A Q&A With VUMC's Dr. Abhi Saxena on Mental Health Strategies for the New Normal

Vanderbilt Health behavioral health expert Abhi Saxena, MD, MBA, recently spoke to Middle Tennessee employers about anxiety around returning to work and navigating big transitions after a tough season of personal struggles and loss. Dr. Saxena is the medical director of hospital services for Vanderbilt Behavioral Health and an Assistant Professor of Clinical Psychiatry and Behavioral Sciences at Vanderbilt University Medical Center. He oversees the 106-bed Vanderbilt Psychiatric Hospital and the partial hospitalization and intensive outpatient programs.

The Vanderbilt Health Employer Solutions team asked Dr. Saxena about practical ways to handle the near-constant level of anxiety we have experienced during the COVID-19 pandemic, as well as ideas for transitioning to a post-pandemic world with stronger mental health coping strategies.

What do you tell people who feel anxious and burned out despite the world opening back up?

As a psychiatrist, I often get asked, “What is normal?” We are experiencing a new normal—normal in 2021 and 2022 will look different than normal did in 2019. And that’s okay. That's not something to be worried about. It may require adaptation to get us back to doing the things that we love and enjoy. If you are feeling bit on edge, not quite back in your rhythm or not where you need to be—it's okay.

Nothing has been normal since about February of last year. Unfortunately, in Nashville there have been a series of “hundred-year flood” type of events—we have experienced another destructive flood, tornadoes and a bombing on top of the pandemic. So, I want to start with a simple reminder that it's okay to not be okay. I don't mean that if you need help that you shouldn't reach out, but it is okay to not feel exactly like yourself at this current moment.

Where does anxiety come from, and is there anything positive about it? 

Anxiety does have a protective role. Going back to when we were nomads, anxiety is what kept us safe from peril and attack. So at its core, a little bit of anxiety and worry can protect us. If you'll remember back to when you were in school, what made you study or turn in a paper? The fact that there was a deadline brought out our critical thinking, creativity and productivity. Anxiety can keep us safe. It can keep us motivated. It can keep us going forward. So not all anxiety is bad. 

The problem comes when anxiety turns to fear or when it becomes more generalized and chronic. It’s harmful when anxiety brings about social dysfunction—when we’re not working as well, feeling as well, or hanging out with friends and family—and it's happening chronically over long periods of time.

People are allowed to have bad days and bad weeks, but when this turns into bad months and bad years, that's when we get concerned. Or if the severity reaches a certain threshold where we're not able to work, care for ourselves and others, or do the things that we usually like doing, that’s when we need to seek out help. 

What happens to our bodies when it comes to chronic stress?

And as a reminder, anxiety isn't just a feeling. It’s not something that someone needs to just “get over” or try harder to just “snap out of it.” It's not that easy. If it were, most people who are having trouble with anxiety would just do it. It would be like if somebody's pancreas isn't making the right amount of insulin, and we were to tell them, “Just make your pancreas work a little harder.”

We cannot always gain control of our brain’s neurocircuitry. Different parts of the brain are responsible for different symptoms, from the way our heart is beating, our blood pressure, how much stress our body is under, and how we're socially interacting. There is physical evidence that after stress or chronic trauma, our brain physically looks different. It can look bulkier in some areas, such as the amygdala, our emotional response center. After periods of stress, parts of your brain that are supposed to be more robust can actually lose the ability to function in normal ways.

Why have people reacted so differently to the threat of the virus? 

The prefrontal cortex helps us assign value calculations and assess probability—in other words, to help us anticipate the cost of future events. These value calculations are our brain telling us how likely something is to happen. It has been very interesting to me as a psychiatrist to watch how Americans have responded to this pandemic when it comes to their value calculations.

There are groups of people in America that have over-quantified or overvalued the fear of death or serious consequences from the virus. Now that's not all bad because this has propelled people to want to wear masks, socially distance themselves and do what they need to do to stay safe. But if people have overvalued the fear, that could have prevented them from returning to a new normal. On the other hand, some groups have undervalued it, saying things like, “I don't have to worry about this virus or follow guidelines. I don't need to get the vaccine.” These are just two ends of the same type of brain circuitry that are forcing folks to be off track. What's funny is these two groups of people probably look at each other as being very different, but really they're on the same core level. We're more similar than we are different. It's just two different directions to take to anticipate the cost of future events. 

What are some of the common reactions people have had to the constant stress?

