JO’S JOURNEY: A Personal Story of Healing From Fear & Anxiety

Sahil Ahuga and Dr. Warren Bell Interview Transcript

You can download a pdf of the transcript here. The entire transcript is also found below:

RICK  0:10

Welcome to the Heads Up Community Mental Health podcast. Join our host Jo de Vries with the Fresh Outlook Foundation, as she combines science with storytelling to explore a variety of mental health issues with people from all walks of life. Stay tuned.

JO  0:32

Hey, Jo here. Thanks for joining me and my two special guests as we delve into my own story of healing from anxiety attacks that started when I was 12 years old. Now 67, and after multiple rounds of medication, the latest one lasting almost 20 years, I'm in the process of seeking freedom from fear and anxiety with help from two medical professionals. The first is Dr. Warren Bell, a GP who also practices psychotherapy in Salmon Arm, BC. He's guiding me along a path of discovery to find the root causes of my disorder. Hi, Warren.

Warren  1:12

Hi, Jo, I'm delighted to be here. And I just like to say that the fact that you are sharing your story in this public way is an act of courage on the one hand, but it's also something that I think will lead to many other people who listen to this podcast, understanding your dilemma and the trials you've been through, and also be grateful for the fact that you have shared this very personal voyage that you've been on.

JO  1:41

The other vital member of my team is pharmacist Sahil Ahuja, who's advising me on how to safely taper off two medications. Welcome Sahil.

SAHIL  1:52

Hi Jo. Thank you for having me. Likewise, very grateful to have this opportunity, and appreciative that you're willing to share your story. We talk a lot about decreasing stigma around these concerns. I think this will be beneficial to a lot of people.

JO  2:07

I can't tell you how grateful I am to have you both on my side and here today for the podcast. Two things before we get started. First, a big thank you to our sponsors for this episode, the Social Planning and Research Council of BC, Emil Anderson Construction, WorkSafeBC and AECOM Engineering. And second, please note that I'm sharing my story for informational purposes only. This is very important. If you're experiencing mental health challenges or want to taper off medication, please seek advice from your doctor and/or mental health professional.

Okay, so imagine you're lying down tied to a railway track. You start to feel vibrations in the ties and a hum on the rails that can mean only one thing, a coming train. As it rounds the corner, you hear the whistle scream warning you to jump or else, but you can't. As the scenario unfolds, your breathing shallows while your heart rate spikes. You feel increasingly weak, dizzy, sweaty, and/or nauseated. You quickly move from feeling agitated to being terrified you'll die, and then maybe even wishing you would so the overwhelming physical and emotional sensations would stop.

After what could be minutes or hours, the train roars over you, the danger seemingly past, but in its place comes the fear of what will happen next time you're tied to a track, or more likely must give a speech, or take an exam, or feel uncomfortable, insecure, or unworthy. That's anxiety's gift that keeps on giving. The continual fear of fear itself.

My panic attacks started when I entered puberty when my hormones raged for the first time. My second bout was triggered again by a hormonal imbalance after the birth of my first daughter. That time it was more serious and involved depression as well. To make a long story short, I started thinking, what if I hurt my daughter and then spiraled into terror so visceral, I couldn't be alone for fear I'd go crazy and do the unthinkable. I was trapped in a vicious cycle. Feeling depressed made me more anxious and feeling anxious worsened the depression.

My father who was a doctor said I was experiencing postpartum depression and prescribed an antidepressant. I also saw a psychiatrist who said that with the medication, I would recover. That's how it was done in 1983. No mention of lifestyle changes, counseling, or other potential treatments. The pills worked, so I took them until after my second daughter was born, too afraid to again face postpartum symptoms.

When life settled down and my marriage and career seemed stable, I weaned off the medication and managed well for a number of years. My next experience with paralyzing fear came at the end of my first marriage, emotions were high, my anxiety levels were higher. Again, I was prescribed medication, this time by my GP. I did get counseling, but unfortunately, the counselor decided my husband was a jerk, and that I'd be better off without him. So I concluded the anxiety was situational, and didn't see the need for further counseling to get to its root causes.

Fast forward to the beginning of my second marriage. I'm feeling good and decided to taper off medication again, which was fine until I accepted a job that turned into the worst experience of my working life. Eighteen months later, just after I resigned, I descended into what can only be described as hell on Earth. I lived in the emotional storm of an acute, unending, anxiety attack for three days. I couldn't think, I couldn't eat or drink without vomiting. I couldn't be alone for fear I would die. And at times, I wished I would because I didn't think I could stand another minute.

I was prescribed three medications in large doses. A benzodiazepine for sleep, an antidepressant, and an antipsychotic, which is sometimes used to treat anxiety and depression when just the antidepressant isn't enough. Well, I don't regret taking the medications as they dulled the anxiety and lifted the depression to manageable levels. They did make me look and feel somewhat like a zombie for a number of months.

With that first stage of recovery under my belt, I started thinking again about tapering off my medications. Like many other people who take them, I thought I was weak and wanted to prove to myself that I wasn't. First, I tapered off the sleeping pill. Then I significantly reduced the antipsychotic but decided to stay on the same dose of antidepressant, and there I sat for almost 20 years. In the early years, I tried a few times to wean off the antidepressant, but always experienced low-level anxiety and other minor side effects such as disturbing dreams. Mainly though, I was still afraid of being afraid, not wanting to look inside to find what was hiding there.

Fast forward again to a little more than a year ago when I was 65. I must have been ready for a change of perspective, because a transformational book came across my desk while I was researching a Heads Up podcast about depression. It's called Lost Connections, Uncovering the Real Causes of Depression, and the Unexpected Solutions. It's by John Hari, an award-winning journalist and best selling author who has an experience of depression that he weaves throughout his book.

