Treating high blood pressure could reduce risk of memory loss

On February 13, we will be wearing red to raise awareness about women’s heart health. Scroll to bottom for more information. 

What’s good for the heart is also good for the brain. A study released last month adds to growing research that blood pressure and other measures of vascular health have a role in cognitive health.

The SPRINT MIND study published in JAMA found that people with hypertension who received intensive treatment (resulting in blood pressure dropping below 120) to lower their blood pressure were less likely than those receiving standard blood pressure treatment (which brought blood pressure just under 140) to develop minor memory and thinking problems that often progress to dementia. This finding was a secondary outcome of the study and requires further research.

As a result of the encouraging findings, the U.S. Alzheimer’s Association is funding another two years of cognitive monitoring. For the time being, the trial has changed how the lead author of the study treats patients.

“I now offer those with blood pressure over 130 the intensive treatment,” says Dr. Jeff Williamson of Wake Forest School of Medicine. “I’ll tell them it will give you a 19% lower chance of developing early memory loss.”

Should you be changing how you manage your blood pressure to maintain your brain health? Here’s what the Medcan experts have to say.

Are these findings a leap forward?

“These findings are an important addition to our understanding of vascular and brain health”, says Dr. Beth Abramson, Director of Cardiology at Medcan. “Over the years the areas getting inadequate blood supply to the brain may lead to a gradual change in thinking or even stroke. Clinically, I advise my patients to work on lifestyle adjustments to reduce blood pressure in addition to taking appropriate medications with their health-care provider. Find out what works for you. For some people this means limiting alcohol intake, and for others it’s about reducing salt. Everyone can check their own blood pressure and know your numbers.”

“I would encourage all of us to work toward as low a blood pressure as possible with lifestyle changes, and discuss with our doctors additional medications on an individual basis,” says Dr. Abramson.

Study’s cognitive findings raise more questions than they provide answers

Would you advise your patients to follow the intensive blood pressure management strategy as advised by Dr. Williamson?

“Dr. Williamson’s statement is an an over-reach from the study findings,” says Dr. Sharon Cohen, Neurologist and Director of Toronto Memory Program. “As treatment targets for hypertension still need to be individualized based on age, presence of diabetes, and other factors.  I agree that one should definitely consider more aggressive targets in certain individuals.

“Furthermore, it is important to realize that the study does not address the scenario of individuals who already have mild cognitive impairment. For cognitively healthy individuals concerned about future development of mild cognitive impairment and dementia, it would be fair to say that the take home message is that: Aiming for lower blood pressure measurements than previously recommended in the treatment of hypertension may reduce the chance of mild cognitive impairment by about 19%.”

What do we know about blood pressure and brain health?

“High blood pressure damages large and small blood vessels in the brain and increases the risk of stroke and dementia. Poorly managed blood pressure increases one’s risk of vascular dementia as well as Alzheimer’s disease,” says Dr. Cohen who was at the AAIC conference in July 2018 when the study was presented.  “High blood pressure is a treatable risk factor and therefore should not be ignored.”

Mid-life hypertension linked to Alzheimer’s disease

Estimates suggest that 8% of cases of Alzheimer’s disease may be attributable to mid-life hypertension.  A 2014 Johns Hopkins study found that people with high blood pressure at midlife had greater decline in key thinking skills later in life than those with normal blood pressure readings. It was the equivalent of 2.7 extra years of brain aging in their 70s, 80s or 90s, enough time to push someone from mild cognitive impairment to a diagnosis of dementia.

Don’t wait for symptoms – start monitoring by age 40

Since high blood pressure has no (or very subtle) symptoms, people can go for years without addressing the condition, which hardens arteries and vessels that transport blood to key areas of the brain.

“It’s never too late to make changes to your lifestyle,” adds Dr. Abramson. Adopting lifestyle changes in diet and exercise could also reduce dementia risk in later life. Exercise triggers release of nourishing chemicals to the brain and helps with the creation of new brain cells and brain cell repair.

Dr. Abramson recommends that by age 40, it’s important to know your family history of hypertension (parents or siblings) and share this with your physician. It may be necessary to periodically keep track of blood pressure and take hypertension medication.

Healthy heart, healthy brain (not in equal measure)

Achieving other markers of a healthy heart – such as not smoking, maintaining a healthy body weight and keeping cholesterol in check— also have a positive impact on your cognitive abilities.

Dr. Cohen regularly conducts dementia risk assessments and memory checks in cognitively healthy patients to establish an individual’s cognitive baseline should memory concerns arise in the future. Baseline cognitive testing is particularly relevant for those with a family history of dementia or other cognitive risk factors.  Dr. Cohen notes that “over the past few year, more and more individuals are interested in a proactive approach to their brain health and we are responding to that important need.”

Dr. Cohen says the evidence for benefit to cardiovascular endpoints (i.e., the heart) was much greater than the evidence for benefit to the brain.

“The main trial ended early because of its unequivocal benefit to the cardiovascular endpoints while the primary cognitive endpoint (protection against dementia) was not met and the secondary cognitive endpoint (protection against mild cognitive impairment) was statistically significant but much less substantial than for cardiovascular events. This tells us that the parallel between brain and heart only goes so far.”

Participate in the Wear Red Canada campaign! All you need to do is to Wear Red on February 13, share key messages on Women’s Heart Health with colleagues and friends, and let them know where they can get more information by sending them the link for this Wear Red Canada page. Be sure to take pictures of yourselves, your groups, or your organizations wearing red and share them on social media using #HerHeartMatters

Long-term changes start with values, not necessarily goals

Here we are in peak “goal-making season”. How many of us have already written down Goals for 2019? The problem with these lists is that they don’t tap into our deepest and long lasting source of internal motivation. They’re too superficial. The secret to real behaviour change — from eating better to getting to your best weight — is a totally different approach.

“Being aware of one’s values can help foster a willingness to choose worthwhile health behaviours even if they are associated with short-term discomfort, such as not giving into a craving or exercising even when tired,” says Christine Melanson, a registered dietitian with Weight Management at Medcan. “Values provide a strong reason to work hard over the long run.”

