How to get a good night's sleep; cancer survivor explains the disease to children; training mental health providers: Upstate Medical University's HealthLink on Air for Sunday, March 27, 2022
Pulmonologist and sleep medicine specialist Dragos Manta, MD, discusses sleep disorders and how to get good quality sleep. Author and childhood cancer survivor Anne Bramlage, EdD, shares the children's book she wrote about cancer. Child and adolescent psychiatrist Nayla Khoury, MD, discusses new training for mental health providers.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a sleep specialist tells how to get good quality sleep ... "
Dragos Manta, MD: "... There are a lot of factors involved in maintaining a good sleep habit. Probably the most important is to maintain regular sleep hours ..."
Host Amber Smith: ... A childhood cancer survivor from Cazenovia shares the friend's book she's written about cancer ...
Anne Bramlage, EdD: "... Every cell in your body has a job to do, just like every ant in a colony has a job to do. And when some ants don't do their job, the whole colony kind of suffers ..."
Host Amber Smith: ...And a child and adolescent psychiatrist explains how a new training program is meant to help solve the child mental health crisis ...
Nayla Khoury, MD: . "... It's a year-long commitment to really diving in and working with this underserved community ...."
Host Amber Smith: ... All that, and a visit from The Healing Muse, coming up after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, a childhood cancer survivor shares the children's book she's written about cancer and set in her hometown of Cazenovia. Then we'll hear about a new training program for child and adolescent mental health providers. But first, a pulmonologist talks about sleep disorders and what you can do to improve the quality of your sleep.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." How is sleep tied to our mental health? What can improve our ability to focus during the day? How can fatigue weigh a person down physically, mentally, and emotionally? I'll talk about all of this with Dr. Dragos Manta. He's a doctor who specializes in sleep medicine at Upstate. Welcome to "HealthLink on Air," Dr. Manta.
Dragos Manta, MD: Thank you for having me, Amber.
Host Amber Smith: I'd like to start by asking you about the impact the pandemic has had on sleep disorders, overall. Have you seen more people with trouble sleeping over the past couple years?
Dragos Manta, MD: Yes. Unfortunately, the pandemic has been a major problem for the sleep community. At the beginning was definitely very disrupting for the care of our sleep patients. So I remember we had to go through a lot of changes, and we could not see patients. We had to switch to telemedicine. The sleep lab had to be closed. And then, although initially it sounded like with close downs, we had more time to sleep, you know, that was just a transient issue. And over time, we've had been seeing a lot of insomnia, a lot of people having trouble sleeping because of the stressors that were associated with this pandemic, having to do with health stressors and economic stressors. So it has been a definitely a high increase of insomnia cases during the pandemic and has definitely worsened the sleep of our general population.
Host Amber Smith: So if the sleep disturbances are tied to stressors -- economic, or the fears of COVID and that sort of thing -- is there a risk that those disorders would become chronic or will they resolve when the stress resolves?
Dragos Manta, MD: In some patients definitely a stressor can cause long-term consequences. A significant stressor can be a precursor or a risk factor for chronic insomnia. Not in everybody. A lot of people can recover from a stressor, but some people will develop chronic insomnia after a significant stressor. Or we see a lot in patients that undergo a major accidents for example, or major health issues that chronically can have problems. So yes, it could be a problem in a certain subset of patients.
Host Amber Smith: Well, let's talk about how the quality of sleep helps maintain mental health. What happens in our bodies while we sleep? And what physical impact does that have on our mental state?
Dragos Manta, MD: Well, a lot happens during sleep. I think we know a lot about it, but there's a lot that we don't know. But in general, we know that sleep is essential. There is no way we can survive without sleep. Sleep is restorative, for your brain and your body. So, it's imperative to have a certain amount of sleep every night. And people that are sleep deprived have significant long-term consequences, both medical and then psychological.
Host Amber Smith: So definitely I think people feel a difference if they've had a good night's sleep, you know, they tend to wake up feeling better than if they've had a bad night's sleep. What happens physically and mentally and emotionally when we're fatigued? Are we more likely to make mistakes?
Dragos Manta, MD: Yeah. Definitely there are numerous health consequences of poor sleep quality or sleep deprivation. Definitely your performance will be decreased. Definitely. You are going to be at higher risk of accidents, for example. The one that comes to mind right away is increased risk of motor vehicle accidents. There are long-term medical consequences. You know, sleep deprivation and insomnia are associated with increased cardiovascular risk on the long term. There is an increased risk of dementia with sleep deprivation. There's also an increased risk of cancer. Non-restorative sleep or sleep deprivation have a lot of short term and long term consequences.