Hari's book made me look at my situation differently through a lens of evidence-based findings, on the effectiveness of medication for depression and/or anxiety. And it made me question the medical system's long-standing pharmaceutical approach to symptom management, and the crutch it had perhaps become for me. So with input from Warren and Sahil, I developed a plan for tapering off the medications. I felt ready given that my life is now vastly different than it was 20 years ago, and that I'm truly invested in optimizing my physical, mental, emotional, and spiritual health.

The three of us agreed that tapering off should be done very slowly. Given that I'd been on hefty doses for almost two decades. And because I'd had side effects when I last tried to cut down. You'll learn more about this from Warren and Sahil a little later.

Starting last spring, I cut my antipsychotic medication over several months by almost 90 percent. It surprised me that I experienced no anxiety during that time, and it thrilled me that I felt increasingly more energetic and alive as the doses dropped. I delayed tapering down from the antidepressant until this spring, given that winter can be a challenging time for me.

In April, I reduced the dose of my antidepressant a small amount. As with previous tapering attempts, I felt stirrings of anxiety and had vivid, sometimes disturbing dreams. But I persisted and that past. A week or so ago, I tapered down again, and I'll stay on that dose for a month or so before deciding whether to cut down further. That's slower tapering than people typically do. But I'm fine with that. Most importantly, Warren, Sahil, and I agreed that I needed to be realistic about my ability to taper off completely. I've accepted that and we'll take this process one day at a time, watching for symptoms that might be too much for me. I realized I may have to take medication for the rest of my life. And I have no shame or guilt around that. Nor should you if you're on medication that improves your mental health and quality of life.

My journey of finding freedom from fear and anxiety has led me to new places, both within myself and in the world around me. I've embraced proven science while being embraced by compassionate care. I now have feelings that are big, and raw, and real, and so welcome now that I understand they're to be revered, not feared. As Eleanor Roosevelt recommended, I also try to do one thing every day that scares me. Today, it's being vulnerable by sharing my story, which I hope will inspire you to get the help you need.

If you're struggling, start by making an appointment with your doctor and/or a mental health professional. And please check out the resources in the Show Notes page on our website at freshoutlookfoundation.org/podcasts.

Time now to bring in the experts who can add some meat to the bones of my story, and John Hari's book. Let's start with you Sahil. I found you at Two Nice Guys Pharmacy in Kelowna, BC. Great name by the way. My daughter recommended this because of your amazing, personalized service. We met, and you agreed to help me taper off the medications. You also promised to read Hari's book and then share your insights on this podcast. Let's start by you telling us your story, and why you find such meaning in helping people along their healing journeys.

SAHIL  12:31

I'm glad that you've had a good experience. I've never had someone ask me to read a book and be on their podcast. So, it was a neat experience for me as well.

My story, the part that's kind of relevant to the mental health conversation here, is that in undergrad I was in sciences and living at home in Kelowna, going to UBCO. And everything was good. But when I was accepted into pharmacy school, and I had to move to Vancouver and go into this Doctor of Pharmacy Professional program, that's where things started to unravel a little bit, I would say.

When I moved away, it was great. I was living with one of my friends. But in those first couple of months of being away from home and being in a new program and in a new city, I started to feel a lot of discomfort. I remember times when I was studying, and I couldn't focus anymore on the slides in front of me, and I would have to go lie down. Eventually, I got to the point of having a conversation with my doctor, and we realized that I was having panic attacks, which was very foreign to me. And the identity that I had for myself of being this high achieving person who just is able to do anything and everything, and to have that, quote unquote, what I felt as a setback was tough to process.

And I wasn't able to really get a handle on the anxiety in those first few months, then kind of depression was becoming a part of that as well. And they are sometimes related but also very distinct things, and I felt the distinctions there. I eventually started on medications, and I found them to be very helpful. I remember in those first few months of being on fluoxetine that I felt that if everyone was taking this medication, that there would be less crime in the world, everyone be happier. It was amazing.

But as in the book, I had a similar experience as the author where that effect faded, and then we would increase the dose I would feel well, and the effect would fade. And that cycle continued whether with new medications or new doses for a few years.

And then near the end of pharmacy school, I was getting tired of it. And I tapered myself off the medications and it took probably a year after that for me to feel like okay, I'm actually through this phase of anxiety and depression. It was interesting for me because I subscribed very heavily to the chemical imbalance narrative, in part because I had everything else going for me in life. I had amazing support systems in my family and friends. Even though I had left my family, they were still very supportive. And I had friends there. I had a great career ahead of me with meaningful work. It didn't make sense to me. And that was one of the most frustrating parts of like, why am I feeling this way.

So, the chemical imbalance narrative really helped, to be like hey, it is out of your control, but kind of working through it and getting through it. I think it was the purposelessness that really got me and meaning to life that got me, and I found it in social connections, I found it in really savoring the moments that I have with friends. Meaningful conversations like this one, when you're 40 minutes into a cup of coffee with someone, I find so much meaning and joy in those moments, and I soak in that joy. And I would say it's still a work in progress. And not every day is a great day. But I definitely have much more joy in my life. I have more good days than bad days, and the bad days aren't as bad anymore.

JO  16:00

Thank you so much for being vulnerable and laying that out for us. And I agree your story too will help other people. How has your experience impacted in a positive way your ability to help your clients who are experiencing mental health challenges?

SAHIL  16:17

I think my experience gives me an insight into what the human in front of me is experiencing. I understand how difficult it is to even get to the point of standing at the pharmacy counter. There are so many pieces in between one of just recognizing and understanding what's happening that took me a bit of time, then being willing to address that concern and eventually talking to a physician or whichever healthcare provider getting to the point of like, okay, I have this prescription in my hand, am I going to go fill it?

