Q&A with Dr. Dawn Elise Snipes

Hey there to everybody. We will wait about, you know, another minute or so for anybody who wants to log in. How is everyone doing today? I just got your Scream name. I love that Wiley Coyote cartoon. That's one of my favorite episodes. Let me introduce myself. My name is Mud, if you're not familiar with that. It's a Wiley Coyote Bugs Bunny cartoon. Kind of funny. I'm sure you can look it up on YouTube. But anyway, so let's go ahead and get started. I'd like to welcome everybody to today's live weekly discussion with me, Dr. Donnelly Snipes. We're going to be talking about a lot of different things today, really, based on questions that I've gotten from you guys in and in prior live weekly discussions. So I'm trying to answer those for you as best I can. As always, if you have questions that come up or you're just have some burning question that you're bringing to the discussion, please feel free to share it in the chat box, in the discussion box and I will answer it as quickly as possible. One of the questions that I had last week that I wanted to provide a little bit more answer to is what are some treatment issues specific to prisons or people who are in jails or prisons? And one is trauma and hopelessness. The majority of people who are involved in the criminal justice system have experienced trauma either prior to going to jail or prison or while in jail or prison. So. So we need to be sensitive to that trauma. Informed care is obviously something that we want to embrace. We want to resist retraumatization as much as possible. And there are a lot of things in the jail and prison environment that can be traumatizing. Anything that involves restraints, anything that involves taking away a inmate, inmate sense of control, anything that involves the inmate not feeling safe. And guess what? A lot of inmates do don't feel safe in jails and prisons. So we want to work with them to the best of our ability to help them feel as safe as they can and create an environment that is conducive to non traumatization. I won't say healthiness and happiness because ain't nobody going to be happy in jail, but we want to make it as least detrimental, if that's not even grammatically correct as possible. We also want to examine for the people who are in jail and trauma the underpinnings of some of their symptoms. A lot of people who are in jail or, or prison have what is considered an antisocial or a criminogenic personality. And we really Want to look at? What does that look like? What are those symptoms that we are characterizing as antisocial or criminogenic? What function do they serve? For example, lack of empathy and manipulation. What functions do those behaviors serve? They are protective in some way and a lot of times people learn those in able to in order to keep themselves safe while in jail or in prison. So we want to help them understand the functions of those behaviors and maybe develop some healthy, healthier alternatives for when they get out. One of the first things we're going to do, remember those behaviors serve a protective sort of function. One of the first things to help people stop using dysfunctional protective self mechanisms is to help them feel safe. We really need to work on that as much as we can. In jails and prisons. We need to look at the underpinnings of their trauma symptoms. Is there anything that's going on in the jail or prison that might be triggering some of their trauma symptoms that we can help them address? Same thing with their mood symptoms. What is going on biochemically with them as well as cognitively that might be contributing to their feelings of fatigue, difficulty concentrating, apathy, hopelessness, helplessness? What might be going on? Thankfully, in most jails and prisons there is a pretty regular structure. So hopefully your, the circadian rhythms are staying as balanced as possible. In most jails and prisons there is out time, outside time, not necessarily every day, and that is really important to help the circadian rhythms get set. In jails and prisons, meal time is at about the same time each day. So there are some things that are working to people's advantage. But we do want to look at anything that could be disrupting the circadian rhythms, disrupting the endocrine hormones, keeping that HPA axis, that threat response system over activated, which will lead to a variety of mental health and mood symptoms and you know, anything else that might be traumatizing. Substance abuse is another issue that needs to be addressed in jails and prisons. And there are a lot of correctional facilities that offer substance abuse treatment programs and that's wonderful. However, there are also a lot of correctional facilities. I'm not going to say all, but I've worked with the correctional population long enough to know that it is not a drug free environment and it's harder to get drugs in in a correctional environment, but it is not impossible. It is important to examine, you know, regular drug testing as well as providing support groups and hope and, and tools in order to deal with what was triggering the substance abuse on the outside, which may also relate to co occurring mental health disorders. One of the best things that we can do, and I know a lot of correctional facility operators are not going to want to hear this, but one of the best things that we can do to prevent recidivism is to identify and address the substance abuse and mental health issues while they are in incarcerated, while they are in prison, in order to help them have a better shot at dealing with life on life's terms when they get out. If they get out of the correctional system and they are still struggling with depression or PTSD or anxiety, even if they're theoretically clean and sober, it's likely that they're not going to stay clean and sober for very long. We need to