Some writers read a lot more into that statement than was actually there. Science 2.0 — a website that claims it houses “The world’s best scientists, the Internet’s smartest readers” — had this headline, “NIMH Delivers A Kill Shot To DSM-5.” Psychology Today made the claim, “The NIMH Withdraws Support for DSM-5.” (The DSM-5 is the new edition of the reference manual used to treatment mental disorders in the U.S.)

So is any of this true? In a word, no. This is “science” journalism at its worse.

NIMH’s Research Domain Criteria

For the past 18 months, the NIMH has been working on a different categorization system to classify mental disorders, to help further its research efforts (the NIMH is primarily a research-driven organization). It’s called the Research Domain Criteria project:

NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system.

The proposed classification system works under these assumptions:

• A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,

• Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,
• Each level of analysis needs to be understood across a dimension of function,
• Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.

In short, the NIMH is trying to find a new categorization system that takes into account more of the biology, genetics, brain circuitry and neurochemistry that we’ve discovered in the past three decades’ worth of research is becoming increasingly relevant to understanding mental disorders.

Does it Replace the DSM-5?

Will this replace the DSM-5? No, because as Dr. Insel notes, “This is a decade-long project that is just beginning.” If the NIMH effort ever replaces the DSM, it will be a long time from now.

Somehow, though, Science 2.0 and Psychology Today believe this letter suggests the NIMH has “withdrawn” support for the DSM-5, or has delivered a “kill shot” (whatever that is!). Are these kinds of characterizations accurate — or indeed, helpful?

We reached out to Bruce Cuthbert, Ph. D., the director of the Division of Adult Translational Research at the National Institute of Mental Health for clarification.

“As with most shifts in science, changes in research priorities require a transition,” said Dr. Cuthbert.

“Because almost all clinical researchers today grew up with the DSM system both clinically and in research, it will take some time to get a “feel” for the relationships between DSM disorders and various kinds of RDoC phenomena (both in terms of the types of symptoms, and in overall severity), learn how to write grant applications with the new criteria, and evolve new review criteria. So, there will be a period of some time while these crosswalks are worked out.

“I also should point out that these comments reflect [only] our translational research portfolios.

“Our Division of Services and Intervention Research mostly supports research conducted in clinical settings that is relevant to current clinical practice and services delivery. Thus, [...] grants in these areas will continue to be predominantly funded with DSM categories for some time.”

That’s a far cry from the entire NIMH withdrawing support for the DSM-5. The NIMH is simply saying (in my opinion), “Look, we’re unhappy with the validity of the DSM and its lack of support for biomedical markers for mental disorders. We’re working on a different schema, especially targeted at researchers. It may have greater relevance someday — that’s our hope and vision.”

Why a New Diagnostic System?

But then again, researchers in mental illness have been promising biomarkers for at least two decades as well — with little notable progress to show for their efforts.¹

Why is a new diagnostic system needed?

“For psychiatric disorders, we cannot effectively use very much of the knowledge we have gained about the brain and behavior over the last 30 years because of our symptom-based diagnostic system. In other words, the categories defined by symptoms simply do not map onto all the knowledge that we have gained about brain circuits, genetics, and behavior,” replied Dr. Cuthbert.

“We know that many different mechanisms are involved in any one DSM disorder (heterogeneity), while any one mechanism (fear, working memory, emotional regulation) is typically involved with many different disorders. [This] heterogeneity frustrates attempts to develop new treatments.”

Indeed, as John Horgan over at Scientific American wrote,

Ironically, some pharmaceutical companies that have enriched themselves by selling psychiatric drugs are now cutting back on further research on mental illness. The “withdrawal” of drug companies from psychiatry, Steven Hyman, a psychiatrist and neuroscientist at Harvard and former NIMH director, wrote last month, “reflects a widely shared view that the underlying science remains immature and that therapeutic development in psychiatry is simply too difficult and too risky.”

Pharmaceutical companies say that, on average, a marketed psychiatric drug is efficacious in approximately half of the patients who take it. Dr. Cuthbert from the NIMH suggests that, “One reason for this low response rate is the artificial grouping of heterogeneous syndromes with different pathophysiological mechanisms into one disorder.”

So the NIMH’s regrouping appears to be as much of an effort to spur new drug development as it is an effort to rethink the classification system of mental disorders. Which is a bit odd, if you think about it, since there is a rich research foundation showing that non-medication treatments — such as psychotherapy — work equally well (if not better) for the treatment of many mental disorders.

If these were pure medical diseases with clear and readily defined biomarkers, that shouldn’t be the case. After all, positive thinking can’t cure cancer.²

“Thus, mental disorders are an area where we must transcend the current symptom-based system if we are to advance,” concludes Dr. Cuthbert. “Among other things, if you have to wait until a full-blown set of symptoms is present before you can define a disorder (and there is no quantifiable data regarding risk states, as there is for, say blood pressure), then prevention is — by definition — impossible.”

This is simply untrue, in my opinion. There is a solid and growing research base already demonstrating that we can detect mental illness through a number of early screening and symptom measures and implement prevention measures. Other studies demonstrate significant correlations with certain characteristics — signs that can also be used to implement effective prevention.

“The research process will necessarily involve complex science to understand how we can relate more neuroscience-based measures to more specific and quantitatively-defined symptoms and clinical outcomes,” says Dr. Cuthbert from the NIMH. “This does not necessarily mean, however, that the diagnostic systems of the future will necessitate such a complex battery. As with biomarkers in other areas of medicine, a subsequent phase will be to find assessments that can be obtained feasibly in clinical settings (although this is unlikely to mean, as is the case now, that all disorders can be diagnosed simply sitting in a clinician’s office).”

Is It All About the Money?

Horgan suggests, perhaps, some ulterior motives for NIMH’s statement:

NIMH director Insel doesn’t mention it, but I bet his DSM decision is related to the big new Brain Initiative, to which Obama has pledged $100 million next year. Insel, I suspect, is hoping to form an alliance with neuroscience, which now seems to have more political clout than psychiatry. But as I pointed out in posts here and here on the Brain Initiative, neuroscience still lacks an overarching paradigm; it resembles genetics before the discovery of the double helix.

I’m not as skeptical as Horgan, but do believe the timing of Dr. Insel’s letter is a little curious — right before the launch of the DSM-5, and right after the public commitment of $100 million to brain research.

What is clear is that the NIMH is not withdrawing support for the use of the DSM-5 anytime soon. It is the reference manual all researchers and clinicians use today to speak the same language of mental illness. Without the same reference frame, research — and treatment — would become impossible.

Further Reading

Scientific American: Psychiatry in Crisis! Mental Health Director Rejects Psychiatric “Bible” and Replaces with… Nothing

Science 2.0′s article: NIMH Delivers A Kill Shot To DSM-5

1. David Kupfer, who chairs the DSM-5 Task Force, told Pharmalot: “The promise of the science of mental disorders is great. In the future, we hope to be able to identify disorders using biological and genetic markers that provide expreciseact diagnoses that can be delivered with complete reliability and validity. Yet this promise, which we have anticipated since the 1970s, remains disappointingly distant. We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting.”
2. Although, to be fair, positive thinking can definitely help in its overall treatment.

Colleges and university are cutting back on their involvement with ADHD, primarily due to abuse of the psychiatric medications — stimulants like Ritalin — prescribed to treat the disorder. Students — whether they are malingering the symptoms or actually have it — are prescribed a drug to treat ADHD (sometimes from different providers in different states), then sell a few (or all the) pills on the side. Profit!

Now universities are becoming wise to the epidemic nature of the problem, as some studies have suggested up to a third of college students are illicitly taking ADHD stimulants.

This might help curb the abuse problem, but will it also make it harder for people with actual ADHD to receive treatment?

