Depression is more than just a state of mind – Part III: Success is not a destination

(Originally posted August 28, 2018; reposted with edits)

As a brief prequel to this post, I feel compelled to clarify that the purpose of the previous one was not to draw sympathy to my situation but to create a picture of depression that is both real and precise.  We all go through stuff.  What I have learned from my “stuff” is that we probably all have more in common than we realize, and I am hoping to pass along a similar realization.

Please also allow me to clarify that while relaying the story of my own journey, I disclaim any implication that your journey is supposed to follow the same path. Not at all. Instead, I have again included subtitles to paint a bigger picture relative to what I see as a legitimately clinical (albeit, nonmedical) “treatment plan” to a legitimately clinical problem (as indicated by subtitles in the previous post).

My objective here is to illustrate that anyone’s individual path towards redemption, while remaining unique, also contains certain critical elements, towards a whole/sound/healthy/insert-wellbeing-related-term-here life, that are FUNDAMENTALLY HUMAN.

Sure, people live without such elements, but I propose that without them, a life is closer to mere existence. And I propose that existing without living is tantamount to seeing one’s own life as not worth living. Which can progress to a desire to stop existing. And this is a state of mind to which we as a society have illustriously applied the term: “Depression.”

I propose that fullness of life … that is, THRIVING … necessitates all of the following subtitles.

My story is here merely an illustration, not a map or an example or a pattern to be followed. The best way to come away from this story is to develop determination, in some form or fashion, to seek whatever path feels like the “rightest” fit for you to discover and fulfill VALUE.

At the end of this, I hope you will be inspired to find that fit for yourself. Then find it again. And again. Because as long as there is breath in your body, the journey keeps rollin’ on. And on. And on.

For now, let’s just get on with the story.

* * * * *

Physical exertion

My husband Keith started going to CrossFit® around 2009 when our first son was an infant, and my scorn for it was thinly veiled.  Not only did he frequently come home from workouts vomiting, but the lingo of “WOD”s and “AMRAP”s annoyed me.  Meanwhile my job at the time was to admit patients to the hospital where “CrossFit Rhabdo” became a well-known entity.  This is a situation where otherwise healthy individuals had pushed themselves too hard at the gym, resulting in uncontrolled breakdown of muscle tissue called rhabdomyolysis, flooding the bloodstream with proteins which can potentially clog the kidneys in critical fashion if left alone.  As such, they require admission to the medical service for IV fluids and close monitoring.  Thankfully, this never happened to Keith, but amidst all this I swore off the program for myself.

We moved in 2013, Keith found a new gym, and I continued to scoff.  But he wasn’t vomiting anymore.  In fact, many things were drastically different.  It was hard to pinpoint, other than that he typically came home from workouts… happy.  Fulfilled.  And …inspired?  He was bursting at the seams to share what seemed to be a regular ration of new skills with ridiculous names: “clean”, “jerk”, “snatch”.  The new place was clearly more systematic than where he had gone previously, but the benefit was greater than mere organization.

I figured I could quiet his insistence for me to try it by doing the introductory classes.  I had found a Groupon anyway, so what the heck?  After the intro classes I felt I had done my duty and had no intention of going back.  This was right around the beginning of September 2015.

One month later, broken and swimming in a sea of emotion after the loss of my brother, I decided to throw some weight around and showed up for my first “WOD” (Workout Of the Day).  Exerting myself like that was a first, and I was quite sure my whole body would explode before the workout was over.  But I survived!  And I will never forget the sense of release afterwards, like nothing I have ever experienced before.

To this day, Keith and I both know the surest antidote to bad moods – for both of us – is a strenuous workout.  It certainly isn’t as easy as popping a pill might be.  But it eff-ing works, and the only side effect (as long as it is approached with wise supervision, especially when new to it) is becoming physically stronger.  There are worse things.

Real food

There was far more than one instance, though I couldn’t tell you quite how many, when I twisted my face in confusion as Keith would talk to me about “real food” as opposed to “processed food.”  I honestly was mystified.  My deeply seated impression was that if you eat something and it doesn’t immediately kill you or at least make you sick, it was food and that was that.

You see, having completed nearly all my higher education in institutions of the Seventh-Day Adventist Church with its embedded Health Message consisting largely of vegetarianism also eliminating alcohol and coffee (I’d say “caffeine,” although I’m pretty sure there was Coke or Pepsi in the soda fountains), I was well acquainted with a variety of meat substitutes which I took as healthy simply because they contained no animal products, although it clearly takes pretty advanced processing to get vegetable proteins to resemble meat in any way.  I had a friend from medical school wildly entertain my husband by declaring my nutrition during that phase of life consisted of “veggie meat out of a can.”

Having long lived according to a mantra of “eat to live, not live to eat,” I considered food a necessary evil to be overcome day-to-day, which might occasionally provide enjoyment in the form of chocolate or cookies.  Since most “foods” didn’t immediately render death or severe illness to myself or my kids, I easily took for granted that dino nuggets, 3-minute mac-n-cheese and yogurt squeeze tubes were adequate staples.  Our erratic work and life schedules lent to mealtimes that were all over the place, too, so we rarely ate dinner together, and we rarely ate the same thing for dinner.

To my dismay, Keith began to insist that we sit together for dinner and teach the kids to eat the same thing as us… which was to include a simply prepared meat with some vegetables on the side (along the lines of a “paleo” diet).  Period.

I did not take kindly to this at all.

It seemed like a hopeless venture to adjust the eating habits of a toddler and a fussy kindergartner but little by little, we discovered small victories here and there – lettuce with blue cheese dressing for one, carrot sticks for the other, etc. – and worked these into every meal.  We taught them to try new things.  I never really minded eating anything in particular; I was just a nervous wreck in the kitchen.  That came with time and effort, too.  My chopping skills have come a long way, and I even know how to “toss” in a pan while sauteeing… it’s all in the wrist!

The greatest shift occurred, though, in early 2016 when I agreed to partner with my husband in a 6-week “clean” diet challenge through our CrossFit gym that also encouraged hydration, exercise and mobility.  I detailed this experience rather extensively at the time in another series within this blog called “Confessions of a Carbaholic” so I’ll keep my message simple here.  I started out angry and starving, but week #3 of diligence yielded a shocking payoff.  I can best summarize it as wellness like I never knew existed.  I felt energetic, clear-headed, optimistic.  Even the quality of my sleep improved.  It was a whole different version of being “healthy” that I think most Americans haven’t ever had the benefit of experiencing because of the toxins that we treat as basic rations even before birth (that is, relative to mom’s diet during pregnancy — which, as a mom myself, I now realize all too well).

Bottom line: changing dietary habits does not happen overnight, and every single snack and meal is a new opportunity to make a choice for better or for worse.

Also, there is no such thing as a “perfect” diet.  Food still accomplishes various objectives in the human body.  Achieving a balance between physical nutrition and emotional enjoyment through eating is a lifelong endeavor.  There will be ups and downs.  Try to embrace the journey and learn about what you put in your body.  It REALLY MATTERS.

