Dr. Judith Joseph: Episode Link
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Dr. Judith Joseph, a board-certified psychiatrist, discusses the relationship between mental health and menopause. She explains that menopause is not a mental health issue, but it can mimic one due to hormonal fluctuations. This often leads to misdiagnosis and inappropriate treatment. Dr. Joseph emphasizes the importance of distinguishing between perimenopausal mood symptoms and major depressive disorder, as the treatments can be different. She also discusses the need for women to educate themselves about menopause and actively participate in their treatment. Dr. Joseph introduces the TIES method, which stands for Thoughts, Identity, Emotions, and Sleep, to address the cognitive, emotional, and sleep-related challenges of menopause. She suggests cognitive behavioral therapy and mindfulness techniques as effective interventions. Additionally, she highlights the importance of lifestyle factors such as stress management, social support, exercise, and nutrition in supporting mental and physical well-being during menopause.
TRANSCRIPT:
Welcome back to Hot Flashes and Cool Topics today. We have a really great conversation on mental health and menopause. And we have invited Dr.
Judith Joseph, who’s a board certified psychiatrist, and you may recognize her from social media because she has like over a million followers. followers. But we’re going to talk about mental health and menopause.
So let me start by saying welcome to the show, Dr. Joseph. Thank you for having me. Well, we appreciate it. We know you’re very busy. And I think this information is going to help a lot of our listeners.
I wanted to start with a statement you had made when you were talking on the Oprah show, and it’s probably a statement you’ve made before, but you mentioned menopause is not. a mental health issue,
but it mimics one. And I think that’s, like, I don’t think a lot of women or a lot of doctors even realize that. Can we start there and talk about what you mean by that? Absolutely.
Menopause, by definition, happens after a year of a loss of a period. And it is really a transition in a woman’s body that occurs occurs due to changes with the ovaries.
Now, mental health conditions such as depression or anxiety can have a lot of the symptoms that are similar to what you see in perimenopause due to the hormonal fluctuations.
And because of that overlap and seemingly, you know, the similarities, it’s often missed. misdiagnosed as major depressive disorder.
So perimenopausal mood symptoms can mimic a major depressive disorder, but they’re not equivalent. And the reason that’s important to distinguish the two is because the treatments can be very different.
For example, there are some studies that indicate that if a woman is experiencing these mood issues early in perimenopause that changes. may benefit from hormonal treatment.
But if that same woman, let’s say a decade earlier, was having these symptoms, we would not be thinking about hormones, we’d be thinking about other evidence -based treatments like an antidepressant or cognitive behavioral therapy or other issues,
other types of treatments for depressive symptoms. And I think this is confusing. confusing because when we say depressive symptoms in psychiatry and in psychology,
depressive symptoms are things like poor sleep, changes in appetite, hopelessness, low mood. And these symptoms can be seen in conditions that have more of a medical etiology,
a medical route. And so I think that’s why it can be very confusing. for people going through these changes because what they appear to be experiencing can mimic a major depressive episode,
but it is not identical. Yes. And then you also, you know, went to Washington DC for the menopause to have menopause recognized with,
let’s talk with the research. Yes. How, you know, how can we get this word out to people and to women that these issues are important and that maybe,
you know, yes, you could see a psychiatrist for it, and yes, there’s issues there. What can we do to help women in this situation? I do think that it’s important to educate yourself and,
you know, it’s somewhat controversial because it’s the onus shouldn’t be on women. However, we have to be aware and acknowledge that these gaps of knowledge exist within the medical system,
not because doctors don’t want to treat patients or because they don’t have a desire to do what’s right. But because there are very known gaps within medical education.
For example, there were a huge study in 2019 that showed that when you sampled a lot of people who had just graduated medical school and who were in fields that were more traditional in terms of serving women’s health like family medicine,
GYN, and primary care, that many of these recent graduates had very little menopause education in medical school and even during their their training post medical school,
they, something like only 58 % had one lecture in menopause. So it’s not that the doctors don’t want to know, it’s just that there were gaps in medical education that existed.
And so for that reason, many doctors can make an incorrect diagnosis because of that gap in their knowledge. So how do we address this gap?
