Psyched! a psychiatry blog - Episodes

In the final part of our discussion with Janae Sharp, Janae further discusses the loss of her husband and how best to support others through grief. She details some unique differences in responses by others when her husband died by suicide (eg, no GoFundMe pages, but requests for donations!) and emphasizes the importance of other survivors and their stories to her and her new community. She responds to the question of whether she is "sensationalizing" her husband’s death, but focuses on her ability to do good as a result. She is particularly interested in digital solutions and discusses a few that she has been working on here. Finally, she explains what she feels the role of psychiatry is in this important topic.
TRANSCRIPT
Welcome to Psyched!, a podcast about psychiatry that covers everything from the foundational to the cutting edge, from the popular to the weird. Thanks for tuning in.
David Carreon: You've been through such a difficult experience just in what happened, but what are things that people did or didn't do that were helpful after the suicide? How did people support you or fail to support you? And maybe more generally, how do people support or fail to support families who've had someone die by suicide?
Janae Sharp: Oh, that's a great question. It was hard because the first few days, people ask you what they can do. The first few days, you're really in the closet, not recovering at all. That was hard and it was hard for me to feel like my children were getting less. That was heart-breaking how some people supported it. People who had lost someone though, they were really good at following up and being thoughtful.
I had a friend who would send me articles about grief, and she did that for several years after John's death, just randomly saying, "Hey, I saw this and I was thinking of you." That's something I always tell people is important to schedule something further out, like six months from then and say ... Think of what you would do right after someone dies. Maybe you would go to their house and help them. Maybe you would make them a meal. Don't do it the day after, schedule it for a year later. Schedule it for the next birthday of that person, for any holiday is hard for people.
Purposefully do something instead of asking what you can do because we're socialized to not accept help and when you have grief, you don't always know what you want, it's too overwhelming. The people that were the most supportive were the people who had been through some kind of death and understood the cyclical nature, that some dies will be hard and some days are easier. That it's harder the second year when everyone has forgotten, and you're still taking your kids to a grave, or talking to your kids about their dad who's dead. So just keep that in mind.
I did have some friends who were really supportive and still understand that it's a permanent loss. It's not always permanently devastating. It's not always so immediate as right when they die, but they're still gone. So that's what I tell people.
Jessi Gold: Yeah. And then you mentioned that you were surprised afterwards, like some of the bad reactions, or some of the lack of things that you maybe thought would be around or given to you that weren't.
Janae Sharp: Oh yeah. Well, some of that is surprising because like with suicide prevention, some people they'll reach out to you. Some people asked us for money to donate to suicide prevention, and that was really overwhelming. If you look up things like GoFundMe, they raise less ... or like a memorial for kids ... they'll do it a lot of times if someone dies of cancer, but not necessarily with a suicide death.
That stuff was hard and then it's so strange talking about finances ever. When you're like, "Oh, wow. That's interesting that my kids didn't have a memorial fund." But then, you survived so what do you say? It's this horribly tacky topic where like, "Oh, that's weird." And then people are asking you for money for like awareness and ... Actually, Loss Survivors are the number one funder of suicide prevention initiatives. You're also a number one funder then for a topic that is really hitting you personally, and it kind of makes you ... it's kind of off-putting, but it's also ... now I like want to help those things. It's like the people who are hurting you in some ways, also some of those people were the most supportive. I don't know if that answers the question.
David Carreon: No, it does and I think that I've heard mental illness described as the no potluck disease. The no casserole disease.
Janae Sharp: We did not have funeral potatoes.
David Carreon: Yeah, it's like you get cancer and you get a casserole. You have a broken leg, you get a casserole. But you get mental illness and you get no casserole.
Janae Sharp: Yeah, you just can't post on Facebook, "Guys I just really could use a casserole today because of my depression. I am sad ...

In the second part of our interview with Janae Sharp, she discusses why she feels she has been a different kind and less restricted voice for physician suicide awareness. She notes that it is important for physicians to speak on this issue and that there is true power in community. However, she feels physicians are more silent on this issue as they tend to avoid "unsafe" and "uncertain" topics and are ultimately afraid of the potential repercussions to their licensure. Using her background in social determinants for health, she also answers a challenging question of whether physicians "deserve" our attention and help.
TRANSCRIPT
Welcome to Psyched. A podcast about psychiatry that covers every thing from the foundational to the cutting edge, from the popular to the weird. Thanks for tuning in.
David Carreon: I think there is a lot of bravery in approaching this topic no matter where you come from or what your background is and I think that especially so, when some people might say that this is kind of a intramural problem, that this is a physician problem and physicians need to deal with it. Or maybe alternatively that this is a health care problem and so physicians need to deal with it. What would you say to that perspective? Are you, you said you've been silenced, but should this be something that is only for physicians to talk about?
