, responsibility, resilience Long-term plan for addressing underlying destabilizing factors How to engage psychiatrist or other medical provider: Slide 65 Integrative Health Resources Institute for Functional Medicine www.functionalmedicine.orgwww.functionalmedicine.org Dr Mark Hyman: www.drhyman.comwww.drhyman.com Ultramind Solution or Ultrasimple Diet Dr. Christiane Northrup: www.drnorthrup.comwww.drnorthrup.com Women's Bodies, Women's Wisdom Dr Margaret Christiansen: christensencenter.com Other Books: Henry Emmons (Chemistry of Joy; Chemistry of Calm) Michael Pollan (Food Rules, Omnivores Dilemma) James Hollis (Finding Meaning in the 2nd Half of Life) Articles of interest: Limitations of acute care approach to chronic conditions and a call for medical education reform ( Holman H. JAMA 2004;292:1057-1059) Slide 66 Slide 67 Slide 68 Slide 69 CBT in depressed teens was effective, but not if they had a parent who was currently depressed (JAMA. 2009;301(21):2215-2224) Treatment of depression in children not effective unless addressing needs of parents Recovery from depression is a family affair Slide 70 Slide 71 Mother-Baby Model of Care Provide treatment for maternal psychiatric disorders while maintaining and supporting MB relationship Specialized intensive outpatient/inpatient programs for pregnant women or mothers and babies Incorporates baby into mothers mental health treatment Eliminates childcare barrier Eliminates separation from baby and disruption in breastfeeding Supports a healthy attachment relationship Slide 72 Staffed by psychiatrists and other mental health providers who specialize in perinatal and infant mental health Include expertise in meds for preg and nursing women Peer support Reduces stigma Assessment of MB relationship Mother-Baby Model of Care Slide 73 Australia: 4 MB inpt units just in Melbourne, Australia (15-27 night stay) United Kingdom: 20 MB units that offer both outpt and inpt United States: Outpatient MB Programs: Women and Infants Day Hospital Program, Rhode Island (2000) El Camino Hospital MOMS Program, San Francisco, CA (2008) Pine Rest Mother-Baby Partial Hospital, Michigan (2013) HCMC Mother-Baby Program, Minneapolis, (2013) Inpatient Perinatal Program: -- UNC Perinatal Psychiatric Inpatient Unit, (2012) Mother-Baby Programs in UK, Australia, US Slide 74 HCMC Mother-Baby Program Partial hospital program for pregnant and postpartum mothers Fills gap in service for perinatal women with moderate-severe depression or anxiety Goal of treatment: to support mentalizing/mindsight capacity in mothers and promote positive parenting practices 4 hours/day, 4 days/week, for 3 weeks Services: Group psychotherapy Medi...</p>