This value-based approach requires you to answer “Why am I doing all of this? Why do you want to cut back on potato chips, exercise three times a week or drink fewer glasses of wine?”

“You’d be amazed at how many people haven’t answered the question ‘Why do you want to be healthy?’ ” says Dr. David Macklin, Director of Weight Management at Medcan and at Toronto’s Mount Sinai Hospital High Risk/Special Pregnancy Body Mass Index unit. He’s also a science committee member of the Canadian Obesity Network.

Keep asking yourself the question until you get to the crux of your value system, like this:

Why do you want to work out three times a week?

Because I want to be healthy.

Why do you want to be healthy?

So I can be a healthy father and grandfather.

Why do you want to be a healthy father and grandfather?

So I can play sports and travel with my family, and make memories for many more years.

“So all of a sudden, in this example, we are talking about a clear direction, rather than a vague goal. This direction is permanent and immutable,” says Dr. Macklin. “With this approach you can tune in every day and ask yourself, ‘Was my behaviour aligned with the direction I want to go with my life?’ If the answer is no, then make changes or get the support you need in a non-critical way. If the answer is yes, then celebrate that and keep it up.”

The cookie example: Acting in line with your values

Dr. Macklin likes to use this cookie example to show how our values can influence our behaviour:

Let’s say it’s your birthday and I give you the choice of two cookies.

One is baked at a specialty, luxury, organic chocolate bakery and it’s served to you fresh out of the oven.

The other one is three days old, has your least favourite cookie ingredient — raisins — and it’s burned.

Which one would you like?

Oh, one more additional detail: the second cookie was made very carefully by your child for your birthday.

Chances are you would choose your child’s cookie, right?

“Here is an example of someone being WILLING to forgo an immediate gratification experience with ease because the decision is aligned with a fundamental value, something very important to them,” says Dr. Macklin. “So if you can start to find the underlying purpose as to why you want to make this change, what may otherwise be tough decisions become easier, less controlled by a drive to immediate-gratification and more driven by purpose.”

Pause before making that healthy choice or unhealthy decision

Melanson encourages her clients to pause before acting on impulsive food choices and on thoughts of sedentary behavior (when physical activity was planned) and ask themselves, “Is this decision aligned with my values? Of course, I can eat this, drink this or forgo this activity, but … is this decision in line with the direction I want to be going, towards the things that are most important to me?”

It’s amazing how powerful pausing and asking these questions can be in helping with long-term behaviour change.

To learn more about Weight Management at Medcan, you can arrange an introductory consultation by contacting Kelly Cloutier, Program Coordinator, at kellycloutier@medcan.com or call 416.350.5918. 

If you book your Annual Health Assessment between January 9 and January 31, you will be entered for a chance to win your choice of one of the following add-ons: 10 personal training sessions; Liver Health Assessment; or Genetics and Genetic Counselling.

Ask a psychologist | How can I enjoy family gatherings (without losing it)?

by Jonathan Danson, PhD, Clinical Psychologist
as told to Tania Haas

Family gatherings are often thought of as times to talk, laugh, reconnect and reminisce. For others, however, these dinners or parties are dreaded and, if possible, avoided. As a psychologist, this matter peaks around the holidays, when some clients feel it is a good time to break from therapy and others double up on their sessions. For those who cringe at the idea of spending time with your warring family, oversharing uncle, judgmental parents, bully of a sister-in-law, or whatever other version of dysfunction that makes gatherings a strain, here are some tips to help get you through them relatively unscathed.

Plan ahead.

Before the event, consider which topics you’re comfortable taking about and which are off limits. How might you respond to unwelcome or prying questions? I suggest you keep responses to these questions concise (“that’s not something I want to talk about”), and don’t feel obligated to provide an explanation. When we are caught off guard, we are more likely to overshare, find ourselves talking about something we wish we weren’t, or being overly harsh in our rebukes. A little bit of planning can go a long way in preparing you to respond effectively.

Pick your battles.

When we have differences of opinions from family members, it can be difficult to hold ourselves back from getting into old debates. This is especially the case when those opinions are extreme or relate to sensitive topics like politics. Before engaging in a verbal sparring match, consider what your goal is and whether you’re likely to be heard. When you don’t think arguing will help you meet your goals (e.g., if you know someone is not going to change their opinion, or you want to prioritize keeping the peace), it is likely better to back off. Think of it as doing what is effective over what might be justified.

Practise mindfulness.

Mindfulness is all the rage today, and for good reason. Among other benefits, building skill in mindfulness has been shown to help with stress reduction. If you already cultivate a mindfulness practice, try to apply those skills during the event. If you’re not too familiar with mindfulness, consider trying some guided meditations in the days leading up to the event (e.g. using the Headspace app). This won’t necessarily make the event more pleasant, but it may help you stay rooted in the present rather than getting lost in past frustrations, conflicts or old wounds.

Limit alcohol.

Faced with yet another stressful family event, you might be tempted to drink to take the edge off. While this might feel like it provides some relief, it also puts you at higher risk for crossing boundaries, saying things you don’t mean, and having trouble managing your emotions. If you feel that drinking might be the only way to get through the event, it might be time to leave.

It’s okay to leave.

If you’ve decided to go to a family event despite your expectations that it will be unpleasant, you likely feel that there are benefits to attending. You might feel obligated to be there or know that not going will cause you even more headaches later. That being said, there does come a point where leaving is the best choice. If you feel that things are about to turn sour, that you’re going to lose control, or that staying will cause you undue stress, there is no shame in walking out the door.

In the end, even with the best use of these and other strategies, family gatherings might remain unpleasant and intolerable. Just know that you are not alone, and make an effort before or after to spend time with people you truly do feel connected to.

Cancer prevention | Do you know your breast density?

In 2014, Michelle Di Tomaso was sidelined after being diagnosed with breast cancer. It came as a shock since her last four mammograms revealed no issues. But there she was, facing multiple surgeries, chemotherapy and radiation. She would go on to spend 25 days in hospital and undergo three unsuccessful reconstructive breast surgeries.