This last year and a half have been quite traumatic to a lot of people. Trauma does not have a single concrete definition—it's very personal, and different traumatic events cause different reactions in different people's brains. One person could live through a tornado or other devastating event and have no lasting or very minimal symptoms afterward. Other people could experience the same event and it would elicit a different response. In psychiatric research over the last 10 to 15 years, we have learned that repeated microtraumas—which are lower-level stressful moments that are happening daily or regularly—are leading to anxiety symptoms similar to what we traditionally think of as post-traumatic stress disorder, or PTSD.

In these scenarios, people can begin to lean more on substances like alcohol or drugs to get them through the tough days, which can lead to misuse and addiction. And that's what I'm worried about—because it has been 15 to 16 months of our entire society being chronically stressed. That has led us to having a never-ending series of adjustments. Every two weeks it has felt like there's something new that we have to learn or adjust to and cope with. And this is on a plate that was already full for most Americans, who were at their limit of working hard and taking care of families. There was not much room on the plate to add more. 

And on top of all of this stress, core parts of our coping system were put on hold. Being able to go to school, gather for parties or church, go to concerts or sporting events, or even go to our doctors appointments—all of that was eliminated at least temporarily. Simple tasks like going to the grocery store suddenly became perilous. Two years ago, if I had told you that you would be on edge and have to really focus before you go to a grocery store, no one would have believed me.

I still remember that first news event where San Francisco looked like a ghost town. And then slowly, we all had to do some version of that. Every state and every city handled it a little bit differently, but to some extent, we all had to shut down and reevaluate our lives in so many ways. And so I go back to my first statement: It is okay to not to be okay. It makes sense.

How do we get back in the game—back to work, back to doing the things that we want to do?

Those of us who are vaccinated have to lead by example and show everyone how to get back to being a society again. You want to be patient because there's a large variation of normal. There will be people who want to hang out all the time versus those who are not ready for that. Both reactions are okay. Be understanding of other people’s discomfort and don't judge them or make disparaging remarks. Don't give up on them—check back in with them often. 

If you’re still experiencing some measure of anxiety out in the world, know that there's nothing wrong with branching out slowly, but don’t allow fear to cause you to be so isolated that you're experiencing social dysfunction. We have to turn the corner and move to our next steps as a society.

What can workplace leaders do to help workers’ anxiety subside as we return to the office?

I think trying to elicit feedback is important. Find ways within your organization to poll or survey your employees and be ready to change course based on what you learn. It’s important to constantly get the pulse of the people who work with and for you and then be adaptive. If you've got a really good worker who is worried about working in the office, but you really need them to come back in, try to build a hybrid model. Perhaps allow the option to work from home a few days a week. Incorporate different people's needs the best that you can. 

I can't emphasize this enough: Practice active listening. Don't make any assumptions about why someone's not coming in. Just try to listen and understand, and then adapt as best you can.

What about children who may be suffering with anxiety with COVID-19? What advice would you have for their parents?

First look in the mirror: As a parent or a caregiver, how much of the anxiety they're feeling is radiating off of you? Make sure you're not bringing a lot of stress or worry home to young people who can’t understand the full picture. Again, don't make any assumptions; ask open-ended questions and listen to try to understand where they are. You may think they're at a certain level because they're younger, but they might know much more information, and even misinformation, because social media is everywhere. 

Next, validate their feelings and let them know it's okay not to be okay. There's no one answer, but it’s important to make sure the next generation isn't overly fearful or overly distrustful of authority. We want people to live in a society that trusts one another, and it starts with the kids.

Where can people get help?

Help is one phone call away. If life feels overwhelming, call somebody for help. If you’re noticing that issue in someone else, reach out and listen, be supportive and get that person help. Vanderbilt has psychiatric assessment specialists available 24/7 via telehealth, in our clinics and in the ER. Behavioral health experts can help you get back to the basics and do things like monitor your sleep and get your nutrition back in balance. They can also help you get back to what you enjoyed doing before the pandemic so that you’ll feel more like yourself.

What are final thoughts about how to build stronger mental health in this transitional period? 

Be intentional about what you're adding back into your life. Remember there are multiple roads to happiness: What's right for one person is not necessarily the way for another person. One of the positives about these last 15 or so months is that people have simplified their lives. People now have a better grasp on what they truly value and better understand what they were doing previously that was extra and simply too much. Don't add back in activities that stress you out or that have been toxic in the past. Have boundaries, know your limits and never be afraid to ask for help. 

And remember, we're all in this together. We can do anything. We can move step by step to get our lives back and have fun again and enjoy this great city of Nashville.