Mindfulness/Meditation

I have come to realize, when it comes to grief, that the first anniversary is the hardest.  It may or may not get easier after that, but whatever coping mechanisms a survivor of a lost loved one may have constructed over the course of a year all come crashing down when the air feels familiar, certain holidays resurface, and myriad other reminders arise that someone who had once been there is definitively gone.

September 2016 came and went.  I suppose I expected things would get easier after that, especially since there was mercifully little ongoing onslaught of new drama.  My family was well, work was miserable but this was no change (haha), and my own physical health was in a better place than ever in the past because I was eating, hydrating, and exercising with some distinct regularity.  But I felt awful, deep in a hole and couldn’t drag myself out.

Off I went to my therapist, who I hadn’t seen in close to a year (of course there had been a bolus of visits after Abe’s suicide the year before).  My big question was, “What is wrong with me?”  Overall, I wanted for nothing in life: healthy kids, caring husband, good household income.  What more did I want or expect?

She pondered my conundrum, and told me simply: “You need mindfulness.”

I almost fell off the couch.  Good ol’ Hubby had been talking to me about mindfulness meditation for the better part of TWO YEARS by that point.  I had repeatedly responded to him with “I’m already mindful!” and would promptly return to my flitting activity of motherhood and doctorhood.  Again, I had been annoyed with the soothing monotones of guided meditation voices, somewhat resentful over being left to handle all manner of household and parenting duties while Keith laid in respite, listening and breathing.  He offered to switch places multiple times over, but I just couldn’t be bothered.

Albeit irritated about taking a stance of “you were right” relative to my husband, I was fascinated that this was being offered by my deeply trusted therapist as real advice, rather than mere spousal harassment.  I asked for a distinct recommendation for something structured, an “app” I could use.  She told me there were many but upon my insistence she mentioned “Headspace.

Much like cleaning up my diet, the first two weeks of sifting through my mind were awful, abject torture.  I loyally popped in earbuds and spent 10 minutes a day sitting upright but relaxed, eyes closed, and soon became ragingly aware of the chaos inside.  I discovered the content of my thoughts was almost exclusively self-deprecating.  For example, while driving down the road to my house one day, I attempted mindful awareness of my surroundings, cast my gaze upon a neighbor’s front lawn, and caught myself thinking, “My lawn looks terrible compared to theirs.  I never make time to take care of my home and property, because I’m a terrible homeowner, not to mention a terrible wife and a terrible mother…”  This was a typical reaction for me.  I had just never paid attention to it before.  Every single thing I looked upon seemed to be a reason to berate myself.  I could never keep up at work, and my overflowing inboxes reminded me of this.  I could never keep up at home, and the clutter from corner-to-corner in the house constantly reminded me of this.

Not that more details are needed, but I also discuss my journey with mindfulness in a previous blog post.  Suffice it to say, success in this endeavor also came only with time and persistence.  The most poignant lesson I have personally drawn from mindfulness is self-compassion – learning to observe without judgment.  Evaluation and decision-making have their place, but the ability to calmly take note of something without creating internal stories about it is a skill that in and of itself is impactful and universal.  Entire books – libraries by now – have been written about it, so I don’t pretend to be able to explain all the benefits in this single blog post.  It’s simply life-changing, I’ll leave it at that.

Tribe

I’m a bit of a lone wolf; I got used to this early on, being raised to believe my religion “set me apart from the world.”  Being different and separate was a badge of honor, of sorts.  Also, pride was a big deal in my Asian family — we were to be beholden to no one.  Leaning on others is just not my style.

Turns out the human organism is not meant to subsist independently.  We joke about whether someone “was never held as a child” but legitimate development of certain fundamental neural channels depends on interactive contact with others.  Rugged independence is often regarded as strength, but the strength required to conquer the toughest obstacles can only be generated through interdependence.

I would say the first time this hit home to me was with my CrossFit experience, at the ripe old age of 38.  From my very first Intro Class, through Foundations training and my first few real “WODs”, I remained flabbergasted at the steady stream of warm, fuzzy remarks from people I barely knew, who were eons more physically fit than I: “Great job!”, “Way to go!”, “You got this!”  It felt essentially impossible to not keep going.  Everyone else was finishing the grueling workout… including people who appeared less physically fit than I.  So clearly I should, too.  It was an oddly refreshing, new form of peer pressure.

Go figure, this is a phenomenon I’ve blogged about before as well.  But I have grown in so many more ways than what is alluded to in prior posts, on account of actually becoming a part of the tribe, as opposed to just being present in the setting.  There is a reason people thrive in religious communities, where going to church or temple or coming together for worship in one forum or the next is so successful at yielding happy people.  At the risk of sounding blasphemous, although I find it a widely proven truth: this is far less a product of the dogma, or beliefs, than of the community that happens to revolve around a common set of beliefs.

At CrossFit, we congregate around fitness.  The fitness is great.  But to me, the true primary benefit is that we congregate.  This has been by far and away the most efficacious antidepressant I have come across.  I would go so far as to say interactions in the form of friendship, community and romantic love are what flood the brain with serotonin: manifesting as happiness that feels substantial, lasting.  But my natural inclination is still to gravitate away from it and be a stubborn individual.  Old habits die hard.

It is not just about being ‘around people’, by the way.  I personally find there is no worse emotion in the world than being in a crowd of people but feeling entirely alone.  It is about connecting with people who are likeminded to you.  That is the essence of having a tribe, or community.  This is what has set CrossFit apart from other “workout classes” where you can walk in and walk out without anyone noticing, which is easier up front but far less healing and also far easier to quit.

A tribe that suits you is rarely easy to find, often follows lots of trial and error, then entails overcoming a long, steep hurdle of integration that typically takes – again – weeks to months of persistence through initial discomfort (notice a common theme here?).  Most of the time, successful community experiences are thrust upon us through motivators that have nothing to do with “seeking a community” – e.g., growing up in a church, joining the military, sports teams, college majors or other intensive training experiences.  In these scenarios, people come together for a common objective, and the togetherness happens by necessity then provides them with more meaning than ever sought or imagined.  Worth writing books and movies about.  Over and over, again and again.  This is the essence of being human.

There is something powerful about being part of something bigger than oneself.  Sharing experiences with others – and sharing in others’ experiences through conversation, storytelling, reading, teaching and learning – is truly expansive for an individual.  When we feel closed in, shut out, locked down, trapped… what we need is each other.  It can sound very cliché, but that’s only because it’s that important, that repeatable, that life-essential.

Actually, I think the best way to summarize the fundamental human attribute here is: What we need is to belong.

Personal Achievement

Much like Maslow’s Hierarchy of Needs, being able to fully realize one’s own potential is more of a pinnacle attainment as opposed to fulfillment of a day-to-day need.  However, there is something to be said about a sense of accomplishment even in little things, that provides us with shots of dopamine: manifesting as thrills that feel great but are fleeting.