Mammograms miss about 50% of breast cancers in the densest breasts

She later learned that her diagnosis had been delayed because her dense breast tissue had camouflaged the tumor. Had the cancer been caught earlier, she was told, her treatment would have likely been less invasive.

Today, Di Tomaso is working with other breast cancer survivors and health care professionals, to help other women avoid the same fate. Through Dense Breasts Canada, the women have three goals: (1) to increase awareness about the risks associated with dense breasts; (2) to make it mandatory to report breast density to family doctors and women; and (3) for health providers to give ultrasounds to women with extremely dense breasts and other high risk factors.

We sat down with Dr. Carl Bloom, Director of Radiology at Medcan, to help us understand breast density and his recommended prevention and treatment plans.

What is breast density and how common is it?

Breast density is comprised of everything that makes up the breast tissue other than fat. That includes: the supporting tissues made of collagen, as well as ducts, and glands. Fat appears black on a mammographic image. Collagen, ducts and glands appear white.

Approximately 60% of women under the age of 50 have dense breasts. That percentage decreases as women age to approximately 30% of women aged 50 and older. Paradoxically, despite breast cancer risk rising with age, breast tissue becomes fattier.  This paradox is likely explained by a combination of  unrelated factors (slowly growing malignancies manifesting later in life, faulty gene repair mechanisms associated with ageing, latency in developing malignancies related to prior insult to breast tissues (radiation, viruses, severe hormonal fluctuations, alcohol use, etc.).

Does breast density increase your risk of breast cancer?

The answer is yes. Women who have dense breasts – i.e. greater than 75% fibroglandular tissue elements in their breasts based on mammography stratification – have anywhere between two to four times the risk of breast cancer in their lifetime (2x greater than average, and 4x greater than a woman with completely fatty breasts). The latter risk (4x) supersedes the risk of breast cancer in women with a first-degree family history of breast cancer.

Furthermore, increased breast density can lead to masking of breast tumors on mammography, which reduces the sensitivity of the examination (50% sensitive in very dense breasts and 90% sensitive in fatty breasts).

Image courtesy of Dense Breasts Canada

Across the board for all women, the risk of developing breast cancer in a lifetime is approximately 10%. If you are genetically predisposed, the risk could go as high as 50%.

What increases the risk of having high breast density?

Your genetics. It’s known that some women have high dense breasts all through their lives, while some women’s breasts get fattier with age. This is thought to be predetermined genetically.

Women who are on hormone replacement therapies.  We know that HRT causes increased breast density; and we do know that there is a purported higher risk of breast cancer in women who receive unopposed estrogen replacement. This has led to tailoring or stoppage of HRT in post-menopausal women.

The reverse is also true: if you are on Tamoxifen, a drugs who’s metabolites act as an estrogen-receptor antagonist, a reduction in breast density is noted mammographically  as well as a reduction in the  incidence of breast cancer.

Should women who have high breast density on a mammogram be told?

Yes.

They should be told everything they need to know about their risk of breast cancer and be encouraged to continue regular testing-screening.

What else should women with dense breasts do to prevent missed diagnoses?

I’d suggest that instead of only having a mammogram every two years, they should have one annually, This practice is recommended by Radiological societies and most Oncologic societies in North America.

Should women consider alternative or adjunctive testing?

I believe that women should still have an annual mammogram, because that’s a critical screening test. It is a particularly sensitive screening test in women with fatty breasts and also can help stratify breast cancer risk by identifying high breast density.

But should they have MRIs instead? The answer is yes in a perfect world.

With MRI testing, the MRI identifies up to 14 breast cancers per 1,000 women screened. Mammograms pick up 4 cancers per 1,000 women screened with dense breasts and between 6-8 cancers in woman with fatty breasts.

There are, however, many challenges with MRI: availability, cost, and the low specificity of the modality (high false positive rates) which leads to more testing and biopsies.  It’s a huge cost to society, and ultimately very stressful to the patient. As well, studies indicate that patients are more likely to cancel their screening MRI studies due to claustrophobia, fear of injectable dyes etc). In patients who have a high risk of breast cancer, such as those having dense breasts on mammography AND a first degree relative with a diagnosis (mother, sister or daughter) or those patients who have a previous diagnosis of breast cancer; OR those patients with a genetic mutation (i.e. most commonly:  BRCA I and II) – the lifetime risk and pretest probability of cancer supports adjunctive MRI screening.

Should these women get breast ultrasound?

Dense Breasts Canada wants health providers to provide ultrasounds to women in Category D (Extremely Dense Breasts) and to women in Category C with a family history (Heterogeneously Dense).

A large study of breast ultrasound screening in dense breasts (the ACRIN 6666 trial) has concluded that ultrasound alone will identify four additional breast cancers per 1,000 patients than mammography alone. In other words, ultrasound screening would be doubling the chance of identifying a breast cancer when compared to mammography alone. Furthermore, the tumors identified on ultrasound tend to be small, receptor positive, locally invasive malignancies, with no nodal involvement. The prognosis of women diagnosed with breast cancer is heavily dependent on negative nodal status and positive receptor status.

Breast ultrasound adjunctive screening has been our practice at Medcan for the past 10 years long before this was adopted by the general imaging community.  We have long believed, based on personal experience as breast imagers and supported by data from large Imaging trials, that this was the best practice for our patients and referring doctors.

In summary, in lieu of having a breast cancer pick-up rate of 4/1,000 on mammography for women with dense breasts, with the addition of ultrasound we can double the rate of breast cancers diagnosis (rate of 8/1,000). MRI is considered the gold standard (nearly 100% sensitivity and can identify up to 14 cancers/1,000; so the assumption is that 6 cancers per 1,000 women screened go unnoticed in women with dense breasts despite screening with mammo and ultrasound. These tumors are invisible to mammography and ultrasound and are non-palpable.

How do you identify the other 6 cancers?

First ask: Do they need to be identified?  The answer is unequivocally yes. Large breast imaging trials have shown between a 20 and 40% decrease in breast cancer deaths through screening. Therefore, it is important to encourage breast screening for all women starting at 40 years of age and earlier if the woman’s risk profile suggests a high lifetime risk of breast cancer. High breast density is determined by mammography and therefore this risk factor is only known after the patient’s first screening test.

