The Buddhi Clinic team first met Raja Mohan a Southern Railway employee, then in service, in early 2019. He was referred to us for rehabilitation following a stroke that had left him bed bound, paralysed and unable to care for himself. Over three months, with our then “new” brand of integrated care, #trimed, Raja Mohan made an amazing recovery, becoming completely independent and ambulant once again. So much so, that his integrative medicine rehabilitation case study was covered in Doctor #Vikatan a popular Tamil language magazine. Raja Mohan went on to rejoin work in the Southern Railway Booking Office, would walk a couple of kilometres every day to catch the bus to work, and resumed a generally active lifestyle. With multiple co-morbidities, Chronic Obstructive Pulmonary Disease (COPD), Hypertension, Diabetes, High Cholesterol levels, and Mild Cognitive Impairment (post Stroke), he remained active, followed up with all his medical specialists regularly, thanks to his loving wife, fulfilled his many roles as husband, father, sibling, uncle to his large extended family of 26 people occupying a block of apartments in Chennai, and worked till his retirement from the Railway in 2019.
Earlier this year, Rajmohan was wheeled back into Buddhi Clinic by his distraught wife. Affected by #Covid-19 he had been in hospital for two weeks, before being discharged. Wheel-chair bound, confused and disoriented, he was uncommunicative, vacant and unable to care for himself, being incontinent of urine, needing feeding by hand and assistance for all activities of daily living. In normal circumstances we would have advised admission to hospital for #delirium management and #rehabilitation. In these troubled times of a second wave, neither were hospital beds available, nor would his condition be considered a priority. Thus began our #home care protocol for #Covid-19 delirium rehabilitation with his wife and extended family assisting his recovery.
At intake the following symptoms were targeted for rehabilitation.
Poor sitting and standing balance
Difficulty in walking
Mild weakness of lt upper and lower limbs-4
Poor food intake
Dyspnea on exertion
Mild tremors in both hands
Medication was substantive and included neuropsychiatric, pulmonology, Diabetology and medical prescriptions, in total a list of about 16 different formulations including some combination drugs. The neuropsychiatric drugs included sodium valproate (for seizure prevention and behavioural control, continued from hospital), donepezil (for cognitive dysfunction, piracetam, citicholine and ginseng. No other psychotropic drugs were prescribed to manage delirium as there were no problem behaviours.
We commence care on 16th April 2021 with our physical therapist (Mobility Lab), tDCS technician (Brain Lab- Neuromodulation) and Complimentary & Alternative Medicine technician (CAM Lab) delivering 10 sessions of care each at home.
Electrotherapy, exercise therapy, gait training & manual therapy
Focal abhyangam and reflexology
tDCS- delerim protocol
With each lab tech visiting Raja Mohan two to three times weekly (as the ongoing lockdown would permit) Rajamohan made a slow and steady recovery. Indeed when reviewed by our founder Dr. Ennapadam S Krishnamoorthy on 10th May 2021 (about 3 weeks on) the clinical notes were “Has made good recovery from post Covid delirium- in home based rehab from Buddhi Clinic. Is ambulant, responds appropriately. Continues to have slowed cognition, mild tremors, some dryness of skin in the feet etc.
At our end of “first therapy cycle” case conference the outcomes were recorded as follows.
End Therapy VAS*
Raja Mohan is no longer confused or disoriented. He is completely independent in all activities of daily life, moves about freely and safely, walking with a broad based but stable gait, and responds appropriately to all questions, with some delay and slowness, but with clarity. Indeed, his wife’s comment was “you have given him a third life”, she having witnessed the devastation of neurological insult twice in the span of eight years, first a stroke and now Covid-19 delirium. From the medical perspective we learn that Covid-19 can cause delirium which is treatable, this being our third success story. From the humanistic perspective we understand the importance of faith, hope and family in rehabilitation and care.
Raja Mohan rides again and in doing so he validates for us the importance of our Buddhi Clinic’ integrated care model in #neuropsychiatry.
A conversation between Dr. Sheela Nambiar MD, Obgyn – (SN) and Dr. Ennapadam S Krishnamoorthy – (ESK), Behavioural Neurologist & Neuropsychiatrist.
SN – Welcome to you all. We are happy to be here to discuss this important topic of depression. Dr Ennapadam Krishnamoorthy is a Neuropsychiatrist and Behavioural neurologist. He is the Founder of the Buddhi Clinic chain which offers complementary and alternative medicine, in addition to, standard neurological & psychiatric care and psychotherapy solutions.
SN – Why would you say the disease of depression has become an epidemic of the 21st century? Is it something that we are calling out more or are people more depressed than say, 20 years ago?
ESK –We understand today that depression is one of the most common medical problems worldwide, a cause of dysfunction and debilitation. At one end it is just a feeling most of us will experience at some point in our lives, due to life circumstances or, a loss. Sometimes it might last for a short spell. At other times it may last for a longer period of time and affect our lives. That is when it becomes a disability.
Let’s say, I break a leg – it is a very apparent disability. But, when I am depressed, no one else may know what I am going through, because it is so personal and internal that it cannot be communicated to others. It is a transient feeling but that which disables an individual and prevents her/ him from having a normal life.
A meta-analysis from BMJ looking at how depression has progressed actually shows that the rates have dropped from 36% to 24% in patient clinics. The paper also says you are more likely to be depressed in your 30s and 40s and then late in your life. So it’s a “U” curve. So I’m not sure if it is indeed more common than before.
SN – So what is the difference between feeling low and having a clinical depression?
ESK – The difference is in the severity. Is it significant enough to need attention? How long has this gone on? The duration can be as less as two weeks. But the most important thing to ask oneself is – ‘is it preventing me from having a normal life?’ If it is, one needs to pay attention to it.
SN – What is really interesting to me is that everybody has problems. I don’t think anyone gets away without problems. How is it that some people are able to withstand them and not become depressed, whereas others having similar issues get depressed?
ESK – So in your introduction you used the term “bio-psycho-social”. The Bio part of it is how each of us is wired. This is a combination of genetics, early upbringing and the like. This is when the brain develops. Your ‘Bio’ is influenced by your genes, by the chemistry in your brain, certain inflammations like the antibody syndrome when your body is attacked by something, the body responds by creating antibodies but which then turns against your own body’s cells. There are metabolic factors that cause depression. These could be hypothyroidism, low B12, D3, having diabetes, and certain skin conditions like atopic dermatitis. We, then, come to Psyche which is your temperament. Certain temperamental patterns, like worriers, obessesive anxious people may be more prone to depression. There are Social-environmental factors which include parenting, family, outside influences etc
So, the question “why am I getting depressed”? has multiple answers – we all have emotional scars of various kinds, some we may not even remember. We also have nurturing factors that make us stronger. People who are worriers, obsessional, anxious, tend to be more prone to becoming depressed than people who take things in their stride and just move on.