The short answer is, yes, of course. Students with a pre-existing diagnosis of attention deficit or attention deficit hyperactivity disorder will still often be able to get their prescriptions filled while at school. The university just doesn’t want to do the diagnosing of ADHD any longer.

I’ve long wondered at the wisdom of universities getting into the ADHD business in the first place. University counseling centers generally shrug off long-term treatment of serious mental illness. So it’s never been clear to me why they were comfortable prescribing medications for ADHD.

The New York Times notes — in a well-written take on this issue by Alan Schwarz — that the changes are sweeping campuses throughout the country:

Lisa Beach endured two months of testing and paperwork before the student health office at her college approved a diagnosis of attention deficit hyperactivity disorder. Then, to get a prescription for Vyvanse, a standard treatment for A.D.H.D., she had to sign a formal contract — promising to submit to drug testing, to see a mental health professional every month and to not share the pills. [...]

The University of Alabama and Marist College, like Fresno State, require students to sign contracts promising not to misuse pills or share them with classmates. Some schools, citing the rigor required to make a proper A.D.H.D. diagnosis, forbid their clinicians to make one (George Mason) or prescribe stimulants (William & Mary), and instead refer students to off-campus providers. Marquette requires students to sign releases allowing clinicians to phone their parents for full medical histories and to confirm the truth of the symptoms.

“We get complaints that you’re making it hard to get treatment,” said Dr. Jon Porter, director of medical, counseling and psychiatry services at the University of Vermont, which will not perform diagnostic evaluations for A.D.H.D. “There’s some truth to that. The counterweight is these prescriptions can be abused at a high rate, and we’re not willing to be a part of that and end up with kids sick or dead.”

Not everyone is convinced:

“If a university is very concerned about stimulant abuse, I would think the worst thing they could do is to relinquish this responsibility to unknown community practitioners,” Ms. Hughes [CEO of CHADD, an advocacy organization] said. “Nonprescribed use of stimulant medications on campus is a serious problem that can’t just be punted to someone else outside the school grounds.”

She has a point. The 2010 suicide death of Kyle Craig, who abused Adderall prescribed by his local physician at home and not by the university he attended, suggests the problem is more wide-ranging than perhaps some university officials understand.

However, this sort of effort on the part of Fresno State is amazing and should be applauded:

And in a rare policy among colleges, students receiving prescriptions to treat A.D.H.D. must see a Fresno State therapist regularly — not for a cursory five-minute “med check” but for at least one 50-minute session a month.

Psychotherapy required for ADHD treatment? Nice — finally an institution that listens to the research and understands that medications are, for most, not a life-long answer.

I think that, by and large, this is a measured response to a very serious problem of stimulant abuse among college students. Students have long enjoyed free healthcare on campus, with counseling an additional free service they receive. But student counseling centers mostly refer students with serious, ongoing mental health or mental illness to local providers in the community — they’re simply not well-equipped to treat people with such concerns. I see no reason why ADHD should be an exception.

What this does for the colleges that are mostly getting out of the ADHD business is to limit the overall amount of prescriptions floating around for these stimulant meds. That should drive down supply, drive up prices, and make it less attractive as a “study” option for students without ADHD.

As for the students who actually have attention deficit disorder? I think they will still be able to get the treatment they need. Having seen people at community mental health centers, I know that if there’s a will, people will find a way to pay for mental health services.

Read the full article: Colleges Tackle Illicit Use of A.D.H.D. Pills

Ya have to admire psychologists who endlessly lobby state legislatures for the right to extend prescription privileges to their profession (with a little additional training). They won’t take repeated defeat as a sign that perhaps their efforts are… insane?

Illinois is the latest state to hand psychologists seeking prescription privileges a defeat, with NAMI Illinois siding on the side of not supporting the bills in front of the Illinois legislature. After intense lobbying by both sides of this issue, they concluded, “NAMI Illinois opposes SB 2187 and HB 3074 in its current form to expand prescriptions privileges to psychologists.”

When will psychologists learn?

The movement that is supported by some psychologists to gain prescription privileges is called RxP. The rationale behind the movement is that, in some communities in the U.S., psychiatrists are few and far between. With too few psychiatrists, patients often have little choice but to wait weeks or months for an appointment, or travel long distances to see another psychiatrist. Psychologists argue that their existing training prepares them to take an additional set of courses (which can be taken exclusively online) and training (supervision under a physician) that results in them being high-quality prescribers — equivalent to a medical doctor.

NAMI Illinois’ statement is worth a read, so we’ve posted a copy of it here. But here’s a highlight:

If we don’t fully address integrated health care needs, mental health needs become moot if people continue to die so early from physical causes. NAMI Illinois cannot advocate for the creation of more silos that hinder full integration of physical and mental health care needs.

Exactly. Instead of working with the profession of psychiatry to help address the shortage of psychiatrists, psychologists seek to circumvent that profession entirely by pushing for professionals with little medical background or knowledge to become medical prescribers.

This is a misguided, failure-ridden effort that has been going on now for more than three decades — with very little success to show for it. The bills are introduced into a number of state legislatures each and every year. Each and every year, they get defeated or never get voted out of committee.

And Illinois is not alone. Ohio’s legislators appear disinclined to keep reintroducing the same bills that keep failing, year after year, according to an update sent out by Janet Shaw, MBA, the executive director of the Ohio Psychiatric Physicians Association:

It appears Senators Burke and Seitz are no longer inclined to reintroduce last year’s bill in its current form.

Instead, Senator Burke suggested, and Senator Seitz agreed, that psychologists in Ohio who want to prescribe medications go the route of becoming a physician assistant since the training is similar and duration the same (approximately two years), to the psychopharmacology programs for psychologists, and since the scope of practice for a physician assistant already allows them to prescribe in Ohio.

I agree. Psychologists — like all mental health professionals who don’t hold a medical degree — already have a path to gaining prescription privileges. It’s called “go to medical school” and become a medical doctor, a registered nurse practitioner, or physician’s assistant. There is virtually nothing unique or special about a doctoral degree in philosophy (the Ph.D., which most psychologists hold) that gives them a leg up on the medical training necessary to prescribe.

Psychologists should be working with psychiatrists to understand how best to address the dearth of psychiatrists in certain geographical areas in the U.S., instead of trying to steal their profession away from them.

Psych Central remains steadfastly against psychologists gaining prescription privileges. It is a waste of psychologists’ time and efforts, and minimizes their specialized expertise and training in being uniquely qualified in the understanding of human behavior.

Specifically, about 1 in 5 Americans will receive a diagnosis of major depression in their lifetime. But Shorter believes that the term major depression doesn’t capture the symptoms most of these individuals have. “Nervous illness,” however, does.

“The nervous patients of yesteryear are the depressives of today,” he writes.

And these individuals aren’t particularly sad. Rather, their symptoms fall into these five domains, according to Shorter: nervous exhaustion; mild depression; mild anxiety; somatic symptoms, such as chronic pain or insomnia; and obsessive thinking.

As he writes in this recent blog post:

… The problem is that many people who get the diagnosis of major depression aren’t necessarily sad. They don’t cry all the time. They drag themselves from bed and go to work and plow through family life, but they aren’t sad. They may well have one of the “D-words”  — dysphoria, disenchantment, demoralization – but they aren’t necessarily depressed.

Instead, what do they have in addition? They’re anxious. They’re exhausted and often report crushing fatigue. They have all kinds of somatic pains that come and go. And they tend to obsess about the whole package.

What they have is a whole-body disorder, not a disorder of mood. And that is the problem with the term depression: it shines the spotlight on mood, a spotlight that belongs elsewhere.

Severe depression, which has been lumped in with depression, is a completely different disorder. It’s a serious illness akin to melancholia, a term used around the mid 18th century to the early 20th century. Melancholia speaks more accurately to the gravity of this severe depression and its serious symptoms, which include despair, hopelessness, lack of pleasure in one’s life and suicide.

