Dr. Fernandez's Clinical Thoughts
Reflection on the New York Times Article
"Taking the Magic Out of Magic Mushrooms"
"Taking the Magic Out of Magic Mushrooms"
Several studies have reported that psychedelic drugs, such as psilocybin, ketamine, and LCD, may significantly alleviate symptoms of depression and anxiety, even among individuals who have responded poorly to prescribed medications. Psychedelic drugs are thought to confer therapeutic benefits like traditional antidepressants and talk therapy, presumably by increasing neural plasticity, or the connection between neurons in the brain. Recreational use of psychedelics alone may worsen one’s symptoms if used without proper psychedelic psychotherapy.
Remarkably, benefits from psychedelic drugs can appear in as little as two to three psychedelic sessions, while most antidepressant medications can take several weeks before benefits appear. Experts consider psychedelic therapy as a sort of “surgery” that solves a problem with a single produce, rather than long term treatment to manage a chronic condition.
Psilocybin is expected to received FDA approval for the treatment of depression by the end of the decade, but in its current form, only a few will have access to this treatment. This is because psychedelic sessions involve full-day intensive trips, which can be emotionally and physically taxing, not to mention expensive. There is also concern that psychedelic therapy in individuals with a family history of schizophrenia may exacerbate an underlying risk for psychosis.
In response to these obstacles, scientistic are currently developing and researching molecules based on psychedelics that provide the same therapeutic benefits of psychedelic drugs, but without the perceptual distortions. Indeed, research conducted on rodents and in petri dishes suggests that these new molecules that act like psychedelics in the brain can maintain their antidepressant properties without causing hallucinations or delusions.
Other researchers are skeptical of how these new molecules will work in humans, since their belief is that the powerful emotional and mystical experiences caused by psychedelics are what lead to the therapeutic breakthroughs. These researchers suspect that the extreme, rapid plasticity induced by psychedelics is what causes hallucinations, emotional changes, and feelings of connectedness, and without these experiences, we may not have the same therapeutic effect.
It is currently unclear whether a psychedelic experience is necessary for one to experience the therapeutic benefits of psychedelic drugs. Researchers will continue their pursuit to answer this question through formulation of new psychedelic molecules, pre-clinical testing, and hopefully clinical trials.
If you are interested in learning more, follow this link to the original NYT article.
Smith, S. (2022). Taking the Magic Out of Magic Mushrooms. The New York Times. Retrieved from: https://www.nytimes.com/2022/07/15/opinion/hallucinations-psychedelics-depression.htm
Remarkably, benefits from psychedelic drugs can appear in as little as two to three psychedelic sessions, while most antidepressant medications can take several weeks before benefits appear. Experts consider psychedelic therapy as a sort of “surgery” that solves a problem with a single produce, rather than long term treatment to manage a chronic condition.
Psilocybin is expected to received FDA approval for the treatment of depression by the end of the decade, but in its current form, only a few will have access to this treatment. This is because psychedelic sessions involve full-day intensive trips, which can be emotionally and physically taxing, not to mention expensive. There is also concern that psychedelic therapy in individuals with a family history of schizophrenia may exacerbate an underlying risk for psychosis.
In response to these obstacles, scientistic are currently developing and researching molecules based on psychedelics that provide the same therapeutic benefits of psychedelic drugs, but without the perceptual distortions. Indeed, research conducted on rodents and in petri dishes suggests that these new molecules that act like psychedelics in the brain can maintain their antidepressant properties without causing hallucinations or delusions.
Other researchers are skeptical of how these new molecules will work in humans, since their belief is that the powerful emotional and mystical experiences caused by psychedelics are what lead to the therapeutic breakthroughs. These researchers suspect that the extreme, rapid plasticity induced by psychedelics is what causes hallucinations, emotional changes, and feelings of connectedness, and without these experiences, we may not have the same therapeutic effect.
It is currently unclear whether a psychedelic experience is necessary for one to experience the therapeutic benefits of psychedelic drugs. Researchers will continue their pursuit to answer this question through formulation of new psychedelic molecules, pre-clinical testing, and hopefully clinical trials.
If you are interested in learning more, follow this link to the original NYT article.
Smith, S. (2022). Taking the Magic Out of Magic Mushrooms. The New York Times. Retrieved from: https://www.nytimes.com/2022/07/15/opinion/hallucinations-psychedelics-depression.htm
New Approach to Psychiatric Symptom Assessment
When assessing a symptom for a patient, we consider your assessment along the following 4 areas of consideration based on newer perspectives of psychiatric symptom considerations:
Using these 4 perspectives will not only help you understand the etiology of the symptom better, but also help the patient understand where the symptom is coming from and make it easier to develop a problem-solving plan with them.
- “Is it something you (the patient) have?”
- That is, is it biological? Is it related to their basic psychiatric disease state?
- “Is it because of who you are?”
- This addresses the psychological/developmental aspect of the patient’s illness.
- “Is it something you are doing?”
- This addresses the behavioral aspect and problematic behaviors (and cognitions), including learned bad habits (OCD, insomnia, medication non-adherence, addictions, depressive/neurotic cognitive distortions).
- “Is it because of something you have encountered?”
- This addresses the experiential aspect. The stressors/traumas recently encountered in a patient’s current existence.
Using these 4 perspectives will not only help you understand the etiology of the symptom better, but also help the patient understand where the symptom is coming from and make it easier to develop a problem-solving plan with them.
"Drug Shows Promise in Easing Dementia-Linked Psychosis"
A recent clinical trial published by the New England Journal of Medicine, suggests Nuplazid, also known as Pimavanserin, a drug that eases hallucinations in people with Parkinson’s disease, may also help hallucinations in those with dementia.
The trial was conducted in separate stages. First, 800 dementia patients (who were having hallucinations and delusions) were given counseling and behavioral coping skills. After 5 weeks, 351 of the 800 patients who were still symptomatic entered an “open-label” trial; all were given Nuplazid for 12 weeks. After 12 weeks, 62% of these patients had a lasting response to the medication and moved to the final trial phase. At that point, half were randomly assigned to stay with Nuplazid and the other half were switched to a placebo. After 18 weeks, 28% of placebo patients were suffering hallucinations or delusions again, compared with 13% of Nuplazid patients.
These results are very promising to those suffering with dementia, Alzheimer’s, or Parkinson’s. Currently, there are no medications officially approved for the treatment of dementia-related hallucinations and delusions. Doctors commonly prescribe antipsychotic medications. The trouble with most antipsychotic medications is side effects, including mobility problems, sedation, and dizziness, as well as possibly long-term negative effects on cognitive functioning. Researchers are hopeful that Nuplazid may treat dementia-related psychosis and do so without all the risks associated with current available medications.
