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By Robert Wilbur, Truthout | News Analysis

A new treatment for major depression – and possibly other maladies, including pain and post-traumatic stress disorder – seems as effective as the alternatives, with lower cost and fewer side effects. Psychiatrists say TMS is showing much promise in preliminary studies.

Until four years ago, psychiatrists had only two options for treating major depression: drugs and electroconvulsive therapy (ETC), formerly known as electroshock.

Antidepressant drugs can take as long as four to six weeks to kick in, and they have many side effects: cardiac toxicity, urinary retention, impotence, loss of libido, blurred vision, dry mouth, somnolence, overstimulation and assorted other complications that vary from drug to drug.

Surprisingly, ECT, which passes an electric current through the brain, is considered to be safer than drugs for patients with many physical illnesses, but it also has a steep downside of its own: A course of ECT can wipe out crucial memories like Ajax scouring out a sink.

Most psychiatry textbooks write that a first trial of an antidepressant is effective only 60 percent of the time. ECT is generally said to be effective 70 percent to 80 percent of the time.

In 2008, the US Food and Drug Administration approved a new device for treating major depression: Transcranial Magnetic Stimulation, or TMS. TMS has its roots in the research of Michael Faraday, the giant of 19th century physics. He could scarcely have dreamed that his law of induction would one day be used to treat mental illness.

Faraday's Law is simple: It states that an oscillating magnetic coil – that is, a coil moving back and forth – generates an electric field. Now if a magnetic coil sets up an electric field inside the brain, the electric field will stimulate the neurons to release brain chemicals called neurotransmitters, of which the three most familiar are serotonin, dopamine, and noradrenaline (although there are dozens more under varying degrees of investigation).

Serotonin is a sedating neurotransmitter; dopamine is energizing; noradrenaline resides somewhere in between. The increased availability of one or more of these neurotransmitters is believed to lift the depression.

The instrument that was approved by the FDA is called "NeuroStar." It is manufactured by Neuronetics for "major depression that does not respond to a trial of an antidepressant drug."

This is very generous labeling by the FDA, and in reality the labeling doesn't amount to much, because once a drug or medical device has been approved for marketing, it can be used by the physician for any indication he sees fit.

Already NeuroStar is being used to treat chronic anxiety, bipolar depression (the depressive swing of manic-depressive illness) and chronic pain. I've also been told the military has bought several TMS instruments for treating post-traumatic stress disorder.

As for "major depression," it is an entity that has paraded through the psychiatric literature under a variety of names, among them: "unipolar depression" (to signify that it is not the depressed phase of manic-depressive – bipolar – disorder), "and "endogenous depression (which is intended to signify that it is a biologically, and probably a genetically driven, disorder)."

The condition is marked by mental symptoms such as low mood and morbid or outright suicidal thoughts, as well as physical symptoms like sleep disturbance, loss of appetite and anxiety.

According to Sue McMonigle, vice president for marketing at Neuronetics, there are currently 424 facilities in the US, ranging from hospitals to private offices that use the device. So far, McMonigle said, about 9,000 people have undergone treatment with TMS.

Small-scale studies indicate it is effective about 70 percent or more of the time – in the same range as ECT, but definitive studies are needed to nail this figure down.

The potential for TMS is enormous. According to the Centers for Disease Control, one American adult in ten suffers from depression, by which the CDC means major depression or the milder condition, dysthymia.

This number does not include manic-depressive (bipolar) patients in the depressed phase. Nor does it factor in all the other psychiatric and neurological disorders for which TMS is already being used.

Truthout spoke with two practitioners of TMS – Dr. Alan Manevitz, clinical associate professor of psychiatry at Weill Cornell Medical School, and Dr. James Halper, MD, clinical associate professor of psychiatry at New York University School of Medicine, who set up the first TMS facility in New York City.

The doctors said that, second to depression, the best-established indication for TMS is pain. They called TMS a "new pathway of treatment" without the problems of antidepressant drugs or ECT.