Janae Sharp: The difficult thing about having physicians be the only people who talk about it is that a physician has a direct financial impact in their lives by this topic. If you have a serious mental illness as a physician, that can mean you lose your job. If you have a financial incentive as a health care system to not employ a physician with a mental illness, what does that mean in terms of disability rights and what does that mean in terms of our ability?
So I think physicians know a lot. I think they're super accomplished and I think they really value academics and I really like that they want things that are validated, I like the healing belief. I also think they don't have the freedom that the system, the system isn't designed for them to criticize itself. It's designed for them to perform. Or not perform.
So someone like me, it had the biggest direct financial impact as like the loss of the, you know the loss of all that medical school and all that training directly impacted my kids financially, obviously, and I had a bigger loss than a specific physician would have. I mean not a physician that's losing their job, or passing away, but those voices are sometimes lost and the people in the conversation can't, they aren't as unfettered as we want to, we need them to be to make honest decisions and discuss that honestly.
Jessi Gold: But you feel less limited by external forces, because it's your life and your story not some story controlled by their job?
Janae Sharp: Yes. Like this is something where I don't have to put it on my licensure, my complete mental health history, which I think in 29 states they ask you to do that, even in your renewal. I don't have to report to my employer. When you've already had a suicide loss, there's nothing to do lose anymore. And physicians want that stability and they want that safety that they've confined in academic medicine and within knowing what's right and wrong, but this isn't a safe topic.
So I think it's important for people like me, to be there and say, "Yeah, but, you guys are saying all this stuff." Even when you talk about it sometimes, it's like an alternate universe. They talk about it as if physicians are all saints or all so sad, instead of they're really just human, you know. Some of them are jerks. Some of them that you work with, you don't like and you can talk to nurses and doctors about that. So maybe it needs more sarcasm.
David Carreon: Oh, I don't know if I've ever met a nurse or doctor that I don't like.
Janae Sharp: Never. Never. I've never, I've literally never met an unreasonable either and neither have you.
Jessi Gold: It's just like, you know, it's the same. Like there's sad ones, there are happy ones, there are people who get better, there are people who don't. It's the same.
Janae Sharp: Right. Yeah. Like everyone knows that one guy who they just didn't like, and like how when we're talking about mental health and when we're talking about a healthy system, we need to separate those two. So it's not just like that one selfish guy who thought he was the best person ever, now he's talking about how he's the best person ever with mental health, and he's going to make things better for everybody if you were just more like him. You know? Because that's a little off putting.
Jessi Gold: Yeah.
Janae Sharp: Yeah. So I think it's, I actually think it gives me more freedom, because I can say things like, "Yeah, but it was shocking to me how much some of the people that I've met in medicine do coke, or other performance enhancing drugs...

In Part 1 of our 3-part interview with Janae Sharp—a physician suicide loss survivor and the Founder and CEO of the Sharp Index, a nonprofit dedicated to better physician mental health—Janae shares her story of loss, grief, and her call to action to start her non-profit.
She discusses how suicide loss is different from other losses, in part because it is a "messy topic," but also how grief itself is imperfect. She details the experience of telling her 3 children and why she feels compelled to create "better memories" for them. She constantly reinforces the power and complexity of humanity.
​Janae is always looking for collaborators (she wants more psychiatrists!) and donors, so if you are interested in getting involved contact her at [email protected]. For additional information or to learn more about Janae’s work for physicians, survivors, and families please visit the following websites: Mdsuicide.com and Sharpindex.org. Find her on Twitter @CoherenceMed.
TRANSCRIPT:
David Carreon: This is David Carreon.
Jessi Gold: This is Jessi Gold.
David Carreon: And this is Psyched!, a psychiatry podcast. Today we have Janae Sharp. Janae is a physician suicide loss survivor and the founder and CEO of the Sharp Index, a non-profit dedicated to better physician mental health.
Her main work involves health care data and analytics marketing to improve health care outcomes for the underserved. Python is her preferred code language, but her true passion is match making companies to create elegant health IT systems and to improve health.
She's worked with interoperability and social determinants of health and is an expert on patient and physician engagement. Janae has 3 children, enjoys hiking, triathlon and quilting. Janae, thank you for joining us.
Janae Sharp: Thank you. I hate writing bios as well. I feel like that's important.
Jessi Gold: Yeah, it is really important.
David Carreon: We should have added that to your bio.
Janae Sharp: Yeah.
Jessi Gold: And writing a bio was not your favorite thing to have done.
Janae Sharp: Hearing my own bio I'm always like, "That's a terrible bio. Someone should rewrite that. That poor lady."