Shorter also describes melancholia as a “dejection that appears to observers as sadness but that patients themselves often interpret as pain.” It’s recurrent. “Melancholia digs deep into the brain and body, putting patients in touch with their most primeval – and often sinister – impulses. Fantasies of murder and suicide are common themes.”

So how did everyone become depressed?

Shorter names three main culprits: psychoanalysis, which shifted the emphasis away from the body and solely to the mind; the pharmaceutical industry, “the marketing to the public of drugs for depression on the grounds that they rested on an unshakable foundation of neuroscience”; and the Diagnostic and Statistical Manual (DSM).

Before 1980 (and the DSM-III), psychiatry had two depressions: melancholia, which was also called “endogenous depression;” and nonmelancholia, which was called a variety of names, such as “reactive depression” and “neurotic depression.”

After 1980, with the publication of the DSM-III, we were introduced to one term. The manual did include melancholia as a subtype of “major depressive episode.” But, according to Shorter, this was “a pale shadow of the historic melancholia, with its crushing burden of intolerable pain.” It was there “in letter, not in spirit.”

In the book Shorter harshly criticizes this diagnostic decision. He writes:

Whereas melancholia designated a small population of people with life-threatening illness, the diagnosis called simply “depression” was applied to millions. Before DSM-III in 1980, psychiatry had always had two depressions, and now it had only one, and that depression, which began life in 1980 as “major depression,” was a scientific travesty, a poor limp thing of a diagnosis that did not necessarily mean that the patient was sad at all – which is what a depressive mood diagnosis is supposed to convey – but was unhappy, aggrieved, tried, anxious, uncomfortable, or had nothing at all really wrong; the doctor had put her on antidepressants because he or she could think of nothing else to do.

Throughout the book Shorter features stories, case histories, diary excerpts and experts’ quotes along with research and survey data that bolster the need for separate diagnoses.

For instance, he cites one study where “depressed” patients most frequently picked words such as dispirited, sluggish, empty and listless — not sad — to describe how they felt. In the National Comorbidity Survey of 1990-1992, lack of energy appeared to be a prominent symptom for people with depression and anxiety.

Shorter also cites Bernard Carroll’s work. In 1968 Carroll, a psychiatrist and endocrinologist, discovered a biochemical marker for depression, a “promising lead” that’s largely been forgotten. According to Shorter:

…Carroll discovered that administering a synthetic steroid drug called dexamethasone to melancholic patients uncovered an unsuspected dysfunction of their endocrine system: It keeps their cortisol levels high.  Cortisol is a stress hormone. Unlike normal subjects, if you gave them dexamethasone at midnight, their systems did not experience the normal late-night-early-morning reduction of cortisol; this nonreduction correlated with the severity of the illness, and it disappeared after patients were successfully treated for their depression. Later studies found that the endocrine systems of patients with most other psychiatric diagnoses showed normal suppression in response to dexamethasone. Thus, melancholic patients had a distinctive dysfunction of the hypothalamus-pituitary-adrenal axis called ‘DST nonsuppression.’

Other illnesses share this suppression. But they’re not mistaken for melancholia, Shorter says. In fact, he compares the accuracy of the DST to the diagnostic test for epilepsy.

The marker of cortisol nonsuppression is not biologically unique to melancholia: it occurs in severe physical illness and in some psychiatric disorders that are unlikely to be confused with melancholia, such as anorexia nervosa and dementia. Yet the dexamethasone suppression test, or “DST,” has about the same ability to diagnose melancholia properly, without too many “false negatives” and “false positives,” that the interictal (between seizures) electroencephalogram has in epilepsy: useful but not perfect. The DST provides evidence that most melancholic patients, whether unipolar or bipolar, have an underlying biochemical homogeneity that is entirely lacking in other psychiatric disorders.

Ultimately, Shorter calls for a de-emphasis of sad mood in depression. “People with the nerve syndrome are not necessarily sad, weepy, or down in the dumps any more than the population as a whole. They feel ill at ease in their bodies, preoccupied with their state of mind, and are unable to get their thoughts off their internal psychic condition.”

He also calls for a division of depression. He believes that lumping melancholia with depression is dangerous. “…[P]oorly diagnosed patients are denied the benefit of proper treatment while being exposed to all the side effects of classes of medication, such as Prozac-style drugs, that are ineffective for serious illness.”

In sum, having one term to describe melancholia and “nervous illness” simply makes no sense. As Shorter writes, these two illnesses are as different as “tuberculosis and mumps.”

According to a National Council on Disability report, people with psychiatric illnesses are routinely deprived of their civil rights in a way that no other people with disabilities are (2). This is particularly so in the case of people who are involuntarily committed to psychiatric wards.

Under present standards of most states, a person who is judged by a psychiatrist to be in imminent danger to self or others may be involuntarily committed to a locked psychiatric ward and detained there for a period of time (3). Some would argue that involuntary civil commitment is a necessary approach justified by safety and treatment concerns. Others would counter that it is an inhumane and unjustifiable curtailment of civil liberties.

Let’s look at the example of recent suicide survivors in order to examine this debate in more depth.

On one side of this argument are the vast majority of mental health specialists and an uncertain percentage of former patients. They argue that forced confinement is, at times, justified by safety concerns and to ensure that proper treatment is administered. Psychiatrist E. Fuller Torrey, eminent advocate of greater use of coercive psychiatry, criticizes the reforms gained by civil rights advocates (4). He says that these reforms have made involuntary civil commitment and treatment too difficult and thus have increased the numbers of mentally ill people who are homeless, warehoused in jails, and doomed by self-destructive behavior to a tortured life.

D. J. Jaffee claims that the high-functioning “consumertocracy” anti-psychiatry people do not speak for the severely ill and homeless (5). If you are suffering from serious mental illness, “freedom,” Torrey and Jaffee say, is a meaningless term. Many a family member has bemoaned the difficulty in getting a loved one committed and kept safe. Torrey pleads with passion that involuntary commitment should be facilitated and the time of commitment lengthened.

No one can contest the problems that Torrey describes, but a nation dedicated to civil liberties should question the solutions he advocates. Prominent critics of coercive psychiatry include early activist psychiatrist Loren Mosher and psychologist Leighten Whittaker, the consumer organization Mindfreedom.org, consumers (or service users) such as Judi Chamberlain, and civil rights attorneys.

In presenting counter-arguments against the use of involuntary commitment with suicide survivors, I consider here the interlinked issues of safety and science-based medicine, as well as civil liberties and justice. Here are my concerns:

• There is no reliable methodology behind the decision of whom to commit.

  Despite studies and innovative tests, doctors still cannot accurately predict who will make a suicide attempt even in the near future. As Dr. Igor Galynker, associate director of Beth Israel Department of Psychiatry said in 2011, it is amazing “how trivial the triggers may be and how helpless we are in predicting suicide.” (6) In fact, an average of one out of every two private psychiatrists loses a patient to suicide, blindsided by the action. (1)So how do hospital psychiatrists choose which people recovering from a suicide attempt they should commit? There are patient interviews and tests, but commitment is primarily based on the statistics that a serious recent suicide attempt, particularly a violent one, predicts a 20-40 percent risk of another attempt. (7) However, this statistics-based approach is akin to profiling. It means that those 60-80 percent who will not make another attempt will lose their liberty nonetheless. So should we accept locking up individuals when evaluation and prediction of “danger to self” is so uncertain?

• Confinement does not offer effective treatment.