SN –And there is some research on how more creative people tend to be more prone to depression is there not?
ESK – Oh yes. There is a lot of literature on mood swings and creativity. There are a number of examples of poets, artists and people in the creative field who were depressed. That’s also because depression is more of a right-brain than a left-brain phenomenon. Having said that, there are forms of depression that are left-brain too. There is a social aspect to depression, one interesting statistic is that you are seven times more likely to have a mental health problem in the 6 months after your marriage than in any other time in your life!
But interestingly there is another counter-statistic is that one of the things that makes sure that you have a good outcome from a mental health problem is being married.
ESK – Women are twice as likely to experience depression in their lives than men are. Due perhaps to all the life events they go through and the hormonal changes.
SN – Hormonal fluxes can be quite drastic from menarche, to pregnancy and delivery to menopause. These events do influence a woman’s mood. Would you say that social support also plays a role in depression?
ESK – Absolutely. Both in protecting you against depression and in helping you overcome it. Having a good social support system, work and employment, activities you resonate with and a healthy financial status.
SN – I deal mainly with women being a gynaecologist. I find that women, once they cross the age of 40 or so, find themselves wondering what else to do, now that their children are independent Once they are given some support, they make a change that they perhaps could not attempt in their 20s and 30s. It may be maturity or that after a point they no longer want to please society, norms or the people around them all the time. One of the triggers for this change is that they start to feel depressed. Have you come across situations like this?
ESK – Absolutely! Menopause/Perimenopause also plays a role. Mood, memory etc. are affected around this time. Apart from life circumstances, there are biological changes that are happening so symptoms of depression etc. can set in.
SN – What do you have to say about this concept of depression being connected to ‘weakness’ and the stigma behind it? Does this hold back people from coming forward to get help? In fact, even family members may brush it off saying, “you need to get over it”.
ESK – That is the most common thing we say, “pull yourself together’. But they cannot! That is why one needs to understand that it is a disability. If one were paralyzed, one would not say “get up and walk”. There is, also, a burden of expectation we all place on ourselves. The expectation – to be normal and fulfil our obligations. When you are depressed, however, these obligations may seem big. Getting better, just like with a paralysis, is a slow process.
SN – Can you tell us the different symptoms experienced by a depressed person? Do different personalities express depression differently?
ESK – Children and elders express depression differently. A child might be irritable, agitated or angry. Elders might also show similar signs. Though they are both likely to be depressed. In adults, it can be expressed as low moods, or
” Anhedonia” which is the inability to feel pleasure in things you would normally find in, “Hedonism”- to seek pleasure mindlessly, or “Alexithymia” which is the difficulty in verbalizing an emotion.
Language has an interesting connection with depression. There is no word for depression in Tamil for instance. There is no word to say I am depressed in Tamil. You only express things like ‘the mind is tired”.
There are linguistic barriers to expressing depression. Our culture does not encourage you to express your emotions like Western cultures do. Most of us would not for instance, go on the Oprah Winfrey show and talk about our glorious or miserable lives! This is because our culture does not encourage us to express our emotions. People often use ‘as if” terms to talk about emotions rather than talk about their emotions directly. In a number of Indian and other native languages also lack words for certain emotions. Friends from Africa tell me they don’t have a word for depression.
SN – Coming to the treatment of depression, can you tell us something about anti-depressant drugs?
ESK – Anti-depressants have had some bad press. But they have a unique mechanism of action. We used to think they correct the chemical imbalance in the brain and that is what relieves symptoms depression. We now know that some of these drugs actually help to grow new neurons. They have a neuro-protective effect. This may be why they take a long time to produce relief from symptoms. Antidepressants take a long time – 6 weeks to 3/6 months. The most common reason for ineffectiveness of treatment is non-compliance to treatment. The second is the failure to try a drug at an adequate dosage for an adequate period of time. So, often, if 3 months later you don’t feel better, you may change your doctor, your drugs etc.
All drugs have side effects, of course. I think a patient should try anti-depressants under the guidance of a good doctor before they give up. In my experience, most people give up the treatment too easily. It requires a therapeutic alliance between patient and doctor.
SN – Can a patient go off the drugs completely at some stage?
ESK –You cannot stop them suddenly, they need to be withdrawn slowly and gently. Typically, the drug needs to be taken for at least 6-9 months.
SN – Have you come across many patients who complete the course of drugs and do well?
ESK – Depression is one condition where you can actually say you are “cured”. The chances of cure become better when besides taking medication you do other things like psychotherapy. Psychotherapy helps you understand the roots of your depression. Where is it coming from? It reflects the gap between expectation and reality. So, it is important to engage in good therapy and use this opportunity to understand oneself. Good psychotherapy will help you prevent further episodes as well.
SN – So Cognitive Behavioural Therapy would be one such form of Psychotherapy?
ESK – Yes, absolutely
SN – Talking about prevention and lifestyle management of depression, I would like to add about why exercise is so important for the management of depression. Exercise does produce endorphins; it makes you feel better and puts you in a better frame of mind. Diet is also of utmost importance. The gut produces as much if not more serotonins than the brain. The microbiome in the gut is responsible for much of your mood. If you do not feed the gut with the right kind of food, the microbiome in the gut is altered. It has been shown that people with very poor eating habits – highly processed food, sugar and so on have altered microbiome and are more prone to depression. Something as simple as a change in your diet and exercising on a regular basis can be a support system to the medication if you need it.
SN – What can you typically expect from a psychotherapist?
ESK – A good therapist is not someone who will tell you what to do. They will not advice you what to do. Instead a good therapist will show you a mirror to yourself. She/he will be able to help you understand your emotions and verbalize them. A therapist is a professional, and has no prejudices. All the solutions are within us. We may not see them. So, we may need the help of a good therapist.
SN – Is depression genetic?
ESK – Yes, when the Human genome project was underway a number of single gene disorders were discoved. Certain disorders of brain and mind also got unlocked. General thumb rule is that 10% of people have a genetic form of neurological or mental health condition.