So exactly what is NeuroStar? Manevitz and Halper invited me to visit their private clinic on New York's chic Sutton Place, where their clinical coordinator, Yoko Kanamori, demonstrated the workings of the Neurostar for me.

The treatment room looks like a dentist's office, with a comfortable recliner and the magnet mounted in an armature, rather like the dentist's drill, that is connected up to a box that allows the operator to adjust the number of magnetic oscillations per second and, applying Faraday's Law of Induction, the strength of the electrical field inside the brain.

The magnetic field is weak – it would take 30 treatments with the NeuroStar to equal the degree of magnetic exposure of a single scan with a magnetic resonance imager (MRI), Kanamori told me.

The business end is the magnetic coil under a padded headpiece that covers the prefrontal cortex, a region of the brain associated with depressive mood and morbid, sometimes suicidal, thoughts. The prefrontal cortex sends and receives bundles of nerve fibers to and from a region of the brain, the limbic system, that is responsible for what are called the somatic or "vegetative" symptoms of depression like disordered sleep, loss of appetite, anxiety and other symptoms not ordinarily amenable to will power (which is one good reason why it is stupid and cruel to tell someone suffering from depression to "snap out of it").

Kanamori switched on the NeuroStar and held the back of my hand against the cushion. I felt a mildly annoying rat-tat-tat of the magnet oscillating back and forth, then a longish respite, followed by another burst of magnetic activity. Not surprisingly, headache is a rather frequent complaint from TMS, but it can be easily treated with Tylenol or aspirin. Otherwise, TMS is largely free of side effects.

The definitive study on the indications and side effects of TMS was conducted last year by a "blue ribbon" panel of experts chosen by French medical societies. After reviewing the literature on TMS, the authors concluded that the only significant side effect was the rare occurrence of seizures, and these occurred as a rule when the practitioner departed from the instructions for using the instrument, or rarely when the patient was taking an antidepressant that lowers the seizure threshold.

In TMS, the patient is fully awake, sitting comfortably in the recliner, and reading or watching a video. There are five sessions a week, and each session lasts for one hour. A complete course of treatment lasts four to six weeks. Since this is about the same as the time it usually takes for antidepressant medication to go to work, what's the advantage of TMS?

First, far fewer side effects. Secondly, some studies show that it works when drugs fail. When the magnet is lifted off the patient's head, out she walks.

The same cannot be said of ECT. Practitioners vary in their methods, but ECT is usually given every couple of days for a total of seven to 10 treatments. The patient is wheeled into the ECT suite on a gurney, where a minimum team of a psychiatrist, an anesthesiologist, and an ECT nurse await him.

The anesthesiologist promptly administers a short-acting anesthetic such as brevital. Next comes succinylcholine, an agent that paralyzes all the skeletal muscles of the body – including the muscles involved in breathing. An ECT nurse at once begins to "bag" the patient, that is, force oxygen into his lungs or else he would soon die.

With the patient all "prepped," the psychiatrist positions electrodes on the temples (or on just one side, if he opts for the unilateral procedure) and hits the "on" button, which sends a jolt of 225-450 volts of electricity through the brain.

Were it not for the muscle-paralytic effects of succinylcholine, the patient would experience violent convulsions that often shattered bones in the past. As it is practiced today, just about all there is to see that suggests a convulsion is a brief bending of the feet.

The ECT nurse continues to bag the patient until he starts breathing on his own; then he is wheeled into the recovery room where he is observed by a nurse until the anesthetic progressively wears off, and he emerges from his experience disoriented and confused.

Today, ECT is almost always administered to hospitalized patients, but there are "buzz shops" to be found that give ECT on an out-patient basis. Usually it takes the patient a couple of hours before she's steady enough to leave, but the patient is usually warned not to drive herself home.