  Erring on the side of caution and confining all people who have made a serious suicide attempt is particularly unjust and harmful because the vast majority of psychiatric wards do not offer effective stabilization and treatment. A report by the Suicide Prevention Resource Center (2011) found that there is no evidence whatsoever that psychiatric hospitalization prevents future suicides. (8) In fact, it is widely recognized that the
  highest risk of a repeat attempt is soon after release from a hospital. This is not surprising, given the limited therapeutic interventions usually available on wards beyond the blanket administration of anti-anxiety and psychotropic medications. What the hospital can do is reduce the risk of suicide for the period of strict confinement. Despite this data, in Kansas v. Henricksthe U.S. Supreme Court found that involuntary commitment is legal even if there is an absence of treatment.

• Involuntary psychiatric hospitalization is often a damaging experience.

  Psychiatrist Dr. Richard Warner writes: “…we take our most frightened, most alienated, and most confused patients and place them in environments that increase fear, alienation, and confusion.” (9) A psychiatrist who wishes to remain anonymous told me that voluntary psychiatric programs often see patients with post-traumatic stress from their stay on a locked inpatient ward. Imagine finding yourself surviving a suicide attempt, glad to be alive, but suddenly locked up like a convicted criminal with no privacy, control over your treatment, or freedom.

• Involuntary confinement undermines the patient-doctor relationship.

  The prison-like environment of a locked ward and the power dynamics it entails reinforces a person’s sense of helplessness, increases distrust of the treatment process, reduces medication compliance, and encourages a mutually adversarial patient-doctor relationship. Hospital psychiatrist Paul Linde, in his book, Danger to Self, critically labels one of his chapters, “Jailer.” (10) Yet, like some other hospital psychiatrists, he talks about the pleasure of winning cases ‘against’ his patients who go to mental health courts, seeking their release. The fact that judges almost always side with hospital psychiatrists undermines his victory and patient access to justice. (11)

• Finally, coercive treatment of people with mental illness is discriminatory.

  Doctors do not lock up those who neglect to take their heart medications, who keep smoking even with cancer, or are addicted to alcohol. We might bemoan these situations, but we are not ready to deprive such individuals of their liberty, privacy, and bodily integrity despite their “poor” judgement. People who suffer from mental illness also are due the respect and freedoms enjoyed by other human beings.

One might think from the widespread use of involuntary civil commitment that we have few alternatives. On the contrary, over the past decades, there have been several successful hospital diversion programs developed which use voluntary admission, peer counseling, homelike environment, and noncoercive consultative approaches, such as Soteria and Crossing Place. (12)

Community-based cognitive therapy has been fairly effective with suicide survivors at lower cost, yet we continue to spend 70 percent of government funds on inpatient settings. (13) Yes, many underfunded community clinics are in a disgraceful state, but the same may be said of some psychiatric hospitals.

For a nation that prides itself on its science, its innovation, and its civil rights, we have too often neglected all three in our treatment of those tormented by mental illness and despair who have tried to take their lives.

Endnotes

1. Civil commitment refers to involuntary commitment of individuals who have not been convicted of a crime.
2. “From privileges to rights: People with psychiatric disabilities speak for themselves.” National Council on Disability.(1/20/2000). http://www.ncd.gov/publications/2000/Jan202000
3. ”State-by-state standards for involuntary commitment.” (n.d.) Retrieved September 4, 2012 from http://mentalillnesspolicy.org/studies/state-standards-involuntary-treatment.html.
4. Fuller Torrey, E. (1998). Out of the Shadows: Confronting America’s Mental Illness Crisis. New York: Wiley.
5. Jaffee, D.J. “People with mental illness shunned by Alternatives 2010 conference Anaheim,”
   Huffington Post. 9/30/ 2010. Jaffee is found at Mentalillnesspolicy.org which argues his views.
6. Kaplan, A. (5/23/2011). “Can a suicide scale predict the unpredictable?” Retrieved 9/23/12 from
   http://www.psychiatrictimes.com/conference-reports/apa2011/content/article/10168/1865745. See also Melton, G. et. al. (2007). Psychological evaluations for the courts. Guilford Press, p. 20.
7. There are a wide variety of estimates of the heightened risk found in different studies.
8. Knesper, D. J., American Association of Suicidology, & Suicide Prevention Resource Center. (2010). Continuity of care for suicide prevention and research: Suicide attempts and suicide deaths subsequent to discharge from the emergency department or psychiatry inpatient unit. Newton, MA: Education Development Center, Inc. p. 14.
9. Richard Warner ed. (1995). Alternatives to the hospital for acute psychiatric care. American Psychiatric Association Press. p. 62.
10. Linde, Paul (2011). Danger to self: On the front line with an ER psychiatrist. University of California Press.
11. Personal observation and comments made by hospital psychiatrists to the author.
12. Mosher, L. (1999). Soteria and other alternatives to acute hospitalization. J Nervous and Mental Disease. 187: 142-149.
13. Op.cit. Melton (2007).

With today’s knowledge, the steps toward getting a valid mental disorder diagnosis and treatment are fairly simple. Unless otherwise required by your health insurance plan, you should generally start with a mental health professional — either a psychologist or psychiatrist. These are the specialists of mental health, and usually have the greatest knowledge and depth of experience to be able to diagnose you and setup a treatment plan with you that will be most effective.

If you haven’t seen your primary care physician or family doctor in some time, it never hurts to also see them at the same time — to rule out any possible physical causes of your symptoms. This is especially true if you have a health condition or family history of certain health problems (because sometimes physical maladies can mimic mental disorder symptoms).

The most important thing to understand about mental health treatment is that it often takes two specialists, working in conjunction with one another, to be most effective in helping you. Most serious mental illness is treated with both psychotherapy and medication, including concerns such as clinical depression and bipolar disorder. Study after study has demonstrated that this is the most effective treatment regimen — to help you get better, faster.

So if your mental health professional recommends one without the other, please, ask questions:

• Why aren’t you recommending psychotherapy? Why aren’t you recommending medication?

• How much direct experience have you had in the treatment of this condition?
• Is there anything else I can do to help me in this process?

Here is the basic outline of good treatment for a mental illness or mental health condition:

Now, this is just a general, basic, and simplified outline of treatment and some first steps — it is not meant to apply to every person and every situation. Many people’s situations will be unique and require a different approach, perhaps with additional treatment providers or different types of treatment.

But for most people and most kinds of mental disorders, this is the basic workflow for getting a reliable mental health diagnosis and getting started on a treatment path. Keep in mind, too, that many commonly-prescribed psychiatric medications take 6 to 8 weeks before you’ll feel their effects, and that psychotherapy changes generally take 6 months to a year of weekly therapy sessions for most common concerns.

Good luck with your diagnosis and treatment!

But the trend for the past decade has been to move away from interpersonal methods of treatment and toward cognitive therapies that allow for short-term treatment of problems, rather than a commitment of months or even years of analysis.

What Kinds of Treatments are Approved?

Very often, mental health treatments that may be approved for payment by the government or private insurance are short-term, cognitive methods (which, in some countries, may be time-limited to four to 12 weeks). These treatments are for mild to moderate depression, anxiety, panic attacks, eating disorders and some transitional issues (retirement, job loss, adoption, divorce, etc.).

Cognitive therapy is focused on resolving the immediate mental health concern and the symptoms that are the most distressing. Cognitive therapies are cost-effective since they require only a dozen or two counseling sessions in order to help the patient, rather than a year or longer of treatment.

Computerized Cognitive Treatment

The use of computer programs is one of the newest innovations in mental health care. In many cases, a client using this treatment does not meet often with their counselor, but instead works with a computer program to reduce anxiety, improve depression or manage pain. The programs track progress and can be remotely monitored by a counselor.

For individuals who live in rural areas without enough counselors available, using computer treatment may be a viable option, particularly if Internet access is available and Internet video cameras are available so that counselor and client can consult periodically.

What are Licensed Counselors?