Okay, I go drop it off at the pharmacy counter, am I gonna go back? There's so many points there, where things could fall off or the mind could change. So when that person is in front of me, I have a sense of like, okay, it was not easy to get here. And I want to make sure that I can hopefully make it a bit easier moving forward.

JO  17:13

Sahil, before meeting you, my interactions with pharmacists had been what I call clinical, which I guess is fair. But the training you received is changing that. Tell us more.

SAHIL  17:26

I graduated in 2019 from UBCs PharmD program, and it is very patient-centered care. We are not just looking at the condition and throwing a medication at it. We're looking at the human that's in front of us and saying okay, this condition is part of what's going on. But let's look at everything else that's going on. And as a pharmacist, our training, the first thing we even think about is, is a medication even necessary, is it even the best treatment?

For example, in school, we were being assessed when we were counseling a medication to a patient. We had to give three or four non-medication ways, non-drug measures to help address any particular concern, whether its mental health related or blood pressure or cholesterol. Those non-pharm measures or non-drug measures are very important, and the first line of therapy, frankly, in the majority of conditions. If those don't work, then we look at medication.

JO  18:22

When you say patient-centered or personalized care, what does that mean?

SAHIL  18:28

It's about assessing what's important to them and what their values are, depending on whether they're in school, what their age is, what their priorities are. It can help us guide the antidepressant we choose, for example, because depending on their side effect profiles, some side effects, for example weight gain, may be acceptable to some and not acceptable to others. So that's where the personalized approach comes in of, okay, let me learn about this person, what's important to them. And then we can make more informed decisions together and give them the appropriate information.

JO  19:02

When you speak to your clients first about taking antidepressants, what do you tell them?

SAHIL  19:07

Sometimes the majority of the times the benefits aren't immediate. And that's really frustrating when you're living through anxiety and depression. You're feeling unwell in all these ways to hear that, hey, I'm gonna have to stick through this for another 246 weeks before I really feel better. So that's one thing, it is a bit of a process. And also, the first one may not be the right one.

We have a lot of options. We have a lot of medications that work in different ways that have different side effect profiles. So we can hopefully over time find the right one. And the things that probably do work more immediately are those non-drug measures, whether it's starting to look at CBT, and there's a lot of free CBT resources out there, whether it's from Anxiety Canada or MindHealthBC?

Maybe the first line of therapy is being more mindful about hanging out with your friends, which is really difficult to do when you're living through it. But if there's a way that you can go for that cup of coffee and feel a little bit better, or go for that walk in nature and feel that sense of calm, those things might be more immediately soothing, and that will give the medication some time to kick in.

JO  20:18

What about the primary potential side effects?

SAHIL  20:24

There's a whole host of things depending on the medication that you take. So to say main potential side effects is a little bit tricky. And everything's in context as well. So I always hesitate from saying things broadly. But I will say some of the big things to watch out for is that, especially in younger patients, there is an increased risk of self-harm. And that's something that is top of mind for me. So when I am talking to my patients I, especially younger patients, I'd like to mention this is something that we've got to watch out for.

There's regular things like nausea, and dizziness, and all of these things that usually, we can help mitigate or get better as the weeks go on. Certain ones might have a higher risk of sexual dysfunction, for example, others have very limited risk of that. Some have a little bit of risk of weight gain, and others are less. Some cause trouble sleeping, some help more with sleeping. That's why the personalization part is really important.

If I have a patient who has insomnia with depression, then we want something that causes drowsiness, depending on if that's what they want. If we have somebody that they are unable to get out of bed at all, they're sleeping 12 plus hours a day or whatever, and I was on that side I would sleep all day long, we want something that might have energized them a little bit more, a little bit more activating. Side effects are also tricky term because sometimes that effect is something we want to happen. So it's very personalized and patient specific.

JO  21:51

What about side effects associated with tapering off, and your tips for minimizing these?

SAHIL  21:58

What I've seen in my short career so far practicing for a couple years is we really want to take it slow; we want to go over weeks or months. And that will help minimize the withdrawal symptoms. So it can be some of the things that patients experienced in the beginning, maybe some dizziness, or the strange one to me that I wouldn't think about is flu like symptoms. People can actually feel unwell in that way. There can be some irritability, appetite affects, sleep changes. You might even feel that irritability or depression coming back, but sometimes it's temporary, right? It's just the body getting used to not having the medication. And it's not necessarily that the depression is actually coming back.

The other one that I hear patients talk about sometimes even if they miss a dose or two, is brains zaps or just that abnormal sensation there. These are the things to look out for. And if they're happening, this is how we can manage it or just even knowing that something can happen, helps mitigate the surprise of when it happens and makes it less scary in that way.

JO  22:59

Thanks Sahil. That's great info and will really help me by the way, which brings us to our next guest, Dr. Warren Bell and his decades-long practice of combining medical and pharmaceutical knowledge with psychotherapy and downhome compassion. Just building on what Sahil was explaining to us, what do you see in the way of side effects or symptoms of people tapering off of these medications?

Warren  23:29

The principle that Sahil referred to, which is to do it slowly, is probably more important than any other principle with respect to withdrawing or tapering off medication of this nature, psychotropic drugs. People experience a variety of symptoms when they start to reduce medication, including symptoms that are very similar to the ones that they experienced before they began to take them. These are withdrawal symptoms, but they seem to be very similar to what they experienced prior to starting medication.

