Sunday, April 7, 2019

What men can gain from therapy

When my eldest was a baby, I remember feeling so torn when she cried during the night. Our pediatrician and my mother both said that it was okay to let her cry for a while and let her learn to go back to sleep. But as I listened to her cry, I wondered: Will this make her too stressed? Will it damage her emotionally? Will it ruin our relationship?

The answer to all of those questions, according to a new study published in the journal Pediatrics, is no. Not only that, if I’d done it (I didn’t, I was too worried), my daughter and I might have gotten a bunch more sleep.

Researchers from Australia worked with families who said that their babies (ages 6-16 months) had a sleep problem. They divided the families into three groups. One was told to do “graduated extinction,” during which they let the baby cry first just for a minute before going in and interacting with them, and then gradually increased the amount of time they let them cry. Another group did something called “bedtime fading,” where they told the parents to delay bedtime so that the babies were more tired. The last group was the “control” group and got education on babies and sleep, but nothing else.

To measure the effects on the babies, the researchers did something interesting: they measured the level of cortisol, a stress hormone, in the babies’ saliva. They also asked the mothers about their levels of stress. Twelve months later, they looked for any emotional or behavioral problems in the babies, and they also did testing to see how attached the babies were to their mothers.

Here’s what they found. The babies in the graduated extinction group and the bedtime fading group both fell asleep faster and had less stress than the control group — and not only that, their mothers were less stressed than the control group mothers. Of the three groups, the extinction group babies were less likely to wake up again during the night. And when it came to emotional or behavioral problems, or attachment, all three groups were the same.

This means that it’s okay to let your baby cry a little. It’s not only okay, it may lead to more sleep all around. Which makes everyone happier.

In another study published about four years ago, researchers looked even further out than a year. They compared families who did sleep training and families who didn’t and followed them for six years. There was no difference between the two groups. Whether parents let babies cry or got up all night to hold them, the kids turned out the same.

We can get sleep and still have well-adjusted kids who love us. How great is that?

Just to be clear, “graduated extinction” doesn’t mean letting your kid cry all night. It just means that you slowly but surely help your baby learn to soothe himself when he wakes up at night, instead of always relying on you to do it. (Dr. Richard Ferber has a great book called Solve Your Child’s Sleep Problems that explains all of this and is very helpful.)

It’s a natural instinct to want to stop your baby from crying. But sometimes, milestones in life involve some crying — whether it’s learning to fall back to sleep, learning to walk (there’s always a tumble), starting daycare or school (leaving parents is hard), making friends (kids can be mean), playing sports (you don’t always win), or learning to drive (oh, wait, it’s the parents who cry with that one). Never letting our children cry doesn’t help them; in fact, it can end up hurting them.

And let’s face it: getting sleep helps us be better parents.

If your baby is waking up crying at night, talk to your doctor. There are lots of reasons babies cry at night. But if your doctor tells you that everything is okay, don’t feel that you have to respond to every single cry. Men diagnosed with slow-growing prostate tumors that likely won’t be harmful during their lifetimes can often avoid immediate treatment. Instead, they can have their tumor monitored using a strategy called active surveillance. With this approach, doctors perform periodic checks for tumor progression and start treatment only if the cancer begins to metastasize, or spread. Active surveillance has become popular worldwide, but doctors still debate which groups of men can safely use this strategy. Some doctors offer it only to men with the lowest risk of cancer progression. Others say that men with intermediate-risk prostate cancer can also make good candidates.

A new study now shows that intermediate-risk tumors are more likely to metastasize on active surveillance than initially expected. “Most men do fine on surveillance, but we have detected a higher risk of metastasis among intermediate-risk patients over the long term,” said Dr. Laurence Klotz, director of the active surveillance program at the University of Toronto’s Sunnybrook Health Sciences Centre, where the study was based.
Taking a look at intermediate-risk prostate cancer

Sunnybrook’s active surveillance program dates back to 1995, so it allows for remarkably long-term follow-up. Nearly 1,000 men have enrolled in the program so far. The majority have low-risk prostate cancer, which means their prostate-specific antigen (PSA) levels don’t exceed 10 nanograms per milliliter (ng/mL) and their Gleason scores are no higher than 6. (Gleason scores describe how aggressive a tumor sample looks under the microscope.) About 200 men in the study have intermediate-risk prostate cancer. Usually, intermediate-risk cancer is determined by a Gleason score of 7 or a PSA level higher than 10 ng/mL. However, these intermediate cancers can also be divided into lower- and higher-risk categories, depending mostly on how much higher-grade cancer shows up in the biopsy.