One of the largest trends in mental health and psychology is the use of licensed mental health counselors as opposed to psychologists or psychiatrists. There are a multitude of reasons for this trend, including cost, training, and specific experience.

Professional counselors are trained to help people understand relationships and how those relationships affect them in their everyday lives. Very often how we relate to others is integrated into every aspect of our life and can affect our self-concept, our mood and our ability to engage in healthy interactions with others. Our ability to maintain healthy relationships can affect our ability to have a job, our happiness with our family and even our ability to move comfortably into our elder years.

Why are We Moving Away from Psychiatrists?

Psychiatrists have a definite role in the realm of mental health. However, in the past psychiatrists played a larger role in the treatment of mental health issues than they do today. Instead, contemporary psychiatrists often evaluate a person’s need for psychotropic medications to address mood disorders, bipolar disorder and other mental health issues. They may meet periodically with a client to maintain and monitor medications and consult regularly with a counselor or therapist treating the client in order to continue monitoring their progress. However, it is very rare today that a psychiatrist will provide counseling and intensive treatment for mental health issues and relationship problems.

What is the Role of Medication versus Treatment?

Much mental health treatment today involves evaluation for medication. This is because research has repeatedly found that the combination of medication and counseling or therapy is the most effective method of addressing mental health issues, especially in depression.

Psychotropic medication helps individuals regain and maintain their cognitive functions. Very often, mental health issues are the result of imbalances in neurochemistry, particularly serotonin, norepinephrine and epinephrine. Contemporary antidepressants and atypical antidepressants help rebalance these chemicals to improve mental health and make it possible for clients to integrate the information being conveyed during counseling sessions.

With the ability to think clearly, clients are better able to utilize the improved coping skills and healthier attitudes that result from counseling. As a result, medication may be considered an important part of mental health treatment and psychology today.

What is Sports Psychology?

Sports psychology is specifically geared toward helping athletes gain focus and maintain a “winning” attitude in competition. Specific areas of concentration may include visualization of activities that will help with scoring (shooting baskets, good kicking body position, hitting the ball, etc.), overcoming performance anxiety, positive self-talk and other activities that increase an athlete’s or team’s desire to compete well.

What is Organizational Psychology?

Therapists, counselors and psychologists who specialize in organizational psychology help businesses understand the organization as a living entity and how personal interactions between business associates and employees can affect the business’s success or failure. Organizational psychologists often are employed to help companies as they motivate employees to reach sales goals or to encourage positive interactions and innovation. Organizational psychologists often evaluate employees and employee positions for optimal performance and placement.

Much harder than most physicians and many psychiatrists are willing to admit.

That’s because most physicians — including psychiatrists — have not had first-hand experience in withdrawing from a psychiatric drug. All they know is what the research says, and what they hear from their other patients.

While the research literature is full of studies looking at the withdrawal effects of tobacco, caffeine, stimulants, and illicit drugs, there are comparatively fewer studies that examine the withdrawal effects of psychiatric drugs. Here’s what we know…

Benzodiazepine withdrawal has a bigger research base than most classes of medications — SSRI withdrawal has much less research. So what’s that research say? Some patients are going to have an extremely difficult and lengthy time trying to get off of the psychiatric drug prescribed to them. Which ones? We don’t know.

One study nicely summarizes the problem experienced in many such patients:

Various reports and controlled studies show that, in some patients interrupting treatment with selective serotonin reuptake inhibitors or serotonin and noradrenaline re-uptake inhibitors, symptoms develop which cannot be attributed to rebound of their underlying condition. These symptoms are variable and patient-specific, rather than drug specific, but occur more with some drugs than others. [...]

There is no specific treatment other than reintroduction of the drug or substitution with a similar drug. The syndrome usually resolves in days or weeks, even if untreated. Current practice is to gradually withdraw drugs like paroxetine and venlafaxine, but even with extremely slow tapering, some patients will develop some symptoms or will be unable to completely discontinue the drug.

Psychiatrists and other mental health professionals have known ever since the introduction of Prozac that getting off of benzodiazepines or the “modern” antidepressants (and now add the atypical antipsychotics too) can be harder than getting symptom relief from them. Yet some psychiatrists — and many primary care physicians — appear to be in denial (or are simply ignorant) about this problem.

Back in 1997, a review of the literature on SSRIs (selective serotonin receptor inhibitors) outlined the problem (Therrien, & Markowitz, 1997):

Presents a review of 1985–96 literature on withdrawal symptoms emerging following the discontinuation of selective serotonin reuptake inhibitor (SSRIs) antidepressants. 46 case reports and 2 drug discontinuation studies were retrieved from a MEDLINE search.

All of the selective serotonin reuptake inhibitors were implicated in withdrawal reactions, with paroxetine most often cited in case reports. Withdrawal reactions were characterized most commonly by dizziness, fatigue/weakness, nausea, headache, myalgias and paresthesias.

The occurrence of withdrawal did not appear to be related to dose or treatment duration. Symptoms generally appeared 1–4 days after drug discontinuation, and persisted for up to 25 days. [...]

It is concluded that all of the SSRIs can produce withdrawal symptoms and if discontinued, they should be tapered over 1–2 weeks to minimize this possibility.

Some patients may require a more extended tapering period. No specific treatment for severe withdrawal symptoms is recommended beyond reinstitution of the antidepressant with subsequent gradual tapering as tolerated.

The conclusion is quite clear — some patients are going to suffer from more severe withdrawal effects than others. And, just like psychiatry has no idea which drug is going to work with which patient and at what dose (unless there’s a prior medication history), psychiatry also can’t tell you a damned thing about whether a patient is going to have difficulty getting off of the drug when treatment is completed.

It’s simple trial and error — every patient that enters a psychiatrist’s office is their own personal guinea pig. That is to say, you are your own personal experiment in finding out what drug is going to work for you (assuming you’ve never been on a psychiatric drug in the past). Our scientific knowledge hasn’t yet advanced to be able to tell what drug is going to work best for you, with the least amount of side or withdrawal effects.

The U.S. Food and Drug Administration (FDA) doesn’t require pharmaceutical companies to conduct withdrawal studies in order to analyze a drug’s impact when it’s time to discontinue it. It only requires a broader safety evaluation, and a measure of the drug’s efficacy. The FDA is concerned about adverse events while a patient is taking the drug — not adverse events when the drug is removed. In recent years, some have been calling on the FDA to require pharmaceutical companies to conduct more analysis on a drug’s discontinuation profile, so that the public and researchers can get a clearer picture.

While all SSRIs have these problems, two drugs in particular appear to stand out in what little research is out there — Paxil (paroxetine) and Effexor (venlafaxine). The Internet is littered with horror stories of people trying to discontinue one of these two drugs.

And they’re not alone — benzodiazepines can also be extremely difficult to stop. “Withdrawal reactions to selective serotonin re‐uptake inhibitors appear to be similar to those for benzodiazepines,” says researchers Nielsen et al. (2012).¹

What Do You Do About Withdrawal?

Most people are prescribed a psychiatric medication because it’s needed to help alleviate the symptoms of a mental illness. Not taking the medication is often simply not an option — at least until the symptoms are relieved (which often can take months, or even years). Psychotherapy, too, can often help not only with the primary symptoms of mental illness, but also as a coping mechanism during medication withdrawal.²

The important thing is to go into the process with your eyes wide open, understanding the potential that discontinuing the medication may be difficult and painful. A very slow titration schedule — over a period of multiple months — can sometimes help, but may not always be enough. In some extreme cases, a specialist who focuses on helping people discontinue psychiatric drugs might prove helpful.

I wouldn’t let the problems with withdrawing from some of these medications prevent me from taking the drug in the first place.