address those co occurring disorders concurrently. Fetal alcohol spectrum disorders are another. Oh, I could go on a whole soapbox about this, which I won't, because y' all probably don't want to hear about that all morning. But a lot of people who are in jails, not necessarily prisons, but jails, have fetal alcohol spectrum disorders. And why do I differentiate? Because people with fetal alcohol spectrum disorders are very often ones who follow. They're very easily manipulated. They tend to follow other people. They can get in with the wrong crowd very easily, but they also don't tend to learn from their mistakes. So when you look at their rap sheet, a lot of times you will see them committing the same offenses over and over and over again. There's no escalation unless they are following, you know, listening to, being manipulated by somebody who, who is escalating themselves. Then you may see them kind of be pulled along with that unfortunate peer group. FASD has a whole lot of symptoms associated with it that include the ability to talk and communicate on a very high level. You know, like someone who is of average or above average intelligence. But their ability to understand the information that they're receiving to, to understand what is being told to them to remember things is much, much lower in many cases. I do have a couple of videos on the YouTube channel on Fetal alcohol spectrum disorders. If you work in correctional facilities, or quite honestly, if you work in mental health, I feel it's extraordinarily important to be aware of the symptoms of fetal alcohol spectrum issues. Not everybody who has FASD has the facial features associated with that FASD that is more on the extreme side of the fasd. So you have a whole spectrum of issues, but the cognitive and impulse control issues are much more th. Those are sort of some of your first issues that you're going to see on the lower end of the spectrum and then they can get worse from there. A lot of people in the criminal justice System do have FASDs. A lot of people who come to treatment do have FASDs. And often their family members also have FASDs. Their family members were born to people who were biological mother who was drinking. They developed FASDs. They didn't learn from their consequences. They had difficulty dealing with life's on life terms. People with FASDs are a higher risk of substance misuse. They may have started drinking alcohol themselves because you know, it's legal, everybody does it. And then they may have consumed alcohol while they were pregnant with your patient. So FASDs actually often you can trace it back and you can see intergenerational patterns where birth mothers have often have FASD themselves. Why am I bringing this up? Because a lot of times we rely on the family as part of the support system. And if the family has the same cognitive impairments that the identified patient does, then we're going to need to alter our treatment approach in order to ensure that they are comprehending it and in order to assure ensure that they are benefiting from treatment. A person with an FASD is probably not going to thrive in a group therapy environment with people who are neurotypical. You're, they're going to need to be in an environment that specifically caters to the special needs of people with FASD. Again, you can learn a whole lot more about FASDs on the website on, on the videos that I have that are already out on the website. There is also a high preponderance of people with ADHD who are in jails and prisons. We want to take a look at that. And I didn't put them on here, but learning disabilities. Let's look at what happens if you go to virtually any preschool or daycare center. You know, when kids are knee high to a grasshopper. It's rare, very rare to see someone that you can point your finger on and go antisocial personality characteristics or whatever. Obviously you don't diagnose personality disorders till much later, but children when they're very young typically are pretty well adjusted based, you know, given what their, their home environment is like. So we want to look at what happened in their developmental course that may have branched them off into a criminogenic way of life. For some people it may be school failure. They don't feel like they fit in at school. They have difficulty. They, they fail at school because of learning disabilities or adhd. They may have difficulty especially with ADHD with organization and impulse control and those sorts of things. Thankfully, we know more about ADHD than we used to, but I think it still goes undiagnosed or under diagnosed in some cases. And we want to look at that and really look at it through a very objective clinical lens and not excuse behaviors for one reason or another. There's a lot of. Cultural factors that go into, in my opinion, missing diagnoses on certain children. So I think it's important to look at, you know, the objective diagnoses and make sure that all children are getting screened for ADHD and learning disabilities to make sure that they succeed. There have been a lot of studies that have shown that as grades go down, mood tends to go down as well as, and behavioral disorders tend to go up. There's a direct correlation because kids are in school all day, every day. And if that's an environment in which they are not thriving, then they're probably going to either drop out or, you know, get kicked out, have behavioral issues and get in with a crowd that is experiencing similar behaviors and that can lead them down a, an unfortunate road. Now, people who are diagnosed, who receive the support that they need, thrive. You know, I having ADHD or a learning disability, you know, my kids, my daughter has dyslexia and my son has adhd and they are both, you know, thriving young people. So any mental health disorder is not necessarily, even FASD is not