Host Amber Smith: I'd like to ask you as a sleep expert, what you think of daylight saving time and how the body reacts to dark mornings versus dark nights?
Dragos Manta, MD: The sleep community for a while has been advocating against daylight saving time, because the forced change in the sleep habits, twice a year, have a lot of consequences, especially during the spring time. There is an increased risk of sleep deprivation, increased risk of motor vehicle accidents. And you have an increased cardiovascular risk, including risk of heart attacks in the week following the fall-back time. The sleep community has been advocating for permanent universal time, rather than switching to the daylight saving time every year.
Host Amber Smith: So our body will just adapt to the natural fluctuations in sunrise and sunset times, without noticing?
Dragos Manta, MD: That's correct. Because the light is the biggest contributor to your circadian rhythm or your sleep rhythm. So your body will just follow the natural light cycle.
Host Amber Smith: Well, I'd like to ask you about the advice you give patients to get quality sleep. What can a person do if they have trouble falling asleep? When they get into bed and lay down, they just can't go to sleep.
Dragos Manta, MD: So there are a lot of factors involved in maintaining a good sleep habit. Probably the most important is to maintain regular sleep hours, , so keeping the same bedtime and waking up time every day. There are two processes that tend to, maintain our sleep cycle. One of them is the homeostatic process. You are sleepier and sleepier, the more you awake. But also there is a innate circadian rhythm. So we all have a certain higher propensity of falling asleep during the night and less chance of falling asleep during the day. So aligning those two processes generates the best sleep. So, keeping the same hours is probably the most, most important. The second one is probably getting enough light exposure during the day, especially during the morning. The light is the one that maintains that circadian rhythm, and getting enough exposure to light during the day is very important -- and not getting too much exposure to light during the night, which is a common thing that happens, you know, with too much light exposure at night, watching TV, staying on the computer all night.
So, those are probably the most important things. There are a lot of other things, like making sure you get exercise everyday. Caffeine is also a big, big problem. So not having caffeine late in the afternoon is important.
Host Amber Smith: Is there anything special someone should do if they go to sleep OK, but then they have a tendency to wake up in the middle of the night and then they can't get back to sleep?
Dragos Manta, MD: We see this in patients with insomnia, and what we recommend is if you wake up and you really can't fall back asleep within reasonable amount of time, which for most patients is probably 15, 20 minutes, we recommend getting out of bed and ideally, even, going out of the bedroom and doing something in low light until you become sleepy again and return to your bed in your bedroom only when you are sleepy and ready to go back to sleep.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Dragos Manta. He's an assistant professor of medicine at Upstate, and one of his specialty areas is sleep medicine.
Do you ever recommend any sleep medications?
Dragos Manta, MD: We've been looking a lot into this because over the years there have been a lot of medications that have been approved and tried for sleep. And just the fact that you've had so many different medications tells you that they don't really work very good. The American Academy of Sleep Medicine and also the American College of Physicians, they really recommend that medication should be a second line treatment. And the first line treatment, it's a combination of what we call cognitive and behavioral therapy where you work with your provider to identify the problems that cause your sleep problems in the long-term and then develop better sleep habits in the first place. And sometimes patients need to see a psychologist to help with that before resorting to medication. So medications are really a second-line treatment. And the current recommendation is to be used just short term because there are a lot of long-term consequences associated with, especially with hypnotics.
Host Amber Smith: How can we determine how much sleep we really need? Because I know some people who exist on few hours and some people who really require a lot of hours.
Dragos Manta, MD: So there is a certain variability in the sleep duration of a population. Most of the people need anywhere between seven and eight hours of sleep. There are people that need, that can get away with, six hours. And there are individuals that need eight, nine hours of sleep. So, between six and nine hours is probably normal as long as otherwise you're doing OK. Most of the people should know how much, it's genetically determined. So most of the people know how much time you need to sleep by your early adult years. You know, teenagers do need a little bit more sleep. So, I wouldn't go on based on how much sleep you need as a teenager. But I usually ask my patients by your mid-20s, what is your total hours of sleep that you need? That's kind of my guiding principle. OK, is this patient needing less than that? If they sleep less than that, then there might be a problem, if that's how much they need. There are people that are short sleepers. There are people that are long sleepers. And as long as they function OK, then that's not necessarily abnormal.
Host Amber Smith: Does it matter when those hours take place within a 24-hour period? Can you sleep anytime and get good quality sleep?