Long-term data is still needed with larger, longer trials. A study comparing Nuplazid with standard antipsychotics would be useful in gauging the safety and effectiveness of Nuplazid.
Click here to read the original U.S. News Article.
The trial was conducted in separate stages. First, 800 dementia patients (who were having hallucinations and delusions) were given counseling and behavioral coping skills. After 5 weeks, 351 of the 800 patients who were still symptomatic entered an “open-label” trial; all were given Nuplazid for 12 weeks. After 12 weeks, 62% of these patients had a lasting response to the medication and moved to the final trial phase. At that point, half were randomly assigned to stay with Nuplazid and the other half were switched to a placebo. After 18 weeks, 28% of placebo patients were suffering hallucinations or delusions again, compared with 13% of Nuplazid patients.
These results are very promising to those suffering with dementia, Alzheimer’s, or Parkinson’s. Currently, there are no medications officially approved for the treatment of dementia-related hallucinations and delusions. Doctors commonly prescribe antipsychotic medications. The trouble with most antipsychotic medications is side effects, including mobility problems, sedation, and dizziness, as well as possibly long-term negative effects on cognitive functioning. Researchers are hopeful that Nuplazid may treat dementia-related psychosis and do so without all the risks associated with current available medications.
Long-term data is still needed with larger, longer trials. A study comparing Nuplazid with standard antipsychotics would be useful in gauging the safety and effectiveness of Nuplazid.
Click here to read the original U.S. News Article.
"How Food May Improve Your Mood"
Many of us turn to sugar-laden, high fat “comfort” foods when we are feeling stressed, or depressed, however, these types of food are not likely to improve mental health. Recent findings from the field of nutritional psychiatry suggest that certain foods, like vegetables, fruit, fish, eggs, nuts and seeds, beans, legumes, and fermented foods, can promote brain health, much like they can promote heart health.
In 2017, the first major study to investigate the connection between food and mood was conducted; researchers wanted to know if dietary changes would help alleviate depression in a sample of 67 clinically depressed individuals. The experimental group received advice from a dietician, while the of control group lacked any dietary advice. Those in the control group continued to eat sugary foods, processed meats, and salty snacks, while the experimental group transitioned to a diet of nuts, fruits, legumes, whole grain bread, oatmeal, vegetables, seafood, and lean, red meat. After 12 weeks, depression scores from the experimental group improved significantly more than those of the control group. Indeed, our diet impacts microbes within our gut and their production of neurotransmitters, like dopamine and serotonin, are used to regulate our mood and emotions.
The results of this study were particularly promising; not only did the dietary changes improve the individuals’ mental health, but the individuals were able to maintain their weight, and actually save money by switching to a healthier diet. The recommended foods were relatively inexpensive and available at most grocery stores (lentils, canned salmon, tuna and sardines, frozen and conventional produce). Several randomized trials have had similar results; one in particular suggests a Mediterranean diet supplemented with fish oil may help reduction in symptoms of depression and anxiety.
Although recent research highlights the influence of our diet on our mental health, most psychiatric professionals have not adapted dietary recommendations into their treatment plans. However, individual clinicians are already incorporating nutrition into their work, including our practice. Notably, Dr. Drew Ramsey, a psychiatrist and clinical professor at Columbia University, begins his new patient sessions by taking their psychiatric history and then exploring their diet. Dr. Ramsey encourages his patients to include “seafood, greens, nuts, and beans” in their diets, as these foods help promote brain-derived neurotrophic factor (BDNF), a protein that stimulates the growth of new neurons and helps protect existing neurons. BDNF also contains a large amount of omega-3 fatty acids and other nutrients that have been shown to improve gut and metabolic health.
It is important to note that that although dietary changes can make a significant impact on one’s mental health, food is not the only factor involved in brain health. Participants in each of the studies mentioned above were treated with a combination of medication management and dietary changes. That being said, food is a useful, empowering tool for improving our health, and more psychiatric professionals should consider a patient’s diet when recommending treatment for mental illness.
If you would like to learn more about this topic, click on this link to be directed to the original New York Times article.
In 2017, the first major study to investigate the connection between food and mood was conducted; researchers wanted to know if dietary changes would help alleviate depression in a sample of 67 clinically depressed individuals. The experimental group received advice from a dietician, while the of control group lacked any dietary advice. Those in the control group continued to eat sugary foods, processed meats, and salty snacks, while the experimental group transitioned to a diet of nuts, fruits, legumes, whole grain bread, oatmeal, vegetables, seafood, and lean, red meat. After 12 weeks, depression scores from the experimental group improved significantly more than those of the control group. Indeed, our diet impacts microbes within our gut and their production of neurotransmitters, like dopamine and serotonin, are used to regulate our mood and emotions.
The results of this study were particularly promising; not only did the dietary changes improve the individuals’ mental health, but the individuals were able to maintain their weight, and actually save money by switching to a healthier diet. The recommended foods were relatively inexpensive and available at most grocery stores (lentils, canned salmon, tuna and sardines, frozen and conventional produce). Several randomized trials have had similar results; one in particular suggests a Mediterranean diet supplemented with fish oil may help reduction in symptoms of depression and anxiety.
Although recent research highlights the influence of our diet on our mental health, most psychiatric professionals have not adapted dietary recommendations into their treatment plans. However, individual clinicians are already incorporating nutrition into their work, including our practice. Notably, Dr. Drew Ramsey, a psychiatrist and clinical professor at Columbia University, begins his new patient sessions by taking their psychiatric history and then exploring their diet. Dr. Ramsey encourages his patients to include “seafood, greens, nuts, and beans” in their diets, as these foods help promote brain-derived neurotrophic factor (BDNF), a protein that stimulates the growth of new neurons and helps protect existing neurons. BDNF also contains a large amount of omega-3 fatty acids and other nutrients that have been shown to improve gut and metabolic health.
It is important to note that that although dietary changes can make a significant impact on one’s mental health, food is not the only factor involved in brain health. Participants in each of the studies mentioned above were treated with a combination of medication management and dietary changes. That being said, food is a useful, empowering tool for improving our health, and more psychiatric professionals should consider a patient’s diet when recommending treatment for mental illness.
If you would like to learn more about this topic, click on this link to be directed to the original New York Times article.