necessarily a sentence to behavior disorders or criminogenic behavior or anything like that, but it's making sure that the person feels accepted and loved and secure and feels like they can succeed in life, that they have hope, whatever their skills and talents are. And that is the crucial part. A final issue that is common to prisons are communicable diseases. The rates of hiv, tuberculosis and hepatitis C tend to be higher in jails and prisons. Therefore, education about these things, about prevention and about symptoms and management of these issues is really important for a lot of our clients. In prisons, there are a lot of things you can't do. You know, you're not going to be doing outpatient. But there are a lot of things that are very helpful. Motivational enhancement techniques are super helpful in jails and prisons. Motivational enhancement increases hope, increases self efficacy, increases a sense of confidence in the person, that they have options and they can make choices that are helpful to their survival and recovery. And you know, non recidivism self esteem is another important issue. A lot of people who are in the criminal justice system have very low self esteem. Now they may be Bold and blustery. But a lot of times that is a protective mechanism because they feel vulnerable. Helping people develop their self esteem based on who they are, not based on who they can make feel intimidated is really important. Important video based psychoeducational lessons can be used. A lot of correctional facilities have libraries with computers that inmates can go take video based psychoed lessons on coping skills, distress tolerance, anger management and even to a certain extent communication skills. That is great for implanting the information, but in order to take it from, from knowledge to practice, they have to be able to use it, to practice it, to try it out. You know, if you are learning woodworking, you could go on YouTube and watch videos on woodworking all day long and think, okay, that looks really cool. I think I know what I'm going to, how to do that. But until you actually got the saw out or whatever it was and started using it, you wouldn't be sure you knew. And a lot of times we think we know a lot more than we actually do know. And when you're in front of that saw, all of a sudden you have an oh crap moment that you're not really sure, okay, what's the first thing I do here? So it's important after they take these video based psycho educational lessons to help them apply them both in support groups, role playing activities and by using video feedback. Now that is one of the unique things about correctional settings is that they are always being videotaped. So it is really interesting if you have a particular person who has maybe some interpersonal challenges, or if you have somebody, for example, who is even starting to act withdrawn, you can actually show them a replay of themselves and help them see their non verbals, help them see them as others see them so they can understand, you know, why the clinician may be worried that they're suicidal or, or why people may be intimidated or picking on them or whatever's going on. There is so much that can be gleaned from these video replays. Pharmacology, including medication assisted therapy is super helpful in jails and prisons because it, when people are incarcerated, it gives them a chance to get stabilized on these medications. We know, for example, antidepressants. A lot of times the first antidepressant a person uses may not be the right one. We also know that psychopharmacology only works for about 30% of people. So that other 70%, they're not going to have a good response or a positive response to it. And that's okay. But for the 30% who do you score for that. But it also takes four to six weeks for somebody to get stabilized on a lot of the psychotropic medications. Same thing with medication assisted therapy. Finding that right dose for that person takes a little bit of time. So doing it while they're incarcerated ensures that when they get discharged, they are stable. When they're stable, they're more able to get a job, more able to maintain housing, more able to follow through with their case plan, more able to prevent recidivism. We want them to get out and be stable. It kills me when I hear that people are taken off of their psychotropics when they go into a correctional facility because they were not considered a danger to themselves or others. Without it, you know, you can be as depressed as you can be, but as long as you're not a danger to yourself or others, we're not going to give you your meds. And then once they get out, they have to start their meds again and try to get restabilized. That is just a recipe for recidivism. People need to be stable at discharge. Job skills and screening for learning disabilities are other things that we can do in correctional facilities to help people prepare for their discharge, to help them know how to answer those questions about on the employment forms about have you been incarcerated? Explain this gap in your employment history. It we can educate them about the federal bonding program so they can educate potential employers about the possibility of getting a bond on them to protect the employer that might be willing to hire a person with a criminal record. We can also educate them about the companies that typically do hire former felons, and you can find all that stuff online. Treatment issues in medication assisted therapy, not necessarily in the correctional environment, include physical issues. People on medication assisted therapy often have issues with chronic pain. When people are taking opioids, it disrupts their natural pain management system. It disrupts the natural flow of endogenous opioids. So people who are tapering on medication assisted therapy or who are not on an adequate