I love this about CrossFit.  Every single impossible-seeming movement done by the beastly, superhuman-appearing competitive athletes has a countless array of corresponding “scaled” movements that engage similar muscle groups but can be completed by “the rest of us.”  Can’t climb a rope?  Lie on the ground and pull yourself up by the rope for a few grabs then lower yourself back down.  Can’t do a handstand push-up?  Do a regular push-up with your knees on the ground, or lift small dumbbells overhead.  Can’t lift 225lb overhead?  Start with a PVC pipe.  Embarrassed because you can’t do what the competitors do?  Let it go and revel in the fact that you are there doing it.  My CrossFit mantra is: “I show up, I win.”

You don’t ever walk away from a CrossFit class without having done your body a huge favor.  Ever.  Unless you overdo it or do it unskillfully.  Good coaches will prevent that.  And there are LOTS of great gyms with amazing coaches, not to mention dozens of people who have bought into the culture of cheering you on even if they’ve never met you before.

Regardless of your level, you grow every single time you are there.  It’s built into the programming.  All you have to do is keep showing up.  I wish life were so well plotted out.

But in life, showing up takes on a different form.  No matter the task, there are scaled versions of it, too.  The key is to proceed without wasting time and energy on critique of self or others.  Judgment that isn’t constructive is the best way to create a setback, and is the essence of depression – it’s a relentless feedback loop on a theme that carries you nowhere, like getting stuck in a hamster wheel.  If something didn’t go well, let it go and take a slightly different path.  But keep showing up.

The following is quoted from the end of the televised 2018 CrossFit Games® in celebration of the athletes who competed:

“To be worthy representatives of us all, they must know defeat and humble themselves to its teachings.

“Continuously, they test and test and test again, for in the testing lies the answer to the question: ‘How will you be better tomorrow?’

“Only those who repeatedly ask and accept the answer, who continue to recognize missteps as opportunity will realize their true potential.  Fear and ego will stop many as they mistake failure for weakness.  It is through their efforts that we come to understand how our own limitations will be tried, that we come to understand what’s possible, that we come to understand what we can choose to be:

“Better.”

That’s all it is.  Just be better today than yesterday.  Or if today is really bad, make the better decision to let it go so you can get back on your way more quickly than you would while ruminating on the perceived failure.

And because there is always a way to be better, there is no goal, no final destination: only new platforms for the next leg of the trip.  Just stick to the journey.  Wherever you find yourself, count it a win because you are there.

Depression is More than just a “state of mind” – Part II: Descent, crash, and rebound

(Originally posted July 18, 2018)

Despite four years of medical school, five years of post-graduate medical training, a second graduate degree, and a history of having been raised by not one but two psychiatrists… I had no idea I was depressed.

Make no mistake, I knew quite clearly that I was unhappy.  But, highly skilled in rationalization, I was able to contrive reasons for my emotional state from various and sundry aspects of day-to-day life with little sense that anything “clinical” might be behind it, nor any interest in applying a diagnosis to my situation.

It took a lot to pry my eyes open.  The headings you see below held no meaning for me when the story originally unfolded.  However, my comprehension crystallized later.  Read on, and you’ll see what I mean.

Post-Partum

My first pregnancy and the four years that followed are a general blur in my memory other than certain poignant moments, like the shock of discovering early in our second pregnancy that our child had an ultrasound abnormality indicating high-risk for major complications.  Even that melted into a steady but whining hum of difficult emotions as subsequent testing yielded reassuring results, albeit always with reminders of the caveat that the worst might still happen.

Anhedonia

Thankfully, both our kids came out healthy, but the poor things now had me to deal with.  I hovered between asinine determination to “do it all” and crushing guilt upon discovering I couldn’t.  Doing anything took exorbitant effort that I could barely muster.  But it had to be done, so I poured every ounce of my energy (and most days there were probably only a few ounces) into the tasks of child care and homemaking, with none to spare for emotional engagement.

To be honest, I knew something was wrong when I couldn’t sing.  For my entire life, since early childhood, music had been the cathartic outpouring of all my passions.  But the rhythm of our life as a family interfered with my ability to participate in the church choir that had once been my outlet.  My husband was in the thick of his own medical training which frequently consisted of those 80-hour work weeks and overnight calls up to twice a week, so he wasn’t exactly available for backup parenting.  One day, unexpectedly alone with our then very little ones, I had to skip out at the last second on a Christmas concert the choir had been vigorously preparing for and that I was particularly looking forward to.  My voice box quit for several years after that.  For one thing, the bitter pain of disappointment didn’t seem worth the hope of what might be high reward.  But even beyond the rationale that joy might break through with a little singing, there was just NO desire to try.

Catatonia

Somewhat rogue and solitary by nature and upbringing, I largely kept the internal chaos to myself.  My pride was so impenetrable, there was no way I would let on how broken I was, although I’m sure it was more apparent than I realized.  On reflection, the truth is that I kind of couldn’t.  My husband would ask… invite me to share.  And I could swear the clearest, most articulate, most heartfelt explanation of my inner thoughts would play itself out from beginning to end.  I said it all, I said everything… but it was stuck in my head.  It just wouldn’t cross the brain-lip barrier.  I remember several moments like this in more detail than one might expect: nothing came out of me but silence and a glazed, directionless stare, even though my mind was not just active, but almost racing with thoughts that fueled disappointment, fear, even rage.  I wanted to move, to yell, to cry.  Instead I just sat there.  (https://www.healthline.com/health/depression/catatonic-depression#causes)

There were a few instances where I attempted to verbally express the eloquent soliloquies circulating in my mind.  I would open my mouth, and my voice was tense, my words halting and the content essentially gibberish.  So I quit trying.  It was a very challenging time in our marriage.

Sleep-Deprivation

I would eventually peel myself out of these cocoons and resume function around the house, knowing I had to.  Meanwhile, I worked graveyard part-time in the hospital and frequently went into my first shift for the week having not slept all day, commonly amounting to 30 hours at a time without rest on a weekly basis, and averaging 3-4 total hours of sleep every 24 hours the rest of the week.  My assumption was that I should be able to handle this, since 30-hour shifts were a standard part of medical residency training, which I had just completed.  As a doctor AND a mother by this point, I felt it my duty to endure seemingly insurmountable obstacles in the name of resilience.  Staying highly functional while critically sleep-deprived was something I considered a badge of honor.

Poor Nutrition

Turns out the two are essentially mutually exclusive, as “high” functionality proved to be very relative in the setting of poor sleep.  Most days my function did surpass catatonia – I guess you could call that a victory.  Still, fueled by pride and repeatedly declining opportunities for self-care, I ate whatever was around which commonly consisted of bread and butter, mac & cheese, Cheerios, and dinosaur chicken nuggets.  My night shifts operated on vending machine loot, usually Snickers bars or Pop Tarts.