Reflection of NY Times Article "I Don't Want Another Person to Lose a Child the Way We Did"
Suicidal thinking is far more common and difficult to identify than most people realize. Indeed, a June
2020 survey found that one in four adults aged 18 to 24 years old reported that they had seriously
thought about taking their own lives in the past 30 days. And despite 50 years of research, predicting
death by suicide is nearly impossible. While impossible to predict, there are still many ways we can
prevent death by suicide.
What if there were “seatbelts” for suicide? This question was posed by a mother who had sadly lost her
daughter to suicide. In the 1980’s, only 15% of drivers wore a seat belt; however, following the initiation
of the “Click it or Ticket” program, significantly more drivers are wearing a seat belt, and consequently
far less deaths by car accidents occur. Today, seat belt safety is taught to all drivers beginning at a young
age, and is encouraged and enforced by authority figures (i.e. police, professionals, parents), and as a
result, 91% of drivers now wear a seat belt.
If we set in place suicide preventatives as thoroughly as we have implemented seat belt safety, it would
look something like this; every healthcare worker, school professional, employer, and religious leader
would be educated on recognizing the signs of suicidal thinking, and respond in an appropriate manner,
we would all know the national suicide prevention hotline, we would suicide proof our homes by locking
up hand guns and lethal medications, and families would ask their children often about suicidal thinking.
It is also about how our culture TALKS about suicide. “Safe Talk” can be used in not only how we speak
to our children but also how we speak to each other and how we hear about suicides from reporting
sources in our media. See second link for a nice poster on using Safe Talk. By speaking about suicide
appropriately, we can stop glamorizing it and decrease its contagion, particularly among the young.
Click on the link below to read more about what steps can be taken to build a more supportive world for
our children.
2020 survey found that one in four adults aged 18 to 24 years old reported that they had seriously
thought about taking their own lives in the past 30 days. And despite 50 years of research, predicting
death by suicide is nearly impossible. While impossible to predict, there are still many ways we can
prevent death by suicide.
What if there were “seatbelts” for suicide? This question was posed by a mother who had sadly lost her
daughter to suicide. In the 1980’s, only 15% of drivers wore a seat belt; however, following the initiation
of the “Click it or Ticket” program, significantly more drivers are wearing a seat belt, and consequently
far less deaths by car accidents occur. Today, seat belt safety is taught to all drivers beginning at a young
age, and is encouraged and enforced by authority figures (i.e. police, professionals, parents), and as a
result, 91% of drivers now wear a seat belt.
If we set in place suicide preventatives as thoroughly as we have implemented seat belt safety, it would
look something like this; every healthcare worker, school professional, employer, and religious leader
would be educated on recognizing the signs of suicidal thinking, and respond in an appropriate manner,
we would all know the national suicide prevention hotline, we would suicide proof our homes by locking
up hand guns and lethal medications, and families would ask their children often about suicidal thinking.
It is also about how our culture TALKS about suicide. “Safe Talk” can be used in not only how we speak
to our children but also how we speak to each other and how we hear about suicides from reporting
sources in our media. See second link for a nice poster on using Safe Talk. By speaking about suicide
appropriately, we can stop glamorizing it and decrease its contagion, particularly among the young.
Click on the link below to read more about what steps can be taken to build a more supportive world for
our children.
Measurement-Based Care (MBC) in Psychiatric Practice
There are highly reliable clinical scales available to psychiatrists in their assessment of patients; specifically, to help with diagnosis, to identify the severity of symptoms, and to follow the patient’s response to treatment. We call this Measurement Based Care (MBC). Evidence-based data[1] shows that MBC facilitates accurate diagnosis and treatment. Furthermore, data suggests that MBC helps patients more effectively achieve remission, without the presence of residual symptoms, which can be disabling and worsen the long-term prognosis of the psychiatric disorder.
Despite this, the evidence-based data [2]shows that 61% of US psychiatrists rarely or never use clinical scales to assist in determining the diagnosis or the severity of symptoms in their patients. Only 6.5% of US psychiatrists use scales almost all the time. In the UK, about 58% of psychiatrists do not use clinical scales, while only 11% use them routinely.
At our practice, a full set of psychiatric scales are used at the time of evaluation, based on the patient’s initial chief complaint. These scales are then used by Dr. Fernandez and his staff to clarify the diagnosis and document the severity of symptoms. This then greatly facilitates the selection of medications and helps identify how aggressively to treat the individual. Additionally, scales are used regularly during follow-up visits to assure complete treatment of the condition.
Complete resolution of symptoms is called “remission”; to be well again and not just better. Too many times in psychiatry patients are treated only to a “response” and not “remission”. We already have ample evidence-based data which clearly documents how patients who are in response, but are not in remission, have persistent, residual symptoms. These symptoms will not only affect their daily functioning but also worsen the long-term prognosis of their psychiatric illness[3].
Clearly, we need to know what we are treating to be effective psychiatrists. Not using clinical scales for assessment and treatment of psychiatric illness (MBC) is an outdated practice, which is not in keeping with the progress shown throughout the rest of medicine.
[1] Guo, T. et al, American Journal of Psychiatry. 2015; 172 (10): 1004-1013.
[2] Zimmerman, M. & McGlinchey, J. B., Journal of Clinical Psychiatry. 2008; 69: 1916-1919. Gilbody, S. et al., Br Journal of Psychiatry. 2002; 180: 101-103.
[3] Nierenberg, A. et al, Psychol Med. 2010; 40: 41-50. Blier, P., Journal of Clinical Psychiatry. 2013; 74: 19-24. Romera, I. et al, BMC Psychiatry. 2013; 13: 51.
Despite this, the evidence-based data [2]shows that 61% of US psychiatrists rarely or never use clinical scales to assist in determining the diagnosis or the severity of symptoms in their patients. Only 6.5% of US psychiatrists use scales almost all the time. In the UK, about 58% of psychiatrists do not use clinical scales, while only 11% use them routinely.
At our practice, a full set of psychiatric scales are used at the time of evaluation, based on the patient’s initial chief complaint. These scales are then used by Dr. Fernandez and his staff to clarify the diagnosis and document the severity of symptoms. This then greatly facilitates the selection of medications and helps identify how aggressively to treat the individual. Additionally, scales are used regularly during follow-up visits to assure complete treatment of the condition.
Complete resolution of symptoms is called “remission”; to be well again and not just better. Too many times in psychiatry patients are treated only to a “response” and not “remission”. We already have ample evidence-based data which clearly documents how patients who are in response, but are not in remission, have persistent, residual symptoms. These symptoms will not only affect their daily functioning but also worsen the long-term prognosis of their psychiatric illness[3].