Jessi Gold: Well, okay, so how about we start with you just telling us more about you and your story and then as much as you feel like telling us, yeah.
Janae Sharp: Oh, well, that could be pretty long, but so the story of starting the Sharp Index, I can talk about. Like it says, I have a background in health care IT, and I've worked with people creating data products and worked in social media a lot, and I am also a physician suicide loss survivor.
My former spouse, John Madsen, was a physician. He died by suicide, and we created the index actually in his memory and through my experiences with his death. We have 3 children, and I've been able to share a lot of our story and trying to create good memories and, really, how that type of loss was pretty different in terms of the support that my kids got.
It was really frustrating. I felt like people didn't really know what to say or had a lot of advice that wasn't helpful or advice that really was hurtful in some ways. And we wanted to create something that brought awareness to physician suicide but also addressed that, created a better place, and that's really our hope, to have better memories for people.
But also, the index is focused on reducing burnout. So you can look at scores and information about your burnout risk or reasons for that or mental health. And we want to create a network of peer support that's outside of your employer because when ... physicians are really driven to succeed and to accomplish a lot, and that doesn't always ... You don't always want to tell your employer you're really struggling.
And in addition, people aren't always aware. If you've always been really in a work environment where you have a lot of stress and you've been a higher achiever, you aren't always aware and in touch with things that might put you at risk.
So that's been kind of my personal story is just that we had just kind of this impossible situation, and I wanted ... And when people would ask me, “What should you do? What are solutions?” I didn't feel like there was a lot out there that was focused on a realistic approach and not just doing lip service to the topic, especially since I was a family member and didn't ha...

Charles Nemeroff, MD, PhD, discusses the role of social influences on biology, using the example of early life trauma. He explains brain changes, inflammation, and genetic risk factors that modulate the development of PTSD or depression in patients with a history of trauma.
Keeping in line with epigenetic theory, Dr. Nemeroff discusses what happens to genes during psychotherapy, exploring the interaction between attachment to the therapist and how this contributes to the efficacy.
Finally, he answers our rapid-fire questions and describes the challenges without parity in mental health care. He leaves us with excitement and hope for what he feels is the “golden age of psychiatry.”
TRANSCRIPT
David Carreon: I think that on the positive end, I think there's more research to do, but I think thinking about this relationship between the mind and the body, and the person's experience ... It makes me think of things like a difficult childhood, child abuse, or something like that could very well increase a person's stress level and inflammatory markers.
Dr. Nemeroff: Well, you're prescient, because that's exactly what the data show. There's a wonderful meta-analysis by Andrea Danese at the Institute of Psychiatry in London. We've confirmed the findings in our own studies. Early life trauma is associated with a very persistent increase in inflammatory markers, and it's probably one of the reasons why those patients have a poorer response to psychotherapy and pharmacotherapy.
Jessi Gold: And what counts as early life, and is it one trauma, multiple traumas, or is it different?
Dr. Nemeroff: So another great question. The data is still being generated, but overall pre-pubertal abuse and neglect. The more severe, the worse the outcome, both in terms of inflammation, but also a host of other factors. Neuroanatomical changes ... The human brain doesn't mature until age 24, and we know that developing protoplasm is susceptible to insult. Susceptible to lead toxicity, susceptible to fetal alcohol, and in my way of thinking, it's susceptible to behavioral teratology, namely child abuse and neglect. So it's not surprising that we've seen these robust effects that we have.
David Carreon: Yeah, and I think there's been an interesting body of literature developing around the social influences on biology. Rats that are isolated versus rats that are in paired housing versus rats that are in enriched environments have entirely different profiles of how they do and how they behave, and what that means for them. And I guess thinking about that both in childhood, but throughout the life, that environment plays a huge role ... And social environment plays a huge role in-
Dr. Nemeroff: Well, remember that for major depression ... Not talking about bipolar disorder, but for major depression, about 35 to 40% of the risk for the disease is genetic. That means 60 to 65% is environmental, and I think a lot of this has to do with attachment. I think early life trauma disrupts attachment, and I think subsequent life stressors disrupt attachment, and if you follow these kids who've had terrible early lives, it's a very rocky adolescence and adulthood indeed.
David Carreon: Is it possible that somebody who has had a difficult childhood would be able to overcome that and fully remit or fully...
Dr. Nemeroff: Yeah, so most of our studies in this area have focused on trying to uncover genetic risk factors, that interact in a gene environment way to increase or modulate the risk for depression or PTSD in adulthood. What we've discovered is that there are some critical genes, of which certain of the SNPs, the variants, unfortunately markedly increase your risk for depression if you've been exposed to early trauma, and then their counterparts which are resilience genes that prevent it.
