When you think of stress, it probably brings negative emotions to mind. But some stress is good for you, like the anticipation you feel when you start a new relationship or job. It can fuel excitement and make you want to do and achieve more. Stress can also help you be prepared to face challenges or respond to dangerous situations.
Good stress doesn’t stick around. It boosts your mood to meet the moment, then goes away. If you’re under stress for long periods of time, it can become overwhelming and affect you both physically and emotionally.
“Our stress response does pretty good in the short term, but it doesn’t do very good if you activate it in the long term,” says David Prescott, PhD, associate professor of Health Administration and Public Health at Husson University in Bangor, ME.
“If we stay under chronic stress, our physiological stress response is taxed beyond what it’s designed to do, and it starts to impair us.”
20 Dec, 2022
Starting any medical treatment for the first time can leave you with questions, especially if you’re looking forward to the benefits it may bring. It’s no different when you’re preparing for your nasal esketamine treatment. Your previous mental health treatments may have consisted solely of taking antidepressants at home or visiting a therapist’s office for cognitive behavioral therapy (CBT), so nasal esketamine is probably a new treatment experience for you. If you’re wondering what it’s like to start nasal esketamine and get ready for your first session, keep reading. Getting Started with the Nasal Esketamine Treatment As with any new treatment, you’ll first talk to your primary care provider or psychiatrist about whether nasal esketamine is a good fit for you. Alternatively, you can schedule your esketamine nasal spray consultation with a treatment center (such as Greenbrook) that has certification by the FDA’s Risk Evaluation and Mitigation Strategy (REMS). At Greenbrook’s REMS-certified nasal esketamine treatment centers, our Greenbrook-affiliated psychiatrists and psychiatric nurse practitioners will review your medical history and also conduct our own assessment to help determine whether nasal esketamine treatment is right for you. Certain conditions, including blood vessel disease and a history of psychosis, may make treatment a risk for you. Make sure you discuss all previous and present conditions with your doctor or nasal esketamine provider before beginning treatment. If the medication is deemed a good fit, you’ll receive your prescription from the Greenbrook-affiliated provider. Your Greenbrook Care Team will put together a personalized care plan for the weeks and months to follow. Keep in mind that you will need to take a standard (oral) antidepressant along with your nasal esketamine treatment. There are two important regulations to note when it comes to preparing for treatment: Each treatment is followed by a mandatory two-hour observation period. This means you will need to plan to stay at the center for at least two hours following your self-administration of the esketamine nasal spray. You cannot drive during the rest of the day after treatment and must arrange for transportation. These regulations are mandatory. It may be helpful to sit down and plan out several weeks’ worth of transportation once you know your treatment schedule. In addition, if you’re wondering what to bring for the treatment, we recommend entertainment such as an audiobook or playlist of favorite songs and a pair of headphones. You may want them during the two-hour observation period. What to Expect During Nasal Esketamine Treatment On the day of treatment, you’ll need to stop eating any food two hours before your appointment and stop drinking all fluids 30 minutes before you come in. Your Greenbrook Care Team will confirm that you are prepared for the two-hour observation period and that you have a ride home. You’ll get the opportunity to practice using a “trainer sprayer” that mimics the real nasal esketamine sprayer but does not release any medication. The Care Team will encourage you to use the restroom and set up your preferred environment in your private treatment bay or room. Some patients like reduced lighting, for example, while others don’t request light adjustments. You’ll complete a depression scale before each treatment session. Your Greenbrook provider will confirm that the dose kit is yours, show you how to administer it, and then hand it to you. Each sprayer contained 28mg of Spravato esketamine nasal spray. Patients usually start with two sprayers (56mg) and soon increase to 84mg (three sprayers) per treatment. But, your dosage maybe vary. Should you be left with a metallic taste by the spray, the Care Team will offer suckers to help make the flavor dissipate. After your dose, you’ll be encouraged to lie back in your comfortable recliner. While most patients enjoy a quiet setting, Greenbrook is prepared to accommodate patients with a more animated reaction to the medication. You may feel sleepy, dizzy, mildly dissociated, and/or nauseated during treatment. Greenbrook’s Care Team is readily available if you need assistance. How to Prepare for after your Nasal Esketamine Treatment Most side effects begin to wane in the second hour of observation, but if you’re wondering, “Is it safe to drive immediately after nasal esketamine treatment?” the answer is a resounding no. In addition to the mandatory ride home, you will need to block off time to rest and let side effects fully dissipate. This extended rest period is especially important in the first weeks of treatment when you’ll have treatment twice a week. Do not drive or operate machinery of any kind until the day after treatment. Just take it easy, relax, and take care of yourself. If you’re unsure what activities you can do or should avoid during this time, talk to your Care Team for more information. While side effects tend to dissipate completely after a good night’s sleep, many nasal esketamine patients begin feeling relief from depression symptoms within hours of their treatment. Other Tips in Preparing for Your Nasal Esketamine Treatment At Greenbrook, we make every effort to schedule your treatment in the afternoons or whenever it is most convenient for you. We encourage you to see each treatment session as an opportunity to relax and take care of your mental health. If you have any questions or concerns, talk to your doctor or the Greenbrook Care Team. At Greenbrook, we’ll help you feel at ease when preparing for each treatment session. Schedule A Free Consultation To get started with nasal esketamine, schedule your free consultation today.
