mental illness


Is It Possible To Prevent Suicide? 2 Psychiatrists Map Out The Ways

By Gene Beresin and Steve Schlozman

Suicide is awful, more common than you’d think and, in many cases, highly preventable.

Perhaps most important, in virtually every culture and every ethnic group on the planet, suicide is highly stigmatized. It therefore makes sense for the international health community to designate a day when we stop to actively contemplate this potent cause of misery and death. That’s today: World Suicide Prevention Day, though the harsh facts surrounding suicide are so much bigger than a single day.

The statistics, from the International Association for Suicide Prevention, are staggering:

*There are an estimated 800,000 deaths every year throughout the world that are directly attributable to suicide.

*This number is probably under-reported, given the stigma associated with suicide, and the fact that deliberate, self-harming behavior is often misclassified as an accident. The teen that drives into a street lamp at 100 mph could very well be attempting suicide, and not be the victim of an automobile mishap.

*Suicide is the 15th leading cause of death on the planet.

*Suicide is more common among older people (70 years of age and up), but also occurs in middle-aged and younger individuals at alarming rates.

*Lower income nations endure more suicides, but suicide remains a major cause of death in developed nations as well.

*Suicide has been tied to numerous psychiatric illnesses (mostly mood disorders), to difficult economic or traumatic situations and environments, to substance use disorders (both with and without addiction), to the loss of loved ones, and to a lack of good follow-up care following suicide attempts.

*The number one predictor of death by suicide is a previous attempt.

2013 U.S. suicide rate by age group, via CDC

Why So Common?

In other words, we know a lot about suicide. So if we know so much, why does suicide remain so stubbornly common?

The answer to this question is actually much less concrete than we might think. Studies on post-suicide-attempt intervention are lacking and under-represented. Studies on pre-suicide-attempt intervention are also insufficient in generating a simple and generalizable prevention methodology. Moreover, the likelihood of creating a one-size-fits-all approach is minimal. This might be why we know less than we’d like to.

There are studies that show that email, phone and in-person communication following an attempt can make a positive difference, but these studies have relatively low numbers of participants and clearly need follow-up. We also have studies that show we can increase the understanding of suicide and its risk factors in high schools and colleges, but it isn’t clear whether this understanding leads to decreased suicide rates. We do know that treatment as usual — that is, telling someone to go to an appointment with a yet-to-be-met clinician following his or her discharge from an emergency room or hospital — falls short of other more personal interventions.

All of this points to a common flaw in the understanding of suicide.

Suicide isn’t a formal disease. We don’t treat suicide itself. We treat the causes of suicide.

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Stressed-Out Undergrads And The College Mental Health Crisis

In case you missed it this morning taking your possibly stressed-out kids to school, check out On Point’s excellent segment about the mental health crisis among college students.

The bottom line: undergrads are struggling, many of them suffering from mild, moderate and severe mental illness. And colleges are scrambling to figure out ways to cope, from setting up automated counseling kiosks to launching campaigns promoting the message that it’s all right to ask for help.

A special report, “An Epidemic of Anguish,” published in The Chronicle of Education is featured on the show:

“Colleges are trying to meet the demand by hiring more counselors, creating group-therapy sessions to treat more students at once, and arranging for mental-health coordinators who help students manage their own care. A couple of colleges have even installed mental-health kiosks,which look like ATMs and allow students to get a quick screening for depression, bipolar disorder, anxiety, and post-traumatic stress.

Meanwhile, the Boston Globe reports that MIT, a well-known hotbed of stress, is enhancing its mental health services for students:

Starting this academic year, the Cambridge school will provide more mental health counselors, create a drop-in center for students to talk with professionals, and make it easier for students to seek professional services off campus.

The changes come after campus officials reviewed the results of a survey administered to students in April and May, which found that 24 percent of undergraduate respondents have been diagnosed with one or more mental health disorders by a health professional.

Alli Stancil/Flickr

Alli Stancil/Flickr

The reality that many college students suffer from mental illness isn’t exactly new. Earlier this year, for instance, researchers at UCLA surveyed 150,000 college freshman and found an increase in the number of students who report they were “frequently depressed.”