So I believe many of our patients are probably patients who've just had pretty bad luck. They've pulled a bad hand. They have three, four, five or six of the vulnerability genes coupled with early life trauma that result in an increased risk for depression. What's really interesting is in our studies, in the absence of early life trauma, these genetic variants have no impact on whether you get depressed or not. It's only in the face of early life trauma. It's sort of like ... Imagine the guy who has the risk gene for lung cancer but never smokes, right? No effect, right? But smokes three packs a day and 80% likelihood. That's what Caspi saw with the serotonin transporter gene. It's we've seen with the CRH and the FKBP5 gene. I don't want to bore you with the nomenclature, but there are gonna be a category of genes.
Now there is some data that both epigenetics is important, so the notion that life events change gene expression, not by changing the structure of the gene but by changing the expression of genes. That could be good or bad. It may be, if I was a betting person and I was Jessi's age, what I would do ...

Here: Part 3 of 3 with Emeran Mayer, MD, PhD on the mind-gut connection. Dr Mayer talks about the role of the gut in psychiatric illnesses and mood-from a history of forced colectomy in psychiatric patients to an inflammatory diet influencing mood. He answers the question: are we happier when we don’t eat sugar or gluten and should we all be gluten-free? Dr. Mayer is a pioneer of medical research into brain-gut interactions and author of The Mind-Gut Connection: How the Hidden Conversation Within Our Bodies Impacts Our Mood, Our Choices, and Our Overall Health.
Transcript
David Carreon: Let's also talk about nutrition and diet and microbiology of psychiatric conditions. I know there's been some discussion and some work that you've ended up with around depression and probiotics or depression in the microbiome. How good is this evidence, or what is the relationship between something that we would consider a psychiatric illness and the gut?
Emeran Mayer: As you know, some 100, 150 years ago, there were psychiatrists who are actually obsessed with the role of the colon and fermentation and it led to this unfortunate situation that many psychiatric inpatients in hospitals had to forcefully undergo colectomy and many died because ... There was a phase where psychiatry was actually very much interested in the microbes playing a major role in the psychiatric disease. That obviously has completely disappeared. Today, there's something new that's sort of come up, and that's the role of diet in influencing the nervous system. Felice Jacka in Australia has recently published the SMILE Study. She and her colleagues found that in a randomized study, if they compared the outcomes of patients, I think it was with major depressive disorder, who underwent conventional therapy and their regular diet vs with conventional therapy with a Mediterranean-type diet, there was a significant difference. She has written about this topic.
One explanation of that is related to this concept of an inflammatory diet. We know that high fat, high sugar diets change the microbiota in a way that there's a whole series of events. Increased permeability of the gut is the result of that, increased access of micropolysaccharides or other pro-inflammatory molecules, the gut-associated immune system, which then creates a ... It's not full-blown inflammation, like in inflammatory bowel disease, but a low-grade inflammatory state which then often becomes systemic, so you have circulating LPS levels. My opinion, that's most plausible explanation. As you know, neuroinflammation has been so implicated for depression and other psychiatric diseases as well, so it could well be that diet plays a role in exacerbating it. Certainly not diet is the cause of psychiatric disease, but it's a significant modifier.
Jessi Gold: I've heard people say that when they went on sugar-free diets, or when they went on gluten-free diets that their mood improved. Do you think that's true with what you're seeing in research? Is it totally subjective and they just believe in the diet?
Emeran Mayer: There's certainly, with anything diet, a huge psychological dimension. I think there's few things that have such a placebo effect as diet has. The high-sugar phenomenon, I do believe, because we know a lot about this. High sugar, high fat, it's sort of like opiates. It makes you feel better right away. That's why people almost self-medicate when they're stressed out you crave for something like that. In the long-term, it has these detrimental effects and leads to this low-grade inflammatory state. I think when people say that when they switch their diet to a healthy diet that they feel better, I certainly believe that. In terms of the gluten, that's a whole other story.
As a gastroenterologist, I'm obviously fully aware of the seriousness of celiac disease. It does appear now probably also related to the microbes and the early interaction with the immune system that people develop more and more hypersensitivities and even allergies to food items that 20 years ago nobody ... Like the peanuts and wheat ... If you have that condition, if you eliminate any agent, most likely you will feel better as well, but then you have, it's like 40% of the US population now, who thinks gluten is toxic for them. That's really unsubstantiated. There's nothing that's been found, sort of like IBS, you can take biopsies, you don't find any possible pathological or pathophysiological mechanism.
There was an interesting phenomenon. This really started with a book that came out by a person, an author, won't mention the name, that before was really on the candida connections. This was an early phase that people say all your symptoms, including IBS and ...