The new analysis shows that 30 of the 980 men evaluated in the study eventually developed metastases (or areas of spread). Of those men, two had low-risk prostate cancer, while the other 28 had either been diagnosed initially with intermediate-risk tumors, or were upgraded to that category while they were on active surveillance. The risk of metastases was therefore 3% overall for all the men evaluated, but roughly four times that for the intermediate-risk men, specifically. The median time to metastasis was 8.9 years, meaning that for all the men whose cancer spread, half experienced it within 8.9 years of diagnosis and half experienced it later than that.

According to Dr. Klotz, the likelihood of metastases was mainly dependent on the amounts of Gleason 7 cancer in the prostate, and whether a man’s PSA levels doubled quickly. He expects that a few more men in the study will develop metastatic cancer with age and longer-term follow-up.
Is active surveillance right for some intermediate-risk men?

Though metastasis is a major problem when it occurs, Dr. Klotz emphasizes that roughly 80% of the intermediate-risk men in the study have so far avoided that outcome. And these men, he said, are also avoiding cancer treatments that would otherwise have a significant effect on their quality of life. Still, Dr. Klotz urges caution when selecting intermediate-risk men for active surveillance. “Based on these findings, I would strongly encourage that these men be further evaluated with magnetic resonance imaging and/or genetic biomarkers,” he said.

“These longer-term data shed new light on the ultimate outcomes of men considered for active surveillance who had components of higher-grade cancer when they were initially diagnosed, or who were found to have it on subsequent biopsies while on active surveillance,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org. “Many variables factor into whether active surveillance should be considered for intermediate-risk men. Dr. Klotz highlights MRI and biomarkers, but medical diagnoses, family history, and the patient’s emotional capacity to address a higher likelihood of metastases should all be considered.” It’s true that a newly published study found that a substance in tequila (called agave tequilana, or tequila agave) might help maintain bone health. And that it could lead to new treatments for osteoporosis. But consider the details:

    The study was performed on mice who had had their ovaries removed. This is by no means a perfect model for human osteoporosis.
    The mice were treated with a type of agave tequilana, not tequila, for only eight weeks.
    When compared with untreated mice, the treated mice were found to have larger thigh bones, and samples of their thigh bones contained more of a protein linked with bone growth (called osteocalcin). However, there was no long-term treatment with agave tequilana beyond the initial eight weeks, nor was there any assessment of whether this treatment would prevent osteoporosis.

The researchers suggested that sugars in the agave tequilana interacted with bacteria in the intestinal tracts of the mice to encourage absorption of minerals needed to build bones. So, a “healthy intestinal microbiome” may also be required for this approach to work.
What’s the catch?

I think this new research is intriguing. It’s entirely possible that certain types of agave (a plant that produces a honey-like nectar) could turn out to help people maintain or improve bone health. And considering the health impacts of osteoporosis — hip fractures, loss of mobility, and complications that can lead to death in some cases — such an advance can’t come too soon.

But any study in animals has to be considered highly preliminary. It’s simply unknown whether the results of this study apply to humans. In addition, the animals did not drink tequila. They were treated with a chemical found in tequila. So, the suggestion that we (humans) might improve our bone health by drinking margaritas is, in my view, just a way to grab attention. Even if we could fast forward a few years and confirm that agave tequilana improves human bone health, it’s unlikely that the treatment would be in the form of tequila.

Unfortunately, many people don’t read past the headlines. This is one time when that would be hazardous. The health impact of the alcohol in tequila — and the sugar content of agave — are just two of several “downsides” that could come about if you were worried about your bone health and took the headlines too literally.
Haven’t we been here before?

This new study on “tequila for osteoporosis” reminds me of past studies touting the health benefits of chocolate, wine, or coffee. The same week as the tequila story broke, other researchers reported that certain substances in red wine and coffee could improve cardiovascular health by changing the intestinal bacteria. Again, the study was in mice.