It will probably have occurred to the reader that TMS and ECT have a common denominator: Both set up an electric field within the brain, although TMS delivers the electricity gradually and moderately over a period of weeks, while ECT serves it up in seven to ten flashes of current.

In fact, one of many theories of ECT efficacy is that the electric field releases a torrent of neurotransmitters.

An important consideration in treating depression, and all the more important when the depression is severe, is a feature called the durability – the length of time from the termination of treatment to the return of depressive symptoms.

For antidepressant drugs, the durability is six months to relapse. Skilled psycho-pharmacologists usually maintain their seriously ill patients on medication for two years, then taper the dose very gradually and kick it right back up again at the first hint of a relapse.

Some depressed patients require lifelong medication. I have been using the word "antidepressant" in the singular, but in fact the art of psychopharmacology is often to use drug combinations skillfully.

The most popular and effective adjunct is to add lithium to an antidepressant. This combination is so effective that results are often seen in a matter of days. Another safe and effective adjunct is thyroxine (T3), and the addition of lithium and thyroxine is more effective that either adjunct alone.

Many other drug combinations are used, such as two different categories of antidepressants – for example, a tricyclic like Elavil, and a monoamine oxidase inhibitor like Phenelzine – or the addition of a stimulant, like Ritalin, to an antidepressant.

In recent years, the addition of "second-generation antipsychotics" – Abilify, Seroquel, Zyprexa and other agents that are more than just antipsychotics; they possess antidepressant and anxiolytic properties in their own right – are gaining in popularity as adjuncts.

This far from exhausts the cornucopia of adjuncts that are used in modern psychopharmacology.

Clinical experience over a period of decades has found that ECT has a durability of six months. Most psychiatrists find it prudent to discontinue antidepressant medications before embarking on a course of ECT; once the patient has completed seven to ten treatments, the psychiatrist starts a regimen of antidepressant medication to prolong the durability of the recovery; some psychiatrists, rather than administering medication, give periodic "booster" doses of ECT. Similarly, two or three booster treatments of TMS will usually effect a remission in patients who have experienced a course of TMS and, after a variable period of time, show signs of a depressive relapse.

One advantage of TSM over ECT is that the patient can safely take antidepressants during TSM therapy, a consideration that strengthens its durability.

Memory loss and, sometimes, confusion are the major side effects of ECT – and they can be major, according to Dr. Maria A. Sullivan, a psychiatrist and psychologist at New York State Psychiatric Institute, who uses ECT so infrequently that she couldn't recall when she last employed it. Her view is that ECT should only be administered to the most severely ill patients – those with catatonia and severe, life-threatening depression that does not respond to aggressive pharmacotherapy and psychotherapy.

Other psychiatrists intervene earlier. Thus, Dr. Gabriella Centurion – a psychiatrist in private practice who is a TMS provider – calls ECT the "gold standard" for treating severe depression. Virtually since its introduction, ECT has stirred controversy between therapeutic "doves" and "hawks." An ongoing study at Columbia University, which compares TMS to ECT and which is large enough to overcome the objections to the small, existing pilot studies, may provide definitive information.

So long as they are interpreted cautiously, the existing pilot studies show that TMS and ECT are comparable. If confirmed, these data will have a major impact on the way that we treat severe depression.

What about the bottom line? Fees vary for the treatment. According to Manevitz and Halper, the usual cost for TMS runs from $10,000-$11,000. ECT costs generally run higher, because the treatment requires a three-person team: a course of 12 ECTs comes to about $24,000, according to the Carrier Clinic in New Jersey.

Pills may be the most expensive of all, though, especially if someone has to take a combination of drugs for two years. According to Mark Bausinger, a vice president at Neuronetics, the insurance industry is slow to pick up the tab for TMS, but one by one they are coming on board as they come to appreciate the cost-effectiveness of TMS. This is often the case with new medical instrumentation.

Inexplicably, but not surprisingly, Medicare is divided on the issue. The New England district picks up the tab for a course of treatment. Other districts won't pay a cent. Still others remunerate at such a miserly rate that few psychiatrists are willing to learn how to use TSM and invest in the apparatus.