And as a consequence, there's a sense that maybe their condition that led to them taking medication has recurred. But it's actually a withdrawal process. And the best way to deal with it is to do it very slowly. I've had people who were withdrawn off medication in six weeks by one of my psychiatric colleagues, experience a terrible withdrawal pattern. And when I was involved with repeating it, because they cut back on the medication, we changed it from a six-week withdrawal to a two year withdrawal, and it was effortless.

JO  24:36

I'd like to build on Sahil's insights about patient-centered care. You and I have talked about your practice of getting to know people in the round, versus using only biomedical measures for treatment. Why don't you share your story of integrating treatment modalities and how it's helped your patients with mental health challenges?

Warren  25:00

My background prior to medicine was not pure sciences. My background was actually, believe it or not, music and creative writing. So I had a sort of artsy kind of perspective on life. So when I came to medicine, it was with a very different perspective from many of my fellow students. I understood science, but it wasn't the only thing that I had studied. As I went through medical school, I found the narrow approach on biomedical matters and physical health issues, to be challenging, because I was only too aware of my own psychological responses.

So early on in my training program, one of my preceptors, who was the head of psychiatry at McGill, noticed that I had a bit of an aptitude for exploring the psychological experiences that people were having. And that led to learning about different kinds of approach to therapeutic interventions in that area. And I eventually fastened on a procedure, or a process, or an approach called short-term anxiety provoking psychotherapy, which at the time, short-term meant 12 to 15 visits as opposed to two years of weekly visits that psychoanalysis was focused around. So it was shorter term, but it was still longer term than what is commonly done with psychiatrists these days.

And after I had graduated, I worked in a psychiatric outpatient clinic for a year, and I also engaged in palliative care. Much of it is intensely psychologically oriented. When I came back to BC and began practicing in the small town of Salmon Arm, I just felt the need for a variety of reasons to explore other modalities. And I embarked on what amounted to a 20- 25-year process of learning about every kind of therapeutic opportunity that there is ranging from physical interventions like manual therapies, massage, cranial-sacral therapy, chiropractic, and of course physiotherapy, one of the standards, and osteopathy, and then also mind approaches.

Sahil mentioned CBT, which is a fairly formulaic form of psychological intervention, but it's been used and has been validated as having some value. But then there's other things like yoga and meditation and mindfulness. And side-by-side with them was the process that I was bringing into my practice, which is insight-oriented therapy, where you spend a long time asking challenging questions and essentially, having patient hear themselves say things that they haven't said before, and understanding things inside their own consciousness that are new, and developing insights.

That way, it's not a system where I give people advice. It's a system where I probe, and their responses end up being their therapy. And I've done it now for over 45 years. So it's been a central part of what I do, because once you explore people's minds, you find out what they are like, as you said, in the round. You find out more of the totality of their life experiences, not just the disease, or the condition, or the injury that they present with. So it inevitably makes you think holistically when you approach anybody.

JO  28:42

During my psychotherapy sessions, we talk about many things including the mental health impacts of my upbringing, my Type A personality, my perfectionism, and so on. But my biggest takeaway was the realization that I bottled up what I thought were negative emotions for decades, only acknowledging and sharing the positive side of myself. Warren, you along with Brene Brown taught me to sit with my not so nice feelings, to really feel them, and then to identify them, process them, and maybe most importantly, learn from them.

I'll give you a simple example of that. About six months ago, I was cleaning out my kitchen cupboards, and I came across a set of china that I had inherited when my Mom passed away. And it brought back wonderful memories of Easter dinners, and Thanksgiving and Christmas dinners and us all around the tables. And my mom loved those occasions. She loved her crystal, she loved her china, and her cutlery, and everything was set so beautifully, and she was so proud. And I decided that I really didn't have room for this china anymore. So I called my sister and I said, you have a lot more room, would you like this china? And she said, sure.

I went downstairs, got some boxes, brought them up, and I started packing away this china. And I started feeling increasingly more sad, to the point where I started crying, which is really unusual for me because I'm not a crier. And I just felt worse and worse and worse. And so I went and lay down. And I started thinking about the china and what it meant to me and came to the conclusion that I didn't want to give it away. I really needed to keep this as a connection to my mother. So I packed up the china and I put it in this very special place, and decided that I'm going to use it on occasion, even if it's not a special occasion.

So that, for me, was a cathartic experience of feeling something, identifying what it is, processing it, and then responding in a way that met my emotional needs. It has really played a remarkable role in my healing. I've said all that to ask this question. Warren, in the patients you've seen over the years who are experiencing anxiety or depression, what role do you see unprocessed negative emotions playing?

Warren  31:34

They play a central role, because they embody things that are unresolved in one's own life experience. There is a social pressure on all of us to hold back expression of any kind of negativity. If you meet somebody in the street and they say, hi how are you, you don't say, well actually I'm having a really bad day, and let me tell you about it. Partly because we know that the chance of them stopping and paying attention to those remarks will be very limited, they might be frightened away. But also, it seems like exposing ourselves to having other people see the vulnerability in us. And so it's quite natural, at a social level in many social situations to suppress the expression of negative feelings, fear, anger, frustration, terror, all experiences which we define as negative.

What they are, of course, is responses of our central nervous system to things that are troubling to us, that disrupt our lives, or that appear to threaten our security. When you do that, and those experiences come to the surface, as you described in the story about your mother's china, you often will experience an emotional reaction that takes you by surprise. And if it's the wrong kind of setting, for example, there's a bunch of people looking at you and you're on stage, and you happen to open your mother's china there, you would be under intense emotional pressure internally, to not start to weep on stage. Now, if it was a psychotherapeutic group therapy session, you wouldn't have that same feeling. But if you're on stage, and it's a public performance, you would feel horrified at the fact that you were losing emotional grip on yourself. So setting has a lot to do with it.