dose may experience increased pain. They may also have, even on the right dose, they may have some breakthrough pain. So pain management is going to be really important. People who are on medication assisted therapy may also feel sleepier and have more difficulty staying awake and maintaining their circadian rhythms. It is going to be so important to work with people on the timing of their doses, et cetera, to ensure that they are awake during the day and sleeping at night. Other physical issues can include addressing any other comorbid physiological complications such as diabetes or hepatitis or or Anything like that that may be going on and nutrition is going to be important. When I worked in the methadone clinic, a lot of the people that were in treatment with us had very poor nutrition. Some of some people had poor nutrition because they couldn't afford a lot more. And it was important to work with them to figure out resources so they had access to enough healthy nutrition on a daily basis. And other people were just oblivious to what adequate nutrition looked like because they hadn't taken care of themselves for so long, they had forgotten or the thought of cooking a meal just seemed completely overwhelming. So sometimes with people in medication assisted therapy, even things like cooking skills can be very helpful to their recovery process. Affectively, when people are on opioids, they may feel less anxiety. When they are tapering, they may feel more anxiety. When they are on opioids, they may also feel a sense of apathy or depression. How the opioid affects each individual person affectively kind of varies. So we do need to pay attention to that. But we also know that as they're tapering that they are going to have some issues potentially with anxiety and agitation. So before they start to taper, they need to have really strong distress tolerance skills in place as well as a relapse prevention plan. Knowing that, you know, during that tapering window they are, they may struggle a little bit more. You know, an adequate taper typically takes a year to two years. You know, it's a very, very slow tapering process. So the person doesn't experience enough anxiety or discomfort to trigger a relapse. But they do need to be prepared for the occasional breakthrough issues. Cognitively on medication assisted therapy, sometimes some people have difficulty thinking as clearly because they're a little more foggy headed. This doesn't happen all the time, but it does happen for some people. So if they are on medication assisted therapy, they need to be aware of what they need to do to supplement their memory. Do they need to write more things down? Do they need to practice paraphrasing more? What do they need to do in order to function in their environment to the best of their ability, given the fact that they may feel a little bit foggy environmentally? Obviously, the removal of opioids from the environment is going to be really important. But also the removal of other things like alcohol and benzodiazepines are also going to be really important because opioids potentiate other depressant sedative type substances and it can be deadly really, really fast. So it is vital to survey the environment. It's vital to survey the environment for people, places and things that could trigger emotional or substance relapse for that person. It's also vital to add to the environment things that will support recovery. What do they need? Do they need somebody calling and checking in on them? Do they need a case manager to check in on them once a day? What is it that they need added to their environment to help them feel safer and more confident and be able to follow through on their recovery plan and relationally or interpersonally Making sure that people on medication assisted therapy have adequate communication skills just like anyone else in substance abuse or mental health treatment, but also making sure that they have people in their life, a support system that understands what medication assisted therapy is. It's not substituting one drug for another, how it's beneficial, what the long term treatment plan is and how they can support the person in recovery. That's all going to be super important. Switching gears a little bit here, older adults attitudes towards depression. This came out in the Medscape newsletter, so. And the rest of these things did. So I figured I'd share them with you just because, you know, it's up and coming breaking news, sort of a lot of this doesn't seem like it's all that much new news, but it was put out recently. Older adults attitudes toward depression, they tend to prefer self management strategies. Now older adults they are defining as 65 and above in this particular study and it was done recently. So you still have people that are, you know, a little bit younger than my mother to, you know, the age of my, my stepfather and my grandparents that they were assessing. You want to think about the culture that they grew up in. When we get to be 65, 75, this may look very different because we're going to be used to communicating via zoom, Skype, web meeting text, those sorts of things. So that may not be off putting to us, but for right now, older adults prefer self management strategies such as socializing with others in their age group and prayer. We want to make sure that if we're working with older adults that we are able to connect them with the area Agency on Aging, I think that's what it's called. And any drop in places that people can go that are geared towards elder care during the day, that socialization connection with other people who are going through similar things is very important. Their experience, they all are experiencing at different levels of cognitive decline, different issues with physical decline. I remember when I was little I used to go to lunch with my grandmother