I asked child psychiatrist Dr. Steve Schlozman, associate director of The MGH Clay Center for Young Healthy Minds and an assistant professor of psychiatry at Harvard Medical School, about the UCLA report back in February and whether depression among college-age kids is getting worse, and he said: “We are reaping what we sow.” He added:

The pressure we put on high school kids to get into college and the pressure then that college follows up with is highly correlated with increased rates of emotional distress that can become full-blown depression. Also, the age of onset of depression is the exactly the age of onset of college — there’s a perfect storm of stressors. Finally, there’s a greater willingness to come forward, which is good. So, despite the fact that we’re using the word ‘depression’ a little more glibly, I’d rather have that and then rule out clinical depression through appropriate channels, like college health services, than miss cases that can lead to real suffering and possibly even death.

Now, Schlozman says, it makes sense for colleges to boost their efforts to make mental health services more accessible. In an email, he writes:

It makes sound ethical, medical and common sense for colleges and universities to increase their surveillance for mental health challenges as the school year begins, and to provide easy and unfettered access for ongoing care. Ideally, a comprehensive plan that has multiple and coordinated entry points and multiple and coordinated means by which care is delivered is the best way to provide the essential help that the last two decades have shown us is sorely needed on college campuses.

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Dr. Mark Vonnegut: On Creativity, Being ‘Crazy’ And Getting Help

By Mark Vonnegut, M.D.
Guest Contributor

Being related to a famous person is somewhere between a cruel joke and a minor distraction. My father was immensely talented and worked very hard at his writing, but the degree of his success was a fantastically unlikely bit of luck. There are lots of talented, hard-working artists who don’t make it.

The important thing in overcoming mental illness, whether or not you have a famous last name, is to want things to be better — and being willing to get help to make that happen.

Dr. Mark Vonnegut (Courtesy)

Dr. Mark Vonnegut (Courtesy)

Both of my parents’ families advised them to stay away from one another, as mental illness was rumored to be in each other’s family. The rumors were true, but it wasn’t like anyone then or now comes with any guarantees. It makes us feel more alive to be able to see, listen to and read great art, partly because great art is often the result of great struggle. The idea that artists and “the mentally ill” have inner demons while the rest of us do not is part of what has made it — and continues to make it — so hard to come to terms with mental illness.

The reason the arts and craziness run in families is because crazy people who can sing and dance and paint pictures and write well do a much better job of convincing others to have babies with them than if they’re just plain crazy. Thus has it ever been.

In my career as a mental patient, I started with schizophrenia, worked my way up through manic depression, and have now settled at bipolar disorder. I can joke about it because I recovered sufficiently to get into and through medical school, internship and residency, and have had the enormous honor and privilege of being trusted by parents to help them and their children. I make no bones about it; I make mistakes just like everyone else, but am very proud of how well I do my job.

I’m also very aware of how easily I could have ended up otherwise — a suicide statistic or just another broken young man who never got well enough to have a life. Continue reading

The Upside Of Admission To The Psych Unit: A Doctor’s Inside View

By Helen M. Farrell, M.D.
Guest Contributor

I met J in the Emergency Department. Dark red blood was oozing out of self-inflicted deep lacerations to her forearms. The surgical team was consulted and the cuts were debrided, cleaned, stitched and neatly bandaged. J was patched up. But she was not healed. Her wounds ran deeper than a surgeon’s instruments could access.

Together, we had a thoughtful conversation that included a review of her suicidal thoughts, intermittent hallucinations and innermost feelings. These vacillated unpredictably between anger and worthlessness. I informed J that she was going to be admitted to the psychiatric unit for her safety and treatment.

“Locked up?!” These are typical words expressed by patients who learn that they are going to be admitted involuntarily to the psychiatric unit. When J heard this news, her own tear-stained face scrunched up in an expression of horror. After several minutes of pleading, she finally resigned herself to the plan.