In the U.S., 36 states have made it mandatory  that you have to report breast density to the patient and eventually it will be all states.

How is breast cancer diagnosis changing?

There’s digital mammography, which has a much higher pick up than analogue (film) mammography. There’s also 3D tomosynthesis mammography, which is becoming adopted widely. It’s a tomographic mammogram that has been shown to reduce callback rates for women undergoing screening. The drawback is a slightly higher radiation risk to the patient – a problem that is being addressed by physicists and will likely be rectified in the near future.

What is your main message for women who want to be vigilant in their breast cancer prevention?

With the knowledge and certainty that breast cancer death rates are reduced through careful breast screening, it is absolutely necessary to encourage breast screening. The question is how frequent and with what modalities? In women diagnosed with dense breasts, the answer is every year – with an adjunctive ultrasound, or an MRI, if it is available. Unfortunately, in the Canadian system, you can’t easily access breast MRIs for every patient due to resource limitations. Just as importantly, breast MRI leads to 25% more testing on patients who are ultimately found to have no cancer. The cost to society and to patients is enormous. MRI should be used judiciously in patients who have a high pre-test probability of cancer. In that select group of patients, the chance of a false positive result is diminished.

The Annual Health Assessment at Medcan includes mammography and ultrasound. Book yours here. Learn more about the Dense Breasts Canada’s campaign here.

Ask a psychologist | 4 back-to-school stress busters

Many people — some kids, most parents — are thrilled when school resumes. But along with the excitement of new beginnings comes back-to-school stress, which can affect both students and their parents.

“Stress is one of those things that doesn’t care if it is a positive or a negative,” says Dr. Mark Rothman, a psychologist at Medcan who works with children, youth, couples and families. “It is cumulative. So when your little stresses add up, they become big stresses. Then our body and our mind is fighting that stress; and that’s what depletes us.”

The best way to offset the negative stress at this time of the year, is to be proactive and prepared — with an emphasis on the ‘pre’. Anything you can do in advance, get done as fast as possible says Dr. Rothman.  Here are four back-to-school stress busters from Dr. Rothman.

Carve out regular time for ‘school-related material’

Ensure that the routine after school includes regular time for “school-related material time”.

“Calling it ‘school-related material time’ makes it a regular occurrence, even when kids say they have no homework,” says Dr. Rothman. “Even without homework, there’s a designated daily time when school-related material is reviewed, addressed or organized.”

This creates a regular schedule for at-home review and study sessions.

Parents must practice their routines, too

Just like students must return to a routine, parents should adopt their school routine: making lunches, managing clothes or uniforms, getting the car ready and ensuring the fridge is stocked with healthy back-to-school foods for lunches, snacks and dinners.

“Doing this type of preparation now minimizes the stress that we experience at the time that the transition takes place,” says Rothman.

At university: Make time management a priority

One of the biggest stresses that university-aged people have is time management. If possible, find a mentor or role model at school — maybe an older student or floor don — who can help suggest a reasonable schedule that includes both recreational and study time.

“It’s important to add routine where it doesn’t exist because in university you aren’t in school 8 a.m. to 4 p.m. Many schedules are very irregular,” says Dr. Rothman. “I recommend students approach school like a full-time job, and put 10 hours a day into school, every day.

“Maybe one day, a majority of that time is in class. Other days, that means you are doing self-directed or group study. Even if you don’t have class, dedicate a set amount of time to study every day. The other hours are designated for socializing, exercise, relaxation and rest.”

Dorm room check-in: Set weekly communication times

As for parents and university-aged kids: there’s a transition period when kids leave the nest for school.

“Some parents can feel very very taken for granted when their child doesn’t keep in touch, while university students could feel smothered if their parents are trying to get in touch regularly,” says Rothman, who recommends a dialogue to set up expectations of communication.  “This is really helpful to avoid parents waiting around and their kids not understanding why there’s anger or sadness when they do make contact.”

The solution? Create “contact times”, which are regularly established times for communication.

“Rather than waiting it out and seeing what it is like; create a plan, and then you can always change the plan. So if it is understood that we will talk on Thursdays or Sundays around 8 p.m. for 10-15 minutes and if those days/times don’t work — you just adjust. No problem! But at least it is a start.”

Your brain on music: the psychology of sound

While anyone with a music streaming app may fancy themselves a DJ, there is a science to the psychology of sound.

The right music can motivate you at the gym, keep you focused on repetitive tasks, and help you unwind. Other sounds can interfere with work and learning.

“I think one theme throughout the research indicates that allowing for personal choice in terms of the type of music used, the timing and duration of its use, and the type of task it accompanies is important in determining its benefit,” says Dr. Amanda Beaman, Clinical Psychologist at Medcan.

That’s why Medcan has eliminated television screens broadcasting mindless babble and partnered with BELLOSOUND. The premium music styling company curates playlists that contribute to a positive feeling across our various spaces, including the Refine by Medcan lounge and our fitness centre.

“Our goal is to create a harmonious experience inside the clinic by introducing a diverse mix of music that is engaging and inspiring,” says Daniel Buckman, Founder and CEO of BELLOSOUND. “Our objective is to design an ever-changing soundtrack that will contribute towards the productivity of the team, clients and partners of Medcan.  And now we have ways to share the signature sound of Medcan beyond the clinic walls.” (Go to the Refine by Medcan station on Spotify here)

Here’s how to use the psychology of sound to your benefit at work, when working out and when tuning out.

Music in the workplace: productivity boom or bust?

As far as productivity goes it seems there are mixed results and many caveats, explains Dr. Beaman. Some research shows that listening to music can improve productivity through its effect on improving mood and reducing mind wandering.

“When it comes to academic performance, music may be disruptive to attention and memory, especially for people who already have lower working memory capacity.  So, adopting an office-wide initiative to have background music may have mixed effects as it may not account for personal choice and individual differences in attentional/memory capacity,” says Dr. Beaman.

Here’s how you can use music to improve your performance at work.