Clearly, we need to know what we are treating to be effective psychiatrists. Not using clinical scales for assessment and treatment of psychiatric illness (MBC) is an outdated practice, which is not in keeping with the progress shown throughout the rest of medicine.
[1] Guo, T. et al, American Journal of Psychiatry. 2015; 172 (10): 1004-1013.
[2] Zimmerman, M. & McGlinchey, J. B., Journal of Clinical Psychiatry. 2008; 69: 1916-1919. Gilbody, S. et al., Br Journal of Psychiatry. 2002; 180: 101-103.
[3] Nierenberg, A. et al, Psychol Med. 2010; 40: 41-50. Blier, P., Journal of Clinical Psychiatry. 2013; 74: 19-24. Romera, I. et al, BMC Psychiatry. 2013; 13: 51.
Oral Lavender Extract in the
Treatment of Generalized Anxiety Disorder
Treatment of Generalized Anxiety Disorder
In treating Generalized Anxiety Disorder (GAD), SSRI’s and SNRI’s often fall short, showing small effects sizes in research. Interestingly, a recent study has suggested that an oral extract of lavender, called Silexan, may be much more effective in treating GAD than certain SSRIs. This 10-week, double-blind study included a large sample of 539 participants. The study was designed to compare two doses of Silexan, 80mg and 160mg, paroxetine 20mg, and a placebo. The results showed that both doses of Silexan worked significantly better in treating participants with GAD than paroxetine, as known as Paxil.
Silexan is a branded extract of lavender developed by Schwabe Pharmaceuticals, and can be purchased over the counter in the US under the brand name of CalmAid. The pharmacological properties of Silexan resemble those of SSRI’s, SNRI’s, benzodiazepines, and even ketamine.
The use of lavender in aromatherapy to calm the nerves and induce sleep has certainly inspired the growing research into Silexan. However, the benefits of lavender have less to do with aroma, and more to do with its anxiolytic effects. In fact, researchers concluded that the most relevant mechanism of Silexan is as a serotonin-1A agonist (Baldinger P et al, Int J Neuropsychopharmacol 2014;18(4):pyu063).
Psychiatrist Dr. Chris Aiken recommends Silexan to most of his patients with GAD and has found its effects to be in keeping with the research. In fact, many patients who were taking long-term benzodiazepines spontaneously reduced their benzo dose after starting Silexan. Certainly, Silexan is a reasonable alternative for patients with GAD who have not responded to FDA-approved treatments, or who prefer a more natural approach to treatment.
Unfortunately, in limited use in our own practice when used as an adjunct to patients with residual anxiety symptoms, it has not shown to be consistently effective but more trials are warranted before we can draw any final conclusions. Certainly, we think that for our patient population, 60 mg (2 tablets) is likely to be the effective dose.
A Guide To Online & Overseas Pharmacies
In recent years, we have seen a dramatic boom in online ordering of prescription medications. While online ordering makes life simple and efficient, most online pharmacies are actually “illegitimate, rogue, or illicit”. According to research done by Kristen Gardner, Clinical Pharmacy Specialist, a shocking 96% of online pharmacies do not comply with regulation by the FDA, nor the National Association of Boards of Pharmacy (NABP). Similarly, the World Health Organization has determined that more than 80% of medicines are counterfeit in some countries, making these unregulated pharmacies a huge safety concern.
There are a few simple ways you can make sure that the online pharmacy you are using is safe. The key sign that an online pharmacy is legitimate is if the web address ends with the “.pharmacy” domain. This means that the pharmacy participates in on-site inspections from the NABP. It is important to note that online pharmacies in Canada may be verified and regulated by NABP’s “.pharmacy” program, yet these pharmacies are only approved to distribute products to Canadian citizens. Ultimately, it is illegal for a non-US pharmacy to import drugs into the US.
Other red flags you can look out for to determine whether your online pharmacy is reliable and legitimate are as follows: A url that ends in .com, .net, or .ru; An online pharmacy were no prescription is required; An absent, incomplete and unverifiable address and contact information; A lack of a verifiable pharmacy license; A pharmacy that ships worldwide; A pharmacy that offers extremely cheap prices and lastly a pharmacy that approaches you through unsolicited emails or texts.
If you are planning to order online, here are a couple of safe options. Two websites with reliable lists are VIPPS program and BuySafeRX. Alternatively, patients can check if an online pharmacy is safe by entering its Internet address at www.VerifyBeforeYouBuy.org.
There are a few simple ways you can make sure that the online pharmacy you are using is safe. The key sign that an online pharmacy is legitimate is if the web address ends with the “.pharmacy” domain. This means that the pharmacy participates in on-site inspections from the NABP. It is important to note that online pharmacies in Canada may be verified and regulated by NABP’s “.pharmacy” program, yet these pharmacies are only approved to distribute products to Canadian citizens. Ultimately, it is illegal for a non-US pharmacy to import drugs into the US.
Other red flags you can look out for to determine whether your online pharmacy is reliable and legitimate are as follows: A url that ends in .com, .net, or .ru; An online pharmacy were no prescription is required; An absent, incomplete and unverifiable address and contact information; A lack of a verifiable pharmacy license; A pharmacy that ships worldwide; A pharmacy that offers extremely cheap prices and lastly a pharmacy that approaches you through unsolicited emails or texts.
If you are planning to order online, here are a couple of safe options. Two websites with reliable lists are VIPPS program and BuySafeRX. Alternatively, patients can check if an online pharmacy is safe by entering its Internet address at www.VerifyBeforeYouBuy.org.
To learn more, click here to be directed to the original article by Kristen Gardner, PharmD.
Vitamin D and Risk of All-Cause and Cause-Specific Mortality
Recent findings by a group of scientists in the United Kingdom suggest that maintaining a serum Vitamin D3 (25-OH) serum level of 45-60nmol/L may lower the risk of cardiovascular disease (CVD), and reduce the risk of premature death.
The longitudinal study was conducted using 365,000 participants without prior history of CVD. Measurements of participants Vitamin D3 levels were collected regularly over the course of several years.
During a median follow-up of 8.9 years, 18.1% of participants had died from CVD, 56.4 % had died from cancer, and 25.5% had died from other causes.
Interestingly, participants with 25(OH)D greater than or equal to 60nmol/L had a much lower risk of all-cause, CVD, or other mortality. Similarly, participants with 25(OH)D greater than or equal to 45 nmol/L had a much lower risk of cancer mortality.