The failure of Medicare to pay for TMS is yet one more burden on the elderly, who have an even higher prevalence of depression than younger people. With their multiple illnesses and failing memories, our senior citizens are often poor candidates for medication or ECT, but as Kanamori told me, old people tolerate TMS well.

Neuronetics has a special program for TMS patients that helps them to fill out insurance forms to receive remuneration from insurance carriers. Manevitz and Halper reported that, at least in their practice, 75 percent of patients receive some reimbursement from their insurance carriers after taking their case to appeal – but the remuneration often is not adequate, and depressed people may have a hard time coping with the complex appeals procedures of public and private carriers. It will be interesting to see how much – if anything – the Affordable Care Act allows for TMS.

At this point, Manevitz and Halper told me in our three-way phone conversation, major depression and chronic pain are two indications for which TMS therapy is well-supported by the evidence from clinical trials and psychiatric practice.

It is being looked at closely for other indications; some will hold up under the weight of rigorous clinical trials and others will turn out to be disappointing. But right now, hopes are high in the psychiatric community.
 

Rate rose by 28 percent since 1999; recession may have played a role, experts say

By Steven Reinberg, HealthDay Reporter (HealthDay News) — The number of middle-aged Americans who have committed suicide has risen sharply in the past decade, federal health officials reported Thursday.

Experts aren't sure why the jump in deaths has occurred, but point to the recession as a possible contributing factor.

According to the U.S. Centers for Disease Control and Prevention, suicides among those aged 35 to 64 have risen by 28 percent since 1999 — from 13.7 suicides per 100,000 people that year to 17.6 per 100,000 in 2010.

More Americans now commit suicide than are killed in car accidents. In 2010, the CDC reported, 33,687 people died in car crashes, but 38,364 took their own life.

"We have known about this trend for a while now, the CDC is merely documenting it," said Lanny Berman, executive director of the American Association of Suicidology, who was not involved with the report.

Why the rate has risen so dramatically among the middle-aged isn't clear, Berman said. "I and most of my colleagues are dumbfounded to explain it," he said.

"The best we can come up with is maybe this is the group most likely to be affected by the recession and unemployment and [home] foreclosure," Berman said. "It affected suicide rates both nationally and internationally."

What isn't known, however, is how many of those who took their lives were having financial problems, Berman said. Whether the recession is the actual cause will take years to unravel. "All we can guess at now is association," he said.

Thomas Simon, deputy associate director for science in the Division of Violence Prevention at the CDC's National Center for Injury Prevention and Control, said one possible explanation for the increase in the suicide rate in this age group is that it includes the baby boom generation.

"Historically, we have seen high rates of suicide in that [group of people] at earlier ages in their lives in adolescence and young adulthood," he said.

In addition, the burst of the dot-com bubble and the recession may have played a role, Simon said. "Another explanation is the increase in prescription drug abuse and prescription overdose deaths and the risk of suicide that comes from prescription drug overdose and abuse," he said.

"Suicide is an important public health problem across the lifespan," Simon added. "Traditionally we have invested in prevention for adolescents and young adults and prevention for older adults. What we are seeing now is suicide is the fourth leading cause of death for the middle-age group. We need to better understand how to address the needs of middle-aged adults so that we can prevent suicide."

Suicide rates for those younger people aged 10 to 34, and seniors aged 65 years and older did not change significantly over the study period, the CDC researchers noted.

The report was published in the May 3 issue of the CDC's journal Morbidity and Mortality Weekly Report.

Berman believes a lot needs to be done to identify those at risk and get them help. "People at risk are help-able, but we have to get them into help," he said. "Most suicides are preventable."

CDC Director Dr. Tom Frieden said in an agency news release: "Suicide is a tragedy that is far too common. The stories we hear of those who are impacted by suicide are very difficult. This report highlights the need to expand our knowledge of risk factors so we can build on prevention programs that prevent suicide."