Dragos Manta, MD: Well, you can sleep anytime if you are very, very tired, but generally you should try to align those hours to that circadian rhythm. And most of the people, they are sleepier during the night, but there are people that work the night shift and they train their circadian rhythm to be more sleepy during the day by constant exposure to light at night and then sleeping during the day. So, as long as you maintain your sleep during your determined circadian rhythm, those are the best hours to sleep. And some people do get a little benefit from a nap in the afternoon because there is a certain dip in the circadian, in the alertness during the afternoon. That's also natural. Some patients in some cultures that observe the siesta, they get a benefit from a nap in the mid-afternoon hours.
Host Amber Smith: Now, what about someone who's really, really busy during the week? Can they plan to catch up on their sleep on the weekends?
Dragos Manta, MD: It's better than not to catch up. The ideal is you should have the same type of, the same sleep hours every day. But if you are sleep deprived, it's OK to catch up. I would say, make sure you catch up during the same time period that usually sleep during the weekdays. Maybe add, maybe go to sleep a little earlier or add another hour. I would not add a lot of sleep time because that can change your circadian rhythm.
Host Amber Smith: Well, I imagine everyone may have trouble sleeping on occasion, but I wonder how much of the population has a real disorder like insomnia, or sleep apnea, or restless leg syndrome. Do you have an idea how common sleep disorders are?
Dragos Manta, MD: They're very common. So insomnia and sleep apnea are probably the most common sleep disorders. The estimations vary, but depending on the population that you look at, they vary anywhere between 5% and 15, 20%of the population might have what is called chronic insomnia. And also, there's a high incidence of sleep apnea, again with incidences between 5 and 20%, depending on what patient population you look at. But yeah, unfortunately, sleep problems are very common.
Host Amber Smith: So how long should a person struggle with sleep issues before they consult a specialist?
Dragos Manta, MD: In general short-term insomnia, it's related to a stressor and tend s to get better after the stressor disappears. But if patients have problems falling asleep at least three times a week for three months, then we call that a chronic insomnia disorder. And for that, I always recommend to see somebody because it can become a long-term condition.
Host Amber Smith: So if someone comes to see a sleep specialist like yourself you may recommend a sleep study. Can you walk us through what that is and what a person should expect?
Dragos Manta, MD: Not everybody needs a sleep study, but a lot of patients do. I would say insomnia by itself, most of the time, it's a clinical diagnosis and did not need the sleep study. We would recommend the sleep study for somebody that we worry about sleep apnea, which is a condition where the breathing is impaired during sleep or other abnormal behaviors during sleep like sleep walking, sleep talking, or acting out your dreams. So in situations like that, we would recommend a sleep study, which basically it's a recording of your sleep, looking at several parameters, looking at your brainwaves, looking at your breathing, your muscle tone and other, EKG, oxygen saturation. Most of the patients come to the sleep lab, and they get pretty much a room, almost like a hotel room, where technologists will apply all these leads and sensors. Believe it or not patients do fall asleep despite of all that, and then we record what happens during sleep and then we will send the patients home in the morning, we review the data and then, we try to make a diagnosis of what is causing the patient's sleep problem.
Host Amber Smith: Do you think if someone's partner is snoring at night, that they need to see a sleep specialist?
Dragos Manta, MD: Snoring is very, very common. Not everybody who snores needs to see a sleep doctor. I would say if a bed partner were to observe breathing problem during sleep, like what we call apnea or an episode of stopping breathing during sleep or choking during sleep, if that happens more than occasionally, that would be a reason to maybe consider seeing a sleep doctor. If somebody who snores very loudly is also very sleepy that's also an indication that somebody might be at risk of having sleep apnea. So I would say not everybody that snores. I'd say snoring with some other signs that there might be something going on more than just snoring.
Host Amber Smith: I know that there's a lot of people that rely on sleep apnea machines when they're sleeping. I wonder if, are there alternatives to sleep apnea machines? Because I think a lot of people look at the contraption and the tubes, and they're just like, "there's no way I can sleep with that."
Dragos Manta, MD: I would say that yes, there are alternatives, but the C-PAP machine, despite all the contraptions, is still the best treatment for sleep apnea. And I have to tell you that I've been thinking of so many patients that came to me and they said, "no, I don't think I can use that." You'd be surprised how many patients that initially wouldn't even consider it, they feel so much better and they swear by it. So it's definitely something that initially sounds like and looks a little bit more difficult, but, it is the gold standard treatment. And I would be very reluctant to go to a second line because all the other lines of treatment are really, I wouldn't even call them second line. I would say maybe third or fourth line of treatment. But yes, you're right. Some patients, after that trial, a lot of patients feel better, but some patients cannot tolerate. And in that situation, we do have other options. The most popular one would be an on oral appliance, which is a device that a dentist will make that the patients will have to sleep with at night. It's effective, although a little less effective and mostly effective in maybe mild to moderate cases of sleep apnea.