It’s a damp, midweek afternoon. Even so, Cardiff’s walk-in stress management course has pulled in more than 50 people. There are teenagers, white-haired older people with walking aids, people from Caucasian, Asian and Middle Eastern backgrounds. There is at least one pair who look like a parent and child – I’m unsure who is there to support whom.
The course instructor makes it clear that she is not going to ask people to speak out about their own stress levels in this first class: “We know speaking in public is stressful in itself.” She tells us a bit about previous attendees: a police officer whose inexplicable and constant worrying prevented him from functioning; a retired 71-year-old unable to shake the incomprehensible but constant fatigue and sadness that blighted his life; a single mother unable to attend her daughter’s school concert, despite the disappointment it would cause.
What is the common theme that links these people – and the varied group sitting there this afternoon and listening?
Stress may once just have been a kind of executive trophy – “I’m so stressed!” – but recent research suggests it is a key element in developing mental health problems such as depression and anxiety.
The constant, stress-induced stimulation of key brain regions seems to be a major contributor to anxiety. And, in turn, vital brain regions becoming unresponsive and inflexible is believed to be a fundamental element of depressive disorders. Why do these regions become unresponsive? Possibly because they’re overworked, exhausted, by the effects of stress. This would explain why anxiety and depression regularly occur together.
So what is stress? In essence, it is the first stage of the fight-or-flight response, the classic reaction to danger, the ingrained reflex that compels you to tackle danger head-on or run screaming from it. A third option, freeze, is also included in the modern-day understanding, which explains that inability to move when you’re truly scared.
This potent fear response isn’t like a switch, a simple yes/no thing. There are neurological and biochemical systems that prepare your brain, and body, for having to deal with a threat. It’s regulated by a complex suite of brain networks and hormonal reactions, and one key element in the stress response is the amygdala, the part of the brain that (among other things) decides whether or not stress is warranted.
The stress response has numerous potent effects on us. It increases our focus on negative things, such as whatever is causing the stress, because when you’re dealing with a problem you can’t afford to waste time pondering irrelevant things. It puts your brain and body into a more alert state, meaning you become more sensitive to hazards and risks, both physically and mentally. It’s useful for keeping you safe, but again leads to you focusing on the negatives, the unpleasant aspects of your current existence, and downplays the potentially distracting positives.
Illustration: Jamie Cullen
Problematically, because of these things, stress is also very stimulating. It releases several potent chemicals into your bloodstream – cortisol for instance, which amps up your heart rate, muscle tension, glucose uptake, even your immune system responses.
The trigger, the activation of the stress response, comes from our brains, with the hypothalamic-pituitary-adrenal (HPA) axis – a complex association between the hypothalamus and the pituitary and adrenal glands – as the key element. The HPA axis is basically the link between the brain and the body when it comes to stress. When our brain decides that stress is required, signals are sent to the HPA axis, which in turn releases a complex sequence of chemicals that ends up with stress hormones, such as cortisol and glucocorticoids, being released into our bloodstream.
But here’s the problem. In many people, this ability of the HPA axis to recognise when there’s enough stress chemical in the body and so cease production is disrupted in some way. The HPA axis can start the physical stress response but doesn’t seem to know when to stop.
This might sound like a mild annoyance but there’s mounting evidence to suggest that it’s a cause of multiple mental health problems, particularly depression. Those who have chronic depression, and many who have killed themselves, have been shown to have significantly elevated levels of glucocorticoids, cortisol and other stress chemicals in their blood and tissues.
The constant bombardment from stress chemicals potentially underlies many of the physical symptoms of depression. Weight gain, hypertension, a suppressed immune system, heart problems – all can be attributed to the persistent action of stress chemicals in the body. For example, these stress chemicals and hormones seem to have a potent effect on neurons, and therefore the functioning of the brain. Specifically, they seem to stimulate areas such as the hippocampus and prefrontal cortex to enhance our memory, thinking and focus, because when you’re in a stressful situation, you need to have your wits about you, and you need to remember what happens in case it happens again.