According to the report, the increases in middle-age suicides were particularly significant among whites (up 40 percent), and American Indians/Alaska Natives (up 65 percent).

The most common means of suicide for both men and women were hanging/suffocation, poisoning and guns, all of which showed an increase, the CDC found. Guns and hanging/suffocation were the most common method of suicide among middle-aged men, while poisoning and guns were the most common among middle-aged women.

Suicide rates increased in all states and the increases were statistically significant in 39 states, according to the report.

Other findings:

The biggest increases in suicide rates were among people aged 50 to 54 years old (48 percent) and 55 to 59 years old (49 percent).
Suicide rates rose by 23 percent or more in all four major regions of the country.
Suicide rates increased 81 percent for hanging/suffocation, 24 percent for poisoning and 14 percent for guns.

One psychiatrist said people who are suicidal need to get proper help.
 

"People have to take it seriously when somebody says they are suicidal," said Dr. Alan Manevitz, a clinical psychiatrist at Lenox Hill Hospital in New York City. "You can't assume that, because you don't think this is worth being suicidal about, that that person feels the same way. It's not how bad the problem is, but it's how badly the person is experiencing it. Usually, that's a cry for help."

To collect the data for the new report, the CDC relied on its web-based Injury Statistics Query and Reporting System.

More information

For more information on suicide, visit the U.S. National Library of Medicine.

SOURCES: Lanny Berman, Ph.D., executive director, American Association of Suicidology, Washington, D.C; Thomas Simon, Ph.D., deputy associate director for Science, Division of Violence Prevention, National Center for Injury Prevention and Control, U.S. Centers for Disease Control and Prevention; Alan Manevitz, M.D. clinical psychiatrist, Lenox Hill Hospital, New York City; May 3, 2013, Morbidity and Mortality Weekly Report
 

We have an exciting event occurring tomorrow at the Spectrum Neuroscience and Treatment Institute in Manhattan.

Doctors Eric Hollander, Tarique Perera, Stefano Pallanti and Alan Manevitz will be discussing TMS Therapy for the treatment of depression. We still have room for you to attend.

Details:

Where: Spectrum Neuroscience and Treatment Institute
901 Fifth Avenue. NY, NY 10021

When: Wednesday, May 15th

Time: 12:00 – 2:00PM

RSVP to: sw@askstefanie.com
 

Alan Manevitz, MD is a clinical psychiatrist at Lenox Hill Hospital in New York and has been a volunteer onsite for 9/11, Hurricane Katrina, TWA 800 and other national tragedies. He is an expert on trauma, PTSD, anxiety and depression and he contributed this article to LiveScience’s Expert Voices: Op-Ed & Insights.

This last week was surreal. We were traumatized as a horrific bombing killed and injured many; we felt the impact of social media during a disaster as an alerting and informative tool, and as a tool for spreading false rumors and, ultimately, as a tool for calming and engaging us; we actively participated in the identification of the perpetrators of this heinous crime; we experienced a major city undergo "lockdown"; we watched as one suspect was killed, and one was captured on live TV.

Everyone watching the horrific events — seeing bombings and mangled, bloodied, crying people on TV and the Internet — experienced trauma. It is normal to have an acute stress reaction, which consists of anxiety, hyper-vigilance, greater startle response, grief and horror for the terrible events experienced by the victims and their families and wonder about our own safety and that of our families. These emotions were normal.

People who have experienced trauma in the past or individuals who suffer from existing post-traumatic stress disorder (PTSD), anxiety and depression are more vulnerable to the trauma and may experience exacerbations of their past PTSD or other symptoms.As we watched transfixed over the live manhunt and shootouts leading up to the lockdown, we were both desensitized by past experiences of viewed violence from computer games and movies, but at the same time we were sobered by the reality of what guns and homemade explosives can really do to innocent bystanders and how much pride and security we have as our designated protectors and heroes work on our behalf to make us secure.