Self-Loathing and Social Isolation

Probably the most crippling feature of this period for me was the isolation.  I had gotten chubby, my hair was thinned, my skin dry and splotchy, and I felt perpetually bloated.  I simply loathed myself and couldn’t bear to subject others to my company, so I avoided public appearances.  As a mom of young kids, though, there were inevitable trips to the grocery store, “Target runs,” and visits to local playgrounds.  Everywhere I looked, I found evidence that I was an inadequate mom: everyone seemed to have it together more or have better-behaved kids than I.  On rare occasion I found myself at times seeking out “worse” family situations to prove I wasn’t as bad a mom as I felt. The judging and comparing only proved more emotionally exhausting, so I would quickly retreat to my living room and the warm, fuzzy distractions of PBS Kids and Nick, Jr.

I never really talked it out with anyone else, I had no idea who to talk it over with.  Most of my friends had not started having kids yet, and those historically closest to me were distanced not only by miles but even time zones, so coordinating a conversation simply felt beyond my capacity.  The occasional times I would chat about parenthood were with my mother or mother-in-law, who provided extremely valuable help on a weekly basis, so I could –theoretically– rest after my night shifts (although I proved to never be a good day-sleeper).  They were soooooo well-intentioned, but most of those conversations ended in advice I couldn’t fathom following for one reason or the next such as “Cook and blend your own baby food,” or pat reassurances like, “Your kids will survive you.”

Deep down I knew it wasn’t advice I was looking for anyway; I didn’t expect or even want some magical solution to make motherhood easier somehow.  I wanted to be validated.  Just to be heard and understood.  I had no idea where to go for that, so I just turned further inward and wallowed in resentment.

Mood Symptoms

If anyone were to ask on any given day how I felt, the honest answer (which I never provided) would have been one of two things: upset or numb.  I wouldn’t really have described myself as “sad” most of the time.

I was certainly irritable, and the unfortunate most frequent recipient of my snapping and snarling was my older son, as the younger was still too infantile to grasp it.  My husband was more frequently dealt the silent treatment.

I was angry, which is an emotion generally tied to a cause: we become angry “at” something or “because of” something, rather than thinking of anger as arising on its own.  Therefore, it was reflexive to pin my frustrations on what was happening around me, things I perceived as happening “to” me.  Because the needs of my family filled out my time every day, I felt they didn’t care about my needs, which made me angry.  Then, I would think as a good Christian my own needs should always be secondary to caring for others, so I became angry at myself for spending even a moment coveting attention to self-care.

Largely, the anger was straight up exhausting and interfered with getting things accomplished so I taught myself to numb the emotions and just function.

Suicidal

That self-oppression could only last for but so long, though, and eventually I was having suicidal thoughts every night, typically when trying to get my restless kids to sleep.  I mostly wanted escape from the mental chaos, but I will now openly admit there was an element of me that wanted to inflict the punishment of my loss on those who I saw as the authors of my turmoil: my family.  My ideations of suicide were so vivid and advanced (yes, I came up with multiple plans) that it would inevitably lead to visions of being found by my children.  At this point I would realize there was NO way I wanted to damage them that badly for the rest of their lives.  You could say that would be when I would “chicken out,” and just cry myself to sleep.

A turning point of sorts

My personal unraveling eventually came to a head, but as a family we somehow survived it and started working more constructively towards collective recovery.  This included the good fortune of finally finding a therapist I connected with (I had seen a couple of therapists through the years prior, but without much progress).  Part of the reason she worked for me was that she listened without applying a diagnosis, at least not in my hearing.  As such, I had some opportunity to feel validated without worrying that I might be “crazy.”  Painful, arduous, but effective, this embarked me on what would be a very long journey towards recovery.

Meanwhile, some major career changes happened in our household for both my husband and myself at roughly the same time.  For me, this involved changing from a shift-working hospital doctor to regular office hours practicing Primary Care, which I was certain would mark a positive turn for my sense of well-being, expecting the regular office hours to help reset my badly deranged Circadian rhythm.  I also predicted job satisfaction would improve as I built longitudinal relationships with patients.  Some of this turned out to be true (http://www.thriveapc.com/2014/10/the-worst-patients/), but I had another thing coming (http://www.thriveapc.com/2017/06/thriving-part-1/).

Then it happened

In September 2015 I was struck by the phenomenon of depression from a whole new angle like an anvil to the cheekbone when it claimed the life of my only sibling.

http://www.thriveapc.com/2015/10/in-loving-memory/

From the moment of learning he was gone, I pulled a tact from my previously built frameworks of coping with death of close young people (nope, this was not my first experience with devastating loss, nor would it be my last): “I have to care for the living, and the living includes me.” 

Among other things, this firm resolution at least played a role in carrying me through meeting the officer tasked with reporting his death to me, reading farewell notes, viewing the body while my parents cried on my shoulders (although this was a detached and surreal moment for me, still unemotional to evoke it even now), organizing the memorial service according to his wishes (whereas his clearly stated preferences were simple: not in a church, but in a way that would provide comfort for those left behind, and with me in charge), writing and delivering the eulogy, and eventually spreading his ashes on the side of a mountain.

The most difficult moments were on the plane ride home, while reading through his smartphone.  All the darkness and torment he had so skillfully kept under wraps could be found there in blistering detail, between self-hateful memos he kept for himself, message chains with certain impactful people ranging from devoted to broken and spiteful, discoveries of habits and preferences he was clearly ashamed of and had hidden even from those who had thought themselves closest to him, and all the stages of his planning including drafts of farewell notes dating back more than 6 months… including notes written to his nephews, my sons (which he didn’t leave behind to be found, they were only in the phone).  Along with a handful of other deeply guarded traumatic memories that will never see the light of day, I have locked the contents of that phone into a mental vault, which otherwise dissolved with the phone’s loss of battery power.  I don’t plan to ever bring them back for anyone else’s viewing.

The “other things” that bolstered me through this episode, when falling seemed like the obvious next step, would clearly be the vast list of family and friends pouring from the woodworks to provide love and support in all forms.  I dreamed of doing justice to all these caring inputs with some form of online memorial or publishing/performing one of the songs I’ve written in his memory, or something.  My lack of capacity to pull this together in some form fueled my ongoing internal struggle for a while after.

But I guess you could say my contribution to honor Abe’s loss is what you are reading right now.  It’s taken me a while.  But here it is.

Realizations

If you were to read the eulogy linked above, you would see I had already become fully cognizant of depression as a disease.  I knew there were parts of it I could relate to, but still wasn’t so ready to apply the diagnosis to myself.

Several months later, my husband and I were spending time with good friends, one of whom happened to be trained as a psychiatrist.  She was talking to me about a member of her own family struggling with post-partum depression.

I don’t quite know why it took me so long to connect the dots, but here I was, listening to a psychiatrist talk about this well-known condition as she basically described my life 3 to 6 years hence.

I finally managed to apply enough insight to review what had simply seemed to be “life circumstances” but now read more like a “history of present illness” and the above bold/italicized headings came to light.  Some describe causative factors, some describe symptoms.  All form a picture of clinical depression.