and I never understood why we would get together with this group of like 15 ladies and the entire lunch they would talk about, you know, different health problems they were having. And I never understood that as an eight year old, why they wanted to talk about their health conditions. But in retrospectively I realized they were supporting one another and they were receiving validation and empathy and people were saying, oh yeah, you know, bladder control, I'm there, been there. So they didn't feel so all alone. So they were getting support and input from one another. And that is really important however it takes place. Professional interventions are sometimes considered as necessary for more severe depression, but participants typically have mixed views. And I can tell you, with my grandmother, for example, she was very adamant that she did not want to take Xanax. The doctor had prescribed her Xanax and she was adamant she didn't want to take it at 85 years old for her anxiety because she didn't want to get addicted. She had heard that you could get addicted to Xanax and she just wasn't going to go there. It would was important to educate her about Xanax and, you know, if she's using it once, once a day or something, that she's not going to get addicted to it in order for her to feel safe enough to take it. A lot of older adults also see a huge stigma associated with taking medication. We do need to be sensitive to that and, you know, destigmatize it as much as possible, but also respect the their wishes. Willingness to try treatments in this population is based on perceptions about potential harm. Again, think of my grandma. She was afraid she would become addicted and that was the last thing she wanted. And it's also based on attitudes of trust, familiarity and past experiences. My grandfather had been prescribed Valium and he had been prescribed it on a regular, pretty regular basis. Benzodiazepines, typically in the elder population, have a lot of side effects, such as increased falls, increased problems with cognition, and in some cases, especially at higher doses, it clears the liver a lot more slowly in older adults. So it can lead to, it can become toxic in the system at a certain point. And that's what happened to my grandfather, which was another reason grandma didn't want to take the Xanax. She was afraid that she would end up in the hospital like my grandfather did. Older adults react differently to medications, all the medications, not just psychotropics, based on the ability of their liver to clear the medications, they can build up faster and based on the other medications that they're taking, because a lot of older Adults are also on cholesterol or blood pressure medications or, or something else. It is imperative that older adults work with a physician and, or a psychiatrist, anyone who's prescribing medications that is specially trained in geriatric medicine. And as I mentioned earlier, societal and cultural factors can also impact people's willingness to seek help from a professional or to acknowledge that they have depression. In some cultures, mental illness is still seen as very shameful for the family. And nobody in the culture, let alone an older adult, is going to want to bring that shame on their family by admit admitting or asking for help for a mental health issue. We need to do as much as we can to put information about prevention and self help treatments and, you know, options that are out there, make that publicly available so people don't feel as stuck with their current condition. They feel like they can start doing something. We also want to educate about the prevalence and do a much better job about educating about the prevalence of many of these disorders so people can see that they're not alone and providing culturally sensitive and culturally responsive treatment options. So for those people in cultures that, that feel that mental illness would bring shame or stigma to their family, working with representatives from people from that culture to identify, okay, you don't want to walk into a community mental health center and be seen in the lobby and, you know, be outed, so what kind of services or how can we provide services to you in a way that is acceptable and meaningful? Sometimes that means working with faith leaders in that, in that culture and serving sort of as a consultant with the faith leader in order to encourage participation. Ask the people that are representative of the culture. Don't assume, you know, what the best intervention is going to be. Another interesting article came out and this isn't another one that's very new again is about diet and dementia risk. The Mediterranean diet, which emphasizes high intake of plant foods and low consumption of meat and dairy, among other factors, is associated with a lower risk for cognitive impairment and Alzheimer's disease. Similarly, the Mediterranean or dash, Intervention for Neurogenesis, Neurodegenerative delay or the MIND diet promotes intakes of berries, green leafy vegetables and other plant based foods, limiting consumption of saturated fat and animal foods. So the, the mind, the DASH and the Mediterranean diets are all very similar in that they reduce the consumption of saturated fats and animal foods and focus a lot on fruits and vegetables and berries and those sorts of things. It's important to know and you know, obviously as mental health clinicians, we are not going to, you know, give a nutritional prescription to anybody. But it is important to know that these are recommendations that are out there and if you have a client who is at risk for dementia, to encourage them to talk about their diet with their doctor. An additional interesting point that did come out of this article was the fact that they found that how foods are consumed, not only the quantity, may be important for dementia prevention. So