Music at Work

Use music to drown out a noisy workplace and put you in a better mood

This is especially suitable for those in open offices: where chatty desk mates may be distracting. Hiding behind one’s headphones, can lead to faster work completion. “When music evokes a pleasant mood and an increased arousal state, participants perform better on non-musical tasks,” writes Teresa Lesiuk, associate professor of music education and music therapy at the University of Miami.

Background music can support you in repetitive tasks

If your work is clearly defined and is repetitive in nature, music is definitely useful. Researchers say it’s likely the improved mood that results from listening to positive sounds that leads to the boost in productivity. This study found assembly line workers displayed signs of increased happiness and efficiency while listening to music.

Choose lyric-free songs or ambient sounds for focus, creativity

For immersive tasks, choose music without lyrics to avoid activating the language center of the brain. Baroque-period tunes were found to be beneficial in this small study. For creative sessions, the research suggests pressing play on ambient noise at a moderate level. Think white noise or similar mellow sounds like rainfall or river sounds.

Does music make you exercise harder?

“With respect to using music to enhance our experience and outcomes during a workout, there is evidence to support both,” says Dr. Beaman of the research. “When we select our own music it has been shown to enhance our mood, reduce our ratings of perceived exertion during a workout and improve our energy and output.  The beneficial effects of music seem to be most prominent during self-paced exercise.”

Research has linked the following benefits to working out with music:

• distracts us from pain, fatigue and boredom

• elevates mood

• reduces perceived effort

• may even promote metabolic efficiency and performance

• Your heart rate and breathing increase – these biochemical reactions – motivate you to move faster

Choose music you associate with happy memories and feelings

Create playlists full of music affiliated with motivational movie scenes (i.e. Rocky) or songs that will take you to your happy place.

Pick songs with the right tempo

Curate songs with appropriate tempo (speed) and rhythm response (i.e. does your body want to boogie when the song comes on?). Research suggests that anything higher than 145 beats per minute (bpm) does not seem to contribute to any additional motivation. That being said, most people prefer songs around 160 bpm. Songza and jog.fm can help you match the tempo of your workout with songs as fast as 180 bpm.

Serenity sounds, serenity now

“With regard to relaxation, there is certainly evidence showing that music is an effective strategy to help reduce activation of the stress response in both laboratory and every day settings.  This seems to be particularly so when people report that they chose the music for the explicit purpose of becoming more relaxed.  There is some preliminary research showing that having social support present while listening to music, amplifies its stress reducing effects,” says Dr. Beaman, Clinical Psychologist at Medcan.

Research includes a meta-analysis of 400 studies, including one that followed patients who were about to undergo surgery. Those who listened to music had less anxiety and lower cortisol than people who took drugs. Similar results were found in patients with fibromyalgia, another with elder patients with delirium.

Nature sounds may be the most soothing

For when you’d like to escape your current reality, nature sounds may be the grounding sounds you need. Rainstorms, crackling fires or ocean waves can lower anxiety and stress levels. A 2016 study found that people who listened to ocean waves for 15 minutes showed a decrease in pulse rate, muscle tension and self-reported stress  — a reported difference to the classical music, which showed no significant changes on any of these measurements.

In 2017, researchers researchers reported that listening to natural sounds for as few as five minutes helps trigger the nervous system’s restorative state.

“…the earth has music for those who listen”

“Overall, it seems that music can have many benefits across different contexts,” adds Dr. Beaman. “However, like art, it tends to be quite personal — what might have an enhancing effect for one person could be distracting to another.  This is important to consider when developing a playlist for others.”

Headphones in and volume up may be your go-to strategy – just choose your playlist carefully.

Marijuana and the teenage brain

The rise in marijuana’s accessibility — and soon to be legality — has decreased the stigma of this controlled substance. While more physicians may soon consider its use for specific medical conditions, the socialization of the drug may have downplayed its dangers on the teenage brain.

The danger exists because the brain’s executive function – the part of the brain responsible for reasoning, problem solving, and planning – is not fully developed until a teen’s mid-20s.

Studies over the past three years have linked regular teen marijuana use (which is considered once a week) to memory loss, real or perceived lower IQ, increased risk of mental disorders, car accidents, addiction, and chronic bronchitis. But that hasn’t stopped teens from inhaling and ingesting.

The Canadian Medical Association says Canadian youth (aged 15 to 24) has the highest rate of marijuana use among 29 developed countries. Almost a quarter of the population aged 15 to 24 years reported past-year use.

Teens usually smoke for two reasons: recreation and managing anxiety. Dr. Mark Rothman, Clinical Psychologist for Child and Youth at Medcan, says regardless of the reason, any type of dependency can lead to unintended consequences.

Cannabis use is an unreliable coping strategy

“Any time someone uses anything external as a way to cope more effectively – be it alcohol, video games, internet, drugs – if people are using them as a primary coping strategy, development of other coping strategies (like communication skills, time and energy management, stress management or exercise) is weakened,” says Dr. Rothman.

“Dependency on using that substance increases. A teen with anxiety who self medicates with pot will likely start using it more frequently for that purpose, and then will develop other problems that they didn’t foresee. Maybe they were using marijuana to help with social anxiety, but it can cause school issues to arise, or money or health issues to develop. So instead of one problem solved, they develop six more.”

Dr. Rothman cites alternative strategies for anxiety, such as cognitive behavioural therapy, improved sleep and eating habits, a diagnosis and/or a prescription of right medication by a physician.

Marijuana use in teens increases chances of psychosis and mental disorders

In addition to derailing reliable coping strategies, frequent marijuana use can have a destabilizing effect on a teen’s mental health. Often psychosis can be triggered earlier in marijuana users if they are predisposed to mental disorders, or are genetically likely to develop psychosis.

“Teens using weed have experienced increased mental health concerns or new mental health symptoms such as depression, anxiety, paranoia, or hearing voices,” says Chantal Wiggins-McKinnon, a registered nurse and Program Lead, Child and Youth at Medcan.

Cannabis use in teens has been linked to increased cases of delusion, psychosis and hallucinations.

“There is evidence of serious harms including poor psychological function, increased anxiety, depression and psychosis,” says Dr. Janice Weiss, Director of the Child and Youth Program at Medcan. “There is an association of cannabis use and development of schizophrenia in later years.”