Talking of psychotherapy – Everyone may not be suitable for psychotherapy. You cannot offer psychotherapy in all stages of depression. You may need to work with some people in other ways.
SN – Lets open the floor for questions
Question – When you are looking after family member with depression, how do you deal with them when they don’t comply with medication? What is the right approach when they refuse to take responsibility?
ESK – The role of the family and in having someone empathetic is important. Sometimes, when the patient refuses to come to the hospital we, at Buddhi Clinic will send someone to their home to try and engage with them.
Using holistic care like Yoga and Ayurveda, (which is offered at Buddhi clinic), we can get them started on a self-care journey.
Then, there are head massages. What a head massage does, which we now understand through research in other areas, is that it probably changes the energy metabolism of the brain.
So, engagement, having the family involved, offering people courses that they truly believe in and are willing to explore have a hugely beneficial effect on the management and better cure of depression. I became interested in these other forms of treatment after I found that often people with mental disorders when they try alternative forms of treatment like yoga etc. they are told to stop all other forms of treatment. So I decided why not offer them everything so they can continue their medication when required and also have the option of other treatment under supervision. We don’t understand the power of what other systems can offer.
A friend of ours who does research on Yoga has shown that after a set of Yoga sessions which are aimed at improving mood, the brain changes are the same as taking medication.
SN – With reference to this first question it is important to also rule out other disorders isn’t it? It may not be pure depression. It is possible that it may be a combination of mood disorders, psychosis and so on?
ESK – Thank you for pointing that out. It is important to recognize that what seems to be depression may be something else. It could be a disorder of the brain or body.
SN – It could be a simple deficiency like a B12 or D3 deficiency.
ESK – Yes or it may be an inflammatory condition of the thyroid for instance. Thyroiditis that is completely treatable.
Question – Is it true that depression can teach you something and it is there for a reason? Can the person be depressed because he needs to withdraw and ponder?
ESK – That’s a very interesting question. If you read the life stories of Ramakrishna Paramahansa, Jiddu Krishnamurthy and others you will find that for many, transformation and realization started with depression. “Pathos” is the word used. That does however, not hold good for everyone.
ESK – One of the things we have not mentioned about depression is the Becks Triad – this is the negative view about the world, the self and the future.CBT is circled around this thought process to identify the thoughts that are making you depressed and work on how you can re-think.Today we also have Transcranial Magnetic Stimulation TMS. For some this works very well. It modulates your brain and makes the chemicals more available. We have this treatment available at Buddhi Clinic. You need 20 sessions of about 30 minutes each. No anaesthesia is required.
Question – What do you advice people who are the caregivers of depressed people?
ESK – It has a profound effect on the family and caregivers. Caregivers go through a lot of stress. An important part of caring is to also extend it to the caregiver. Caregivers go through guilt, blame and remorse. Usually the psychotherapist is the best person to discuss this with. You don’t always have to do something active with a person who is depressed. Just sitting with them, going for a walk with them, listening to music may be sufficient. Just being there sometimes makes all the difference.
Question – What is the relationship between substance abuse and depression and what effect do they have on each other?
ESK- It is a kind of chicken-and-egg story. With some, being depressed may make them turn to substances like alcohol. In others, the alcohol is the problem and leads to depression. So, the drinking and the mood may be cyclical.
Questioner – What about food? Is that also a form of substance abuse?
ESK – There is a lot of association between eating disorders and mood. Anorexia and bulimia are associated with mood disorders. So, eating disorders and mood disorders can co-exist in a number of people. One can influence the other, the treatment of one can cure the other.
SN – There is evidence that obesity is related to depression and vice versa. So, when you are depressed, you reach for food as comfort, gain weight and then you get more depressed. Frankly I think food is as addictive as any other substance (abused), because it is so easily available, acceptable and accessible unlike alcohol and drugs. Especially sugar, not just white sugar but processed food that has added sugar is highly addictive.
SN I would like to thank Dr. Ennapadam S Krishnamoorthy who has been so generous to spare his valuable time to come here and spend this hour with us to discuss depression. It is silent, pervasive and so easy to miss. If you have any doubts about anyone (including yourself) heading down that road, there is no stigma. It is like any other disease. Just as you would not hesitate to go to a doctor to treat gastritis, there should be no stigma associated to going to a psychiatrist.
I hope Dr. ESK has made it clear and that is all the more reason we should pay close attention to it.
As World Yoga Day 2021 dawns, it could not have come at a more relevant time. For over a year, our world has been gripped within the jaws of a pandemic that comes in waves and disrupts our lives at will. It is a time when much of humanity is paralysed into inaction, by fear of an invisible enemy. Indeed, never before has Yoga and its modern offshoot, mindfulness, been so relevant. When one considers the term Yoga, one often thinks of it as being a physical discipline with mental effects; the adoption of postures in order to achieve a state of mental calmness and equanimity.
Modern science tells us that Yoga is not just about postures and mental states; it has substantive effects on the human brain, indeed effects that one is able to study on dynamic brain imaging such as functional Magnetic Resonance Imaging (fMRI).
Yoga is one of many important mindfulness traditions, perhaps the most ancient, from across the globe. Yoga which originated in India is derived from the Sanskrit word “Yuj” and means “Union”, indeed a method of spiritual union. In the Patanjali’s Yoga Sutra, the ancient and definitive treatise, it follows eight aspects or limbs- yamas (abstinence from immoral behaviour), niyamas (self-discipline), asana (physical postures), pranayama (breath control), pratyahara (sensory withdrawal), dharana (concentration, dhyana (meditation) and samadhi (pure consciousness). Let us focus on the breath, prana, which indeed is the focus of most modern mindfulness practices. Pranayama is the yogic practice of focussing on one’s breath and is meant to elevate “prana Shakti” or “life energies”. To be able “to restrain and control” one’s breathing is a very key element of the pranayama practice which is the fourth of eight limbs in the Ashtanga Yoga mentioned in the Yoga Sutras of Patanjali. Indeed, this focus on the breath is as old as The Buddha who incorporated it into his enlightenment discovery, with little success, at least initially.
And, the focus on the breath is very much part of the modern secular mindfulness practice, techniques such as Mindfulness Based Stress Reduction developed by Jon Kabat-Zinn, having made it integral practice.