These findings indicate the importance of maintaining a healthy vitamin D threshold in order to reduce the risk of developing CVD, cancer, or other premature deaths.
The longitudinal study was conducted using 365,000 participants without prior history of CVD. Measurements of participants Vitamin D3 levels were collected regularly over the course of several years.
During a median follow-up of 8.9 years, 18.1% of participants had died from CVD, 56.4 % had died from cancer, and 25.5% had died from other causes.
Interestingly, participants with 25(OH)D greater than or equal to 60nmol/L had a much lower risk of all-cause, CVD, or other mortality. Similarly, participants with 25(OH)D greater than or equal to 45 nmol/L had a much lower risk of cancer mortality.
These findings indicate the importance of maintaining a healthy vitamin D threshold in order to reduce the risk of developing CVD, cancer, or other premature deaths.
Do Sleeping Medicines and Benzodiazepines
Increase your Risk of Dementia?
Increase your Risk of Dementia?
Previous research by Gallacher et al. (2012) has suggested a causal relationship between long-term benzodiazepine use and the development of dementia, which has caused a growing concern over the use of benzodiazepines and Z-drugs. Conversely, recent findings by Osler & Jorgensen (2020) suggest there is no causal relationship between benzodiazepines and Alzheimer’s, and in fact, researchers observed a “protective effect” in the use of benzodiazepines and Z-drugs for treatment of dementia.
The study followed a cohort of 240,000 Danish adults with a first-time hospitalization due to an affective disorder from 1969 until 2016. During follow-ups, patients with incident dementia, and all prescription refills for medication were identified. While 75.9% of patients with affective disorders had any use of benzodiazepines or Z-drugs, the use of benzodiazepines or Z-drugs was not associated with subsequent dementia. Interestingly, patients with the highest use of benzodiazepines or Z-drugs were significantly less likely to develop dementia compared to patients with medium or low use. This was found to be the case amongst all drug types, including long, medium, and short-acting drugs.
Why exactly does increased use of benzodiazepines protect an individual from subsequently developing dementia? Researchers have hypothesized that adults facing the stress of mid-life and memory decline, who are still highly functional and have good insight, are likely to become anxious about their capacity. The calming effect of benzodiazepines and/or Z-drugs in elderly people with anxiety may reduce the effects of stress, and ultimately reduce the risk of developing Alzheimer’s disease.
These findings are important and imply that anxiety be a marker of Alzheimer’s disease in patients with mild cognitive impairment. The results also imply that the proper use of benzodiazepines and Z-drugs will not lead to the development of Alzheimer’s.
The study followed a cohort of 240,000 Danish adults with a first-time hospitalization due to an affective disorder from 1969 until 2016. During follow-ups, patients with incident dementia, and all prescription refills for medication were identified. While 75.9% of patients with affective disorders had any use of benzodiazepines or Z-drugs, the use of benzodiazepines or Z-drugs was not associated with subsequent dementia. Interestingly, patients with the highest use of benzodiazepines or Z-drugs were significantly less likely to develop dementia compared to patients with medium or low use. This was found to be the case amongst all drug types, including long, medium, and short-acting drugs.
Why exactly does increased use of benzodiazepines protect an individual from subsequently developing dementia? Researchers have hypothesized that adults facing the stress of mid-life and memory decline, who are still highly functional and have good insight, are likely to become anxious about their capacity. The calming effect of benzodiazepines and/or Z-drugs in elderly people with anxiety may reduce the effects of stress, and ultimately reduce the risk of developing Alzheimer’s disease.
These findings are important and imply that anxiety be a marker of Alzheimer’s disease in patients with mild cognitive impairment. The results also imply that the proper use of benzodiazepines and Z-drugs will not lead to the development of Alzheimer’s.
If you would like more information, click on the links below to read the original articles.
Do Benzodiazepines Cause Alzheimer's Disease? by Carl Salzman M.D.
Associates of Benzodiazepines, Z-Drugs, and Other Anxiolytics With Subsequent Dementia in Patients With Affective Disorders: A Nationwide Cohort and Nested Case-Control Study
by Merete Osler M.D. & Martin Jorgensen M.D.
Do Benzodiazepines Cause Alzheimer's Disease? by Carl Salzman M.D.
Associates of Benzodiazepines, Z-Drugs, and Other Anxiolytics With Subsequent Dementia in Patients With Affective Disorders: A Nationwide Cohort and Nested Case-Control Study
by Merete Osler M.D. & Martin Jorgensen M.D.
Patient outcomes during the COVID-19 Pandemic
With the onset of COVID-19 Pandemic this late winter, our practice has had a growing concern about the psychological impact on our psychiatric patient population. The initial idea centered around the concern that if patients were already compromised by psychiatric illness, they most likely would be more incapable of coping with the major stressors and demands of dealing with a pandemic, which could then make their illness worse again.
However, after 3 months of telemedicine psychiatric treatment through this pandemic, we found quite the opposite. We actually found that the large majority of our patients were dealing with the pandemic just like people without psychiatric illnesses.
Upon further examination, Dr. Fernandez concluded that since the goal of our practice is to treat to remission and not just response, and that the large majority of our patients in our practice are in remission, and not simply “just better”, our patients were dealing with COVID-19 just like people without psychiatric disorders. Actually, in many situations, better than most people. In discussion with our patients, they often felt that they had dealt with so many more stressful issues in their life when psychiatrically ill that, now that they are in remission, this pandemic, though an inconvenience, seemed far from unsurmountable.
As a matter of fact, Dr. Fernandez is now implementing a new clinical perspective: If a patient is NOT coping well with the pandemic, it is more than likely a reflection of the fact that the patient’s underlying psychiatric illness may be active once again and that a more aggressive clinical intervention is required.
It makes sense: If you are emotionally well you deal with the pandemic just like everyone else who is emotionally healthy, but if you are psychiatrically symptomatic, it is hard to cope like others.
This is why it is so important to make sure that psychiatric illnesses are treated to remission; to full resolution of symptoms, and not just “better” (response).
However, after 3 months of telemedicine psychiatric treatment through this pandemic, we found quite the opposite. We actually found that the large majority of our patients were dealing with the pandemic just like people without psychiatric illnesses.
Upon further examination, Dr. Fernandez concluded that since the goal of our practice is to treat to remission and not just response, and that the large majority of our patients in our practice are in remission, and not simply “just better”, our patients were dealing with COVID-19 just like people without psychiatric disorders. Actually, in many situations, better than most people. In discussion with our patients, they often felt that they had dealt with so many more stressful issues in their life when psychiatrically ill that, now that they are in remission, this pandemic, though an inconvenience, seemed far from unsurmountable.