Claims that some of our favorite foods and drinks are actually good for us are not new. Some claims are better supported than others. For example, the evidence that coffee consumption may reduce the incidence of certain types of liver disease in humans is compelling. Still, it’s relatively rare that doctors actually “prescribe” these foods to prevent or treat disease. Perhaps they should. But, enthusiasm for doing so is tempered by concerns that excessive consumption may cause other, unhealthy effects.
Stand by

We’ll need much more research before tequila or anything in it can be recommended for bone health, or any other health concern. Until then, I hope medical writers — and readers — will be careful in how they interpret preliminary research. It’s one thing to hope t ha t what you like is also good for you. It’s quite another for that to be any more than wishful thinking. When I was in medical school, the nurses in the newborn nursery taught me how to swaddle babies. They taught me how to lay the blanket down and how to tuck the edges around the baby so that he became a little “papoose.” Sometimes it worked like absolute magic to calm a cranky newborn. Over the years, I’ve taught parents to swaddle and have swaddled my own babies.

But not only does it not always calm a baby, it’s not always a good idea. And as with everything we do in life, it’s important to use common sense when you swaddle.

Swaddling has been part of caring for babies for centuries — millennia, really. It makes a baby feel like he’s back inside the womb — or like he is being snuggled close. It has been shown to help many babies sleep better. It can be particularly helpful for babies with neurologic problems or colic, or for babies born addicted to drugs.

It also can really help some parents get their babies to fall and stay asleep on their backs, which is what we recommend to help prevent sudden infant death syndrome, or SIDS. Some babies have trouble with sleeping on their backs because they startle themselves awake; when they are swaddled, that’s less likely to happen.

But there are downsides to swaddling. Because it keeps the legs together and straight, it can increase the risk of hip problems. And if the fabric used to swaddle a baby comes loose, it can increase the risk of suffocation.

The most recent warning about swaddling comes from a study just published in the journal Pediatrics, which found that when swaddled babies were put on their sides or bellies, their risk of SIDS went up a lot. For those put on their bellies, especially babies more than 6 months old, the risk doubled.

Although the study can’t tell us exactly why the risk doubled, one can imagine that a tightly swaddled baby might not be able to get her head up if she started having trouble breathing — and if that swaddling blanket came loose and she was face-down, it also might make smothering more likely.

This is what I meant before about common sense. Just because something works sometimes doesn’t mean it’s right for everyone or every situation — and doesn’t mean you shouldn’t think before you do it.

Here’s what parents should consider when they think about swaddling:

    Babies don’t have to be swaddled. If your baby is happy without swaddling, don’t bother.
    Always put your baby to sleep on his back. This is true no matter what, but is especially true if he is swaddled.
    Make sure that whatever you are using to swaddle can’t come loose. Loose fabric and babies is a dangerous combination.
    For the healthy development of the hips, babies’ legs need to be able to bend up and out at the hips. Swaddling for short periods of time is likely fine, but if your baby is going to spend a significant amount of the day and night swaddled, consider using a swaddling sleep sack that lets the legs move. It may not be quite as effective from a calming standpoint, but it is safer for the hips.
When I was in medical school, the nurses in the newborn nursery taught me how to swaddle babies. They taught me how to lay the blanket down and how to tuck the edges around the baby so that he became a little “papoose.” Sometimes it worked like absolute magic to calm a cranky newborn. Over the years, I’ve taught parents to swaddle and have swaddled my own babies.

But not only does it not always calm a baby, it’s not always a good idea. And as with everything we do in life, it’s important to use common sense when you swaddle.

Swaddling has been part of caring for babies for centuries — millennia, really. It makes a baby feel like he’s back inside the womb — or like he is being snuggled close. It has been shown to help many babies sleep better. It can be particularly helpful for babies with neurologic problems or colic, or for babies born addicted to drugs.

It also can really help some parents get their babies to fall and stay asleep on their backs, which is what we recommend to help prevent sudden infant death syndrome, or SIDS. Some babies have trouble with sleeping on their backs because they startle themselves awake; when they are swaddled, that’s less likely to happen.

But there are downsides to swaddling. Because it keeps the legs together and straight, it can increase the risk of hip problems. And if the fabric used to swaddle a baby comes loose, it can increase the risk of suffocation.

The most recent warning about swaddling comes from a study just published in the journal Pediatrics, which found that when swaddled babies were put on their sides or bellies, their risk of SIDS went up a lot. For those put on their bellies, especially babies more than 6 months old, the risk doubled.

Although the study can’t tell us exactly why the risk doubled, one can imagine that a tightly swaddled baby might not be able to get her head up if she started having trouble breathing — and if that swaddling blanket came loose and she was face-down, it also might make smothering more likely.