Host Amber Smith: You called it a C-PAP machine. What does that stand for?
Dragos Manta, MD: It stands for continuous positive airway pressure. So it's a device that maintains a certain pressure into the airway to prevent the airway collapse that is the main problem that happens with sleep apnea.
Host Amber Smith: Well, I really appreciate you making time for this interview, Dr. Manta.
Dragos Manta, MD: You're welcome. I hope this helps.
Host Amber Smith: My guest has been Dr. Dragos Manta. He's an assistant professor of medicine at upstate who specializes in sleep medicine. I'm Amber Smith for Upstate's "HealthLink on Air."
A children's book about cancer written by a childhood cancer survivor -- next, on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Adults may find it difficult to talk to children about complex circumstances, such as a friend's cancer diagnosis. Today, I'm speaking with Dr. Anne Bramlage. She's a native of Cazenovia and the author of a children's book that may help. It's called "Lakeside Friends, a Story About Cancer." Welcome to "HealthLink on Air," Dr. Bramlage.
Anne Bramlage, EdD: Thank you Amber, for having me. It's great to be here.
Host Amber Smith: Now, your book takes place in a village with a lake. Were you inspired by your hometown of Cazenovia?
Anne Bramlage, EdD: Yes, I was. I grew up in Cazenovia. At the age of 4, my parents moved to Caz, and there I attended elementary, middle and high school. And then actually went off to college, and then later in life, I moved back for a few years. So Cazenovia has always been my hometown, and I still have family and many friends there.
Host Amber Smith: Were you always interested in becoming a writer when you were growing up? Is that something that you aspired to do?
Anne Bramlage, EdD: It's funny. I enjoyed writing, but I never thought it would be anything of importance or anything surmountable. I majored in elementary education and then became a teacher. And then later on, went back to get my doctorate. So education and reading has always been a fundamental key important aspect for me. And so now becoming a writer, I've really been able to embrace how I can further educate children.
Host Amber Smith: What grade do you teach?
Anne Bramlage, EdD: I was an elementary school teacher, so I taught in grades kindergarten and then 2nd grade for a little bit. And then 3rd grade. And then my last position was in more in middle school, kind of like a 5th grade, 5th and 6th grade.
Host Amber Smith: Interesting. Well, let's talk about this book. Can you give us a synopsis of the story?
Anne Bramlage, EdD: Sure thing. Brook invites to Joel to come to the lake. And Joel can't go to the lake because he has cancer. And so Brook learns through a real-life analogy. I use an ant colony to kind of educate Brook about what cancer is. And at the end of the book, Brook gives a gift to Joel as a way of encouraging him as he goes through his, as he goes through his journey.
Host Amber Smith: And these children are elementary-age children?
Anne Bramlage, EdD: Yes. The book is for ages 3 to about 7. But I've also had many young children read it -- 10-, 11-, 12-year olds read it. In fact, one of my close friends bought it for his son, and he sent me an email saying, "Anne, your book is great. Thank you. My 11-year-old now understands cancer." And to my knowledge, they did not have any, there was no cancer diagnosis in their family at all. It just, his son now understands what cancer is.
Host Amber Smith: Well, tell me a little bit more about how the ant colony helps describe cancer for children.
Anne Bramlage, EdD: Yes. The ant colony. I wanted to really create a picture or an image or a way for children to understand what cancer was, because it's really, it's a complex thing, and there's many different types of cancers and different treatments and everything like that. So I use a simple ant colony to really describe the fundamental of what cancer is. Cancer is uncontrolled cell growth, and every cell in your body has a job to do, just like every ant in a colony has a job to do. And when some ants don't do their job, the whole colony kind of suffers in the same way. When some out-of-control cells don't really do their job within the body, the body kind of suffers.
Host Amber Smith: Now, your name is Anne Bramlage. How did you decide on using A.B. Namy as a pen name?
Anne Bramlage, EdD: So A.B. Namy, I kind of took the first initials Anne Bramlage, and put it as A.B., and then Namy is my maiden name. So having the books come from my hometown, it just kind of made the best sense to kind of use a pen name of my maiden name.
Host Amber Smith: Well, I understand that you survived childhood cancer. Can you tell us about that?
Anne Bramlage, EdD: Yes, absolutely. At the age of 6, I was diagnosed with non-osseous Ewing sarcoma, which in easy terms just simply means cancer, not in the bone. So it was in the tissue located under my right arm. And for about a year, my whole first-grade year, actually, I was not in school. I received treatments, chemotherapy and radiation. And from then on, well, during that time I lost my hair. I had a tutor that whole year. I did not go to school. So it was a challenging time, but I got through it. My parents were very supportive. And so were my friends.