As a matter of fact, Dr. Fernandez is now implementing a new clinical perspective: If a patient is NOT coping well with the pandemic, it is more than likely a reflection of the fact that the patient’s underlying psychiatric illness may be active once again and that a more aggressive clinical intervention is required.
It makes sense: If you are emotionally well you deal with the pandemic just like everyone else who is emotionally healthy, but if you are psychiatrically symptomatic, it is hard to cope like others.
This is why it is so important to make sure that psychiatric illnesses are treated to remission; to full resolution of symptoms, and not just “better” (response).
What is the Difference Between Full Spectrum CBD, Broad Spectrum CBD, and CBD Isolate?
Not every CBD product is made the same, and some may be more effective than others, depending on an individual’s specific needs. Full spectrum CBD products contain everything that is naturally found within the hemp plant, such as plant proteins, terpenes, and cannabinoids, including up to 0.3% of THC. Similarly, broad spectrum CBD products contain naturally occurring terpenes, proteins, and cannabinoids from the hemp plant, yet are processed in a way that all trace amounts of THC are removed. CBD isolates are 99% CBD and 0.0% THC. This is the purest form of CBD available, processed in a way which removes all other molecules except CBD from a full spectrum extract.
There is some evidence that supports the motion that for CBD to be effectively used by the human body, a bit of THC must also be included in the preparation. Additionally, there are those that say that the terpenes and other cannabinoids found in full spectrum products also have therapeutic effect. However, there is no clear scientific evidence to support these ideas, so it is very possible that alone CBD may have therapeutic benefit in the isolate form.
If you want to try CBD, we recommend you try the CBD isolate form first, and then move to the broad spectrum CBD, then full spectrum CBD only if the previous products have not been effective for your symptoms. Minimizing the THC diminishes any potential “high” effect of the CBD product. For those of you who are concerned that THC may show positive in a urine screen, a THC-free product should not test positive, as it only contains CBD.
There is some evidence that supports the motion that for CBD to be effectively used by the human body, a bit of THC must also be included in the preparation. Additionally, there are those that say that the terpenes and other cannabinoids found in full spectrum products also have therapeutic effect. However, there is no clear scientific evidence to support these ideas, so it is very possible that alone CBD may have therapeutic benefit in the isolate form.
If you want to try CBD, we recommend you try the CBD isolate form first, and then move to the broad spectrum CBD, then full spectrum CBD only if the previous products have not been effective for your symptoms. Minimizing the THC diminishes any potential “high” effect of the CBD product. For those of you who are concerned that THC may show positive in a urine screen, a THC-free product should not test positive, as it only contains CBD.
Compensation for executives of non-profit healthcare organizations has risen dramatically over recent years, while physicians and medical staff have experienced largely flat salaries.
From 2016 to 2017, the top executives of non-profit healthcare organizations experienced an average salary increase of 33%, compared to physicians who saw a mere 5% increase in compensation. The Chief Executive Officer of Kaiser Permanente makes $16.1 million annually, including pension and benefits. Likewise, the CEOs of the top 25 health organizations make a combined yearly compensation of $197.9 million. The fact that the compensation of healthcare executives has been rising to such levels, while the compensation of providers of clinical care has diminished, suggests that healthcare organizations are keeping the surplus, rather than letting it pass through the system towards more health benefits.
Large amounts of revenue paid by consumers and insurers of medical care is going towards the compensation of nonprofit healthcare executives, rather than towards medication, doctors’ visits, or hospitalizations.
From 2016 to 2017, the top executives of non-profit healthcare organizations experienced an average salary increase of 33%, compared to physicians who saw a mere 5% increase in compensation. The Chief Executive Officer of Kaiser Permanente makes $16.1 million annually, including pension and benefits. Likewise, the CEOs of the top 25 health organizations make a combined yearly compensation of $197.9 million. The fact that the compensation of healthcare executives has been rising to such levels, while the compensation of providers of clinical care has diminished, suggests that healthcare organizations are keeping the surplus, rather than letting it pass through the system towards more health benefits.
Large amounts of revenue paid by consumers and insurers of medical care is going towards the compensation of nonprofit healthcare executives, rather than towards medication, doctors’ visits, or hospitalizations.
If you would like more information, here is the link to the original article.
Dr. Fernandez's clinical thoughts regarding a recent article in the JAMA Psychiatry,
"Association of Maternal Prenatal Vitamin Use with
Risk for Autism Spectrum Disorder Recurrence in Young Siblings."
This very recent article in Psychiatry JAMA (2019 Feb, 27; 76: 391) showed that mothers of children with Autism Spectrum Disorder (ASD) who then became pregnant again, were able to decrease the risk of recurrence of ASD in their next child by 50%. Pregnant women who did not take prenatal vitamins had a 32.7% risk of recurrence of ASD with their next child, while women who took the prenatal vitamins in the first month of pregnancy had a 14.1% chance of recurrence. It is also interesting to note that only 36% of all the women in the study were taking vitamins before pregnancy.
The take home part here is that in a culture where ASD seems to be increasing for unknown reasons, a minimal intervention of starting prenatal vitamins as soon as you know you are pregnant can produce significant benefits with your subsequent children. The study also found that 64% of women of childbearing age in this study were not taking vitamins.
Since pregnancies can occur and women may not be aware for at least one month, one can postulate that perhaps women of childbearing age who are considering new pregnancies should be on prenatal vitamins before they conceive so that the protective benefits can start from day one, rather than thirty days later.
The take home part here is that in a culture where ASD seems to be increasing for unknown reasons, a minimal intervention of starting prenatal vitamins as soon as you know you are pregnant can produce significant benefits with your subsequent children. The study also found that 64% of women of childbearing age in this study were not taking vitamins.
Since pregnancies can occur and women may not be aware for at least one month, one can postulate that perhaps women of childbearing age who are considering new pregnancies should be on prenatal vitamins before they conceive so that the protective benefits can start from day one, rather than thirty days later.
If you would like more information, here is the link to the original article.
Dr. Fernandez's clinical thoughts regarding an article by the New York Times,
"How to Quit Antidepressants: Very Slowly, Doctors Say".
More than 15 million Americans take antidepressant medications for at least 5 years according to a New York Times analysis of federal data. With all those patients, researchers are learning more about how to comfortably discontinue the medicines when clinically appropriate.