But I would want to know about it beforehand. And I’d want to be working with a caring, thoughtful psychiatrist who not only acknowledged the potential problem, but was proactive in helping his or her patients deal with it. I would run — not walk — away from a psychiatrist or physician who claimed the problem didn’t exist, or that I shouldn’t worry about it.

This article was edited to clarify a few sentences on Feb. 14, 2013.

References

Kotzalidis, G.D. et al. (2007). The adult SSRI/SNRI withdrawal syndrome: A clinically heterogeneous entity. Clinical Neuropsychiatry: Journal of Treatment Evaluation, 4, 61-75.

Nielsen, M., Hansen, E.H., & Gøtzsche, P.C. (2012). What is the difference between dependence and withdrawal reactions? A comparison of benzodiazepines and selective serotonin re-uptake inhibitors. Addiction, 107, 900-908.

Therrien, F. & Markowitz, J.S. (1997). Selective serotonin reuptake inhibitors and withdrawal symptoms: A review of the literature. Human Psychopharmacology: Clinical and Experimental, 12, 309-323.

1. Thanks to Beyond Meds for the suggestion of this blog topic.
2. Tellingly, I could find no similar withdrawal syndrome associated with leaving psychotherapy, although certainly some people have difficulty with ending psychotherapy.

But electroconvulsive therapy (ECT) treatment has developed considerably since the days depicted in “One Flew Over the Cuckoo’s Nest.”  A current study at JAMA Psychiatry examines a treatment called transcranial Direct Current Stimulation (tDCS).

Could this fairly new form of electrical treatment for depression really be effective — and without the negative side effects of ECT?

This new treatment, which involves stimulating the brain with a weak electrical current, is starting to be considered as an alternative — and potentially effective — treatment for depression.  tDCS, unlike traditional ECT, passes only a weak electrical current into the front of the brain through electrodes on the scalp.

Patients receive the treatment once a day for 30 minutes and remain awake and alert during the entire procedure.

Why is New Treatment for Depression So Essential?

Depression in adulthood remains a common and often under-treated condition.

Depression can occur at any age, but it typically emerges in the mid-20s. Women experience depression twice as frequently as men, and symptoms can vary from mild to severe. Major depressive disorder, which may be diagnosed when depressive symptoms last for 2 weeks or more, is understood to occur in 15 to 17 percent of the population.

Symptoms of major depressive disorder can include a depressed mood, loss of interest and enjoyment, reduced energy, increased fatigue, diminished activity and reduced concentration and attention.

These and other symptoms, particularly when prolonged, impair a person’s ability to function in day-to-day life, making effective treatment essential.

Research continues to improve our knowledge about the impact of depression on our ability to process information and the underlying processes in the brain that are associated with depressive symptoms.

With increased information, psychologists and mental health professionals have made significant progress in identifying effective treatments.  A combination of cognitive behavioral therapy and medication has evolved the most effective treatment to date.

However, it is not fully understood exactly how and why antidepressants work. And despite significant advancements in medications, treating major depressive disorder remains a challenge. Although medication helps, it can be costly and produce troublesome side effects.

Recent Advances in Electrical Treatments

Noninvasive brain stimulation, such as tDCS, has been increasingly investigated for the treatment of major depression.

In previous research out of the University of New South Wales (UNSW) and the Black Dog Institute, 64 depressed participants who had not benefited from at least two other depression treatments received active or sham tDCS for 20 minutes every day for up to six weeks.

The study found up to half of depressed participants experienced substantial improvements after receiving the treatment.

In a recent clinical trial, Andre R. Brunoni, M.D., Ph.D., of the University of Sao Paulo, Brazil, and colleagues examined the safety and efficacy of electrical current therapy compared to treatment with sertraline hydrochloride for major depressive disorder (JAMA Psychiatry).

Participants included 120 patients with moderate to severe nonpsychotic unipolar major depressive disorder who were not taking antidepressant medications. A three-point change in a depressive rating scale at the six-week mark was considered clinically significant.

Participants were divided into groups to compare sertraline to tDCS or a combination of both.

In major depressive disorder “the combination of tDCS and sertraline increases the efficacy of each treatment. The efficacy and safety of tDCS and sertraline did not differ,” the study concludes.

According to the study reports as noted in JAMA Psychiatry, there was a significant difference in the depression rating scale score when comparing the combined treatment group (sertraline/active tDCS) vs. sertraline only (mean difference 8.5 points); tDCS only (mean difference, 5.9 points); and placebo/sham tDCS (mean difference 11.5 points).

Side effects of participants who received active tDCS treatment were fairly minimal, with skin redness at the treatment site and an increased potential for hypomania or mania episodes being the primary adverse effects.

More research is needed to confirm the results of this latest study. But increasingly, it looks like tDCS may offer people with depression another alternative to more traditional forms of treatment.

Reference

Andre R. Brunoni MD, PhD, Leandro Valiengo MD, Alessandra Baccaro BA, Tamires A. Zanão BS, Janaina F. de Oliveira BS, Alessandra Goulart MD, PhD, Paulo S. Boggio PhD, Paulo A. Lotufo MD, PhD, Isabela M. Benseñor MD, PhD, Felipe Fregni MD, PhD. The Sertraline vs Electrical Current Therapy for Treating Depression Clinical Study: Results From a Factorial, Randomized, Controlled Trial. (2013). Arch Gen Psychiatry, 70, 1-9. doi:10.1001/2013.jamapsychiatry.32

Now, if you’re not someone who has struggled with chronic depression, those stats won’t warrant a happy dance.

But if you’re someone like myself, who assesses her mood before her eyes are open in the morning, hoping to God that the crippling anxiety isn’t there, then those numbers will have you singing Hallelujah.

They are better than the statistics released by a large, six-year, four-step government study called the Sequenced Treatment Alternatives to Relieve Depression trial, or STAR*D. STAR*D looked at the use of popular antidepressants in people with chronic, severe depression who do not respond to a particular drug and may suffer from multiple mental and physical disorders.

The researchers found that trying treatment options such as adding a second drug to a SSRI, switching to a new drug or a different class of drug, and waiting a full 12 weeks to assess results can lead to remission in symptoms in up to half of patients.

That’s not much to celebrate, in my opinion. Good news, but not great.

Folks trudging through the everyday muck of depression and pervasive, annoying, destructive, negative, intrusive thoughts need hope. Lots of it. Daily. Hourly. I know I did. And still do.

In March 2006, I had just finished trying the 23rd combination of mood stabilizers and antidepressants and I still wanted to die. That’s not to mention all the psychotherapy, mindful meditation, light therapy, rigorous exercise, yoga, fish oil, and other techniques I was trying. When my doctor threw out DePaulo’s numbers I did not believe them. However, about two months later, under her care, I was miraculously able to experience a day without any death thoughts. Nada.

The last 18 months have been somewhat of a rerun. I never fully recovered from a crash in August 2011, despite my wholehearted attempts at mindfulness and different kinds of therapy, 10 or so medication combinations, intense exercise, light therapy, diet changes and supplements. Some days were better than others, but I didn’t go much longer than 15 seconds without fighting a death thought. This ongoing silent battle inside my noggin made it very difficult to accomplish anything other than my necessary responsibilities, let alone open space in my life to have fun.

During the last few months, just as in 2006, I have been running dangerously low on hope.

In fact, I began to research transcranial magnetic stimulation, a procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression. That and electroconvulsive therapy are the last-ditch efforts for those of us checking off double digits of medication combinations and every kind of alternative therapy out there. I was even mapping out my schedule as to how I would spend my morning for two and half months at Johns Hopkins Hospital and how I would explain this to my manager at work.

“Before we go there, let’s try one more combination,” my doctor recommended.

Sure. Yeah. Whatever. Like that’s going to make a difference.