A nurse came into the room and took J’s phone. She took her sweater, her belt and the laces from her shoes. J stripped down into a standard hospital gown. It is common for patients to make one last plea and many have told me that they fear the psychiatric unit is analogous to prison.

J is representative of the many patients whom I treat on a day-to-day basis. She is a composite of those actual people who suffer from serious mental illnesses ranging from psychotic and mood disorders to personality disorders that require hospital level care.

Not Your Mother’s Psych Ward
The days of psychiatrists wantonly locking up patients like J against their will are long gone. They have been replaced by a legal process called civil commitment that firmly puts patients’ rights first. Yes, J was being admitted against her will, but she would retain her power to make treatment decisions, summons legal counsel, and even have a hearing with a judge. These safeguards apply to patients like J who are mentally ill and at risk of harm to themselves or others as a direct result of mental illness.

We know about the extreme cases of mental illness — those who involuntarily get locked on a psychiatric unit. An estimated one-quarter of the United States population will suffer from mental illness. But what about those people whom we never hear about? Far too many people, victims of stigma, neglect treatment and suffer in the isolating silence of darkness. They are compelled to withdraw because of fear and shame.

Beyond Shock Therapy

Driving much of that stigma is the fantasy of what happens behind that infamous locked door. Images from “One Flew Over the Cuckoo’s Nest” fill people’s imaginations, as do fantasies of the “shock therapy” room, which many incorrectly think is a place of punishment and not treatment. Continue reading

More resources:

Predicting The Next Mental Health Crisis: Sometimes We Just Can’t Know



By Steve Schlozman, M.D.

When tragedies hit, it is in our nature to ask why. The co-pilot in the horrific Germanwings crash had serious mental health problems, according to reports. How could no one have known how serious his challenges were? How could no one have predicted this terrible outcome?  On its surface this line of questioning seems even a bit ludicrous.  After all, even in the murky face of mental illness, the potentially deliberate and fatal nose-dive of a commercial aircraft seems impossible to imagine.  Nevertheless, this is exactly the question that we’re seeing over and over in the coverage of the crash.

How could we not have known?

The fact is, however, that this particular question glosses over a profoundly uncomfortable quandary that is by no means unique to psychiatry. For all of modern medicine, predictions are surprisingly fraught with difficulty.  For all of medicine’s miracles, for all of its technological wonders and advances, medicine remains a quintessentially human endeavor.  You might even argue that phrases like “medical miracle” are indeed part of the problem.  This more we grant medicine undue and mystical prowess, the more resistant we grow to the grueling trial and error that characterize everyday medical practice.  Doctors are wrong all the time.  That’s a fact.

Nevertheless, physicians are asked to prognosticate. That’s the verb form of “prognosis.” As patients and families, we look to our doctors daily for prognostic estimates.  (Emphasis on estimates.)  These estimates are really hypotheses necessarily based on incomplete data. Rare complications and twists of fate befuddle even the best.

For psychiatry this truth can be especially hard to swallow.  A neurologist might not be able to predict every migraine, but it is the rare migraine that results in tragedy.  Still, remember that psychiatrists cannot read minds. Like all physicians, psychiatrists will try their best to understand what is the cause of suffering.  And, as with all clinicians, psychiatrists will sometimes be right and sometimes not.  Medicine remains an art even as the science continues to improve.

The fact that someone suffers a psychiatric disorder, even a recurrent psychiatric disorder, is not remarkable when compared to the rest of medicine.  The same occurs with ulcers, asthma, allergies, orthopedic injuries, sinus infections and so forth. Most medical illnesses are chronic and many are intermittent. No medical professional can predict with absolute certainty when an episode is going to occur or how severe it may be. To be fair, physicians can and do identify triggers, but the intensity of a presumed reaction is outside anyone’s ability to predict.

And this is where society gets especially flummoxed. No one would argue that the art of medicine is infallible. No one would suggest that medical practice is right 100% of the time. But faced with tragedy, we are much more comfortable as a species pretending that our predictions are foolproof and that our mishaps are exceedingly rare.