You know, yes, number one, we have to start educating medical doctors when they’re in training and when they’re in medical school. But the amount of time that it would take to produce doctors who are competent in menopause health care to meet the demand would be decades.
So one of the ways to address this is to have patients educating themselves. So in the same way that you would, if you became a doctor, if you were a doctor, if you were a doctor, if you were a doctor, pregnant,
you would start reading, you know, what to do when you’re expecting or you’d be reading about, you know, the baby’s health and so forth. You wanna start learning about your own health and start recognizing some of the symptoms of perimenopause that can begin as early as 10 years prior to the loss of your period in menopause.
So start preparing in your 30s and 40s for the changes that are happening so that you have the… best outcome. And that way you become an active part of your treatment team.
And what does that mean? So you’re not just a passive participant in your health care, you’re actually a part of the team. So you’re coming to your doctor with a list of symptoms, with a list of questions, you know,
with data that you read, with things that you’ve seen online that are from evidence -based and reputable sources so that you are an active part of the treatment team. Know what medications you’ve taken in the past,
know your medical history, know your family history, because all of these things gives you a doctor a clear picture of you and you want to be active in the treatment team. You don’t want to be a passive person in your care.
You also talk about when hormones are affecting mental health, the TIES kind of method and I was hoping we could break that down. So the first, the T is your thoughts.
Can you talk about cognitive changes? – Yeah, so I am a psychiatrist, meaning that I can prescribe and I can provide therapy. I went to medical school so that I could do both because sometimes you do need to approach mental health conditions with that holistic view.
And one of the things that I noticed during the pandemic because I do treat children as well as adults. was that there were stimulant shortages. So a lot of people were at home self -diagnosing with having ADHD.
And many times in midlife, not to say this doesn’t happen, but many times in midlife, people will self -diagnose as having ADHD, go to the doctor, and then I get a referral for a woman in her late 40s,
early 50s, who’s like all of a sudden have an ADHD. Well, that’s not the way that ADHD presents. ADHD is a childhood condition. However, and so by definition, it starts the symptoms start before the age of 12.
However, I was having a lot of referrals for women who were saying that they had ADHD for the first time in their in their like middle life. And what I was finding was that many of these women were actually experiencing something called brain fog.
So they were forgetful. They had issues with time management that they never had before. You know, they had memory problems that they never had before. So these were executive functioning issues that they had never had.
And they were suddenly having them. And they, you know, it’s not like a sudden abrupt thing, but they noticed a long over time, especially from being at home and not having that clear boundary between work and home life and having all these distractions that it was becoming more prominent and problematic.
And so, uh, thought issues are something that you, you can see over time in your perimenopause in like the decade leading up to the loss of your period.
Um, but, you know, if you’re not aware of this happening, you, you think, you internalize it and you think there’s something wrong with you and many women are multitaskers, you know, they’re doing multiple things. They’re being a mother, they’re working at home,
but sometimes they’re at work. they have careers, they’re entrepreneurs, they’re doing a million things, they’re taking care of older parents. So having this part of your identity loss,
right? Like not being able to do all these things at once can be a real hit to yourself confidence. And so the eye entices identity loss. So you feel like you don’t know who you are anymore. Because of these changes that also happen in your body,
you may feel that there are limitations or changes in the things that you can do physically. For example, one of the symptoms of perimenopause is, you know, joint pain. And for some people,
they don’t find themselves as flexible as they used to. They may have shoulder pains that they’re not able to engage in activities they used to, or it’s more challenging. So there can be that loss of identity.
And so that’s the eye and ties between mental health and menopause. The E is emotions, like I mentioned previously, hormonal fluctuations. can lead to feelings of low mood or anxiety.
And these are emotional symptoms that sometimes people are moody and they feel like, oh my gosh, I was never this moody or irritable. And it can be really distressing.
And the S is sleep. So sleep issues are known to happen. Usually they present as the latency issues or difficulty falling asleep. and then when you wake up, you don’t feel refreshed.