Host Amber Smith: I was going to ask what you remember about the reaction of your friends, particularly.
Anne Bramlage, EdD: My friends that I knew were understanding. Two stories come to mind here when you ask me that question. The first one is, after each treatment -- and they were one, one treatment per month, just about -- so after treatment, my Dad would take me and whatever friend that I kind of chose at the time to kind of hang out with, so each month it could be a different friend. And we went to, we went to the mall, and so it was an evening where after my treatments, sometime after when I was, feeling better, I invited a friend to go to the mall. It was a time out, and my friends were able to ask questions. We were able to hang out and do real life things together. Because I hadn't missed so much of first grade, my parents didn't want me to lose relationships with friends. So we went to the mall. It was a great time. And that was just one time that I really remember being able to share with my friends, to have my dad around. Sometimes my mom would take me. It didn't matter. Either, either one.
And then on the flip side, I have a different story that is, it's not so great, but you know, it is what it is. One time I was heading to the bus. And this was kind of when I returned back to school, but my hair hadn't really grown in yet. So it was the end of the day. I was heading to the bus and at the bus, or somewhere on the way to the bus, there was this little boy that would always pick on me. And as a kid, I wore baseball caps because I didn't have any hair, and I just didn't want to go around bald, and I really didn't want to wear a wig at that age. So I wore a baseball cap. And he would always tease me that I didn't have hair. And so one of the teachers, one of the monitors there, saw this little boy picking on me. And from then on, I had a teacher escort me to my bus every day after school. But at the same time, I wonder what that little boy, if he would have treated me differently if he understood what I went through, and why I didn't have any hair. And maybe a resource like my book could have really benefited him in terms of what he could understand about it.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with author Anne Bramlage. She's written a children's book called "Lakeside Friends, a Story About Cancer."
Can you explain the process of creating this book? Did you have the complete story in your head before you started writing?
Anne Bramlage, EdD: I did not. So one of my friends asked me -- her mother recently was diagnosed with breast cancer, and she had some young children elementary school age, and she knew my background and everything like that and asked me, "Ann, how am I going to tell my kids that their grandmother has cancer?"
And I said, "Well, I don't know. That's a really great question. Best of luck," type of thing. And I really got to thinking after that. So I did a little digging myself, and I read some books, some children's books about it. The books that I read that are out there were all geared toward children who have cancer, really going to see the doctor, what's going on in their body, really explaining cancer to them. So my book is unique in a way that it explains cancer too their friends, their siblings. Maybe it explains cancer to a family whose grandmother just learned that she had cancer. So that's where the idea came from. And in using a real life analogy is something that I was able to bring into the book where kids would understand it, who are not going through treatments. Not to say that this book is not for kids who are undergoing treatments as well. It is for both. But it really is a resource for parents to use, for siblings, for friends, for teachers to read in a classroom of maybe where they have a student who was diagnosed with cancer.
Host Amber Smith: How closely did you work with the artist? Because it's got really nice drawings all through the book.
Anne Bramlage, EdD: Thank you very much. I really worked with the artist. I wanted to show images of Cazenovia. I wanted to show images of that small town, and I really worked to create character development, so that in more books going forward, I can show the same characters again. And I just went back and forth with them a lot to get the images that I wanted. So I really appreciate that you like the images.
Host Amber Smith: As a survivor yourself of childhood cancer, what would you say to a child who's just been diagnosed?
I would say that they, that they can do it, that they can beat cancer. It might be tough. It will be tough. But they can do it. And this time will pass, and they can beat cancer. And cancer is beatable, and they can go back to having their normal life back, of being a kid and seeing their friends again, and this cancer that has happened in their life won't slow them down.
What would you say to that child's friends?
Anne Bramlage, EdD: I would tell them what's going on, that their friend has some cells that just aren't doing the right job, that they're out of control, that they're, growing uncontrolled in their body. And they're just not doing their job. And the best way to be a friend is to encourage, to support, and do the best that they can in helping their friend out.
Host Amber Smith: You talked about your parents making sure that you maintained connections and friendships and going to the mall regularly, when you were able to. When, as an adult, you look back at what you went through as a child, is there anything you would've liked to change?