I was wrong. It took the 11th or 14th, or whatever number combination it is, to give my tired brain a respite from the death dialogue, and the stamina I needed to push me into the real world again … so that I can practice mindful meditation in a way that doesn’t make me feel demoralized, or swim in the morning without having to hold back tears, or pursue a passion such as reaching out to those with depression — all of which are important facets to my recovery.

The 80-in-80 aren’t exactly statistics that you’ll hear promised in an ad for an antidepressant, but those numbers sure are chock-full of hope for this depressive. I hope they are for you too, and encourage you to keep on keeping on until you can keep on without quite as much effort.

It can be overwhelming if your child is not doing well academically, behaviorally or socially. However, there are professionals available to guide you through the process of finding a diagnosis and getting treatment.

Your pediatrician or family physician is one type of professional to approach for assistance. At the first visit, your physician most likely will get a complete academic, learning and activity history from you and your child. It would be helpful to bring information such as report cards and past evaluations.

If you have had the same physician for years, he may not take a full past medical history, while a new physician more than likely will take one. He or she will want to look for any neurological problems, hospital admissions, history of trauma, poisonings or prematurity as well as a developmental history (milestones such as walking and first word). The next step should be a complete physical exam, including a full neurological workup.

Depending on the results of the history and exam and the physician’s comfort level with ADHD, the next step usually is to have the parents and teachers fill out psychological rating scales for the child. These can give the physician specifics on whether the child has the symptoms for an ADHD diagnosis and the symptoms’ severity.

Once the scales are completed and scored, your physician will sit down with you and your child to discuss them and to discuss treatment options.

Treatment guidelines now advise that parents receive educational information on ADHD; a discussion of the various medications; information on parental support groups; and a possible referral for psychotherapy. I would also include a discussion on the importance of exercise, nutrition (increasing proteins), possibly ADHD coaching, and meditation if age-appropriate.

Many times after the physician has taken the initial history and exam, he may find atypical symptoms, significant findings on the past medical history or exam. In that case the physician may (and should) refer the child for further evaluation by a neurologist; a developmental center for evaluation of autism/Asperger’s; a psychologist for evaluation for psychological or behavioral interventions and/or psychoeducational testing; and a psychiatrist for evaluation of significant depression, bipolar, etc.

Sometimes the rating scales may demonstrate symptoms of anxiety or depression. Again, depending on the physician’s comfort level and training, he or she may address and treat this in the office or refer to a therapist or psychiatrist.

ADHD is a very complicated disorder and its diagnosis requires a lengthy evaluation. The process may take a few weeks or even more if your child requires any referrals. I hope I have been able to give an idea of what is required to evaluate ADHD and take the mystery out of the process.

Learn more about how ADHD is diagnosed here.

As hospitals move to electronic records, the default behavior has been to simply keep things as they are — so no more processes than necessary have to change at the same time. This means keeping the psychiatric information in the electronic record segregated from a patient’s medical information.

But in an intriguing new study just published — on a very small cohort — researchers found that where hospitals allowed any properly authorized medical staffer to access the patient’s psychiatric information in the electronic health record (EHR), hospital readmissions went down.

Perhaps it’s time to re-evaluate whether opening up the sharing of such information among all doctors on a patient’s treatment team might actually be a good thing.

To get the data, the researchers surveyed 18 hospitals on the 2007 U.S. News and World Report list of the “Best Hospitals in the United States.”

“Of that group, eight hospitals (44 percent) kept most or all of their inpatient psychiatric records electronically, and five (28 percent) let non-psychiatrist physicians see mental health records, including psychiatric admission notes, discharge summaries, notes from the emergency department, and consultation notes.”

Just four hospitals did both. Among this latter group, however, readmission rates for psychiatric patients were substantially lower than at the others on the list. Here’s what they found:

Top teaching hospitals that provided non-psychiatrists with electronic access to inpatient psychiatric records had up to 39% lower rates of readmissions within 7, 14, and 30 days of initial discharge than comparable institutions that did not include inpatient psychiatric notes in their EHRs. Full access also cut 7-day readmission rates by as much as to 27% when compared to hospitals that did not let primary care and emergency physicians see psychiatric records in the EHR

I only have one concern — that non-psychiatrist physicians treat the psychiatric information with the same care they would as if it were their own information. Sometimes doctors are a little too loose with a patient’s medical information when talking to other docs — especially in public places where many others may hear (like an elevator).

I’m also concerned that stigma, discrimination, prejudice and misunderstanding are still fairly rampant among some physicians — especially in certain specialties. Without proper education and training, I worry that some doctors may misuse or inappropriately share information gleaned from a patient’s psychiatric record. Proper education and training could readily solve this concern, however.

Patients, too, ultimately benefit from such increased sharing, as this study — if confirmed by others — demonstrates. If patients are afraid of this development, I usually find information is the best remedy — showing patients exactly what is and isn’t in their medical and psychiatric charts. Patients, of course, have a right to view their medical and psychiatric records in their entirety. In most instances, once a patient sees how little is actually in their psychiatric or mental treatment progress notes (if it’s being properly maintained), they’re usually satisfied.

I’m a big believer in the benefits of transparency and open communication. If giving doctors access to all relevant data of a patient — including their psychiatric history — can help patients receive better care, why not do it?

Read the full article: Sharing Psychiatry EHR Data Cuts Readmission Rates

Those words were not written by Adam Lanza, but another school shooter, Eric Harris, whose life was also wrought with themes of alienation and social awkwardness. Eric Harris, a Columbine shooter, compiled journal entries that pulsate with narcissistic rage and reveal a tendency to rely upon the psychological strategy of splitting: separating the world into black or white, weak or strong, good or bad, me or them.

Splitting can be seen in certain personality disorders and might also be used by some to justify bullying someone, starting a militia or cult, deciding to home-school a child, maintaining a survivalist mentality or even getting a divorce. Extreme cases of splitting can even contribute to rationalizing suicide or murder.

Partitioning and compartmentalization are not just becoming more prominent patterns in our ever more paranoid collective psychology, or politics for that matter, but may actually be a consequence of increased fragmentation and isolation found in Westernized societies and family structures.

I remember the first time I saw the movie “Kramer vs. Kramer” and thinking how crazy the idea of another naked lady other than my mom sleeping with my dad seemed. Aside from winning prestigious accolades, “Kramer vs. Kramer” reflected a cultural shift in the ’70s, further normalizing baby boomer ideals of individuation and rejection of traditional values.

While we embrace the technological and capitalistic gains made by the baby boomer culture, I wonder if we are in denial of the insidious social ills that have resulted from unrelenting individualism that sometimes manifests in shared custody situations, decreased social connectedness, or even an unwillingness to relinquish the right to own a gun.

While “Kramer vs. Kramer” was fictional, Roe v. Wade was very real. Some academicians have theorized that the drop in crime in the U.S. in the 1990s is related to the impact of legalizing abortion in 1973. In other words, fewer unwanted pregnancies beginning in 1973 might have something to do with a drop in crime approximately 18 to 20 years later.

Movies can act as a time capsule, reflecting societal attitudes or events for a particular point in time. The United States saw a sharp increase in divorce rates from the 1970’s to the 1980s. If “Kramer vs. Kramer,” released in 1979, reflects a culture that was beginning to accept and normalize divorce, and subsequent fragmentation of family, is it just a coincidence that the U.S. saw a sharp increase in school shootings in the late 1980s and early 1990s? Is it also a coincidence that the early 1990s also saw an increase in disruptive behavioral disorders — which include ADHD, oppositional defiant and conduct disorder?

In the essay, “I am Adam Lanza’s mother,” Liza Long wrote about her perspective on living with a son with mental illness. She mentions ADHD, oppositional defiant disorder and intermittent explosive disorder and advocates for the need to address mental health issues. Even as a child psychiatrist who understands the great need to destigmatize and advocate for mental health, I have concerns with her projecting such extraordinary violence onto her own son and would caution anyone from taking any child psychiatry case at face value. Just because a patient is identified doesn’t mean the problem is an individual rather than a dysfunctional system.