So you’re not feeling as if you’re getting restorative sleep, and this could happen for a variety of reasons. Sleep architecture is thought to be heavily impacted by the hormonal fluctuations. And also in midlife,
some women develop sleep apnea, which can contribute to worsened insomnia and worsened restorative sleep. So the TIES, the Ties of menopause is something that I developed.
as an acronym mostly because I teach young doctors and students, but also because I want to teach my patients because they’re active participants in their treatment plan. I want them to know what to look for so that they don’t feel surprised.
And in mental health, you know, there’s something called affect labeling. If you know how you’re feeling and if you can give a name to your feeling, you actually have reduced anxiety because the human brain wants to know what’s happening.
And if the human brain doesn’t know what’s happening, it’s confused and afraid. So knowing that these things can happen in itself is therapeutic. And if you go to your doctor, you’re like, I’ve been experiencing the ties,
right? And I know the three Ps, right? The three Ps meaning that there are differences between actual hormonal fluctuations leading to mood symptoms versus major depressive disorder.
So the three Ps are are a loss of period. Major depressive disorder does not include a loss of period. Physical changes don’t happen with major depressive disorder. So physical symptoms like hot flashes,
palpitations, skin changes, itchiness, those don’t happen with major depressive disorder. And the last P is a past history. So if you don’t have a past history of depression or family depression,
you know, less likely due to, um, uh, depressive disorder and more likely due to an onset of perimenopausal mood changes.
So those, if you know those things when you go to your doctor, you’re already helping your doctor, you’re already headed to the game. But if you know nothing when you go to your doctor and you’re like, oh, I have all these symptoms and I don’t know what’s happening and I feel like I’m losing myself in my mind.
And what’s going to happen is you’re going to be referred to the wrong source for help and you’re not going to get to the bottom of what’s really at the root of these issues.
And so we want to make sure that patients feel educated and empowered so that they are an active part of the treatment team. And that’s why I use highs as an acronym for psychoeducation because I think it’s easy to remember.
Yeah, it sure is and I am a big follower of yours on Instagram. And I just have to say, your videos are just, they’re so helpful just for a person just watching and the explanations that you use in your videos.
I just find them, sometimes I’m like, that’s what I’m doing, or I’m recognizing things that I’m doing. One of those that stands out to me is high functioning depression.
Can you share? a little bit about what high -functioning depression is? So things like imposter syndrome and burnout.
No one would argue that those things don’t exist, but they haven’t quite made it into the Bible of psychiatry, the DSM -5. But if I go up to anyone on the street and I say,
“Imposter syndrome isn’t real,” they’ll be like, “Are you kidding me? I’ve experienced that before.” High -functioning depression. is something that I’ve noticed over the course of the pandemic. And I not only see patients in a private practice,
but I also have a clinical research site where I do research on several indications, including depression in pediatric and adult populations. And so what I was finding was that when you enroll patients in clinical…
clinical studies, they have to meet criteria for the study for major depressive disorder, when you’re enrolling them in depression studies. And one of the symptoms of major depressive disorder is anhedonia,
which is a loss of pleasure, a loss of interest. A lot of patients were coming in saying, I feel meh, meh, bleh. And they were just not enjoying life.
Um, but these patients weren’t meeting criteria for major depressors sort of because they were actually exceeding functioning and you have to have a loss of functioning or significant distress. And these patients didn’t have either of those.
So they had a lot of the symptoms of depression, including the anhedonia, the meh, blah, but they weren’t really meeting criteria for major depression because they still were,
you know, doing well. They were still meeting all their functioning at home at work. work and they weren’t necessarily in significant distress. So I started to think about this model and how we tell patients,
you know, well, you don’t meet criteria, you don’t fit into a box. Why don’t you come back once you’ve lost functioning and you’re really in distress? Well, I think that’s a broken model. And I get why the model exists. You have to be able to bill,
you have to be able to check a box so that you can then prescribe, then you can… code an insurance. But we as mental health providers, missing an opportunity to intervene before the person who’s dysfunctional,
before they’re in distress, before things are falling apart. And so I started putting out some content about this over the course of the pandemic,
because people were in need of mental health information, but they weren’t necessarily getting it from reputable sources because doctors are so busy they don’t have time to post.