Anne Bramlage, EdD: The one thing that really stands out to me is there wasn't and -- I was six years old, and my siblings were four and one, so I had two younger brothers at the time, so they didn't ask too many questions -- the one thing though that I really, that I noticed looking back now is that there wasn't a ton of resources. And maybe there were more resources for my parents and they just, didn't really go on to share that so much with me, but there weren't books, there weren't podcasts. There wasn't as much awareness or even discussion about it. I remember just going to the doctor and learning more about what was going on in my body from the doctors. There weren't TV shows, there weren't books, like I said.So, that's one of the reasons why I wanted to write this, was to bring awareness, to bring knowledge, to bring understanding to people, to children.
Host Amber Smith: My guest has been Anne Bramlage, author of "Lakeside Friends, a Story About Cancer." I appreciate you making time for this interview, Dr. Bramlage.
Anne Bramlage, EdD: Thank you, Amber. It's been a pleasure.
Host Amber Smith: I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air" -- one way psychiatrists are helping to solve the child mental health crisis.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Children's mental health services are in crisis, with an acute shortage of psychiatrists, psychologists, counselors and social workers everywhere, not just in Central New York. I'm talking about what's being done to help with child and adolescent psychiatrist Nayla Khoury. She's an assistant professor of psychiatry and behavioral sciences at Upstate. Welcome to "HealthLink on Air," Dr. Khoury.
Nayla Khoury, MD: Thank you so much.
Host Amber Smith: Why is there a shortage of mental health providers? Because I understand this was an issue before the pandemic, right?
Nayla Khoury, MD: Yeah, that's right. It's always been an issue nationally and globally as well. And you know, I think frankly the need just has outweighed the supply of mental health providers for a very long time. Mental health disorders such as anxiety and depression are very common. And we know that in the last two years, globally, there's estimates of doubling of disorders such as that, in this pandemic of loneliness now, moreso than ever, the shortage is being felt, which is why we're in crisis, as you mentioned.
Host Amber Smith: Now, what attracted you to child and adolescent psychiatry to begin with, when you got into this profession?
Nayla Khoury, MD: I think as a first-generation immigrant to the U.S. whose parents came from war-torn Lebanon, I've always been interested in global health and trauma. I found a calling for psychiatry and child psychiatry because of the focus on prevention, working with families, being able to support resilience and really try to alter the course for a young kiddo who may be struggling with all sorts of issues, but it kind of came first from my own experiences. And then the joy of being able to work with whole people, hear their stories and families.
Host Amber Smith: It sounds like it would be immensely rewarding as a career. So I'm wondering what factors you think are preventing people from going into this field.
Nayla Khoury, MD: Yeah, that's a really good question, because I do think that most psychiatrists, even, would enjoy the extra training. We think of ourselves as "whole life psychiatrists," those of us who've done the additional training. I think frankly, it's the overwhelming medical school debt that prevents and prohibits a lot of people from taking on an additional two years when they could be, instead, making a salary that is much more than training.
Host Amber Smith: Sure. Well, now I understand Upstate is part of a collaborative training program with Syracuse University. What can you tell us about this program? And what's its mission?
Nayla Khoury, MD: Yeah, this is an exciting partnership with Syracuse University to help meet the needs and to provide behavioral health experiential training opportunities. So there's a couple of goals for this program. One is to diversify the number of mental health providers and to have them have more experiences in underserved settings with multidisciplinary team approaches. The focus is on the city of Syracuse, as well as Onondaga Nation, which we know have a need for mental health providers and working collaboratively to provide interdisciplinary training for both the trainees and the supervisors on site. So it's very exciting, and I think ultimately will help improve the quality of diverse mental health providers in underserved areas that may not otherwise get to have as much access to care.
Host Amber Smith: So if I understand what you're saying, there will be sort of a commitment to providing training for people so that they can get the training they need and get into practice.
Nayla Khoury, MD: Yeah, that's correct. The target is for students who are completing masters level social work or psychology post-doctorate students. So they're already in training, but it's providing them more enriched experiences earlier on. And, at least in the case of the work with the Onondaga Nation behavioral health collaborative, it's a year-long commitment to really diving in and working with this underserved community.
Host Amber Smith: Well, let's talk about the role and specialization of the various professions in the field of mental health. I know that psychiatrists are the medical doctors, the MDs who can prescribe medication. How do the psychiatrists differ from psychologists?
Nayla Khoury, MD: People often get us confused. So psychiatrists, like you said, have gone through four years of medical school and then four years of residency, and then in the case of child and adolescent psychiatry, two more years of training. Whereas psychologists are most often PhDs who have had extensive training in theory and therapies and testing, psychological testing as well. And then there's other mental health providers too, which I'm sure you'll be curious about. And I often have to look it up. I think it's very confusing to sort through both the training, the lens. But this is actually one of the benefits of our program and one of the reasons I enjoy the collaborative training is that I do think we all bring different experiences and lenses to the work.