Barriers to clarity

I couldn’t tell you how many times I have heard people voice frustration over being labeled with Depression or Anxiety by clinicians, asking rhetorically for example, “Why do I have to be ‘Depressed’?  Why can’t I just be sad?”  I once heard these exact questions from a patient whose closest friend had just died from cancer.  Clearly there was a legitimate reason for her to experience negative emotions, so she didn’t like the label of Depression.  Meanwhile, she was repeatedly contacting or returning to the office because her previously stable chronic back pain was out of control.

The issue is that there are both pros and cons to the label.  Often people are seeking an explanation for manifestations of a physical nature that tend to accompany deeply penetrating negative emotions.  On the flip side of that coin, there is dread of an explanation that carries the stigma of mental illness.  The problem with the label of “depression” is that it takes legitimate, recognizable, well-described clinical correlates and ties them together with a mark of “being crazy.”

A system set up to fail

Meanwhile as an overtaxed, overburdened clinical community, we apply the label then are disinclined to properly manage it because… well… because many if not most of us are also victims.  Proper management of clinical depression takes sizeable amounts of time and empathy.  There is a blindingly disproportionate volume of patients relative to the numbers of primary care providers and psychiatric providers available, so the few who are in practice get overwhelmed.  Guess what happens to people who are overwhelmed?

They become anxious and depressed.

Which leaves little room for empathy.

The mask of privilege

Left and right, we judge one another’s character based on their resilience under pressure, or lack thereof.  We tend to be harsher on the socioeconomically privileged, because “They have it all, what reason do they have to be depressed?”  Well it turns out people with means and resources are ironically less likely to seek help, often because privilege accompanies intellect and pride.

Intellect and pride in turn lead to a higher likelihood of successful suicide.  We can pooh-pooh the toils of celebrities all we want because of that “have it all” thing.  But when suicidal depression is real, stardom or no, it still leads to death.  Just ask the families, friends, and fans of Robin Williams, Kate Spade and Anthony Bourdain.  Chester Bennington.  Chris Cornell.

Same goes for doctors, who seem to closely follow celebrities amongst general society as enviably privileged.  It is automatically assumed that physicians make tons of money, but this is not always the case, and also ignores the question of “at what cost”?  https://www.nytimes.com/2014/09/05/opinion/why-do-doctors-commit-suicide.html

Back to that system problem

The bottom line here is that suicide is sadly a real contributor to the attrition of available doctors.  Short of suicide, burnout is a whole other epidemic amongst clinical providers of all varieties, leading to exodus from patient care through multiple avenues: early retirement, transition to non-clinical roles like education or administration, complete career changes, etc.  Fewer available clinicians leads to more burnout for those who remain, and the spiral continues.  All of it ultimately leads to less opportunity to educate and guide patients towards their own options for recovery of this very serious, highly prevalent set of conditions known as depression, anxiety, fibromyalgia, chronic fatigue, irritable bowel, etc.

So, now what?

I have good news and slightly less good news.

The good news is that recovery is possible.  And this is where self-advocacy takes on a whole new meaning.

Because my other news is good but with caveat.  Recovery often (hear me properly: often but not always) depends far less on clinical intervention than we seem to think.  But it does require a personal investment of time, effort, and insight into the various causes.  Oh, and did I mention time?  Patience is critical to success.  And the “effort” piece predicates having to overcome that very real hurdle of “anhedonia” that is nearly universal with these syndromes.  But as much as it feels so… it doesn’t have to be hopeless.

I guess another bit of “slightly less good” news is that I have far exceeded my access to your attention in this post, so stay tuned for Part III about the road to recovery.

Depression is more than just a “state of mind” – Part I: Physician Perspective on the Science

(Originally posted July 08, 2018)

An alarmingly common group of conditions are becoming the bread-and-butter of my practice as a Primary Care Doc.

Depression and anxiety along with their attendants (e.g., sleep disorders, irritable bowel syndrome), metabolic syndrome (consisting of obesity, diabetes, hypertension, lipid problems), and chronic inflammatory conditions (e.g., migraines, hypothyroidism, fibromyalgia, chronic fatigue syndrome, etc.) are gradually proving to be variations of a single but massive entity, not unlike the “autism spectrum” that has gained ground in the world of developmental neuroscience.

We don’t yet have a unifying name for this behemoth, but medical science is showing there are intertwined physiologic mechanisms that overlap, cross paths, both subtly and overtly influence each other, and so forth, manifesting in all these medical issues, in varied combinations depending on a patient’s individual genetics, culture and upbringing, habits, and circumstances.

As indicated above, just as certain conditions are beginning to get lumped together under the umbrellas of chronic inflammation and metabolic dysregulation, what we have historically referred to as “depression” is gradually acquiring a similar identity as a broader category of related conditions of the psyche – rather than merely referring to a single mood disorder. But even these “categories” are proving to not be discrete or separate, but in many ways interrelate on account of sharing hormonal and neurochemical mediators. Two main culprits are cortisol and insulin; others include serotonin and GABA (gamma-aminobutyric acid).

As doctors, we have seen these clinical entities rolling together again and again for decades but have failed to produce a management scheme that demonstrates any semblance of reliable efficacy. Or perhaps more accurately, we propose management plans that appropriately call upon participation from the patient… but without any specifics. Then when we find the patient’s condition declining rather than improving, we turn around and blame the unfavorable outcome on his or her failure to perfectly execute the plan, instead of acknowledging the pitfalls of the advice.

The plan? It generally goes something like this: “Eat right and exercise. Also, take this antidepressant and see a therapist.” And that’s about the size of it. We say this to patients without any further instruction and believe we have done our due diligence. We schedule a follow-up and walk away to document that the “patient was advised” so we can prove that our job was done. Then they come back, as scheduled, having made ZERO progress – or often having only gotten worse.

Doctors are trained to be problem-solvers. If a problem placed before us and addressed according to our training somehow winds up unsolved, we see only one of two explanations. Either there was an error in the execution of the solution on the patient’s part, or the problem doesn’t really exist to begin with – it’s just a figment of the patient’s imagination. Acknowledging that our methods are flawed and/or inadequate hadn’t really entered the realm of possibility. That is, until we have had to come face-to-face with these conditions in epidemic proportions.

It is critical to begin by understanding that we are simply at a particular point on the timeline of history in order to move forward with newfound understanding towards a higher plane: a point at which we have just barely begun to understand the pathophysiology behind “depression”, “metabolic syndrome” and “chronic inflammation”. Perhaps not that long ago (sadly, it is not uncommon in the third world to still find this belief) the notion of demon possession was considered an appropriate explanation for what we now understand to be epilepsy. It has only been upon understanding seizure disorder as a structural brain disease that treatments directed at the root cause of the problem could be developed then eventually improved upon with significant and progressive success.  Continuing to treat it as a moral or spiritual failure can and does leave millions untreated and disenfranchised to suffer in solitude.

And here we are in the modern era still debating about whether conditions like fibromyalgia or chronic fatigue are true diagnoses, or simply moral failures on the part of the victim(s). Someday we are going to look back on this period in bewilderment at our primitive comprehension.