According to an article in the New York Times, thousands or perhaps millions of people who try to quit antidepressant drugs experience withdrawal symptoms and some people report the effects as lasting months to years. Symptoms can include insomnia, anxiety, sensations of electric shock in the brain, and others. This was once attributed to recurrences of the underlying mood problems, but researchers are finding that tapering these medications over months or even years may take sense for many people.
One study by Dutch researchers in 2018 found that 70% of people who had trouble giving up Paxil or Effexor quit their prescriptions safely by following an extended tapering regimen, ultimately reducing their dosage down to one-fortieth of the original amount. This is the regimen recommended in the new paper. Dr. Dee Mangin, chair of family medicine at McMaster University in Canada adds “the other important thing is that is that it validates the patients’ own reports of their experiences.”
According to an article in the New York Times, thousands or perhaps millions of people who try to quit antidepressant drugs experience withdrawal symptoms and some people report the effects as lasting months to years. Symptoms can include insomnia, anxiety, sensations of electric shock in the brain, and others. This was once attributed to recurrences of the underlying mood problems, but researchers are finding that tapering these medications over months or even years may take sense for many people.
One study by Dutch researchers in 2018 found that 70% of people who had trouble giving up Paxil or Effexor quit their prescriptions safely by following an extended tapering regimen, ultimately reducing their dosage down to one-fortieth of the original amount. This is the regimen recommended in the new paper. Dr. Dee Mangin, chair of family medicine at McMaster University in Canada adds “the other important thing is that is that it validates the patients’ own reports of their experiences.”
If you would like more information, here is the link to the original article.
After an episode of depression, what are the chances of life returning to normal and being happy with your later life?
A recent research article published by a group of psychologists stated that a large survey found that only 50% of individuals who had “fully recovered” from an episode of depression reported living at the high end of the well-being scale when surveyed a decade later.
This at first sounds discouraging as it implies that even if an individual felt recovered from an episode of depression, their chances of living a happy life is already diminished by 50% versus individuals who have never had an episode of depression.
I do not believe this is true. I believe that individuals who are successfully and effectively treated for depression can lead normal lives. In my opinion, what this study really reflects is that patients with depression usually receive inadequate treatment and are treated to partial response but never achieve full recovery from their illness.
There is a major difference between a response to a treatment (feeling better) and remission of symptoms (fully well). In psychiatry, as in all areas of medicine, it is well understood that if an individual is treated to response and not remission, their long-term outcomes (prognosis) is considerably worse. Thus, it is very important that when a person is treated for depression, they are treated for a complete recovery (well-being), without any residual symptoms of illness.
This requires a thorough evaluation to determine the type of depression experienced (there are different types of depression), observation of any associated symptoms (such as mania, anxiety, obsessive compulsive disorder, etc.) and the proper and specific selection of an antidepressant (not all antidepressants are the same).
Once the proper medicines are selected (there may be more than one necessary for proper treatment), an individual then needs to be treated aggressively.
Once started on medicines, it is not uncommon for patients to initially report they are “better”. Better, however, is not well. Many clinicians will stop at better instead of continuing to aggressively treat until a total resolution of depressive symptoms is achieved. Once well again, and not just better, formally depressed patients can lead as happy a life as someone who has never suffered from depression.
This at first sounds discouraging as it implies that even if an individual felt recovered from an episode of depression, their chances of living a happy life is already diminished by 50% versus individuals who have never had an episode of depression.
I do not believe this is true. I believe that individuals who are successfully and effectively treated for depression can lead normal lives. In my opinion, what this study really reflects is that patients with depression usually receive inadequate treatment and are treated to partial response but never achieve full recovery from their illness.
There is a major difference between a response to a treatment (feeling better) and remission of symptoms (fully well). In psychiatry, as in all areas of medicine, it is well understood that if an individual is treated to response and not remission, their long-term outcomes (prognosis) is considerably worse. Thus, it is very important that when a person is treated for depression, they are treated for a complete recovery (well-being), without any residual symptoms of illness.
This requires a thorough evaluation to determine the type of depression experienced (there are different types of depression), observation of any associated symptoms (such as mania, anxiety, obsessive compulsive disorder, etc.) and the proper and specific selection of an antidepressant (not all antidepressants are the same).
Once the proper medicines are selected (there may be more than one necessary for proper treatment), an individual then needs to be treated aggressively.
Once started on medicines, it is not uncommon for patients to initially report they are “better”. Better, however, is not well. Many clinicians will stop at better instead of continuing to aggressively treat until a total resolution of depressive symptoms is achieved. Once well again, and not just better, formally depressed patients can lead as happy a life as someone who has never suffered from depression.
If you would like more information, here is the link to the original article.
"Why Do We Love Sad Music? Mourning Our Pain"
By: Robert A. Berezin, MD
By: Robert A. Berezin, MD
As an experiment, my son and I asked the following question on Facebook: "Looking for the sad song you love to listen to when you're down. Open to any and all genres."
We received 71 responses in 24 hours. Each person sent their go-to music or even long playlists. All were very enthusiastic about this question. Surprisingly, people put on music that matches their sad mood rather than music to cheer them up. Paradoxically, it doesn't depress us more; it is comforting. People choose music that fits with their mood. Entering the mood space, one is ensconced in the resonance of feeling; one is at home, is encompassed, and feels held.
We received 71 responses in 24 hours. Each person sent their go-to music or even long playlists. All were very enthusiastic about this question. Surprisingly, people put on music that matches their sad mood rather than music to cheer them up. Paradoxically, it doesn't depress us more; it is comforting. People choose music that fits with their mood. Entering the mood space, one is ensconced in the resonance of feeling; one is at home, is encompassed, and feels held.
Music is both a communal and a personal experience.
It both joins us together and allows for personal space and time.
It both joins us together and allows for personal space and time.
Let's say a loved one has died, or maybe you are going through a bad break up or a divorce. If you are sad, unhappy, feeling miserable, what music do you choose? Sad music carries us deep inside sadness itself. In a state of mourning, one needs to feel the pain. One needs not to be alone and needs emotional holding. Yet one also needs a private space for meditative reflection. One needs time. Music is both a communal and a personal experience. It both joins us together and allows for personal space and time.
Consciousness is a synthetic illusion created by the brain. Communication can only take place indirectly, never directly. The way we communicate is through art forms: language, physical gestures, reading and writing, visual art, music, theater, prose, poetry, and dance. It is how my consciousness connects to your consciousness. If cortically we share the same symbolic codes of an art form, I can communicate my imagination and feeling expressively, and you can receive my imagination and feeling receptively. When you read this article, your brain reads these 26 black symbols on a white page. You receive what I express and fulfill it with your imagination. These symbols operate through our deeply learned visual and auditory mastery of language via reading and writing.