As I read Liza’s descriptions of physically restraining, hospitalizing and receiving verbal abuse from her son, I couldn’t help but wonder where the boy’s father was in all of this. She doesn’t mention another parent helping her at any point and it reminds me of my experience during my child psychiatry fellowship.

When I began to compile a caseload of young boys with behavioral problems, I also began to make a connection between their acting out and a physically or emotionally absent father. By no means am I invalidating the challenges faced by single parents or suggesting that all children with behavioral problems are linked to family dysfunction, but I think we’re kidding ourselves if we keep pretending it’s not a significant factor.

Some might look to the increase in school attacks in China to point out that this problem transcends American society. I would argue that the school attack timeline in China parallels a time of tremendous economic growth that has similarly contributed to social fragmentation and isolation. The difference in China is that knives are most often used in the school attacks and most do not result in mass fatalities. It’s the guns that make our problem uniquely American.

No one will ever know what really was going on in the head of Adam Lanza, and each school shooting case is different in some way. Anger borne out of narcissistic wounds, however, seems to be a common psychological factor in United States school shootings and this dynamic is more likely to arise in an individual who has not developed healthy ego functioning.

A loving, secure and consistent family and social environment can be conducive to healthy ego development. I wonder if America’s biggest problem is our continued refusal to acknowledge the social impact of our increasing difficulty in providing this for our children.

If you’re taking non-steroidal anti-inflammatory drugs (NSAIDs), you may be less likely to experience the beneficial effects of the most commonly prescribed classes of antidepressants, SSRIs (such as Paxil, Zoloft and Prozac).

NSAIDs include ibuprofin (such as Advil, Motrin, and Midol), naproxen sodium (such as Aleve) and good ole aspirin.

According to an article appearing in the recently published The Carlat Psychiatry Report, that was the surprising conclusion of a paper published last year (Warnerschmidt Jl et al, Proc Natl Acad Sci USA 2011;108:9262–9267), and a newly released report reaches a similar conclusion.

Here’s the report:

Using the electronic medical record of a large HMO, investigators identified 1,528 depressed patients who either achieved remission or who remained treatment-resistant after two or more antidepressant trials. Of these, 1,245 (81%) received at least one prescription of an NSAID or NSAID-like medication during their treatment period. Consistent with the earlier report, depressed patients who received NSAIDs were more likely to be treatment-resistant (odds ratio 1.55, with 95% confidence interval 1.21-2.00).

The investigators attempted to factor out other medical problems. After doing so, the odds ratio remained elevated but was not statistically significant (or=1.17, 95% CI 0.83-1.64).

But then the investigators looked more specifically at the type of NSAIDs used. They found that cyclooxygenase-2 (COX-2) inhibitors — drugs like celecoxib (Celebrex) — and salicylates (aspirin) were not associated with treatment resistance, whereas “pure” NSAIDs were.

Thus, NSAIDs alone (drugs like ibuprofen and naproxen) correlate with treatment resistance, while other NSAID-like drugs do not. This result remained significant even when adjusting for medical comorbidities.

The investigators also performed their analysis on the 1,546 subjects in STAR*D (a large, multicenter antidepressant trial in which all subjects received citalopram in phase I) and found a strikingly similar response: NSAIDs were more highly associated with treatment resistance (or=1.23, 95%CI 1.06-1.44). The risk of treatment resistance was particularly high when coX-2 inhibitors and salicylates were removed, and remained high after controlling for medical problems (OR=1.26, 95%CI 1.02-1.55).

TCPR also notes some problems with the recently published research. For instance, it isn’t based upon a randomized population, doesn’t take into account all possible confounding variables, and didn’t look at the dose-response effect of the relationship. “Nonetheless,” notes TCPR, “its main conclusion is worth considering: patients taking NSAIDs may respond more poorly to antidepressants (Gallagher pJ et al, Am J Psychiatry 2012;169(10):1065–1072).

It concludes:

TCPR’s Take: Should you ask your patients to stop NSAIDs when you prescribe an SSRI? Probably not—and that would be impractical anyway.

But the take-home message seems to be that inflammation and medical illness are linked to depression in ways we are just beginning to understand.

Authors of the earlier paper, for instance, hypothesized that the expression of a certain intracellular protein (called p11) underlies antidepressant response and is enhanced by certain cytokines, while other research holds that inflammation and elevated cytokines are responsible for depression. Clearly more research is needed to tease out these relationships.

Based upon an article by Glen Spielmans, PhD for The Carlat Psychiatry Report.

Nowhere is that more evident when it comes to the world of mental illness.

Finding that the word “patient” is too medically oriented, Carl Rogers — 50 or so years ago — suggested a more agnostic term, “client” (such as a lawyer or accountant might have a client). And while I agree client is a more agnostic term, Rogers unfortunately and unintentionally opened up an entire can of worms.

One that haunts us to this day and interferes with our basic ability to communicate when it comes to mental health concerns.

The problem is that once Rogers suggested patients could be called something else, people took that to mean they could use a myriad of different words and phrases to describe themselves.

So now the list lengthens with every passing decade. Here are just some of the labels people who happen to have a mental disorder choose to identify with:

• Patient

• Client
• Survivor
• Consumer
• Beneficiary
• Victim
• Crazy
• Psycho
• In recovery
• Mentally ill
• “Aspie,” “Depressive,” “Schizo,” etc.
• Disabled
• Handicapped
• Advocate (peer advocate, etc.)

Don’t get me wrong… I’m a firm believer that you can use whatever you want to call yourself. If you want to call yourself Queen of Bipolar, be my guest. If you want to refer to yourself as a “survivor” of a mental illness (or of the treatment system), I think you’re absolutely entitled to that.

But to many, it’s also very confusing. It means when you reference yourself with some new term the rest of aren’t familiar with, we have no idea what you’re talking about (since words and language are based upon a shared foundational understanding).

We are all fundamentally human beings. It would be great if we could just strip all these labels away and say, “Hey, I’m just a person. And these are the things I’ve gone through.” Any label will never capture that full and rich experience.

And that’s why for over 20 years, I’ve told anyone who’s asked, “I’m really concerned about my diagnosis. Do you think it’s X or Y?” I say, “Is it important for you to be diagnosed with X or Y? What would that mean to you?”

Because I think labels are great for having an insurance company pick up the tab on your treatment, or for research purposes. But I think they often are a detriment to us talking about ourselves and our own recovery efforts with a mental health concern.

We get tangled in all these labels, these words, these phrases that mean something different to every single one of us.

That’s why when people start talking about these things, you’ll often see me tune out. I love language and I love words. But these words are emotionally charged with very specific meanings to each person who chooses the label that best fits them.

And there’s little point in arguing about such personal, subjective choices if you’re focused on helping change the conversation for large groups of people — like anybody who doesn’t have or relate to that label.

You are not your disorder or label. Nobody with cancer says, “I am cancer.” They say, “I have cancer,” or “I’m recovering from cancer.”

In the same way, I’d suggest it’s not helpful to identify yourself as “bipolar” or “schizophrenic.” You may be someone who has bipolar disorder, or you may be someone who has schizophrenia. But these conditions don’t have to define your very being. They can just be what they are — a component of your life that you’re getting help for, that you’re working on daily, a part of you, but not all of you.

Call yourself whatever you want. But I’d suggest we gain more benefit by staying focused on the issues that people need to understand to help reduce the prejudice and discrimination that occurs in society today against those who struggle with mental illness and mental health concerns.

By having such a colorful array of labels that mean, “a person who has a mental disorder,” I worry that we risk confusing and alienating others — especially those trying to understand a mental health issue for themselves or a loved one.