I personally have become convinced that it is critical for people suffering from depression and anxiety to understand themselves to have a biochemical imbalance, rather than a flawed character or a state of being at odds with God or the universe. Having these conditions certainly causes one to feel that way. And it is also what society tells us. But the simple fact is that there is an imbalance. Another tough fact is that our medical treatments are not yet far enough advanced to provide a cure.

The amazing truth, though, is that effective treatment IS AVAILABLE. But it comes primarily through education, rather than medication, (although medication certainly plays a role in certain cases), followed by practice and persistence. Yes, those latter two steps do require participation from the patient. But have we even taken note as to whether patients are being provided with instruction that can be followed before holding them accountable for following the instructions? If you were vaguely told that the solution to all your problems is to “eat right”, what would you do?

Please allow me to propose a slightly different tilt to the management of patients presenting to front-line providers (i.e., the primary care setting) with non-critical depression and/or anxiety (non-critical in the sense that they are not posing an immediate threat of harm to themselves or others – these individuals should be promptly referred for emergency care).

The initial step comes with determining the level of motivation held by a given individual struggling with one version or the next of Depression with or without the complications of Metabolic Syndrome or Chronic Systemic Inflammation. This alone is a complex endeavor because a hallmark feature of depression is a symptom called anhedonia which manifests as a lack of desire or interest in activities that were once considered desirable or pleasurable. Anhedonia is a well-known, long-described function of inadequate serotonin-mediated stimulation in centers of the brain involved with interest.  As such, a depressed patient may appear superficially to be unmotivated to change. But in seeking medical help, by definition that “seeking” demonstrates some degree of motivation. The fact is, these patients are severely dissatisfied with their condition and want their lives back.

After this, the education needs to be specific to the patient’s needs. While both situations have a very high propensity to lead to depression for example, a patient struggling with obesity does not have the same set of needs as a patient struggling with chronic pain, therefore it is exquisitely short-sighted to manage depression with a cookie-cutter approach (“antidepressant and therapy”) when the root causes are so widely varied.

So yes: this takes time. In case anyone hasn’t noticed, primary care providers typically aren’t permitted much time with their patients. Maybe, just maybe, depression has accelerated into an epidemic at least in part due to the practices and policies that have depleted the value of the primary care doctor-patient relationship, forcing the front line into boiler-plate mode of “triage and refer” (ahem: “antidepressant and therapy”) instead of true diagnosis and treatment with the expertise of a professional.

Obviously, however, depression is a problem that is much larger and extends far further than a doctor can reach. In fact, I dare say that for all the depression diagnosed and managed in a clinical setting, at least the same quantity of disease burden if not more goes completely unevaluated and is self-managed by the victims, often with poor outcomes including addiction and suicide.

I have something to say about that, too. Stay tuned for Part II: The Non-Clinical Patient Perspective.

Understanding Pain

Understanding pain from the inside and enduring it has been a practice I have undertaken with great interest since learning that my ACL (anterior cruciate ligament in the knee) was torn.  It has been a fascinating and fruitful search.

Fundamentally, physical pain is a signal and nothing more. It is a message from the body to the conscious mind [cerebral cortex] stating that something has changed. Quite honestly, in many circumstances a sensation of change can easily be interpreted as something other than pain — but that reinterpretation has to transpire at the level of the mind — that is, using frontal executive cognition, and repeating this until it becomes a habit, at which point the reinterpretation is automated within more central entrails of the limbic system and takes less energy to generate. By then, it is no longer a “re-“interpretation… it is THE interpretation.

This is essentially the story behind physical training of any sort. During the process of exercise, muscles undergo relative hypoxia, which is understood to be uncomfortable and demands a response. This all takes place without any intervention from the conscious mind. Simply, using channels of the autonomic nervous system, the diaphragm is triggered to breathe more rapidly, the heart pumps faster, and blood vessels increase tension, all with the purpose of delivering more oxygen to the starved muscle cells.  In any case, oxygen-depleted muscles hurt, but the process of practicing this increased oxygen delivery ultimately results in a more efficient cardiovascular system, as well as stronger muscles. Eventually, with repeated training, an athlete understands (through cognitive reinterpretation as described above) the sensations that accompany exercise to be positive rather than negative.  Whereas, under the full set of understood circumstances, the same sense signals from nerve endings that might accompany, say, a limb strangled by a python, are interpreted as being constructive (exercise) rather than deleterious or concerning (python).

Personally, having gone through this reinterpretation process enough times now, whether in the post-operative state of recovery or from intense workouts, I have gained a new respect for physical pain and learned some tactics for embracing it rather than fearing it.  Ultimately, the difference lies not in the sensation itself — as in whether or not pain is experienced — but in the question of “embrace vs fear.”

Turns out this very question became the essence of existence in the time that followed my knee injury.  I had surgery to reconstruct my ACL in February of 2020.  As I was learning to optimize strength and understand the difference between pains that could be constructive versus concerning, I recall sitting IN the physical therapist’s office watching the news of the oncoming pandemic, not knowing what would cause more pain on a grander scale: the morbidity and mortality of an unknown virus, or the social consequences of isolation as the entire world was forced to shut down.

The signal was sent and received. Something… no, EVERYTHING… had changed. What would we do, as a population? Embrace? Fear? What to embrace? What to fear?

The answer for most seemed to evolve into embracing fear. That never sat right with me, and still doesn’t.

They say when you’re a hammer, everything is a nail.  Turns out I have some special insights on conditions known as Depression and Anxiety, and have devoted countless hours of attention to learning the truth behind these problems so as to defeat them, both personally and professionally.

Whereas, I will beg your pardon as I present my biased declaration that the pandemic on the horizon — dare I say already present and yet to reach its climax — is not microbial, but rather psychiatric in origin.

The next few posts on this blog will be copied and pasted from the Archives. Several years ago I wrote a three-part series on Depression. I think these lay a basic foundation for what I will write about in upcoming new posts.

Given that I expect a minimal –if any– audience for these missives, this blog is mostly a challenge for myself to balance honesty with wisdom. Without the fear of widespread judgment and without hope for a barrage of “likes”, I feel some liberty to present my authentic perspective. But… just some liberty. Because, authentically, my personal business ain’t none o’ yours. That is: if you are reading this and happen to not be Me, Myself nor I.

But even for fellow seekers, I wouldn’t have to divulge details of my individual story to communicate that there is a common objective amongst those who intend to survive what is coming. I don’t believe the universe is binary by any stretch, but I believe the human mind operates most efficiently by awakening to tipping points in a binary fashion. Meaning: we like to choose between two things — it’s easier than having to process the whole big picture.

So the common objective amongst those who will survive and thrive, is to choose wisely at any given moment, under any given circumstances between the following:

Will I treat this message (i.e., a pain signal) as Concerning or Constructive?

Will I be a Worrier or a Warrior?

Will I be a Victim or a Victor?

In all cases… it is a choice. The conscious mind must be engaged to make the choice, and thinking/judging/deciding is hard. At least, it is harder than NOT engaging. Simple facts.

Whether you like it or not, a choice will be made. If you allow the choice to be made for you, chances are your tipping point will lean you in an undesired direction. Because… well… you elected to NOT make the decision in favor of what you desired.