Host Amber Smith: Right. You mentioned social workers. I mean, I can think of school counselors and you're right. People in those roles have a varied background. So, you know, one social worker isn't the same as another social worker.
Nayla Khoury, MD: Right. One of the unique lenses that social work brings is a focus on systems as well. So systems of oppression and social justice, as well as clinical practice. So that's something I like to learn from the social workers that I work with.
Host Amber Smith: Now your biography lists "cross-cultural psychiatry" among your interests. What is that?
Nayla Khoury, MD: Oh, yeah. And I'm happy to share about that. I first got into and learned about cross-cultural psychiatry in medical school, when I had some time studying and working in Haiti. So it was first sort of learning about how mental illness can be identified, expressed and treated in other cultures. And I think over time, I've come to learn and see how cross-cultural psychiatry also just applies to understanding the culture of medicine and how we interface with different families and cultures, even here in the U.S. and in Syracuse. So even, for example, our DSM-5 -- which carries the diagnoses that we use to diagnose and guide treatment as medical professionals -- is culturally contextualized. And even though I think globally people use the DSM-5, there's also other classifications used elsewhere and a growing recognition that depression here may look a little bit different than depression somewhere else. And just a very interesting interplay and conflict around how do we make sure people learn about the DSM diagnosis, but also be respectful and humble about how our disorders may not present exactly the same elsewhere. And there may be other treatments that are really useful in different communities.
Host Amber Smith: Do you find, are there some cultures where depression is taboo, and you can't really call it that?
Nayla Khoury, MD: Oh, absolutely. I think in many communities, mental health disorders that are less severe or not psychotic in nature are, frankly, invisible. So depression and anxiety isn't seen at all. And so patients will be much more likely to present with a heavy heart or a head that's full than with our typical depression checklists that we talk about in the DSM-5. And there's also just interesting thoughts to consider how consciously or unconsciously people learn what's culturally acceptable ways of expressing distress. Depression is a really good example of that. So whereas we might be able to see someone looks depressed because they are shut down, they're not eating, they're not engaging in life -- and I do think depression exists globally, no matter where you are -- people may not come in saying, "I feel guilty; I have low self-esteem." In cultures that are much more communal the focus might be on how I'm not able to support my family or function in that capacity. So it can look a little bit different.
Host Amber Smith: This is Upstate's "Healthlink on Air," with your host, Amber Smith. I'm talking with Dr. Nayla Khoury. She's a child and adolescent psychiatrist at Upstate.
We've talked about the different cultures. Do you see a difference in patients from different socioeconomic status, people that have wealth versus people who are poor?
Nayla Khoury, MD: Well, yes and no. I mean, mental illness affects people across socioeconomic status, and yet there's much added challenges for families coming from lower SES (socioeconomic status.) For one, they may have less access to care, to even showing up to treatment, partly because of insurance, partly because of being able to make an appointment during regular business hours, transportation, et cetera. And then when they're able to get into the door to see us frankly, folks with lower SES are just more likely to have many other structural determinants of health, many other factors going on that put them at increased risk for trauma-related disorders or intergenerational trauma. So it becomes even more important to be aware of how to support the whole family in seeking resilience. That it's not just about the kid coming in as the identified patient, but how do we support the whole family as best we can, the parents, the grandparents, the extended family? So yeah, it is an important factor, both for access and for treatment.
Host Amber Smith: We hear about the importance of preventive care, mostly like with health screenings and medical checkups and things like that. Are there ways to proactively identify mental health problems in an individual before they become a crisis?
Nayla Khoury, MD: Absolutely. So one of the other hats I wear is as a child and adolescent psychiatrist working with Project TEACH, where we train and work collaboratively with primary care physicians. So, there are rating scales that can be used to help identify those at greater risk, such as scales looking for depression and anxiety. But in general, I think some of the things that are important to keep in mind is observing people's behavior and noticing changes over time. So if somebody is normally very bubbly and extroverted and is all of a sudden shut down and not speaking, that's a red flag or vice versa. If someone, especially when we think about young people, the areas of function to pay attention to, if a kid isn't going to school, that's a huge red flag. They may already be in crisis. If they're all of a sudden plummeting in terms of academic performance or doing much differently than they did before, that's something to inquire more about. If they're unable to enjoy time with friends, if they're isolating more, these are some signs that we may need to evaluate more what's going on.
Host Amber Smith: How does a parent know, if they suspect that their child needs professional help, how does a parent know which therapist, psychiatrist, social worker, psychologist, how do they decide which person or profession would be the most help for their child?