if you are eating vegetables that are cooked till they're mushy and gray, they are not going to have the same health protective benefits as something that is lightly steamed or stir fried. Or if you're eating something that is cooked in, you know, fried in saturated fat, you're not going to get the same health benefits as something that is lightly sauteed in olive oil, for example. So there's a lot to know and that's where registered dietitians can be so helpful. But there are strong connections between diet and nutrient intake and dementia prevention. All right. We couldn't get through something without talking about COVID right now. I'm sorry. So we're going to hit that real quick. In a commentary published online April 21st in Lancet Psychiatry, members of the International COVID 19 Suicide Prevention Research collaboration warn that suicide rates are likely to rise as the pandemic spreads. Well, no joke. Several potential public health responses to mitigate suicide risk associated with COVID 19 include clear pathways for those who are suicidal. We need to make sure that people who are feeling like they're in crisis know what to do. Because right now we're being told, don't go to the hospital. You know, 911 might be overwhelmed, don't do this, don't do that. Or well, they're like, well, what do I do? There are national crisis hotline numbers. People can still go to the emergency room if they are feeling like they're a threat to themselves or others. Psych wards are still open and they can accept people who need 24 hour monitoring. We need to make sure that there are clear paths for those people. Remote or digital assessments for patients currently under the care of a mental health professional need to be more available. I a lot of people are resistant to doing assessments virtually. However, at this point, since people are really not wanting to go see someone face to face, it is better to get them in treatment if they are in crisis than to say, no, you gotta wait because I'm not doing assessment until I can see you in person, do a video based assessment. You're not gonna get everything, but you are going to get the lion's share of Non verbals. You're going to hear their voice, you're going to get their responses. We need to have increased support from mental health helplines and I just published on my YouTube a variety of different support groups that are free and available to the public, ranging from OCD support groups to addiction to chronic pain that are available for people right now. They can access them through, you know, zoom meetings or video based meetings and get the support they need. They don't have to be suffering in isolation. We need to provide easily accessible grief counseling for, for those who have lost a loved one to the virus. Unfortunately, that was the one glaring opening that I did not find resources for. There are a few places that offer like forums or discussion boards or email support, but there were no live groups like chat groups or video based support groups for people who are struggling with grief right now. And there's a lot of people grieving a lot of different things. Not just the loss of a loved one, but a loss of their way of life, a loss of, you know, I heard from one guy the other day who had worked for 39 years, he was retired, he'd been retired for like four years and all of a sudden his retirement is cut by a third and he's going to have to go back to work. And he's devastated because he never imagined that he would have to do that at his age. So there are a lot of different things that people are grieving. We need to ensure that there are financial safety nets and labor market programs, make sure people know where they can go to try to find jobs. Sometimes you have to look online for remote work opportunities. Sometimes people will have to accept jobs that they don't really love, but it will pay the bills for right now until their job opens up. There are, there are options out there. There are companies that are hiring. I was talking to somebody at, who works at Home Depot the other day and he was saying that Home Depot in Georgia is just hopping, you know, it did. It actually seemed to have increased business. I can understand not wanting to work at Home Depot your whole life. If you were, you know, had a different type of job before that and you know, that would be a significant pay cut to what you used to make. However, it may still be more than you're making on unemployment. So encouraging people to be creative with how can I support my family right now? Some people have turned to making masks and selling them online, on Etsy, on ebay. And that has made them a nice little income because it doesn't take very long to make Masks. If you know the basics of using a sewing machine and you have even old clothes, you can turn, you know, old jeans and stuff into very nice little masks for people. We also need to have dissemination of evidence based online interventions which means making sure that professionals and, and paraprofessionals know what to expect, know about the unique issues that people are grieving, the unique complex grief conditions that people are experiencing as a result of COVID the unique anxiety issues that people are experiencing. I have a very dear friend who has obsessive compulsive disorder and she is a self proclaimed germaphobe and she is terrified, literally paralyzed, terrified to leave her house right now because she's so afraid of picking up a germ. And we need to work with people on sleep enhancement. As sleep gets wonky, suicide rate goes up. People who have sleep disruption or sleep disorders are much more likely to commit suicide. And people who are awake between the hours, according to this article, between the hours of midnight and 6am are more likely to effectively complete suicide. They feel hopeless and helpless between 