But if you have desire, if you want to be on the winning side of any fork in the road, the hardest part of the decisions presented above is to BE THE ONE to decide. It takes frontal cognitive effort. In other words, yes it is hard. At the end of the day, being in charge of the unfamiliar circumstances that come at you involves taking the road less traveled, the difficult path. Otherwise, YES, those circumstances will GOVERN YOU.

So… CHOOSE.

Be advised: patients of mine are taught and encouraged to choose more difficult paths in the interest of their survival. If you are a patient seeking a PCP and that’s not what you’re looking for, feel free to move on to someone who won’t push you.

But me… I want my patients to live. If you want it, I will do my damndest to show you how to get it.

Or… let’s get real: I do a lot of geriatrics. In my line of work, often the question is not how to live, but how to die. My answer? With dignity. Which also involves making difficult choices, not just for the patients but for their loved ones. It isn’t fun. But this is what I do. It’s my job.

Nice to meet you. See you again after the aforementioned archives are re-posted.

How good does it feel to get real?

Success! Following my first blog post in a long time, there has been no controversy and probably even no views! I relish in the liberty of tech idiocy, whereas I lack the sense to determine whether or not I have an audience so well, that it simply doesn’t matter. And this is great: I have stuff on my mind, I feel like saying it, but I don’t feel like getting into arguments. I also don’t feel like sugarcoating. I’ve waited a long time to say this and I am already loving it: “I’m too old for that shit.”

I proudly welcome you to the World of the Gen-Xers. Or… at least to my Gen-X world. I was born in 1978, I barely qualify, but… I DO qualify, and I own it with pride. All pretense has been shed, all fear is in the past. I rap, I rock, I cuss, but only because I am. Don’t like it? ‘Fraid I don’t care. Oh, you do like it? Sorry… but I care even less. If I wanted approval, I would be publishing this on a platform that gets views, like Discord or Snapchat. Facebook, Twitter and LinkedIn are already obsolete, MFs! IG is probably somewhere in-between. If you are reading this, thanks for joining me in the Digital Stone Age. Or… nice to meet you, Bot.

We all came away from the tipping point known as The Year 2020 having extracted lessons. At least for me, 2021 has been even harder. And I don’t expect things to get easier, at least not as far as circumstances go. I DO plan to feel more at ease with every passing year… day… minute. But it will not be a result of the world being an easier place to live. It will only be because I have learned to adapt.

At any and every moment, I expect the unexpected. I am never disappointed.

The Next Pandemic is on the horizon. Actually, it is already here… claiming its first victims with increasing frequency day by day. If you want to know what it will look like and how to prepare… check back.

Out. For now.

Coming back, rejoining the pack

Blogging is such sweet sorrow. One pours out his/her/their soul only to discover it dropped into an abyss of emptiness.

Haha! Actually, the reason I decided to resume blogging is the very realization that few, if any, will read this… which opens up a long-sought freedom to express myself with limited inhibition. I see this as practice, of sorts. I have a lot of catching up to do when it comes to throwing one’s thoughts into the pot of collective consciousness, and it is far safer to do so when there is a ‘chance’ for an audience, but without the threat of social shame that inevitably accompanies a large audience. I’m excited!

For now, this is all I will say because every thousand-mile journey begins with the first step. And Step One is to start. Here goes, and hoping to return soon for more!

Dr M Vacation notice July 17-24, 2021

7/9/2021

To our treasured patients and caregivers,

Here we are, past the halfway point of 2021!  Despite what the world has been through, Thrive Adult Primary Care has continued to grow, and we are exceedingly grateful you have chosen us to quarterback the health care needs of you and/or your loved ones.  It is a privilege to participate in such a personal, meaningful way in each of your lives.

With a very hectic and unstable 18 months behind us, we are poising for a slight slow-down.  We normally reach out responsibly to patients with multiple weeks of advance notification when I plan to be away for vacation, but there have been so many transitions recently that it completely fell off my radar to send this message before this moment.  Please accept my deepest apologies.

I will be out of state with my family from Saturday July 17, 2021 until Saturday July 24, 2021

The office doors will be closed that week, although phone messages and emails will continue to be monitored regularly during our office hours of M – F, 9am – 3pm as our amazing staff, Laura (Registered Nurse) and Trish (Medical Assistant) will continue working remotely in my absence. 

For urgent medical matters after hours, it is strongly advisable to be evaluated promptly in an Urgent Care Center or Emergency Department.  Intermittent phone coverage after hours from my medical colleagues will also be made available and information will be updated on the Office Voicemail line where applicable.

While most of my time away will be spent in the mountains, I am happy to report that I will have a cellular signal and internet access for much of that time and will continue interacting regularly with Laura and Trish.  However, in addition to being unavailable for in-person visits during that week, I also will not be performing any Telemedicine Visits.  Please respect any recommendations from our staff to be evaluated urgently (e.g., in a local Urgent Care Center or Emergency Department) should the situation call for it.  Meanwhile, rest assured that more routine matters will continue to be dealt with in a timely fashion.

Please also be aware that these amazing ladies will also be away for their own hard-earned vacation time on separate weeks during the month of July.  When one of us is away, the other two are still maintaining office operations, although appointment availability may be more limited during those times.

Thanks so much for trusting us with your Primary Care needs, and for your patience as we rejuvenate ourselves to remain at our sharpest and best on your behalf.

Warmest regards,

Dr M 🙂

Mary A. Medeiros, MD, MPH
President, Founder, Physician
Thrive Adult Primary Care, PC
mary.medeiros@thriveapc.com

Notes on the pause of Johnson & Johnson COVID-19 vaccines

A quick message to speak to the new public concern regarding Johnson & Johnson COVID-19 Vaccine:

For those who are not already aware, federal health agencies have called for an immediate pause in use of Johnson & Johnson’s single-dose coronavirus vaccine after six recipients in the United States developed a rare disorder involving blood clots within about two weeks of vaccination.

Nearly seven million people in the United States have received Johnson & Johnson shots so far. As such, this complication has occurred in approximately 0.00008% of all J&J vaccine recipients. This calculates to literally less than one in a million. Nonetheless, out of an abundance of caution, the single-dose Johnson & Johnson vaccine will be unavailable until more information on these 6 cases can be obtained and analyzed.

Pfizer and Moderna formulations of vaccination against COVID-19 will remain available, and outpatient administration of these two-dose regimens continue to be scheduled and administered.

*****However, please note the following with respect to homebound patients:*****

The issue with Pfizer and Moderna for homebound individuals has mostly to do with storage and handling requirements. Both vaccines must be stored at sub-zero temperatures, then once a vial is accessed it must be fully distributed within a short timeframe (I believe in the range of 10-14 hours) before it is considered unusable. Each vial typically contains 10 doses. So if there aren’t 10 recipients within easy access for a vial to be fully distributed within the time frame, all unused doses will be lost. This is a significant challenge for administering to homebound patients because not only must 10 doses be fully distributed within the opening of a vial, but temperature control between doses (with an administering provider e.g. nurse traveling between locations), is that much harder to control unless carrying a working freezer in their vehicle, so a vial might actually expire in shorter than the expected time.