Today, we think of mindfulness as secular, process driven and science based. Yet, Yoga, Tai Chi, the many martial arts traditions in the East, native traditions in the Middle-East, Africa, Latin America and among the “Indian tribes” in North America have incorporated practices that lead to “the thing called mindfulness”. At an extended University of Leiden online course that I attended, the instructor Prof. Chris de Goto described mindfulness “as a consciousness discipline that exists in the interface between science & spirituality, a kind of mental praxis”.
Yoga, therefore, is not just a “body-mind” exercise. Indeed, when things were normal and we medical professionals could meet, we the Buddhi Clinic and Trimed Therapy team had a conclave of experts across disciplines, discussing impact of these traditions on the brain and mind. In that Buddhi immersion, presenting a series of studies about Yoga conducted at NIMHANS, Prof. Gangadhar pointed out that there were positive biological and healthcare (including psychological) outcomes with its practice. Dr. Naveen Vishveshvariah of Yogakshema presented a number of research studies both those in which he was involved and others conducted and published from around the globe, that showed structured yoga practice having impact on a range of molecular, biochemical and neurophysiological parameters under study. In a review in the “Frontiers of Integrative Neuroscience”, van Aalst and colleagues* examined 34 international peer reviewed studies of Yoga using Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET), or Single Photon Emission Computed Tomography (SPECT), all of which incorporate dynamic brain imaging. They found 11 morphological (structural) and 26 functional studies, including 3 studies that were both structural and functional.
Apart from increased grey matter volumes in the insula and hippocampus, key structures for memory, emotions and behaviour, they were able to demonstrate increased activation in the pre-frontal cortex and functional connectivity changes within the Default Mode Network.
Their findings mirror modern mindfulness research from around the globe, with increasing evidence that mindful states, whatever their origin, have a profound effect on the brain, memory & emotions in particular.
Which then brings us to where the brain-mind -body connection originates from. Behold the Kundalini, that ancient concept of unlimited reserve power seated in the nucleus of every form of existence. Kundalini is conceptualised as being associated with and coiling itself around the bindu (the point of utmost sensitivity); while in its uncoiled, manifested form, it exhibits nada (the continuum of utmost sensitivity). The mystic 3 coils and a half of kundalini are thought to be the basic disposition of kala (the fundamental, the evolvent principle). Kundalini is a cosmic principle; it is seated principally at the “Base Centre” called muladhara.
When aroused the kundalini ascends along the path of Susumna (the yogic channel of life) and is the nature of ejection not projection (what the source loses, the receiver gains).
The susmna and cakras are not thought to be grossly anatomical, in that certain nerve pathways and ganglia are not to be taken as their “physical and physiological basis.” The cakra is considered to be a subtler more potent apparatus, yantram, that controls the economy of our whole being, physical, vital, conscious.
Thus what does Yoga or indeed any mindfulness practice done well, evoke? Wherein does this mind body connection lie? Well consider this! You are walking down a forest path one dark and lonely evening. You come across a wild animal, say a cheetah. What happens? You are perplexed and frozen, your pupils dilate, nostrils flare, muscles tense, heart beats fast and becomes almost audible (palpitations), you start shaking, sweating and feel short of breath, you perceive a need to empty your bladder (or do so involuntarily), you feel as if you have run a mile. In short, unbeknown to you, your nervous system prepares you to fight or flee. This is the work of your Autonomic Nervous System, nerve pathways that exercise control over our everyday involuntary actions, even as we think and make important (voluntary) decisions, to talk, walk, climb, eat and so on.
This autonomous part of your nervous system (hence autonomic), which connects body and mind, is what is influenced by Yoga and mindfulness practice.
And be aware, it is intimately connected with the deep recesses of our brain, the oldest parts of our mammalian brains, the Limbic system, composed of the hippocampus, amygdala, insula, all of which have a role to play in memory and emotion. And the decisions, to fight or flee, to be aggressive or passive, are derived from the prefrontal cortex, to which the limbic system is intimately linked.
Thus, our ancients probably got it spot on when they described the kundalini and the practise of Yoga. When we practice Yoga, we influence the Autonomic Nervous System and through it the brain, thereby bringing about physiological changes, heart rate, blood pressure, breathing; mental changes, a reduction in anxiety and enhancement of mood and motivation; cognitive changes, improved attention and focus, enhanced memory and quite naturally behavioural changes, behaviour being the quintessential expression of emotion.
It falls upon us, therefore, to celebrate our ancients, who deduced all this without fancy brain imaging, neurophysiology and neuropsychology; who created perhaps India’s greatest export to the world, one that influences “the mindful neuron”!
* June van Aalst, Jenny Ceccarini & Koen van Laere. What has neuroimaging taught us on the neurobiology of Yoga? A review. Frontiers in Integrative Neuroscience, 2020; 14: 34
Dr. Ennapadam S Krishnamoorthy MBBS, MD, DCN (Lond), PhD (Lond), FRCP (Lond, Edin, Glas), MAMS (India) Founder: Buddhi Clinic
In today’s fast-paced world, a large section of the population is denied the opportunity to manage chronic diseases through a wellness, holistic and healing-oriented approach.
Dr. Ennapadam S Krishnamoorthy
The burden of chronic disorders is largely attributed to the perils of modern medicine that prioritises cure through prescription drugs instead of focusing on the entire continuum of human healthcare engagement: rejuvenation, restoration and rehabilitation. The end result: an unhealthy ageing population.This is where India’s ancient and holistic Ayurvedic system as a viable form of alternative medicine comes in. It is about time medical practitioners harnessed the full potential of Ayurveda as it’s based on a strong foundation of scientific research, much like modern medicine’s tenets.
In recent years, a growing body of research points to integrated medical treatments—a combination of complementary (alternative) and modern (allopathic) medicine—gaining popularity. While modern medicine’s thrust is on cure, integrative medicine focuses on disease prevention, comfort and care.
However, despite the marked shift in patients’ preference for alternative forms of healing, I observed a deficit of innovation in therapies that are based on integrative medicine. This is where Buddhi Clinic’s genesis and my entrepreneurial journey can be traced.
I realised there was no other healthcare outfit in the world that provides a unique 360° evaluation of body, brain and mind through an integrated approach. At Buddhi, we take a holistic approach to diagnose a medical condition that combines the scientific rigour of modern medicine’s diagnosis and drug treatments with the therapeutic benefits of ancient healing traditions.