Unfortunately, this causes a problem. Neurons can handle a certain amount of increased signalling, some excitation. But too much leads to excitotoxicity, a phenomenon whereby too much activity damages and impairs the neuron. The complex biochemical processes a neuron engages in are quite demanding. Give them time to restock and replenish after being pushed to their limit and they’ll be fine. But keep pushing them and they’ll suffer.
So, stress chemicals stimulate many areas of the brain. But when the HPA axis keeps pumping them out, those brain areas are stimulated too much, exhausting and damaging the neurons, causing them to lose plasticity. And a loss of neuroplasticity is now believed by some scientists to be a key part of depression. Simultaneously, there’s no reason why other parts of the brain, with neurons that have subtly different properties, can’t respond differently to the stress hormones, possibly being enhanced by them.
There is a possibility that it’s the unhampered stress response that causes some or even all of the issues of depression, inducing the physical symptoms, reducing neuroplasticity in certain key areas by overworking them while enhancing other regions to the extent that they become dominant to a disruptive extent.
Illustration: Jamie Cullen
But what causes stress and how can we deal with it? The “handling stress” course that I attended is based on the works of acclaimed Scottish psychologist and stress-control proponent Dr Jim White. It’s provided by the local NHS trust, and most trusts offer an equivalent. The programme has been running nationally for 30 years, helping tens of thousands of people.
So what stresses us out? Failure to meet expectations. Having to do more than we can handle. A loss of status, or living standards, or security, or something or someone important. But all of our expectations, standards, capacities, understandings and baselines are derived from a mental model of how the world works, a model our brains create and maintain based on our memories, experiences and beliefs.
Stress is largely subjective. It often comes from negative changes or influences in our lives, when they occur with too much intensity. That our lives remain positive overall compared with those of others is irrelevant. That’s why questions such as: “What have you got to be stressed about?” don’t make sense. Thanks to how our brain works, if you don’t like something or don’t want it to happen, it can, and will, stress you out.
Breathing exercises can genuinely help. A new therapy widely in use today that bears a significant resemblance to breathing exercises is biofeedback, or in some cases neurofeedback. The affected person is hooked up to monitors that display the physical outputs of their body, such as heart rate, muscle tension, skin conductance, brainwaves in the case of neurofeedback. These physiological actions typically occur at a subconscious level; we aren’t really “aware” of them. Bio/neurofeedback makes us aware, meaning we can focus on them and try to control them with our conscious minds.
This appears to help because it reduces uncertainty; not knowing what is happening or going to happen can be more stressful than knowing something bad is going to happen. That’s just the way the brain is wired. It reacts much better to knowing than not knowing. And being aware of our breathing or heart rate provides certainty where we didn’t have any before.
Small steps, incremental progress, are something that is emphasised repeatedly on the Cardiff course. This is a way to help break the “stress cycle”, which describes how stress becomes chronic and self-sustaining. Let’s start with a relationship breakdown. This causes stress, with low mood, lack of motivation, etc. This leads to reduced socialisation; your friendships suffer, and you end up more miserable, more stressed. So you drink more to feel better, albeit briefly. But this makes you less healthy, more sluggish, and your work suffers. Now your job’s in trouble, your health declining. This causes more stress. So you drink more. Which means more stress. And on and on.
There is no easy fix. But at the very start of the session, we are given a brief, basic set of instructions that could, if adhered to, tangibly reduce stress. There were just 10 words: “Face your fears. Be more active. Watch what you drink.” While simple-sounding, these things conform to what we know about stress, and even mental health problems, in the scientific sense.
Facing your fears is often easier said than done but it’s a valid approach. When we confront something that scares us, that stresses us, we may not enjoy it but we impose certainty on it. All the things that could have happened and had the power to cause stress have been cancelled out. In many cases, facing your fear has a net reduction of your stress due to how our brains work.
Being more physically active is helpful in so many ways. As well as the health benefits, it also maintains a sense of control. My friend Dan found that dealing with his stress and depression has been a lot easier since getting a dog. She needs to be walked no matter what he’s feeling. Taking her means he’s stayed active and achieved something.
And “watch what you drink”. Not just alcohol, with it’s short-term euphoric effects but long-term depressive and anxiety-inducing ones. Caffeine is something to be wary of, too, as it stimulates the parts of the brain already overworked due to stress, and also disrupts sleep, another thing that can enhance/prolong stress.
Ten words. Three simple instructions. But, given enough time, sometimes that’s all it takes to make significant changes.
Dean Burnett is a neuroscientist. His new audiobook, Psycho-Logical, is available at audible.co.uk