But I happen to teach a course at NYU that I’ve taught for about 10 years to young doctors about how to be responsible, giving information over media. And one of the tools that I use is social media to educate the masses.
And so I started putting out these videos about high functioning depression. And my social media team, there were a lot of people who were in need of mental health information. like, I was in the clinics, seeing patients. They were like, you got to check your,
your TikTok, you’re like blowing up. And I was like, I don’t have time. I’m seeing patients end of the day. I went and I checked it and it was like, had gone viral. Millions of people had said, that’s me. And so I thought,
Oh, okay. Maybe it just got viral because I paired it with a viral song. Then I decided, all right, let me see what else I’m seeing in my practice with regards to high functioning depression. So I started putting out videos and I had,
and Hadonia was which is a loss of pleasure and interest that blah, meh feeling. And that went viral. So I thought, okay, there’s something to this. Let me start looking at what we know about depression,
anhedonia, and these people who are not quite loss of functioning, they’re not quite to the point of distress, but they they could eventually get there. And why is this happening? So in medical school,
we learn about the biopsychosocial model. for symptoms and diseases. So the bio meaning the body and genetics, and the psycho meaning the mind,
mental health history, and the social meaning the environment. And I started looking at these individuals. And what I found was that some of them did have histories of depression in their families or personal histories.
So that’s a bio model. model. The psycho part of this biopsychosocial is what from a mental health perspective makes them predisposed to this.
And I think a lot of them have unprocessed trauma, not like necessarily trauma like combat or assault or anything serious, but also like people have had histories of financial stressors that were quite traumatizing like the little Ts and histories of other…
things that happen in their lives like, so let’s say the pandemic, which was a major trauma to us all that we haven’t really processed. And then the social part of that model is what’s happening in society these days where that could be contributed to this,
you know, we have an uptick in the amount of information that we can consume. There’s high social media use. There are multiple stressors in the environment so many.
many like wards and strife and there’s just a lot going on, right? So like, it’s probably a combination of the biopsychosocial stressors that are leading to these people walking around still functioning but not quite feeling like they’re full self and feeling blah and experiencing high rates of anhedonia.
And one of the studies that I’m doing in my lab independently, irrespective of the companies that I work with, is looking at the high functioning depression as a prodrome,
or what it looks like before you eventually develop a depression, or what it looks like before you develop a substance use issue, or what it looks like before your body breaks down because you can’t take it anymore.
I want to see if we can support people before it gets to that point. I wanted to go back a step with the acronym TISE and one of the things that we hear a lot from our listeners is the identity loss is not feeling themselves,
not knowing where they’re going to go. And you talk a little bit about radical acceptance, cognitive, can you talk about your advice for women who are feeling that way? There’s a huge gap in terms of research,
but one of the areas where there is significant research is cognitive behavior. therapy, and we still need more studies. But with regards to the other modalities to support the ties,
I mentioned that over the pandemic people were self -diagnosed with ADHD. Well, that led to a stimulant shortage. And I even did a special for Good Morning America where we talked about how people are just being prescribed stimulants that don’t need to be on stimulants.
But that led to a in psychiatry to become resourceful and to pull out organizational skills therapy, which is a type of therapy that child psychiatrist learn in training to support children with ADHD.
And this includes multiple skills, like using different modalities to organize, using things like a launch pad, which is an area of your home or school or work where you put all of your essential items like your keys,
your wallet, your phone, so you don’t lose them using decluttering methods so that life decisions are simple. For example, you know, with the, with the children and young adults I work with,
we’ll have a part of the closet that is specific for your go -to, what to wear so you don’t have to think about anything else or using old -fashioned filing systems that are color coded so that you know that subjects are in the right place.