In essence, my long-term vision for our healthcare startup that was founded as a project in 2009 and company in 2013, is to make complementary and alternative medicine (CAM) gain acceptance as mainstream therapies. From my experience, I realised this would be possible only by seamlessly integrating them with modern medicine.
Let me tell you how this is done at Buddhi Clinic.
A Game-Changer in Brain and Mind Integrated Therapy
We are the pioneers and innovators of integrated care for the brain and mind. What sets Buddhi Clinic apart from the rest is that we don’t follow a cookie-cutter approach to diagnosis and treatment. Our raison d’être lies in being able to provide unique personalised treatment strategies for patients that is managed by interdisciplinary process-driven programmes.
Since several neurological and mental health disorders and disability are longstanding issues, patients need continuous and comprehensive care. Thus, we strive to offer a better quality of daily life to our patients by curating a range of therapeutic solutions based on considerable clinical and empirical research, and our team’s extensive experience.
Buddhi Clinic’s focus is on neurology and mental health rehabilitation and therapy. We have also created a range of interventions for pain, mental health, lifestyle and disablement conditions.
While our diagnostic approach and internal treatments are allopathic, we also rely on traditional healing therapies to restore the equilibrium of your brain and mind interface. Buddhi Clinic’s seamlessly integrated approach offers 14 non-pharmacological treatment modalities that are an amalgamation of modern science and ancient wisdom.
We offer treatment programmes for each condition customised for children, adults and the elderly. These include: Ayurveda, Acupuncture, Acupressure, Naturopathy- water, mud, aroma and magnet treatments; Reflexology and Yoga; and Rehabilitation therapies – speech, neurodevelopmental, physiotherapy and a range of specialized psychological therapies. We have also curated treatment combinations for Psychology – CBT, CRT, Behavioural, JPMR, ERP, EMDR; and Neuromodulation or brain stimulation (a full house of treatments).
Empowering the Patient Based on the “McDonald’s Model”
One of the guiding principles behind founding Buddhi is respecting and understanding patient preferences and engaging patients in shared decision-making. Towards this end, we perceive our startup to be the McDonald’s of “Brain and Mind Care and Rehabilitation”.
Similar to how a customer can curate his meal in a McDonald’s outlet, Buddhi Clinic, too, offers patients the choice to curate integrated treatment programmes tailored to their specific needs. This is called the “choice model” and is better suited for mild impairment and chronic or progressive health conditions. In such situations, we give patients the choice and flexibility to select a combination of modern and ancient interventions rather than rely on a single medical treatment, procedure and therapy. It is our belief that for best treatment outcomes, the patient should be in control of his own decisions regarding his healthcare options.
That said, our team also draws up a “prescription model” when the patient suffers from a chronic condition and requires continuous restoration and rehabilitation.
Crucially, at Buddhi Clinic, we adopt a holistic approach to healing our patients and focus on their overall wellness and recovery that goes beyond cure. We think different—not just about illness or disablement but also about ability and enablement.
Research and Innovation Led Approach
Nothing fulfils me more than making sustained efforts to give our patients a better quality of life. Our patient-focused approach includes continuously monitoring their progress and offering them quality pre-treatment, mid-treatment and end-of-treatment assessments.
Over the years, we have delivered quality healthcare to over 10,000 patients who have received an excess of 1,00,000 interventions. Our success stories that cover conditions such as autism, epilepsy, depression, Parkinson’s disease and dementia, among others, are documented as detailed case studies in ‘Buddhi Books’. The books are aimed at fostering the spirit of research and continuous learning to enable children, adults and elders achieve a better quality of daily life.
Buddhi Clinic also endeavors to offer innovative products and services to enhance the integrated approach to long-term brain and mind care. For instance, we use Transcranial Magnetic Stimulation (TMS) to treat neurological and psychiatric disorders. Transcranial Direct Current Stimulation (tDCS) and transcutaneous auricular Vagus Nerve Stimulation (taVNS) are also the Neuromodulation innovations we bring in. While the former two, rTMS and tDCS stimulate specific brain pathways for specific conditions and outcomes, the latter tAVNS stimulates the auricular (ear lobe) branch of the vagus nerve (ABVN), an easily accessible target that innervates the human autonomic nervous system. Like this, there are other innovations in the pipeline that we hope will lead to paradigm disruption in this space.
Building a Service-Oriented Approach
In order to create a healing environment based on holistic principles, we aim to continue to provide personalised and meaningful patient experiences at competitive rates. Since today’s patients have greater discernment, patient satisfaction is paramount to us. Our service-oriented approach helps us deliver, on an average, 10-20% more therapy to each paying client, apart from serving the disadvantaged at low cost or free of cost.
In the coming years, it is our goal to collaborate with doctors and diverse talents in the healthcare sector to serve populations beyond Chennai and India. Our objective is to demonstrate our capability as pioneers and leaders in integrated care with a brain and mind focus.
One of my key learnings as a healthcare entrepreneur has been that it’s not enough to achieve a robust bottom line growth. It is equally important to sustain it by creating impact at scale through a committed patient-focused approach.
Recently Mrs. R aged about 55 years consulted us with a range of symptoms that closely followed the first dose of vaccination for Covid-19. They included
Pricking and pulling pain in the hands and feet
Pain in the neck and shoulders
Altered sensation in the soles, feels roughness in them.
Pulling pain in the back of the knees and legs
Palpitations on exertion.
She had visited her family doctor and an orthopaedic surgeon and was diagnosed as having cervical and lumbar spondylosis and carpal tunnel syndrome. When it became apparent to us that her symptoms had followed vaccination, she having not considered this piece of information important in her earlier consultations, we proceeded to carry out our comprehensive 360* evaluation at Buddhi Clinic. Mrs. R met our team- physician, physical therapist, psychologist and electrophysiologist and was evaluated for a neuropathy as well as dysautonomia.
Lo and behold we discovered evidence of both a peripheral neuropathy (responsible for the pain in her hands and feet and altered sensation in her soles) as well as clinical autonomic dysfunction (Postural Orthostatic Tachycardia Syndrome being the diagnostic indicator) contributing to fatigue, palpitations and sleep dysfunction. There was also considerable health related anxiety about her new and unusual symptoms. A working diagnosis of “post vaccination neuropathy and clinical autonomic dysfunction” was made and Mrs. R inducted into our comprehensive care program. From a drug perspective we used pregabalin (a nerve membrane stabilising agent and weak anti-epileptic drug that helps with both neuropathy and dysautonomia), nortryptyline (a conventional antidepressant with anti-pain and anxiety relieving/ sleep promoting effects) and baclofen (for muscle spasm identified in clinical evaluation).