Nayla Khoury, MD: It's a really good question. And I don't think it's a parent's role to know that necessarily. I think first and foremost, sort of seeking out the supports that exists for that parent. So going to the primary care physician or pediatrician or family doctor and asking for help. And that person can be one person to help guide where to go next. Or within the school system, touching base with the school counselor or psychologist, asking for more testing if needed or some more support. And these professionals can help guide what's needed from there. So there's sort of a tiered approach. Most kids won't need to see a child and adolescent psychiatrist. We're kind of for the most severe kiddos. But there's a lot of steps in between. And I don't think it's really about the professional so much as it is about the connection between the kid and the therapist. The other piece is, it also depends on what kind of therapy the kid needs and what type of training the therapist has had. And so some of that takes assessment before you can know entirely.
Host Amber Smith: Do you have advice for how to choose a therapist, or do they match up a child's characteristics with a therapist's characteristics to find a relationship that's going to work?
Nayla Khoury, MD: Yes, and no, I mean, there's an increased, focus and attention to sort of tele telemedicine and telehealth. And even here within Upstate, we're looking to figure out if we should purchase as a hospital system tele-health options to increase access for everybody. And in some of those systems, they do more matching, like you said. Frankly, most systems don't have the luxury to be able to match as well as we'd like to. We often cannot match based on gender -- it's an overwhelmingly female field -- or race, or ethnicity. And so the choices are often limited. One of the goals and missions of this grant is to increase diversity in the workforce. So there is a focus and intention to picking trainees that look more like the community in different ways, and I do think that's important. The advice I would give to a young person and a family, too, is to give it time, that you don't really know until you start meeting with somebody if it's going to work. And then it takes a little bit of time before, I mean, I would say, give at least three sessions before you make a decision about whether to proceed or not, because relationships take time. And even though a kid might go into a relationship thinking, I want somebody who looks exactly like this or meets this criteria, it may not be in fact, what they need for therapy, for healing. So it's both practical that we can't always match and, I think, really can be very beneficial to know that we can be healed by all sorts of different types of people with different backgrounds.
Host Amber Smith: What should a person do if they aren't clicking with their therapist? And especially now when there's such a shortage, I mean, in one sense, shouldn't a person be grateful that they have a therapist because they are hard to come by right now?
Nayla Khoury, MD: I think it depends. On the one hand, making sure that the patient and family have given it enough time. I also encourage all families that I talk to where there's a question of fit to let the therapist know and give direct feedback about what's not working. Because in fact, some of the most important therapeutic work happens when we repair a misrepair, you know, where the kid is able to say, when you said that the other day I felt judged and the therapist apologizes and says, "I didn't mean that. And now I know." And so that gives the therapist an opportunity to grow and the child an opportunity to speak up for themselves. So, not easy to do. Most often people would like to just switch and avoid the discussion. But that discussion is very important to have. On the other hand, it's so important that a kiddo, and anybody, feels safe and that they have choice. And so having choice is also the choice to say, "this isn't working," and to switch providers. So it's a both, and. I always encourage kids to talk to their therapist and then say, if it's not working, you can always switch or try to switch.
Host Amber Smith: My guest has been Dr. Nayla Khoury, a child and adolescent psychiatrist at Upstate. Thank you for making time for this interview, Dr. Khoury.
Nayla Khoury, MD: Thanks so much for having me today.
Host Amber Smith: I'm Amber Smith for Upstate's "HealthLink on Air."
And now, Deirdre Neilen, editor of Upstate's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: Austin poet Kasha Martin Gauthier talks about social distancing and what it suggests about human nature as we tried to follow the early guidance we were given. Her poem "How I've Survived This Long, Part 3," begins with an epigram:
-- CDC Tip: hold your arms out toward the person next to you. Your 3-foot arm plus theirs will equal the recommended distance.
Of course, it is strange to inhabit this earth,
only connected by the air we breathe.
If we all spread out across the world's landmasses,
our fingertips touching, we'd make a giant corporeal net --
a grid of electric human energy
upon which anything might be communicated.
A virus replicates -- desires its host
come into contact with another host. Honestly,
I desire the same.
What am I, if not a host for touch?
I'm unaware of what I carry within me. With my touch,
I convey consequence beyond what I intend --
14 days later, a death on the other side of the world.
And I'm unable to trace back along the web I created --
unable to trace myself back to the source.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air." An important overview about kidney health. if you missed any of today's show or for more information on a variety of health science and medical topics, visit our website at HealthLink on Air dot org. Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Stephen Shaw. This is your host, Amber Smith, thanking you for listening.