“Cannabis has significant impact on the developing brain, especially when used under 25 years of age,” adds Dr. Weiss. “While we understand that teens are interested in using it to alleviate symptoms associated with mental health concerns, we really do recommend that those concerns are best treated through proper diagnosis and psychiatric care.”

Finding hope and help after high-profile deaths

Are you or someone you love having thoughts of suicide?  If at immediate risk, please call 911 or go to your nearest emergency department.  Or you can get support from the Canada Suicide Prevention Service by phone, text or chat. Resources here. 

On the day the world learned of Anthony Bourdain’s suicide death, journalist Andrew Solomon’s essay “Bourdain, Kate Spade, and the Preventable Tragedies of Suicide” was published in The New Yorker. Solomon, a professor of clinical psychology at Columbia University and repeat TED talk speaker on mental health, wrote about the pattern of highly accomplished people dying by suicide, and how it can both transfix and harm us.

That same week, the CDC reported that since 1999 U.S. suicide rates are up 30% and are now a leading cause of death. In Canada, the statistics have a similar direction. There is a narrowing in the ratio of male-to-female suicide rates, which reflects the accelerated increase in female suicide rates. In our military community, former Canadian soldiers are killing themselves at a significantly higher rate than that of the general population. In the weeks that followed the suicide deaths of Spade and Bourdain, a flurry of reports and opinions were broadcast, many promoting misleading conclusions and assumptions.  I reached out to psychologists and psychiatrists at Medcan in search of clarity, hope and how to seek help.

“It assures the rest of us that a life of accolades is not all that it’s cracked up to be and that achieving more will not make us happier (…) Those of us who have clinical depression can feel the tug toward suicide amped up by this kind of news. The gap between public triumph and private despair is treacherous, with the outer shell obscuring the real person even to those with whom he or she had professed intimacy.”

— Andrew Solomon, The New Yorker, June 8, 2018

Suicide is preventable. Help is available.

Suicide is far more complex than headlines make it out to be. Clinical research, however, is certain that mental health issues are a key component of factors contributing to suicide. “More than 90% of people who take their lives by suicide have an underlying psychiatric illness that is potentially treatable,” says Jodi Lofchy, MD, FRCPC, a psychiatrist at Medcan, the University Health Network, and an associate professor at the University of Toronto. “There are treatments available and life will look very different and well again. If you are suffering, reach out and get help. Concerned friends and family should also be aware of resources – from family doctors to emergency services – to connect their loved ones to.” With proactive medical screening, asking and monitoring through social relationships, suicidal feelings can be recognized, and addressed through the right medical channels.

Suicidal thoughts are a sign to seek help. Recognizing them is a sign of strength.

“People who have struggled with suicidal thoughts or have attempted suicide can, and do have fulfilling and active lives,” says Gina Di Giulio, LLM, PhD, Clinical Psychologist and Director of Psychology at Medcan. “Admitting how you are feeling to yourself, and then to others, is a sign of strength. Having the conversation with someone is not a sign of weakness; it takes incredible courage to open and admit to difficult feelings. Openness leads to accessing help that is available and can prevent suicide.”

With the right support, life will look very different, and well, again.

Suicide is often referred to as a permanent solution to a temporary problem. It is often considered when someone faces challenges or obstacles that have no sense of resolution at the time. Depression, relationship problems, addiction, financial difficulties – these are usually time limited or can be solved, says Dr. Di Giulio who works with clients using a problem-solving, structured therapeutic approach aimed at solving or ameliorating problems that clients often believe to be insurmountable. Finding and holding to hope is key. The number one predictor of suicide is a sense that of hopelessness; that things won’t get better. “Social isolation or seeing yourself as a burden to others can be a risk factor,” says Ricardo Flamenbaum, Ph.D., C. Psych., also a psychologist at Medcan. “Conversely, research shows that a sense of connectedness and belonging is an important protective factor.” Dr. Flamenbaum’s dissertation focused on identifying psychological predictors of suicide, and he has published research in the areas of perfectionism and chronic pain as well.

High performance is not a protective factor to suicide. Reaching out for help is.

Even the highest performing people are at risk to suicide. Michael Phelps, the most decorated Olympian of all time, has shared his battle with depression and suicidal thoughts. He has said how grateful he was that he didn’t take his own life. “Having a perceived sense of purpose is very important. However, it is also possible to be depressed or suicidal even if one has a purpose, so it is not deterministic in that way,” says Dr. Flamenbaum. “One of the challenges with depression is that it involves a distorted view of oneself, the world, the future. So even if one has very meaningful activities and relationships in one’s life, depression may cause the individual to fail to appreciate or recognize them.” Having a purpose, determining your why, having strong social connections – these are all important for performance and for imbuing meaning into your life. But they aren’t always enough of a protective factor against suicidal tendencies. Opening up and seeking support are.

Depression and suicidal thoughts can affect anyone

There are populations that are more at risk than others: having a history of suicidal thoughts or attempts, or clinical anxiety or depression can place someone into a higher risk category. Among vulnerable individuals, even just reading about suicide deaths can further increase risk. There are other factors contributing to one’s susceptibility to suicide: sleep and technology are just two to consider. Sleep deprivation has a devastating effect on mental health; 40% of adult Canadians suffer from sleep disorders. While habitual technology habits can create incredibly alienating cultures; isolation being another significant suicide risk.

Suicide is a public health issue. Clinicians, employers must be proactive.

In 2014, I wrote about the need to break down barriers to teen mental healthcare for Canadian teenagers for a cover story in Hospital News. The lessons then shared by the pioneering psychiatric teams at Sunnybrook Health Sciences Centre are the same as those shared by trailblazers in the U.S. today. “We need to beef up our mental-health system: we are not training enough clinicians, not getting enough clinics built across the country,” says Victor Schwartz, the chief medical officer of the jed Foundation, a suicide-prevention group, in Solomon’s article. “Many clinicians are untrained in suicide prevention. We need preventive public-health initiatives on managing depression and anxiety in the pre-crisis stage. Every school should have an approach—but so should every employer and every small town.”