Well, guess what? what? Organizational skills therapy supports people with executive functioning issues, even in some cases where people are experiencing brain fog. So I’ve utilized a system to support women who are experiencing these cognitive issues by using these organizational skills therapy modalities that we typically use for ADHD or mild cognitive impairment.
in dementia to support women while they’re going through these temporary executive functioning issues. The identity part of TAIS is of utilized mindfulness techniques from something called dialectical behavioral therapy,
which is a therapeutic modality that draws from Eastern philosophies and incorporates cognitive behavioral therapy into it to allow women to feel grounded because when you’re feeling identity loss,
you become dysregulated. So we teach women how to use practices and mindfulness so that when they’re feeling this way, in that moment, they can challenge these thoughts by staying present in the moment so that they’re,
they have the capacity to regulate their mood and to pick and choose which moods they decide that they want to feel, which is, if you can give a woman that agency and mastery, you can. can help them through any moment of emotional dysregulation.
But if you don’t know that these type of tools exist for this, then you won’t be able to use them. And so dialectical behavioral therapy principles can be applied to these identity issues.
And the reason I thought of that was because dbt is traditionally used to treat certain conditions like borderline personality disorder. And in borderline personality disorder, there’s something called identity diffusion,
where people feel as if they’re constantly trying to figure out who they are. Well, we use a lot of DBT methods to help people to have less of this identity diffusion.
And if we can train women who are going through these identity issues with menopause, how do you utilize mindfulness in these moments of discussion? distress, then they have more agency and mastery.
And I mentioned cognitive behavioral therapy is one of the few therapy modalities where there’s sufficient data to support women during perimenopausal mood changes.
Cognitive behavioral therapy can help women to challenge automatic negative thinking that comes with the anxiety and the depressive symptoms. that can happen in perimenopause.
And using CBT methods and practicing them when you’re not in moments of distress will allow you to be able to pull on them when you need them. But again, it’s hard to start implementing these things in a moment of distress.
It’s better to start learning and preparing for them when you’re in a calm state. And then in Somnia, or sleep issues also respond to cognitive behavioral therapy.
So the insomnia part of cognitive behavioral therapy is proven to be just as effective, if not more effective than certain sleep aids.
So rather than taking like a sleep medication, if you’re able to utilize tools learned in CBTI, you may be able to utilize tools learned in CBTI. to have better sleep,
and sleep is so restorative. We need sleep to think better, to feel better. We need sleep for just about anything to fight off viruses and illnesses. If you’re able to start learning proper sleep hygiene,
learning CBTI before these changes occurred, then you’re going to be set up to be in a better place. [BLANK _AUDIO] that’s why this is important because you don’t want to start doing these things when you’re in crisis mode.
In my line of work, we always try to teach skills before you’re in crisis because anyone who’s under a great amount of stress, try teaching them during that time. It’s like the worst time to learn. The stress that brain is not the best retainer of knowledge and so practicing these things beforehand,
learning about these things. things before your body and your mind goes through these changes is really going to prepare you for having the best outcome. Yeah, we had spoken to someone that said your IQ goes down when your emotions get really high that your IQ goes down.
And I can, you know, when you were talking about to help someone where they’re in that stressed situation is not the best time to do that. And So what would be a good example to give someone just to start with a cognitive behavior therapy?
– You mean like if they can’t do what they used to do? – Right, or if they get this moment of anxiousness and they’re not knowing what to do, what is a good first step? – Well,
cognitive behavioral therapy is typically something you do with a therapist, but there are practices. practices that you can do. If you Google cognitive therapy, there are online free resources where there are worksheets that you can download and activities that you can do to challenge negative thoughts.
And some of these activities look like, okay, what is the thought? How strong is the thought on a scale of one to whatever you want to choose? How does it make you feel? Okay, how can we challenge that thought? So you’re basically learning how to put these these thoughts on trial and then practicing putting these thoughts on trial and then seeing how you feel afterwards so And the reason that this is helpful is
because sometimes feelings can feel like facts But they’re not feelings are not facts and if you learn that Early in the process of life Then you learn how to regulate your emotions and when you learn how to regulate your emotions then you can can have more thought agency more mastery and also you know how to control your behaviors and the way that you respond so the idea is that you want to start working on these
mindfulness and psychological practices early in life the same way that I tell women that I work with you know if you if someone works with you and you know how to control your behaviors and you know how to control your know how to control your behaviors and you know how to control your behaviors and you know how to tell you to start saving for your retirement in your fifties,
you’d look at them like they were crazy. Well, why would you treat your body any differently? Start preparing for your, um, your body’s longevity early in life.