Regarding language, if you and I both master English, then we can communicate through the learned art form of speech. If I only speak English and you Russian, it will sound like gibberish. We need shared, learned symbolic form. It is the same with music. If you and I both share the same symbolic code for scales, we can communicate expressively and receptively via music. Music, unlike most other art forms, has no visual referent. It always creates feeling and mood. Music proceeds through the auditory centers, and always through the amygdala and limbic system (generally speaking, our emotional centers). Through creating a mood, you can indirectly paint a visual picture that you can invent with your own imagery.
Let's focus on sadness: The mourning of a loved one's death is the specific and literal biological operation for the repair and healing of emotional pain. The mourner must face and go through the pain of all of the feelings from losing his attachment. This process digests and deactivates the loss of a deeply held old play where the loved one is present, in order to accept a new play where the loved one is gone.
Consciousness is a synthetic illusion created by the brain. Communication can only take place indirectly, never directly. The way we communicate is through art forms: language, physical gestures, reading and writing, visual art, music, theater, prose, poetry, and dance. It is how my consciousness connects to your consciousness. If cortically we share the same symbolic codes of an art form, I can communicate my imagination and feeling expressively, and you can receive my imagination and feeling receptively. When you read this article, your brain reads these 26 black symbols on a white page. You receive what I express and fulfill it with your imagination. These symbols operate through our deeply learned visual and auditory mastery of language via reading and writing.
Regarding language, if you and I both master English, then we can communicate through the learned art form of speech. If I only speak English and you Russian, it will sound like gibberish. We need shared, learned symbolic form. It is the same with music. If you and I both share the same symbolic code for scales, we can communicate expressively and receptively via music. Music, unlike most other art forms, has no visual referent. It always creates feeling and mood. Music proceeds through the auditory centers, and always through the amygdala and limbic system (generally speaking, our emotional centers). Through creating a mood, you can indirectly paint a visual picture that you can invent with your own imagery.
Let's focus on sadness: The mourning of a loved one's death is the specific and literal biological operation for the repair and healing of emotional pain. The mourner must face and go through the pain of all of the feelings from losing his attachment. This process digests and deactivates the loss of a deeply held old play where the loved one is present, in order to accept a new play where the loved one is gone.
Immersed and held in the art trance of sad music, we feel the sadness. It surrounds us...
Digesting the old story and mourning those feelings can take a long time—many years, even. One has to go through the Kübler-Ross stages of denial— bargaining, anger, sadness, and acceptance. The specific stage where sad music works its magic is, of course, sadness. This is contingent on the musician and the mourner having learned the same symbolic form for the scales.
Immersed and held in the art trance of sad music, we feel the sadness. It surrounds us, it enters us. We feel. We feel the painful longings, the painful loss. The mourner has to let go of his deeply held old play of love where he is not alone. He has to move toward accepting the new play where the loved one will never be here again. He can feel and miss the lost love without demanding the old story.
One never completely heals from significant loss. The old play always lives inside, deactivated, but there. Sad music will always touch us and bring back the nostalgia of loss. The sad music meets your emotional state and allows for the mourning. It holds you and allows it to happen.
How does music penetrate to the receptive insides of the mourner? The two major scales in western music are the major scale and the minor scale. The only difference in the major and minor scales is that the minor scale has diminished 3rd, 6th, and 7th notes. That's it.
Yet, these changes in the scale make all the difference in the world. Scales create mood. The major scale communicates the heroic: Take Beethoven's Symphony No. 3, "Eroica." The minor scale, when soft, communicates sadness ; "Eleanor Rigby," by The Beatles, comes to mind. When loud, it communicates anger: "Why Go," by Pearl Jam. Schubert routinely shifts between major and minor; an example is "The Trout Quintet" in A minor. The minor blues scale—a five-note paring down of the minor scale—can embody the pain of aloneness and loss: "The Sky Is Crying," by Elmore James. Unresolved notes convey suspended feeling: "Blue in Green," by Miles Davis.
Music aids us in mourning our pain. This is no doubt why we listen to it. It's good to give over to the healing and restorative power of music. It's good to take in the communal holding of sad feeling. It's good to go inside to the depths of your own heart to meditatively process your private pain alone. My son and I now have a powerful list of sad music from Facebook. Featured pieces are "Hallelujah," by Jeff Buckley; "Prelude in E Minor," by Chopin; and 'Stars', by Nina Simone. Two of my own favorites are "Adagio for Strings," by Barber, and "Whispering Pines," by The Band.
Immersed and held in the art trance of sad music, we feel the sadness. It surrounds us, it enters us. We feel. We feel the painful longings, the painful loss. The mourner has to let go of his deeply held old play of love where he is not alone. He has to move toward accepting the new play where the loved one will never be here again. He can feel and miss the lost love without demanding the old story.
One never completely heals from significant loss. The old play always lives inside, deactivated, but there. Sad music will always touch us and bring back the nostalgia of loss. The sad music meets your emotional state and allows for the mourning. It holds you and allows it to happen.
How does music penetrate to the receptive insides of the mourner? The two major scales in western music are the major scale and the minor scale. The only difference in the major and minor scales is that the minor scale has diminished 3rd, 6th, and 7th notes. That's it.
Yet, these changes in the scale make all the difference in the world. Scales create mood. The major scale communicates the heroic: Take Beethoven's Symphony No. 3, "Eroica." The minor scale, when soft, communicates sadness ; "Eleanor Rigby," by The Beatles, comes to mind. When loud, it communicates anger: "Why Go," by Pearl Jam. Schubert routinely shifts between major and minor; an example is "The Trout Quintet" in A minor. The minor blues scale—a five-note paring down of the minor scale—can embody the pain of aloneness and loss: "The Sky Is Crying," by Elmore James. Unresolved notes convey suspended feeling: "Blue in Green," by Miles Davis.
Music aids us in mourning our pain. This is no doubt why we listen to it. It's good to give over to the healing and restorative power of music. It's good to take in the communal holding of sad feeling. It's good to go inside to the depths of your own heart to meditatively process your private pain alone. My son and I now have a powerful list of sad music from Facebook. Featured pieces are "Hallelujah," by Jeff Buckley; "Prelude in E Minor," by Chopin; and 'Stars', by Nina Simone. Two of my own favorites are "Adagio for Strings," by Barber, and "Whispering Pines," by The Band.