And often in our early years, we have settings where we are discouraged from expressing our true reactions to things. A parent who tried to be helpful says, "Don't make so much noise in this room, keep quiet." You don't know why they want you to do it, but they tell you to do it. And you want to make a big noise, you feel full of exuberant energy, and you can't do it. And so you learn to put those feelings and that expression away. And then you get into a situation where you start to cheer at a sports event and suddenly you are feeling giddy, you feeling strange and kind of uncomfortable, and maybe a little anxious, like I'm being too exuberant. I'm expressing my feelings too vigorously.

So what the negative emotions that are suppressed or unprocessed do is they influence a lot of our day-to-day behavior. But much of that behavior as an experience is of feeling anxious, or in this case that you just described, you feel sad, but they are highly legitimate emotional responses that are present in us when we're first born. And so to suppress them tends to be kind of unhealthy. It's not so much that you express them anywhere. You find out where it's appropriate to express them as you grow older, but you don't get rid of them. That's the key I think.

SAHIL  34:38

I'm going to jump in here just to add a little bit more of my story and how I think processing those emotions helped out. When I originally had my symptoms, I felt defective in a sense. It's interesting how you would never think that of somebody else but when it's yourself, there's more harsh judgment, something that I have worked through thankfully. But I went on a self-improvement binge. And in doing so, I think developed a little bit more EQ, emotional intelligence, and self-awareness. With that self-awareness, I noticed and was actually able to see those negative emotions, sit with them, and process them in ways that you two have mentioned. So I think it's extremely important to get to that point where you can recognize and deal with what's happening.

JO  35:23

What about the role of chronic stress and depression and anxiety?

Warren  35:29

Chronic stress is usually the result of a habit. We live by habits, our lives are guided by habits, habits are shorthand ways of dealing with events that occur over and over again in our lives, and that we have to develop a sort of patterned response to. If there are patterned responses to all or most expressions of a certain part of our own inner world that is valuable and important to us, then it produces a chronic state of feeling anxious, depressed, or just out of sorts. Because we're putting aside a part of ourselves on a day-to-day basis. And the habit of putting that part of ourselves aside, has been so firmly entrenched in our vocabulary, our emotional vocabulary, that we never think about it when somebody says, are you scared, you say, oh no, even though we could be terrified, because we don't allow ourselves to think that we're terrified. Because if we thought we were terrified, we'd start to act like we were terrified. And that would produce the kind of reaction Sahil was just describing, doing things that you feel uncomfortable, that make you look more vulnerable.

But in fact, as we become more integrated, our personalities become more integrated, and the different parts of ourselves get to know each other better, then stress levels tend to go down markedly. That's one of the reasons why insight-oriented psychotherapy can be so useful, because at the end of the road, you have an understanding of why you get agitated in certain situations, and not in others.

SAHIL  37:04

So just to add to that chronic stress piece, it was stressful to be in a new city and learning how to fend for myself in that way. And the pace of professional school is very different from undergrad. It's hard to keep afloat in those settings sometimes. So I do think that chronic, ongoing feeling of drowning and rat race sometimes, I felt that even in my career, I think that does add to the situation.

JO  37:30

For personal reasons, I'm interested in the link between genetics and anxiety and depression, as there's a history of those in my family. My dad experienced anxiety and depression. My paternal grandfather was hospitalized because of mental health challenges. And my maternal grandmother took her life by suicide when my mom was just eight years old. I also wonder about the impact of trauma and have tried to unearth the traumatic event in my past that might have triggered my challenges. Warren what can you tell us about that?

Warren  38:06

Trauma is something that depends very much on the context in which a particular behavior occurs. And the trauma is not always explosive, violent, and deeply disruptive. Sometimes trauma can be the lack of a response to a certain behavior on our part as children. The adverse childhood experience body of research is often shortened to ACE, A C E, began in 1988. But it's research that really explores something that's deeply rooted in human experience. And that is that if things go really bad when you're young and vulnerable, then it can shape your response to the future quite dramatically. If somebody has a father who's an alcoholic, the father may never be violent or aggressive or invasive into that child's life, but they may be absent, they may be sort of non-existent, the parenting role could be almost completely removed because of a preoccupation with the state of consumption of alcohol. Sometimes parents are away a lot, they're absent.

So trauma takes different forms. I think it's generally recognized that an accumulation of extremely disruptive events, things like a parent going to jail, things like the death of a parent, things like physical, mental, social, and sexual abuse. All of these really invasive, intensely disruptive forms of trauma clearly shake, sometimes shatter the sense of personality, self-esteem, self-trust, trust in others, and that can have impacts throughout a person's life. There's quite strong evidence that if you accumulate a certain number of traumatic experiences in your early years, it will have a permanent effect on your development as a human being.

That said, you mentioned the genetic component of mental distress and mental difficulties. There is some degree of that, but with most genetic components, they offer about five, maybe 10 percent of the reason why things happen. What you may have genetically is a tendency, but not necessarily a condition. And so you might be more susceptible to certain kinds of inputs. But it's not that you're going to go ahead and behave in a certain way because of your genes overwhelming your judgment.

JO  40:49

Warren, you've been doing this for decades. Have the levels of anxiety and depression increased over the last 10 or 20 years?

Warren  40:59

My observation would be that certain kinds of anxieties have increased. And certain kinds of social and environmental, and I mean environmental in the broadest sense of the term, pressures and disruptions have come into the lives of many, many people around the world. On the broad scale, there is widespread anxiety, and particularly among young people, children ages, say six to 15. Anxiety about their future, on a planet that is increasingly degraded by human activity and the presence of so many of us on the planet. That's a genuine anxiety. And there have been surveys. The BBC did one recently that showed in every country, they analyzed children's responses, they found this kind of anxiety underlying their daily lives. They don't go around talking about it all the time, but if you ask them how they feel, they're very explicit and describe quite disabling, sometimes senses of anxiety.