So, and it’s never too late because I don’t want people to listen and be like, Oh man, I wish I started when I was in my thirties and now I’m in my fifties. It’s never too late. Um, so when you start thinking about what to do,
to set you up for a higher quality life and lifespan, things like decreasing your stress or learning how to cope with stress in an adaptive way.
I mentioned some of those tools like the CBT, the DBT, the mindfulness. Start thinking about that now. Start practicing those things now. Decreasing the amount of toxic people in your life.
You know, you– may not be able to cut people off completely and I don’t suggest that, but limiting the amount of exposure to these people, deciding who you want to give your precious time to,
being around people who actually feed your mind, body, soul, and they don’t drain you if possible. These are really important things that, you know, you think that they’re all like loosey -goosey,
but they actually are evidence -based to show that you have a better physical outcome. when you like limit toxic people But toxic behaviors and habits smoking is something that Everyone can start to work on if you’re a smoker decreasing that set you up for better menopause outcome decreasing the amount of alcohol you take in that Really?
Significantly impacts both your your mood symptoms and your physical symptoms as you go through the these this transition You know, the exercises that you did in your 20s are not gonna help you in your 50s.
So you’re gonna have to shift your movement regimen and start to implement more weight -bearing exercises and thinking about things that you can do to improve your balance because your balance and your proprioception,
the way your body interacts with the world and the environment, that changes as you age. So you want to be able to… start preparing your body so that when you go from a sitting to standing position, you have,
you know, more of an anchor and weight -bearing exercises and more high intensity type of exercises help you. And then diet really is important.
Something that’s often neglected, you know, in our 20s, we’re thinking about calorie counting and having like all this like nice juices, but no, we have to think about about protein. So start building up the amount of protein that you eat.
All of these things can support your body and your mind. There’s a whole field called nutritional psychiatry where food is medicine and you’re literally eating foods to help you beat depression and anxiety. So start thinking about reading those books and incorporating those type of nutrients into your diet because you’re you’re it’s like money in the bank right but the bank is huge.
you’re the physical bank. So you’re putting you’re setting yourself up for a rich Healthy life rich not monetary, but physically and mentally rich But you got to start preparing for that today.
That’s not something you can Automatically do it’s never too late, but it’s better to start preparing today And I would actually we had dr. Uma. I do on a few months ago and she talks a lot lot about nutritional psychology,
and I would recommend that the listeners go over and listen to that episode as well and read her book. I wanted to talk about, you know, you’ve been on the news and you’ve been really all over social media,
but you have a book coming out soon called “Golden.” Can you talk about that? – Well, the book is coming out in 2025, so– – Oh, I thought it was coming out in 2024. Then we’ll just– – Yeah,
no. – We can, and for some reason, we thought it said April 2020. – I just probably read the wrong year. (laughing) – No, yeah, it’s 2025,
but I’m looking at high functioning depression and how to get ahead of this biopsychosocial model that’s set us up for like a lack of joy in life. Again, right, you know,
mental stress leads to worsened physical outcomes. outcomes and many of us, you know, like we along the way forget who we are and we have to figure out how to find our way back so that,
you know, we live our most authentic and healthy lives. And so this book will focus on that. But, you know, I’m glad that you have guests talking about nutritional psychiatry because inflammation is a model that belongs to us.
in the bio part of the biosecosocial. You know, things that we eat, our environment can really harm our body and low inflammatory states. They really set us up for better outcomes in terms of our mental and physical health.
And a lot of these diet programs are focusing on nutritional ways to decrease inflammation. Well, we’ve been doing this podcast for four years and it’s so great to see the evolution of the menopause conversation because now,
you know, often neglected are the mental health aspects and how we can holistically help ourselves. So you’re entering this conversation the way you have in the last couple of years.
We just so appreciate what you’re doing and how you’re spreading the word for women so that they feel empowered to go to their doctors and say, “I want to know about this. I want to know about that. What are my options?” So thank you so much for coming on the show,
Dr. Joseph. We truly appreciate it. Thank you for having me. It was my pleasure. Have a great day. You too. Thank you. Bye -bye.