Figure 1: Mental Health Continuum c/o the Mental Health Commission of Canada.

Mental Health First Aid, understanding the Mental Health Continuum

Companies and schools are increasingly taking on the responsibility of looking out for their peers and colleagues through national organizational health programs like Mental Health First Aid, and others conducted by the Canadian Centre for Occupational Health and Safety. The Mental Health Commission of Canada developed a mental health continuum model (figure 1) that illustrates the non-binary spectrum of symptoms people may exhibit, and the recommended actions to take at different stages.

Canadian Armed Forces (CAR) focuses on resilience

One of the ways the CAR is addressing the incidence of depression and suicide among its ranks is by designing training programs that focus on resilience. The CAR defines resilience as “the capacity of a soldier to recover quickly, resist, and possibly even thrive in the face of direct/indirect traumatic events and adverse situations in garrison, training and operational environments”. The Road to Mental Readiness (R2MR) mental health training recently launched an accompanying app that can be used for goal-setting, self-talk, mental rehearsal, tactical breathing, attention control and working memory, and allows users to build personalized scripts and scenarios to achieve personal objectives.

Understand the warning signs and how to reach help

As the stigma of mental health and suicidal thoughts fades, more people are talking about signs, symptoms and reaching out for help.  May that discussion continue to shatter the misleading myth that if you ask people about suicidal feelings, it causes them to become suicidal. When really, any query from a place of concern can open an entirely new avenue to help, healing and, eventually, wellness.

Tania Haas also teaches post-traumatic growth meditation and movement to members of the military.

Are you in crisis?

Are you or someone you love having thoughts of suicide?  If at immediate risk, please call 911 or go to your nearest emergency department.  Or you can get support from the Canada Suicide Prevention Service by phone, text or chat:

• Phone: toll free 1.833.456.4566 or the Gerstein Centre Crisis Line at 416.929.5200

• Text: 45645

• Chat: crisisservicescanada.ca

• For residents of Quebec, call 1 866 APPELLE

Warning signs of suicide

Signs that might suggest someone is at risk of suicide include:

• thinking or talking about suicide

• having a plan for suicide

Other signs and behaviours that might suggest that someone is at risk of suicide include:

• withdrawal from family, friends or activities

• feeling like you have no purpose in life or reason for living

• increasing substance use, like drugs, alcohol and inhalants

• feeling trapped or that there’s no other way out of a situation

• feeling hopeless about the future or feeling like life will never get better

• talking about being a burden to someone or about being in unbearable pain

• anxiety or significant mood changes, such as anger, sadness or helplessness

What to do if someone you know exhibits warning signs of suicide

• Do not leave the person alone

• Remove any firearms, alcohol, drugs or sharp objects that could be used in a suicide attempt

• Canada Suicide Prevention Service by phone, text or chat (see above)

• Take the person to an emergency room or seek help from a medical or mental health professional

Other resources

• The Canadian Association for Suicide Prevention offers resources on suicide for survivors, those thinking about suicide, those who have been affected by someone who has attempted or died by suicide, and anyone who wants to help someone who has been affected in any way: https://suicideprevention.ca/

• The Canadian Mental Health Commission offers tools, readings, information and contacts specifically linked to both suicide prevention and surviving a suicideand surviving a suicide loss

• Distress and Crisis Centres can offer 24/7 support to those who are feeling suicidal. For a list of centres across Canada see https://suicideprevention.ca/need-help/

• Listen to interview and/or read the book: Myths about Suicide by Thomas Joiner (2011)
  

Ask a psychologist | Artificial intelligence that targets depression

Sophia the Robot, Alexa and Tesla are just the tip of the iceberg when it comes to the evolving relationship between artificial intelligence (AI) and human beings. For the field of mind health, AI appears to be a positive disruptor. Engineers have partnered with data scientists and physicians to curate and inform AI platforms on how to appropriately and readily manage symptoms and the treatment of  anxiety, depression and irregular sleep. AI has the potential to be preventive tool in reducing the probability of crises or relapses when mental health and addiction symptoms are flagged early.

I spoke with Gina DiGiulio, Director of Psychology at Medcan, to hear her take on the opportunities and risks of three technology products targeting mind health: Woebot, Ginger.io and Mind Me.

Woebot is a free therapy chatbot that launched as a stand-alone iOS app in January 2018. It was created by a clinical psychologist at Stanford University and uses cognitive behavioural therapy to treat depression by offering scripted and meaningful responses to users (Source: Business Insider, January 2018)

Ginger.io began in 2011 as a free tool that patients could set up to monitor symptoms and send alerts of escalation of mental health symptoms and episodes of crisis to their circle of care, which included their doctors, friends, and family members. Today, Ginger.io offers in-the-moment emotional support to all users via coaching, therapy, and psychiatry services, such as  medication management (Source: Ginger.io, Fast Company 2016)

mind.me uses a “set it and forget it” approach for users to manage mental health concerns. Personal data feeds into the application, which allows mind.me to ambiently monitor behaviour. When mind.me predicts the early symptoms of depression, notifications will be sent to the user’s predetermined circle of trust (Source: mind.me)

Advantages of AI

“These apps offer value and support when incorporated into therapy,” says Dr. DiGiulio. “Meeting with a psychologist, psychotherapist or a family physician can help with the categorization of a mental health condition, which leads to the best treatment strategy. Following that, these apps can help with staying the course and also send the clinician updates and indicators of concern if they arise, so we can offer timely care.”

Other advantages include:

• 24/7 access to care

• offer economic efficiency solutions

• can reach people in under-served areas, or in geographically challenging areas to access help

• are portable, can travel with you wherever you are

• can help reduce stigma associated with mental illness (e.g., if more people accept that depression, for example, is a global epidemic that has not yet been proportionally recognized, funded, or treated — perhaps more people will start getting the help they deserve)

• some of the products monitor symptom changes in real time, so clinicians can reach out to their clients when they need it the most, which can result in early intervention, relapse prevention, and streamlined aftercare solutions

Approach with caution

“Many or most of the apps are not currently regulated, so there is no real way to know how if the marketing promises match the actual outcomes. And, we don’t know if the strategies or approaches are based on empirically-sound science,” says Dr. DiGiulio.