12 midnight and 6am there's less of a chance that people are going to find them in time in order to get them to the hospital. So there are a lot of factors that we need to consider. But, but helping people improve their sleep quality not only will help modulate their HPA axis and help improve their neurotransmitter balance, but it will also help them be awake when everybody else is awake and be asleep when everybody else is asleep. So they have a better chance of being able to access help when they need it. COVID 19 also impacts the nervous system and this article was a little bit Chicken little sky is falling. But I did want to point out that there is some evidence that we need to be aware of as clinicians that in 13 to 15% of people with COVID 19 there are certain neurologic symptoms. Some of them go away as soon as the virus is gone, others not so much. Injury they are hypothesizing may result from an excessive immune response. And we know with people with COVID 19 their lungs are having a super immune response and there's a lot of inflammation in the lungs, but they're also finding that something called a cytokine storm is happening when their temperature goes up when the virus is in their body. Their body reacts so extremely to this virus and causes widespread systemic inflammation that can cross the blood brain barrier, which we know is associated with increased rates of clinical depression. But we also are seeing, or they also are seeing that in Some people, after they're recovered from COVID 19, there is some still a heightened or excessive immune response that presents in the form of various autoimmune disorders. So we may see an upsurgence of people with autoimmune issues who have had severe COVID 19. We do need to be aware of this in diagnosis because there is a strong relationship between the exacerbation of autoimmune disorders and the exacerbation of mental health, mood and addictive disorders. They, you know, when one gets worse, the other gets worse. So we do need to be aware of those and really start screening more for any symptoms or signs of autoimmune dysfunction. Well, that's all I had for current research. I see that we've had several people join us, and I appreciate that. Yes, the sunshine is supposed to be returning. I know in, in Tennessee, or at least in middle Tennessee, we ain't going to get it today. But that is super helpful for people, encouraging them. If you're working from home, you know, I get it. I've worked from home before, and I find it extremely challenging to separate work from relaxation. When you're working from home, creating a space where you work and a space where you relax is going to be really important. Setting some sort of routine that demarcs or demarcates work from relaxation. For me, when I was working, I would actually have on my work clothes, and when it was time to relax, I would turn change into my, into my lounging clothes, my fuzzies or whatever I was going to be wearing. That would help me separate so I could turn my mind off a little bit. And that's important for people. But I've also got several clients right now who are working from home that are getting up in the morning, you know, they're drinking their coffee, whatever, they're starting work, they're working all day inside, you know, in medium to moderate light or, or lower, and then going to bed. And they're never getting outside into the sunshine. With parks being closed and everything, a lot of people have not wanted to or not even thought about just going outside for the heck of it. It is so important to get that sunshine to set, set your circadian rhythms. A lot of us are going to be thrilled when the gym opens again. Even if we were working out from home, getting back into our routine and seeing the people, that's like. My main source of socialization is at the gym because I work by myself and, you know, I live on a farm, so we don't have neighbors very close. So that's where I see most people and I'm really looking forward to getting back into, into the groove again. And public places are also supposed to be opening again soon. So we should start seeing a little bit of return to what we considered normal before, which will help. They've found repeatedly in studies of, of people exposed to trauma and this is has been traumatic, that the sooner you get back to your normal routine, whatever's normal routine for you, the less of an impact that that trauma will have. So after a hurricane or a tornado or a pandemic, the sooner you get back to your routine, the more likely it is that you will not have significant mental health complications. Now, we've all been, you know, distanced for quite a while from what our normal routine is. So the expectation is that there are going to be a lot of people struggling for a while with this and we need to be sensitive to that. Are there any questions? Is there anything else? Like I said in, in today's presentation, I was trying to answer questions that I have gotten over the past couple of weeks and, and providing you with some resources to answer those questions. Is there anything else I can do to be of help or service today? It. Alrighty if there are no other questions. I know this was kind of a mishmash of things, so, you know, I appreciate you being tolerant of that. I usually like to have a theme, but today's theme was really, you know, commonly, commonly asked questions. I do love hearing from you guys and I will put it over here. If you have topics or questions that you want me to answer and you want me to do research on instead of just kind of pulling it out of thin air during these presentations, please feel free to email me at support all ceus.com and I will happily do the research for you. I actually really enjoy spending time in PubMed for some unknown strange reason. Everybody have a fabulous weekend and I will see you next Saturday.