One of my colleagues who works in an emergency room here, had three young people over a period of some months who had all come to the emergency room because they were either feeling suicidal, or they had made a suicidal attempt, because they were so depressed about the future of human society. They felt that there was no hope for us. And I think the heat dome and the fires during the summer really intensified those anxieties. There are also other stressors like the enormous disparity between the very well to do and the very underprivileged and financially insecure.

So I think there are increased levels of depression and anxiety about those kinds of things. But to be honest, the primary things that bring on anxiety and depression are personal factors, elements, and events, and experiences within a person's own life. That's where those kinds of experiences take place. And I would say, there's probably in this part of the world, more of that going on in communities, and neighborhoods, and individuals to some extent than there are in many other parts of the world where connection and interaction and a sense of community are much more strongly developed. But I would say these broad disruptive impacts are being felt by people all over the world.

JO  43:25

Sahil, what's your observation about mental health over the last couple of years since COVID? I have heard that statistically, mental health has declined over that period. But I've also heard very promising statistics about how many people have taken this as an opportunity, like yourself, to build themselves in a positive way.

SAHIL  43:54

It's hard for me to assess the exact statistics on what's happening. But what I do feel confident saying is, it's a conversation that more people are willing to have. It's something that became a societal level conversation during COVID lockdowns on how are you actually feeling. I think it prompted a lot of self-reflection in individuals. So maybe that's why we're seeing both improvements, because people are seeing things that they can work on, and maybe more conversations on people not feeling well because you're actually recognizing what's happening. And not just burying it with the busyness of life.

JO  44:32

A big chunk of Hari's book outlines his research findings about the effectiveness of pharmaceutical solutions for depression and/or anxiety. He also questions the long-held belief that brain chemistry changes are the primary causes of those disorders. Sahil, what do you think about the book and Hari's arguments?

SAHIL  45:00

So I mentioned my story, I did very much subscribe to the chemical imbalance narrative. And I do think there is still some truth to be had there. I think it's good to have a conversation around that on, okay, maybe that's part of the scenario, but maybe not the whole scenario. And there are things that we can work on. I did really enjoy the book. I enjoyed the breakdown of all these connections, and frankly, then all of the solutions that can help chip away at it. I don't know if I bought all the arguments in their entirety. But I think there is enough in that book to reflect on and learn from.

Warren  45:38

The book was interesting for me, because I was familiar with a lot of the research that he explores. From a journalist point of view, he went and interviewed the people who had done, for example, the meta-analysis of antidepressants with the SSRI, selective serotonin reuptake inhibitor category. I was familiar with the fact that the full meta-analysis, which was done by obtaining all the studies that have been done on these drugs, rather than the ones that have been published at the time the drugs first came out. It was possible to do say, a dozen studies, find four that said what you want them to say, and then the other eight said things you didn't want them to say. In other words, they were not so positive about the drugs in question and their therapeutic benefits. And never publish those eight and only publish the four that you like.

So what the researchers on that particular meta analysis did, they went and got all the studies. They nagged the Food and Drug Administration, so they finally gave them the actual raw data from those studies. And when that happened, it showed that the evidence used to promote many of the psychotropic drugs was quite skewed. It was quite directed towards a marketing end rather than a therapeutic end. And that's nothing new. Nobody should be surprised. The nature of the corporation and most large pharmaceutical companies or corporations, is to deal with the shareholders expectation of profit. And that's the sine qua non, the other part of it is of importance, but it's not the central issue.

What I liked about the book was that I was hearing some of the sort of personal trajectories, the narratives of the people who did the research and why they did it, and what they felt about the research when they had done it. And that was adding another sort of personal element to stories that I had heard, written up in clinical journals. I particularly appreciated the fact that Hari was very open about his own struggles, which I think is important. It makes it clear that say an investigative journalist or a public figure, is not somebody who sprang out of the earth fully formed. They are like everybody else, in a process of evolving, and changing, and coming to new understanding about something that they might have thought they understood very well, for sometimes a very long time. So that was helpful for me. And then some of the individual stories about changes that took place in people's lives, I found quite illuminating, and quite heartening, as well.

JO  48:20

What were your favorite stories and why?

SAHIL  48:23

One of my favorite parts is right at the beginning, when the author talks about the initial experience with the medications which paralleled mine, of there was a benefit, it would fade, there was a benefit, and it would fade. And specifically, there was this part where the author felt compelled to evangelize about the medications. And I felt that as well. I was singing the praises because I had felt so down and so unwell. The correction of that, or the fixing of that, however, I felt in that moment was so significant to me, that I felt that everyone should consider whether or not they need these medications. So that point of relatability from the beginning, stuck with me and probably added to the authenticity of the book for me, or added to the reliability of the author's narrative throughout.

Warren  49:15

The story that captured my imagination the most was the story he told about arriving in Berlin, he's originally German so this was kind of like coming home and coming across a small community of people rejected on all sides by society. Some of them were immigrants from other countries that didn't speak English, or German, or other as a first language. Some were people who had been disabled. Some were people with sexual orientation that was not accepted in German society. And somehow, they just didn't feel comfortable in the value system of the society they we're living in. All of them had been kind of isolated from society as a whole but also from one another. And then an elderly immigrant woman decided to just sit out in public and be visible, because she was having trouble with attaining some goals in her life, from the government. And around her coalesced a whole new community that formed, and was established, and strengthened, and sustained by the energy that each of these marginalized individuals brought to the broader nature of their gathering of people.