She started also on our comprehensive care (non-drug therapy) program with our Mobility & CAM labs. The mobility lab team delivered manual and electrotherapy treatments for pain/ dysasthesia and a comprehensive exercise therapy program for dysautonomia. The CAM lab team delivered focal abhyangam with Sahachadhari thailam and kizhi together with acupressure, reflexology and mud therapy sessions.
After 15 hours of each treatment paradigm Mrs. R was reviewed in our case conference, with the following outcomes.
Muscle spasm and pain in the neck and shoulders has reduced completely – the Visual Analogue Scale scores were- Pre therapy-8, Mid therapy-4, End therapy-0
Mild pain in the right brachioradialis continues with a Visual Analogue Scale Score of 2
Altered sensation in the hands and feet has reduced by 50% but tends to fluctuate, being present on and off
Grip, grasp and fine motor skills are improving
Pricking and pulling pain in the legs improved
Her metabolism improved and she perceives overall wellness in her daily functions
Sleeps 5 hours fitfully but would like that to return to her customary 7 hours
The self-application (assisted by family) of lepam (herbal paste) in both palms and soles is helping her; when her night time symptoms are bothersome she has learnt to apply ice packs to the dysasthetic areas and is able to sleep
Abnormal sensation in palms continues to fluctuate
A vaccination is nothing but a minor and contained infection inducer, designed to help people develop immunity. Not just COVID-19 vaccination, but all vaccinations can induce some adverse effects, unexplained neurological and neuropsychiatric symptoms not being uncommon. The temporal relationship between the de novo symptoms that Mrs. R developed, detailed by our comprehensive evaluation and targeted testing, confirmed for us new onset peripheral neuropathy and dysautonomia. As is our practice in Buddhi Clinic we combined modern drug treatment with the wisdom of convention (physiotherapy) and ancient traditions (Ayurveda and Naturopathy) to give Mrs. R much needed relief. Mrs. R continues in a step down program combining weekly clinic visits with our “Do it Yourself” (DIY) Buddhi kits and is on the pathway towards complete recovery. She discovered Buddhi Clinic and in her we have evolved the pathway to helping people with post-vaccination neurological symptoms.
Mr. P from Sri Lanka was brought to our attention, by another patient of ours Mr. A, who had benefitted greatly from our therapy. Four months earlier, Mr. P, a successful trader, had found himself developing abnormal sensations in his hands and legs, followed insidiously by progressive weakness. He went on to develop, over a month, problems with swallowing, speech and a host of other brain functions. As the family was concerned about his progressive illness, he was shifted to a major Chennai hospital. There he was diagnosed to have an acute inflammatory disorder of the brain, Acute Disseminating Encephalomyelitis (ADEM). After a fortnight in hospital during which time he received high dose intravenous steroids and a host of life saving procedures, Mr. P was discharged to home care and physiotherapy. A fortnight later, when the family found progress lacking, the TRIMED team was called in.
When we first met Mr. P he was bedridden, needing assistance for all activities of daily living; being fed by a Ryle’s tube, unable to speak, communicate, even indicate his needs. We were very concerned about his health and longevity. A brief admission in our affiliate hospital showed metabolic disturbances, probably a consequence of poor intake, needing immediate correction, as well as (in endoscopy by our discerning ENT consultant) significant oedema (swelling) of the laryngeal structures. He was stabilised in hospital over 5 days and discharged back to home care by the TRIMED team. We started our work with home based rehabilitation using a combination of Ayurveda therapies, mud therapy, physiotherapy, acupuncture, nutritional management and motivational counselling. In a week Mr. P was being mobilised from his bed to a wheelchair and was able to come to the TRIMED centre in his neighbourhood for intensive therapy. He was acknowledging his caregivers and attempting to communicate. In two weeks he started to stand with support and was able to swallow small quantities of blended food. He was able to speak a few words in a low voice. At the end of three weeks Mr. P was able to walk with assistance, eat most foods given to him; speak well enough to be clearly understood, eat normal meals and enjoy watching TV.
Four weeks on, from the time he found TRIMED, Mr. P boarded a flight back to Sri Lanka. He came to Chennai in a stretcher and boarded a hospital ambulance, acutely ill. Six weeks on, he walked through Chennai airport to board his aircraft. We are sure he will continue to practice the TRIMED way, our one hour program combining hatha yoga, progressive muscle relaxation and ergonomic exercises. His wife, besides herself with joy, has pinned an inspirational message on our centre’s notice board.
No doubt Mr. P needed and benefited from acute medical care, which saved his life. But it was our rich TRIMED blend of modern medicine with ancient medical traditions that got him back on his feet, delivering care beyond cure. Mr. P’s journey to Heaven’s Door and his triumphant return to the Emerald Isle, is our continued well-spring of inspiration at TRIMED
On John Nash and his Schizophrenia- published in Deccan Chronicle
The famous mathematician John Nash is a prime example, the film, A Beautiful Mind, bringing to engaging life the tumults that affect a person with schizophrenia. For the mind is a construct, not a physical entity. Modern medicine sees the mind as software and the brain as hardware. Millions of neurons, linked by chemicals (neurotransmitters) that establish pathways and communicate through them, form it. But when there is major mental illness, such as schizophrenia, this neurochemical system breaks down and there follows a disintegration of thought processes and reasoning.
What lies beneath?
The person so afflicted suffers from a degeneration of the neurotransmitter systems, of dopamine, serotonin and acetylcholine in particular, which serve like chemical messengers of the brain. They are molecular substances that can affect mood, appetite, anxiety, sleep and other parameters. Schizophrenia causes atrophy of critical brain structures, such as the hippocampus, which is the storehouse of memory and a device for comparing emotion. The person is likely to have grown up in an environment that offered limited opportunities for emotional expression or development. He or she also has an inherent over-sensitivity, a tendency to misperceive environmental events and is likely to over-react. It is important though, from a social perspective, for them to be educated, employed and to marry.
Mood swings, happiness or sadness that is out of proportion to the circumstances; hallucinations, seeing or hearing things; beliefs that have no basis in reality or delusions, making assumptions where none are warranted; emotional dyscontrol (anger, laughter, crying, inappropriately); sleep and appetite disturbances; lifestyle issues — these are some of the common symptoms. More severely affected people show a disintegration of language and communication, with stilted speech, odd behaviours and inappropriate gesturing.