This is what I meant before about common sense. Just because something works sometimes doesn’t mean it’s right for everyone or every situation — and doesn’t mean you shouldn’t think before you do it.

Here’s what parents should consider when they think about swaddling:

    Babies don’t have to be swaddled. If your baby is happy without swaddling, don’t bother.
    Always put your baby to sleep on his back. This is true no matter what, but is especially true if he is swaddled.
    Make sure that whatever you are using to swaddle can’t come loose. Loose fabric and babies is a dangerous combination.
    For the healthy development of the hips, babies’ legs need to be able to bend up and out at the hips. Swaddling for short periods of time is likely fine, but if your baby is going to spend a significant amount of the day and night swaddled, consider using a swaddling sleep sack that lets the legs move. It may not be quite as effective from a calming standpoint, but it is safer for the hips.
Speaking for my gender, there are two qualities that define most men: we seldom like to ask for help, and we do not like to talk about our feelings. Combining the two — asking for help about our feelings — is the ultimate affront to many men’s masculinity.

We like to think of ourselves as strong, problem-solver types. But when it comes to emotional and mental issues, men need to quit trying to bottle up their feelings and tough it out, says Dr. Darshan Mehta, medical director of the Benson-Henry Institute for Mind Body Medicine at Harvard-affiliated Massachusetts General Hospital. “Your mental health is equally as important as your physical health. Not addressing negative feelings can carry over to all aspects of your life and have a profound impact.”
When to see a therapist

Depression is the most common reason men should seek professional help. Many life situations — jobs, relationships — can trigger its trademark symptoms, such as prolonged sadness, lack of energy, and a constant feeling of stress. For older men, it can also be brought on by financial anxiety about retirement, the death of a spouse or friend, or even the loss of independence, like losing the ability to drive. Left unchecked, these feelings could cause other health problems, such as rapid weight loss, insomnia, declining libido, and changes in memory. They may even lead to destructive behavior like alcohol or opioid dependence.

“While men may recognize these changes when they occur, they may not know the root cause, or if they do, what they can do about it,” says Dr. Mehta. This is when a therapist can lend a hand — or ear. “A therapist can help identify the source of your problems and then help resolve them,” he adds.
How to find a therapist

First, talk with your doctor about your situation, how you feel, and your symptoms. He or she will no doubt know therapists who can help with your specific issues. There are other places to start besides your primary care doctor, too. For example, many employee health care plans offer confidential help lines where you can ask questions and find therapists in your network. Another source is the National Alliance on Mental Illness Helpline (1-800-950-6264).

There are many kinds of professionals who offer many different types of therapy. Their individual approaches are based on their particular training and experience. The main ones include:

    Psychiatrist. A doctor with a medical degree who can prescribe medication. He or she often helps with more severe issues, such as major depression, bipolar disorder, and schizophrenia.
    Psychologist. A professional who has a PhD or a PsyD in clinical psychology. He or she can treat a full range of emotional and psychological issues, such as depression, anxiety, and substance abuse, but in most states cannot prescribe medication.
    Licensed Professional Counselor (LPC). He or she has a master’s degree plus 2,000 hours of supervised psychotherapy experience. This type of mental health professional focuses on the problems of everyday living, like stress and anxiety, relationship conflicts, and mild depression.
    Clinician Nurse Specialist. Like psychiatrists, he or she can prescribe medication. This type of professional works either independently or in collaboration with a supervising physician.
    Licensed Social Worker/Licensed Clinical Social Worker/Licensed Independent Clinical Social Worker. These mental health professionals assess and treat people living with mental illness and substance abuse issues. By providing group therapy, outreach, crisis intervention programs, and social rehabilitation, social workers help to ease clients back into their communities and daily lives. Clinical social workers provide care through numerous avenues, including hospitals, family service agencies and organizations like the U.S. Veteran’s Administration.

What to expect

Your therapist should help you establish goals of care and then outline a strategy to meet them. This may include a combination of therapy during regular sessions as well as “homework” to follow in between visits. Weekly visits are typical. Yours may be more or less frequent than that depending on how you respond to the therapy. After your initial treatment sessions, you might return periodically for “booster” visits to prevent a future relapse.

Do not give up if you do not feel a strong connection with the first therapist you try, says Dr. Mehta. “Try someone else and do not get discouraged. The goal is to find the right person who can guide you.” While therapy may feel awkward at first, most men soon recognize its value, he adds. “Once they make that connection with a therapist, they are quite receptive to therapy and welcome what it can offer.”

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