It wasn't just a heartwarming story, it was an analysis of how community is established. You reach out, you find commonality, you ignore the superficial differences, you look for the deeper values that you share. And then when you do that, you gain an enormous sense of personal and shared satisfaction. And I think if there was any way to give an example of how to enhance mental health, I would say that story to me stood out very much so.

SAHIL  51:03

I agree. Not only was it heartwarming, I found it to be so empowering. In those most dire of circumstances, they were able to come together. And that sense of community that they built was inspiring and empowering on any time you find yourself in dire straits, you can build that community that will help you through it.

Warren  51:22

And I would compare that to say, a very wealthy suburb in a large urban setting where all the houses are grand, the trees are beautiful, and the neighbors don't always know each other. And they're often sort of in competition to have the nicest lawn, or the biggest swimming pool, or whatever. And sometimes, not always, but sometimes, just very wrapped up in material values. And then at some point in time realizing that what they really want is a sense of relationship with others.

JO  51:58

Much of the book focuses on what Hari feels are the nine major causes of depression and anxiety, including trauma and genetics. He describes them as disconnection from other people, or meaningful values and work and from status and respect. He also talks about us being disconnected from nature, and from a hopeful and secure future, which are inextricably linked. He goes on to talk about solutions, or what he calls different kinds of antidepressants. And we don't have time to talk about all of these, but I would like to dig a little deeper into what I believe is the most important message in the book. And that's the vital role social connection plays in mental health at all scales, individuals, families, workplaces, and communities. So first of all, Sahil being of Indian descent, your experience with social connection is much different than ours in the Western world. Tell us about that, and how it played out in your life.

SAHIL  53:07

My parents are from India, moved here kind of in their 20s. Typical immigrant story, came with very little, have kind of worked their way up the social ladder. I'm born and raised in Canada. Being Canadian is my primary identity. And then I so happen to have this background. And with that background, I think comes a greater sense of family and importance on family. The social connection that I have with my parents and with my sister, that family household connection is so central to my existence.

Leaving that when I left Kelowna to go to Vancouver for pharmacy school, that definitely had a role of being further from my greatest support system. And there was never a sense that I would be abandoned. When I look at more Western culture of kids moving out at 18, it seems such a difficult way of life. I don't know if I would have been able to get to where I'm at in life, if that was the culture that I came from, or if that was the situation I was in. So that value on a family and supporting each other, this mindset of my parents support me until I'm self-sufficient, and then eventually, the responsibility becomes mine to take care of them. So we're always being taken care of and supported in that way. There's no sense of time out in the world by myself.

Warren  54:33

The Indian culture is, in some ways, far more mature than the kind of hybrid culture that we have in this part of the world. And many, many other cultures really have maintained a sense of community and family. There's no question I've observed in many, many situations how having sometimes just one healthy relationship can mean the difference between somebody being really distressed almost all the time, and feeling a sense of relief and security.

Maybe I can recite a story that was told to me by two prominent members of Indigenous community here. They talked about the fact that everything that happened in Indigenous community was for the community. And as a result, everything you did was to make sure the community survived. So if food was scarce, and hunters brought back a deer or something like that, or there was some kind of plant that they could harvest, it would be shared equally among the community. And even if somebody was a hunter and needed more energy, then others would make sure that the hunter had a little bit extra. We certainly don't think of the communitarian values that underlie our behavior all that much. We're doing a better job now, but we've got a long way to go. And I think we can learn a lot from the Indigenous experience.

JO  55:59

Sahil, you have one foot in Canadian culture, the other in Indian culture. Tell us what you've learned about your Indian culture that would help us build more mentally healthy communities here.

SAHIL  56:12

It's hard for me to speak for all of South Asian culture. Even just India is a country of a billion people, and there's a lot of nuances. But what I can say from my personal experience is, I'm lucky to have a good family dynamic. And that's taken work. It's taking conversations, it's taken establishing and respecting boundaries. So I think the takeaway for me is put time and effort into cultivating the relationships, maintaining the relationships, because that is kind of the foundation of everything else. If you have those, you can work through a lot of the other difficulties that life throws at you.

JO  56:55

Warren, you and I have talked a lot about the importance of livable communities that are designed and built to foster social connection. Dig deeper into that for us.

Warren  57:08

Absolutely, and with considerable enthusiasm. How you construct a community, how you actually build the infrastructure in a community has an enormous impact on the ability for people to connect with one another. I remember an article in Scientific American that showed a small English village before the advent of the automobile. And the road was narrow, and the paths on the side of it, what we might call the sidewalk was large. And there were people all over the sidewalk, and very few vehicles, and most of them were horse drawn in the roadway. After the advent of motor vehicles, and a few decades gone by, the roadway had expanded, the sidewalk had shrunk. And the vehicles on the road clearly overwhelmed any walking activities that took place, and the sidewalk was really just a kind of a narrow front in front of stores and other kinds of buildings. And the structure there did not facilitate people crossing the road to talk to one another.

So when we do that kind of change in a town, even a small English village, without realizing it, we've disrupted social patterns and a sense of social connection. The changes that we've introduced with what they call concrete jungles, downtown areas where every surface has been built. And the only place you can actually meet somebody is by going in a door into a building and typically presenting something about yourself. Either it's you want a hotel room, or you want to buy something. But the interactions that are just the casual interactions are very hard to come by.

I live in a small town. I've been here for 45, 43 years, and I walk down the street and it's a social event. I meet people every few feet practically, who I know and have a few words with. So I think how you construct a community has an enormous impact. Walking trails, park benches, park spaces where people can just hang out and be sociable. All of those things and many others make a huge difference in terms of facilitating social connection.