The advent of chlorpromazine in the middle of the last century signalled the advent of a biological ‘mind cure’, and ever since, many psychotropic drugs have emerged that can help restore normal mental functioning and been found to be quite safe and effective. However, drugs are not without side effects and are by no means universally effective, a proportion of people failing to respond to various permutations and combinations. Further, while drugs control symptoms — even banish them — they do not restore normal functioning or the quality of life on their own. The affected person needs to relearn lost emotional, social and pragmatic skills, regain confidence to engage in social intercourse, learn once again to pay attention, concentrate and commit to memory; indeed function as an integrated whole, in family, at work and in society.
A comprehensive programme of psychological therapy for the person and the family is therefore essential. Occupational therapy to regain lost skills and focus; physical therapy, including exercise, to manage attendant physical symptoms and regain bodily fitness; yoga and meditation to manage anxiety, restore calm and enhance well being, are all helpful.
Largely untapped also, are the secrets ancient medical traditions hold, with potential to enhance physical and mental well being, Shirodhara in Ayurveda and Hydrotherapy from naturopathy, being classic examples.
Reintegrating the mind is thus a task for a multidisciplinary team, guided by a qualified mental health professional, and such an approach, with well defined goals, can go a long way in helping the patient.
#Trimedtherapy.com our #innovative #healthcare #enterprise featured in the #start-up files of the Times of India recently- a story by Pushpa Narayan.
After practicing medicine for seven years in India, London returned neuropsychiatrist Dr Ennapadam S Krishnamoorthy understood that while Indians had total trust in modern medicine their heart was often in traditional systems. If an Ayurvedic medicine would work or if a series of yoga sessions seemed to help, they would rather go for that. Like most allopaths, Dr Krishnamoorthy , was initially dismissive but soon realized that he should investigate the science behind “alternative medicine.”
After some years of diligent research and efforts, he launched a small clinic called Trimed, as a pilot, near his house in Sri Nagar Colony in 2009. With seed money from family and friends, Trimed sought to weave allopathy with Ayurveda, yoga, naturopathy and Pilates.
The first task for the integrated medical therapy centre was drawing up treatment protocols that integrate diverse genre whose practitioners have typically worked in silos – with each being mostly dismissive of the other. “In most such integrated centers, we realized that treatment was mostly left to patients’ choice. Many times patients aren’t guided through choices. Ours was a clinic and we decided that treatment protocols will be decided by the doctor,” said Dr Krishnamoorthy , one of the founders of Trimed. For nearly 40 conditions including pain, disability and mental health issues the team has standardized treatment practices.
Patients coming to Trimed meet an allopathic practitioner first, but they are also evaluated by at least four other specialists including a physiotherapist, naturopath, Ayurveda practitioner and a psychologist. The specialists then discuss the treatment plan for each case sheet.”Sometimes treatment plans take more than two hours to formulate,” said Dr Rema Raghu, an epidemiologist/ lifestyle physician, who is one of the core members. The aim is to bridge the limitations of allopathy with the wisdom in traditional medicine. “We made a conscious choice that all medicines prescribed will be only allopathic. Massages and therapy from other traditional streams are integrated with modern medicine. But with every case it is important to offer holistic care,” she adds.
The cloud-based electronic medical records of each patient stored at the hospital showed substantial progress in most patients. For instance, a 92-year-old a wheelchair bound patient walked out of the hospital after 15 days of intensive therapy and young IT professional was taken off the bench and put on projects after he was able to control mood disorders. Soon, Trimed, with its mobile therapy unit -an ambulance converted to therapy centre -extended services to home-care. “When people come to us they realize that almost everyone in the family needs holistic medical management,” said Gayathri Krishnamoorthy, a core administrator at Trimed. The centre, which was exclusively for medical management, is now expanding to offer rejuvenation therapy.
The company received funding of $300,000 from an Indian businessman living abroad. It is planning to start another centre in Coimbatore. “When I first heard about it I was impressed about the holistic approach concept. In fact some members in my family tried and benefited from it. I don’t think such centres should mushroom all over, but I certainly believe they have a place,” said A Vellayan, executive chairman, Murugappa Group, who has invested in his individual capacity.
The prevention of dementia assumes great significance, especially as we exist in an era of chronic and lifestyle diseases. Indeed, the role of hypertension, obesity, lipidemias (high cholesterol) and diabetes (the HOLD construct) as causative factors of chronic and lifestyle diseases including dementia has assumed great significance in the last decade. The American Dietetic Association has opined that food and nutrition play an important role in maintaining one’s health. It is also well known that sub-clinical deficiency in essential nutrients and nutrition-related disorders can lead to loss of memory and other cognitive functions.
Poor performance in memory tests has been shown to be associated with low levels of a range of nutritional factors:
Vit B12 (with elevated homocysteine)
a-carotene, total carotene, b-carotene
There is growing evidence that vitamin supplementation has a significant role to play in lowering the risk of dementia. Evidence for vit C, E, B12 and folic acid being given, as supplementation in higher doses, is particularly strong. However, the benefit seems most when supplementation is introduced in people who need it (with low vitamin levels) than in those who do not. These findings and allied research have also resulted in the US FDA recommending folic acid fortification of foods for the elderly, for example flour and bread. It is important to remember that high vitamin levels due to inappropriate supplementation can also be problematic and the taking of supplements should therefore be done with medical supervision.
There is mounting evidence that the Mediterranean diet, which includes a high consumption of olive oil and fish — and hence elevated intakes of monounsaturated fatty acids and v–3 polyunsaturated fatty acids — is protective against age-related cognitive decline. This maybe partly due to the antioxidant compounds in olive oil (tocopherols and polyphenols) and in part to the role of fatty acids in maintaining the structural integrity of nerve membranes.
There is no doubt that red wine consumed in moderation has been shown to be beneficial to health and well-being; reducing bad cholesterol, preventing blood clots and protecting the heart. In part this has been attributed to the constituents of red wine, which include procyanidins, a class of flavonoids found in plants, fruits and cocoa beans.