In short, due to the risk of losing viable doses in the process, the Pfizer and Moderna vaccines are not appropriate for home administration at this time.

I know it is challenging, but I will continue to ask everyone to be as patient as possible as this massive process of immunizing the world’s population is pursued as efficiently and safely as possible. Public health officials are being called upon to get people safe from the virus while keeping people safe from potential risks of a quick mass-produced vaccine roll-out, and the demands are for all of this to be accomplished “right away.” The urgency is well understood at the level of those making things happen, but the fact that there is a process involved must also be understood by those who are waiting for things to happen. Let’s all remain supportive of one another, uphold safe social-distancing behaviors, and endeavor to exercise kindness and compassion. Rest assured, this whole thing will continue to happen one day at a time, and progress is indeed being made slowly but surely.

Thanks for understanding,

Dr M

Mary A. Medeiros, MD, MPH
Thrive Adult Primary Care
835 W Central St, Ste 4 | Franklin, MA 02038
Phone: 774-318-4205
Email: mary.medeiros@thriveapc.com
Web: http://www.thriveapc.com

COVID-19 vaccination update

Beginning February 1, 2021, individuals aged 75 and older are eligible to receive vaccines.

We are unfortunately unable to vaccinate patients at this time, but we would like to refer patients to other appropriate vaccination sites, and emphasize the importance of being vaccinated.

A map and downloadable list of vaccination sites can be accessed via this web link:

https://www.mass.gov/info-details/covid-19-vaccination-locations-for-individuals-in-eligible-groups-and-phases#find-a-location-to-get-vaccinated-if-eligible-

This includes the following types of sites open for online appointment scheduling:

• Mass vaccination sites launched by the Commonwealth.

• Retail pharmacies who are enrolled with the Commonwealth to receive COVID-19 vaccine.
o Vaccinating CVS pharmacies also have phone-based appointment scheduling by calling 1-800-SHOP-CVS (1-800-746-7287)

• Certain hospitals, health care providers, and local boards of health that will offer vaccination sites open to all who are vaccine-eligible in Massachusetts.

• Some local boards of health will offer vaccination sites open to those who live and work in their communities.

Appointment scheduling for these individuals will start to become available as early as TODAY (Wednesday, January 27th) and must be scheduled WITH THE VACCINATION LOCATION site. We are unfortunately unable able to schedule vaccines on anyone’s behalf at this time.

We will continue providing updates as further information becomes available.

Double Down on Protection

When it comes to defense, does it get better than this?

Only if you have properly vaccinated against Influenza!!
(Come on, this is a medical website — bad jokes are inevitable)

Visit our Open House 10/17/19 and get protected!

We are excited to partner with MBs Pharma Care
in hosting our First Annual Flu Clinic
at the Thrive Adult Primary Care office
on Thursday 10/17/2019 from 9am – 5pm

This event is OPEN TO THE PUBLIC, and ALL INSURANCES are accepted
for coverage of your annual flu vaccine!


Yes, in the medical field we recommend annual flu shots for everyone.  We do this for a phenomenon called herd immunity, meaning that we aim to reduce the exposure of individuals who are susceptible to severe disease by immunizing everyone.  Influenza is not your typical cold virus.  It has been known to cause fatal outcomes in certain populations, generally the very young, the very old, and the chronically ill — that is, people whose immune systems tend to be weaker than average.  Healthy individuals with strong immune systems can contract influenza and have it manifest as nothing more than a really bad cold.  However these people are still contagious and therefore may potentially spread the virus to others who are at risk for a worse outcome.  I am typically pushier about advising someone to get the vaccine if they have regular contact with these susceptible individuals, all the more for someone who is one of them.

I have heard the argument that, “every time I get the flu shot, I get the flu.”  Let’s make it clear that it is impossible for this to happen with the injected flu vaccine.  In this formulation of the immunization, it is as if the virus particle has been broken in half before being introduced to the patient.  A broken virus cannot replicate and therefore cannot generate infection.  However the whole purpose of the vaccine is to activate your immune system to generate antibodies so that if the real flu comes along, your body will be prepared.  The activation of your immune system feels a lot like how it would feel when your immune system is trying to fight off the flu in the case of an actual infection.  So some people will potentially develop low-grade fevers, body aches, weakness and fatigue.  This should last no more than a couple of days, and be assured that it is not an actual infection with influenza.  The nasal flu vaccine (“Flumist”) does in fact contain a live virus, enough to trigger an immune response but rarely enough to cause infection.  For several years in a row, Flumist showed no protective benefit against contraction of the flu virus, and was not recommended for the 2017-2018 season, but for the 2019-2019 season, protection against H1N1 virus has been added to the nasal flu vaccine and is felt to be beneficial for appropriate individuals.

I do advise patients who are actively ill to avoid the flu shot.  Again, this is not because the vaccine can cause an infection with the actual flu virus, because it cannot.  However, when a person is sick, their immune system is already busy trying to heal them from their current illness.  Giving a flu shot under these circumstances only adds strain to the immune system when it has a job to do; as a result, it may both prolong the active illness and reduce the likelihood of developing an effective immune response against Influenza.

Rare adverse effects are possible with the flu vaccine.  Probably the scariest of these is known as Guillain-Barre Syndrome which is a type of short-term paralysis that starts in the feet and legs and may ascend to the upper body.  This is exceedingly rare, but of course anyone who has had this type of reaction to the flu vaccine in the past should avoid it in the future.  Also, the majority of available flu shots are prepared using eggs, so folks with an egg allergy should ask whether an egg-free preparation is available where they are planning to receive the flu shot.  In general, anyone who has been able to tolerate the flu shot in the past should have no problem with the shot this year, either.

Finally, on rare occasion a savvy patient will bring up the presence of a mercury compound in the flu vaccine. This is thiomersal, or thimerosal, which is a widely used antiseptic preservative that suppresses the growth and reproduction of common bacteria. It does metabolize the the human body to a form of mercury that can be toxic in significant amounts. However the quantity of thimerosal in a dose of flu vaccine is less than 2.5% of what is considered safe daily intake. Meanwhile a flu shot is needed only once a year. If you want to reduce your body’s exposure to toxic chemicals you would be better off monitoring your daily intake of sugar, salt, or artificial sweeteners. But that is a blog entry for another day. 😉

All of that said, recommendations are merely that. In medicine, we base our advice on the science of statistics. What we recommend IN GENERAL will offer protection against bad outcomes in the population. But each person needs to make a well-informed decision for his- or herself about what advice they will follow or decline. It is my goal to ensure that the decision you make rests on a foundation of solid information.  In all cases, my wish for you as a reader is that you STAY WELL this cold-and-flu season!

Oh, and feel free to check out the latest post from the CDC on flu as well:

https://www.cdc.gov/flu/season/faq-flu-season-2019-2020.htm