On the plus side of the lockdown, we saw the results of our government and police forces working smoothly together to provide medical and psychological first aid and physical safety to our citizens in Boston. This brought us comfort. In addition, staying home for this initial period of time gave families and friends the time and opportunity to feel safer and to comfort ourselves and our children. This was a real and extraordinary event. Reframed positively, we allowed our police and FBI the time to do their job while we did our job at home. [Boston Lockdown: What It's Like Inside]

In addition, we are a more experienced and engaged citizenry post-9/11, as opposed to 9/11 when we had a more passive and naïve citizenry. Many technologies of communication: Twitter, instantaneous photography and texting were essentially nonexistent at the time of 9/11. Citizens in New York (and everywhere else) stayed home and watched the news unfold on TV. People bonded initially over their fears and then we empowered ourselves over our anger.

When people are traumatized, they feel powerless. That powerless feeling can become maladaptive feelings of helplessness that turn into anxiety, panic and depression. Or we become angry to empower ourselves. Being proactive is adaptive; that is why there was such an outpouring of spontaneous offers of aid, money and memorials — the desire to do something on 9/11 resulted in lines around the block as people tried to donate their own blood in order to help. I was "lucky" — I was able to be an active volunteer on the World Trade Center site from day one; many of my patients supported me, and emotionally felt better as I was their proactive representative.

In Boston, though people were in lockdown, they were engaged electronically, and therefore felt proactive. They were both engaged as a community connecting and soothing each other and engaged as people were searching their own photos or others. There was record traffic to the FBI site minutes after they asked for help. While people were scared, upset and traumatized, there was an informed calmness. We were watching our designated representatives (police, FBI) doing their job in front of us. They were engaged with us and they were asking our help, which allowed us to stay engaged.

Of course, over time, a lockdown will produce extra stress and should be limited to 24 to 48 hours. Luckily, in Boston, it was less than 24 hours. As a guideline, families should not sit at home and watch the news loops over and over. However, they should not be avoidant: Parents should watch with their children and answer their questions honestly and openly. Parents also should do other activities at their home with their family. Children can write get-well cards if they want to do something to help. Make sure you stay hydrated with water, and eat and get rest. Don’t stay up all night watching images over and over again on the TV News. Do not drink excess alcohol.

The general public understood the rationale for the initial lockdown. Being informed, less naïve and understanding the "big picture" vs. the "immediate picture" helps us stay calm, in general. For example, our children may ask us if "the bad men can get us in our schools?" We have to be able to explain to ourselves first, and then our children, that while there are bad men, there are many more good men and women out there helping and protecting us.

Following immediate traumas or lockdowns, getting back to our normal routine is most important for our morale and mental health. Children, especially, need a return to routine. The key to understanding how to handle stress is to distinguish between the possibility of an event (less than 1 percent) and the probability of an event. Panic and anxiety increases when we experience a possibility as if it is a probability. Another example: A teenager may ask, "Is it is safe to run in my track meet?" We need to explain that while the possibility exists of a bad thing happening, the probability is safe and therefore encourage ourselves to go back to that routine.

Many countries have lived with realistic concerns of terror over decades and lifetimes (for example, Israel and Ireland). We all have been cumulatively upset and traumatized over this last year by seeing the safe family institutions of movie theaters, elementary schools and the neighborly good feelings of Marathon Day tragically disrupted by deranged or malicious individuals or terrorists with their disturbed and distorted agendas. We are frustrated by not being able to provide the innocence and safety of childhood as remembered from the past or portrayed in TV, books and movies. [Inside Twisted Terrorist Minds — Where Is the Empathy?]