It has long been known that certain plant formulations have pro-cognitive properties and may enhance memory function. Many of these are the subject of active research today, Brahmi (Bacopa Monnieri), Tulsi (Basil), Ashwagandha (Withania Somnifera) for example. Curcumin, an active ingredient of turmeric, is also the subject of worldwide research. Among the fruits the pomegranate and walnut are thought to have pro-cognitive properties. While a variety of plants and plant formulations are under study, the jury is still out with regard to their specific benefits. The evidence for over-the-counter plant formulations is, therefore, not yet existent, notwithstanding their many claims.
Lifestyle & Attitude:
The jury is still out as to whether it is the aforementioned constituent factors that render protection, or indeed whether the overall Mediterranean lifestyle — physical activity, healthy food, abundant sunshine, meals eaten at a leisurely pace with plenty of socialisation — is responsible for the health, well being and good levels of memory/ cognitive function in that population. For example, therefore, red wine consumed in moderate quantities may be good for you, but only when it’s accompanied by such a “healthy” lifestyle & attitude.
A is a generally healthy and active woman professional of about 48 summers. I know her socially, well, and was curious when she sought an urgent appointment to see me professionally. “I am losing my memory doc”, was A’s first statement as she walked into my office. Probing further I found A was complaining of much more that absent mindedness. Word finding difficulties, struggling with routine skills like driving, becoming disoriented on arriving in a hitherto familiar location, not precisely remembering why she was there anyway, the list seemed endless. “Am I getting Alzheimer’s doc” was her genuine concern, expressed more than once as our interview progressed.
I asked her about her general health- whether she had any of the four key lifestyle risk factors which predispose to memory loss: Hypertension, Obesity, Lipid (high cholesterol) or Diabetes. While she did not have high blood pressure, blood sugar or cholesterol, she had been overweight until 2 years ago when she went ahead and elected to have bariatric surgery abroad. Following this she has lost considerable weight and had been on a rather severe diet that was recommended for about 18 months after. “I am slowly resuming a normal diet, but the quantities I eat remain small”, said A. On questioning she reported normal thyroid function, no lupus or other such inflammatory condition, both of which can also predispose to memory problems in younger people. Her heart and kidneys had been declared “fit and well” by her physician, during her last master health evaluation. What about your monthly periods, I demurred? “Menopause finally set in doc, about 2 years ago”, said A. When did the memory problems start, I wondered? A thought for a few moments before responding; “about the same time as my periods started tapering off” she responded. A clarified to leading questions that she was not under any significant emotional stress, nor were there any stressful life events in recent times. Indeed, with both children off to college and her husband having come into considerable wealth recently, A felt life could not be better, especially as they now had the time, resources and freedom to travel, something they both enjoyed. I asked her about neurological events or symptoms during her lifetime: head injury, seizures, fainting episodes, strokes, to all of which she replied in the negative.
On physical evaluation A was completely well and there were no signs of concern. On the bedside evaluation of memory and cognition, though, I found A struggled a little with tasks of attention (focus), recent memory (recall) & executive function (ability to perform tasks in sequence), resulting in her working memory being somewhat affected. She did manage to remember and perform most tasks: however, she was a little less efficient and speedy than I expected her to be, considering that she was a smart & efficient professional. The obligatory brain scan (as a measure of safety) was normal, but her blood tests revealed that she was deficient in vitamin B12 (an outcome of her dietary restrictions following bariatric surgery) with elevated homocysteine, a brain chemical that is associated with memory problems. I concluded therefore that A had two reversible causes of memory impairment: vitamin B12 deficiency & menopause.
The Menopause Effect
The World Health Organization defines the perimenopause as the time immediately preceding the menopause, beginning with endocrine, biologic, and clinical changes, and ending a year after the final menstrual period. The Study of Women’s Health Across the Nation (SWAN) published in the American Journal of Epidemiology (2000) showed that of 12425 women aged 45-55 years across sociodemographic categories who participated, between 31 and 44 % of perimenopausal women, endorsed forgetfulness. Overall perimenopausal women were 1.4 times more likely than premenopausal women to be forgetful, this finding not being just due to emotional stress. Indeed, there is considerable research today to show that in the year after the final menstrual period, women do demonstrate deficits in attention, working memory, visual & verbal memory and motor speed. Interestingly, studies like the “Harvard Study of Moods & Cycles” show that in the perimenopausal period, women are twice as likely to be depressed, and while this is not related to negative life events, it is associated with vasomotor symptoms (hot flushes). This links up with the theory that the brain hormone cortisol (which exercises an influence on the reproductive hormones) may be associated with both memory and mood; that higher cortisol levels and/or greater cortisol reactivity may be the biological link between hot flashes, depressive or anxiety symptoms and perimenopausal decrements in memory. Indeed, research has shown that young women have lower reactivity to cortisol than older (perimenopausal) women. This of course brings up the inevitable question, which A asked me “doc, should I be on Hormone Replacement Therapy”? HRT has been both praised and vilified (like many medical procedures) in equal measure. The summary evidence suggests that HRT commenced during the perimenopausal period has the potential to help symptoms of mood, anxiety and perhaps importantly, memory. However, HRT started outside these time periods does not appear to have a similarly beneficial effect, indeed may even be detrimental.
Prevention & Cure
I had identified in A, apart from menopausal transition, a reversible cause of memory impairment, vit B12 deficiency with elevated homocysteine; which has an impact on memory and makes one vulnerable to having strokes. Other reasons why middle aged individuals like A have problems with memory include depression, infections, inflammations and metabolic (including thyroid) problems (all reversible); cancer, strokes & brain tumours (potentially reversible, at least in part); and brain degeneration (non- reversible but can be slowed, partly arrested). It is for this reason that people with memory complaints in middle life like A, need to be thoroughly evaluated for a range of causes. A did go through such an evaluation before we concluded that her problems were due to menopausal transition and B12 deficiency, both of which we proceeded to address. We recommended to her, all those things that can help a person stave off memory loss (and indeed lifestyle disease): a healthy and predictable life, an antioxidant rich diet, adequate rest and sleep; regular aerobic exercise (walking, jogging, gymming); yoga, pilates or tai chi as mind-body interventions; moderation in all that one does, including and especially social consumption of alcohol. Turmeric is today in advanced trials and extra virgin coconut oil in early phase trials as a memory protecting agent. The former is adequately present in Indian diets generally; the latter easy to add, admixed with rice etc. We recommended both to A.
We learnt from her too, as we do from all patients; the links between mood, memory & menopause, preventive health and the importance of holistic evaluation and care. All memory loss is not dementia and women like A in menopausal transition would do well to consider and address that aspect of their health.