SAHIL  59:17

This theme of the environment, and how ever you define it keeps coming up and is really important. And I think that starts even in your bedroom. What do you have there, and what is that promoting in your life? All the way to, yes, the greater community and the planet. And something that I've been reflecting on more recently is cultivating as much as I can, the environment that's going to bring the behaviors out of me or create the mindset in me that I'm wanting.

JO  59:45

I've been a public outreach and engagement consultant to local governments in BC for 30 years. And I'm thrilled to say that things are definitely getting better at the community scale. When I started in the early 90s, municipalities didn't have sustainability plans or programs, climate action plans or programs, and very few were thinking about the social and cultural considerations of community well-being. I'm thrilled to say that there have been dramatic changes in these areas. Communities of all sizes across Canada are working with residents to plan and mobilize efforts to enhance and integrate social, cultural, environmental, and economic well-being.

Warren  1:00:32

Joanne, that is such an important thing that people who are in governance systems can do to make communities what they have the potential to be, which is hubs for people interacting at multiple different levels and in multiple different ways. And in almost all of them positive. And there are many ways you structure both the physical structures and the social structures. The way support systems are given to people or not given to people can make a huge difference in the way their lives work out. And I think that is a critical element that all leaders and communities can play and make a huge difference.

JO  1:01:13

Warren, I know you're also passionate about the social determinants of mental health, and how they impact people's well-being. These include things like housing, employment, education, physical environment, security, and financial stability, to name just a few. Knowing that you promote universal, basic income at every opportunity as a way to optimize these factors, tell us more and why it would improve mental health across the board.

Warren  1:01:45

There's two pieces of evidence around mental health and what a universal basic income does to that part of our lives. The empirical evidence is that every experiment that has been done in this area has shown a massive uptick in positive emotional state in the people receiving the universal basic income in whatever form it occurred. There was an experiment done in Dauphin, Manitoba in the 70s and early 80s. And one of the universal findings there was everybody felt so much better about their life. There was an experiment done in Ontario for about three years before it was shut down by a new government. And it showed exactly the same thing, something like 87 percent of people had this enormous uplift in their state of mind, because they felt cared for. They felt nurtured by the community at large.

It wasn't that they were given this cheque and they just went off and spent it. They looked at the cheque and they said, "This is all the other people who live in this community, contributing a few cents to my financial security." And that was a very powerful thing. The other piece of evidence is drawn from human health. And if you look at physical health outcomes in countries where there's more income equality, and what a universal basic income does is it puts a floor under which nobody will sink. The evidence from many different countries in the world shows that human health at the physical level improves very significantly. Countries with greater financial disparities between the wealthy and the financially underprivileged. Every study shows that people use hospitals less often, they go to doctors, less often, they suffer from chronic illness less often. So I think it's very hard to argue against universal basic income.

SAHIL  1:03:39

I think on a broader scale, it's a great idea. We want everyone in society to be taken care of, to be fed, to be housed. The social determinants of health are something recently learned in school. Income inequality is such a predictor of health along with education and the other determinants. We talk about medications a lot, but these basic foundational societal concerns, if these can be addressed, then were working on prevention rather than treatment, and I think that's a great approach. I am probably not as well educated on the economic consequences of these policies and decisions, but definitely something I'm curious about and want to learn more about, because the promise, I think, is there.

JO  1:04:30

This has been an informative and inspiring journey with you both personally and as a producer of this podcast. Thank you from the bottom of my heart, for sharing your stories and your incredible insights and passions. So let's close with a question for each of you. Warren, you've been doing this a long time. What are you seeing in treatment modalities and health care now that gives you hope for the future?

Warren  1:04:59

I've been reflecting on this quite a bit recently because I'm veering towards retirement, and it makes you think about what is the nature of healthcare and your role in it. And what is the system itself doing, which I've been observing for nearly five decades overall. One of the big changes is that the information that is now available to people is far more abundant than it once was. At one point, you could only get information about health from either a specific healthcare practitioner or from somebody who was selling you a product. Abundant and accurate information about human health, in all its aspects and every aspect that we've talked about today, it's now available online. Now, there are of course, sources of information that are entirely questionable and distorted. But much of the information is really eye opening for many people. And that's taking the emphasis off just say going to the doctor or going to see another health professional, and sort of democratizing access to information, which I think is a really important step. And I think that's revolutionizing how healthcare happens.

JO  1:06:19

Sahil giving your lived experience of depression and anxiety, your expertise as a progressive pharmacist, and what you've learned from Hari's book, how do you see the future for the one in five Canadians who have or will have depression and or anxiety?

SAHIL  1:06:37

I see a hopeful future. I think it starts with that first step of that self-awareness and identification of what's happening before it's becoming too severe. Trying out all the non-medication measures, some mentioned in Hari's book, and some we've mentioned throughout the podcast, and then having your health care team in place if you're needing it to work on from the psychotherapy aspect or the medication aspect. I see a hopeful future because there's a lot more resources available. There's a lot more awareness, and awareness is sometimes a buzzword, but I do think those conversations are happening, like this one are really important to create that sense of you aren't alone. And hopefully that will help people work through that journey more comfortably, knowing the support systems are there.

JO  1:07:30

So that's a wrap and what a great way to end. To connect with Sahil or Warren, visit freshoutlookfoundation.org and look for Jo's Journey under podcasts. There you'll find their contact info, bios, a list of resources, and the podcast transcript. Another big thank you to our sponsors for this episode, the Social Planning and Research Council of BC, Emil Anderson Construction, WorkSafeBC, and AECOM Engineering. And thanks to you as well for hanging out with us, you're very much appreciated. In closing, be well and let's connect again soon.