Other risks and areas of concern with robot therapists:

• there is not enough long-term data on their effectiveness

• managing expectations when it comes to adherence: how long will people be willing to stick with an app as opposed to seeing a professional with whom they develop a productive and supportive rapport with?

• there may be valid privacy issues; users need to be aware of how their data is being collected, stored and possibly used

Final say … for now

“With mental health, as it is with most aspects of health, there are usually no cure-alls or magic pills. The best approaches are personalized and consider the evidence-based medicine as well as psycho-social and emotional health, lifestyle choices, as well as genetic history.

“The app advantage is the wider net of support to people in a timely and easy way, and doing so, break down the stigma of mental illness.  Through regular symptom monitoring, they can help detect symptoms of depression, anxiety, irregular sleep much more quickly, thus facilitating earlier intervention, which we know improves treatment outcomes. They can also be a great complement to therapy ‘homework’ and can help make inter-session time more effective by having clients track their mood and work on thought records,” says Dr. DiGiulio.

“These apps can certainly open the door to someone being introduced to therapy but the relationship component is missing, and sometimes you need that live connection with a person in order to really make an impact. We know that the therapeutic alliance is a vehicle through which progress in therapy can occur – an app can’t replace that human connection. And sometimes that human connection is the most therapeutic aspect of the live therapy session.”

Gina Di Giulio obtained her doctorate in psychology at the University of Ottawa and earned a masters in law with a health specialization from Osgoode Hall. In her clinical practice, she sees clients for a wide range of conditions including stress and anxiety, depression and relationships counselling. She is often consulted on individual counselling, organizational psychology as well as corporate wellness programs.

Pain management | When good backs go bad

By Andrew Miners, Director, Sports Therapy and Rehabilitation and Marlo Goldstein, Personal Fitness Trainer as told to Tania Haas

Back pain is extremely common. Up to 70-85% of adults will experience an episode of back pain in their lifetime, and it’s probably why you clicked on this article.

That being said, not all lower back pain is the same, nor should it be addressed in the same way.

In this article we are referring to non-specific, back-dominant pain.  It is called “non-specific” because clinically, and even from a research-based perspective, it can be very hard to differentiate from muscle, joint, sacroiliac joint or pain originating from the disc itself.  Non-specific (back dominant) pain is by far the most common type of lower back pain, with 90 to 95% of  patient cases categorized as non-specific back pain.

Additionally, this article is referring to different approaches that could benefit (i) acute and (ii) sub-acute types of non-specific, back-dominant pain. Acute lower back pain lasts less than 4 weeks, and sub-acute lower back pain lasts between four to 12 weeks. The next category, and not addressed here today, would be pain that lasts longer than 12 weeks. This is referred to as chronic back pain or chronic intermittent back pain.

The spectrum of pain also includes chronic-complex pain, which is widespread body pain and is not restricted solely to the back. If you’d like to read more on chronic and complex pain, please read here.

The Big 5

Here are five approaches, based on the latest guidelines, that you can do for yourself if you know you have acute or sub-acute non-specific, back-dominant pain:

1. You can adopt a positive outlook because science is on your side

Remember that the prognosis is good. The vast majority of acute onset lower back pain will get better from 10-14 days or up to four weeks. That’s if you do nothing to treat it. The natural history of back pain — despite the level of pain or intensity of pain — is that people do get better. This is important to note because many people seek help with an accompanying fear that they’ve injured their back and they are going to have persistent, on-going pain. The research shows us that, in the vast majority of cases, that fear is unfounded.

2. Realize that the risk of a serious back problem is low (even when it hurts a great deal)

Despite that level and intensity of pain you experience, the actual chance of having serious, underlying problems with your back is small. The level of pain does not correlate to the amount or presence of tissue damage.  Remember, your prognosis is good and your recovery is closer than you think.

3. Immediate imaging is (usually) not needed

For this type of lower back pain, using X-ray, CT scanning or MRIs is usually not beneficial for your diagnosis, treatments or directly pertaining to your outcomes of care. In the vast number of cases it is a clinical examination that sets your diagnosis and treatment plan.

Sometimes people think ‘If I only had the imaging, I’d know what is wrong with my back’, but the pictures do not always correlate to the pain. Upwards of 40-50% of people, who are not experiencing back pain, could potentially have a disc bulge if they had an MRI done of their back.  So getting imaging done is usually not necessary during the first visit to your physician or chiropractor. A careful examination is.

4. Keep moving

Bed rest is the worst thing to do for acute and sub-acute low back pain. Stay active. Activity is good.  You want to keep as active as possible within your tolerance of pain. Move to pain, not through pain.

5. Learn self-care strategies and/or exercises

Doing things early in the injury is better than waiting for the pain to disappear.  If you are scared to keep moving or to stay active, it may be necessary to manage your perception of pain and any fears that you may have. Your perceptions around pain and any fear that is stopping you from moving could actually prolong your pain. Remember #1: that in the vast majority of cases, the pain will diminish and you will return to functioning as you were before the pain started.

It’s important to move properly when you have lower back pain, so technique is key. The recommended exercises will likely include hip hinging (where you move from your hips); glute progressions; and mobility and stability movements.  Speak with your chiropractor or personal fitness trainer for a set of personalized exercises you can do daily that are best for you and the pain you are managing.

So here’s a recap:

• Get a clinical diagnosis so you can rule out non-spinal causes, serious conditions unrelated to back pain, and the leg-dominant radicular pain

• The current guidelines say that your prognosis is likely very good, you probably don’t need an X-ray, and the amount of pain does not parallel the amount of tissue damage (#1, #2, #3)

  • Do not hesitate to move (#4)

  • The next posture is the best posture; and movement is medicine (#5)

Managing expectations of recovery: The actual course of lower back pain recovery

This is an excerpt from the recent live webinar “Real relief from back pain – yes it’s possible”, which covered a wide range of topics, beyond what is covered in this article.  You can watch the full webinar recap video here.