The United States is relatively late to the game in getting used to living with the cognitive dissonance of dialectical opposites: wanting ourselves to feel safe yet wanting our freedom and privacy to do what we want, when we want, and how we want. We cringe at encroachments or discussions on our independence: national identity cards, increased screenings at public places of gathering, profiling — but, we also want to feel more secure. We fear totalitarianism but we are voting more monies to create more shades of "1984" than ever before. We are comforted to see the new technologies of face recognition and infrared detection, to have a cooperative citizenry provide the video to help bring the progenitors of these heinous crimes to justice, but at the same time, we realize we are coming under video surveillance "for our own good" by third parties everywhere but in our own homes. And even in our own homes, Google and others are mining Big Data for patterns of Internet use that reveal information about an individual user or families.

Having the natural capacity or learning the skills of perspective, understanding to use probability/possibility thinking and using reality (in other words, stating the positive and then acknowledging the negative) to avoid catastrophizing all leads to resilience and lessening the odds of these acute stress reactions turning into PTSD.

By Amanda Gardner – Health.com/ News&Views

When a senseless tragedy happens, such as the explosions that killed three people and maimed more than 170 at the Boston Marathon on Monday, it can have a psychological impact on people both near and far. And it can be hard to know what to do to help, especially when watching endless media coverage of such events.

“When something as horrific as this occurs, everyone has a stress reaction,” says Alan Manevitz, MD, a clinical psychiatrist with Lenox Hill Hospital in New York City who was also a first responder on 9/11. “That’s a normal reaction.”

Here are some expert tips for how to cope with distressing world events:

Focus on the heroes
“This devastating thing makes us question humanity but we also see people come together and help and put their lives on their line,” says Catherine Mogil, PsyD, director of the child and family trauma psychiatry service at the UCLA Geffen School of Medicine. “There have been many heroes and acts of heroism in Boston in the days since the attacks. That could be the hundreds of Bostonians who opened their homes to out-of-town visitors, the man who served food to people huddled on the street or the runner who shredded his shirt to make a bandage. “Focus on the helpers,” says Mogil. The theme echoes a viral video watched and shared by thousands on Facebook and Twitter in which Fred Rogers, of Mister Rogers’ Neighborhood, talks about coping with tragedy.

Take positive action
Do something positive yourself. A child could write a get-well card and send it to one of the hospitals treating victims in Boston or you could light a candle at your local church, says Dr. Manevitz. Even if you’re far away from the actual scene, you can help by contributing to organizations that are helping victims or by donating blood (although the American Red Cross says that they have enough blood donations in the Boston area at the moment). If you’re a runner, going for a run–as so many commenters vowed to do on the Runner’s World site–might help. Two Virginia college students launched a Run for Boston Facebook page, in which people can run and log their miles to commemorate the victims in the attack.

Turn off the TV
News outlets are covering the deadly blasts 24/7 but that doesn’t mean you have to keep up with all of them. In fact, trying to keep abreast of developments will only stress you out more, says Mogil, “The best guidance is to really turn [the news] off,” she says. If you do find yourself watching or listening to news reports, “be aware that it is affecting you,” she adds. Instead of the news, spend time with friends and family. “Spending time with others reinforces emotional and social bonds that help us feel safe and secure,” says Dr. Manevitz.

Communicate and connect with others
That said, don’t disconnect from the event entirely. If reaching out via Facebook, Twitter, or other social media outlet makes you feel better, do so. Sharing your emotions, memories, or support may help. In general, talking about a tragedy honestly with friends and families can help process intense emotions, says Mogil. This holds true when you’re talking to children as well. Don’t shield your kids from the truth but let them take the lead in asking questions, advises Dr. Manevitz. At the same time, reassure them by letting them know that events such as these are rare and you will do everything possible to keep them safe.

Maintain your routine
It’s normal to feel uneasy and fearful after an attack like this but that makes it all the more important to keep up your usual routines of self care, says Dr. Manevitz. That means making sure you’re drinking enough water, eating well, not abusing alcohol, exercising, and getting enough sleep. “You need to reestablish your routine. Don’t change what you’re doing,” he says. “Life carries on. We can’t stop living.”