Why can’t we always know? Medicine is post-modern. We cannot know because we can’t. Continue reading

Medicated (And Unmedicated) Women Are Talking

By Alicair Peltonen
Guest Contributor

I think a crucial step in decreasing the stigma surrounding mental illness is talking about it openly. And it seems readers want to talk.

My post, “The Medicated Woman: A Pill To Feel Better, Not Squelch Feelings,” on mental health and medication, was shared on Facebook more than 15,000 times and now has over 200 comments, so I thought it was worth a follow-up.

One thing readers wanted to discuss is the safety of antidepressants during pregnancy, a complicated topic which has been covered here and here on CommonHealth. Safety studies are mixed in many cases so women should consult their doctors. Here’s what it says on the Mayo Clinic website:

A decision to use antidepressants during pregnancy is based on the balance between risks and benefits. Overall, the risk of birth defects and other problems for babies of mothers who take antidepressants during pregnancy is very low. Still, few medications have been proved safe without question during pregnancy, and some types of antidepressants have been associated with health problems in babies.

Other comments underscored that stigma still exists but may be slowly diminishing.

(Flickr Creative Commons)

(Flickr Creative Commons)

Jackie wrote: “It took me until I was in my 50’s to accept that medication wasn’t the ‘weak”‘ way. I now see how much I lost and am living through a tremendously stressful life without those urges to accelerate into other cars or cement walls.”

“It’s in our family, but I was the first to seek help, and was probably the worst off. It was a secret that my grandfather had committed suicide,” wrote lilycarol.

And here’s a comment from helentroy4: “My mother was much like me. But to her dying day she never acknowledged that her behaviors were anything but ‘perfect mothering.’ I think had she been able to take advantage of this medication (or others of its kind), she would have been able to have the calming of her heart and soul that I have been blessed to have.”

There were many who suggested that lifestyle changes, including more exercise and sleep, meditation or yoga might be safer and more beneficial than medication. Continue reading

Anorexia: Potentially Deadly, Treatable And Still Not Always Covered By Insurance

(Mary Lock/Flickr)

(Mary Lock/Flickr)

By Drs. Gene Beresin and Steve Schlozman

People die from Anorexia Nervosa.

This is true of other psychiatric syndromes, but with anorexia, the cause of death couldn’t be more straightforward. People with anorexia literally expire from the complications of malnutrition.

They starve and they die.

Your heart cannot beat if you don’t feed it. Your immune system can’t protect you without food. Your bones crumble, your kidneys fail, your liver sputters and your brain wanders, all as a result of inadequate food.

Suicide is common. Without proper nutrition, depression is prominent and thinking is blurred. Coping mechanisms falter. Life can seem unlivable.

So, here’s the really strange thing about anorexia: Despite its awfulness and potentially fatal outcomes, despite a death rate more than 12 times higher than any other psychiatric syndrome, insurers still balk at providing adequate coverage.

In 2008, the Federal Mental Health Parity and Addiction Equity Act put special restrictions on the coverage of the treatment of eating disorders. While the explanations for this exception vary — some have suggested that this is because eating disorders are thought to lack a biological basis — it is clear that getting standard of care treatment for anorexia remains problematic even to this day.

In 2010, the U.S. Court of Appeals for the 9th Circuit found itself facing what was essentially a logic problem. The case of Harwick versus Blue Shield of California noted that while the insurer agreed that the residential treatment requested for a patient with anorexia was medically necessary — thus making it in compliance with existing parity statutes — coverage for residential treatment was not authorized because residential treatment was not part of the health plan. The court ruled in favor of the patient in this case, but the fact that this even ended up in court is shameful. Can you imagine an insurer refusing to pay equally for the medically necessary care of any other disease with such clear risks?

So, while patients, their families and physicians continue to fight for coverage, we know that treatment for this disorder can be life-saving.

In this context, here’s the story of a young woman who recovered.

Nicole (who asked that her last name not be used) is a remarkable 16-year-old. She is academically and socially accomplished and she speaks with wisdom that belies her age. She also faced Anorexia Nervosa head on and here discusses her struggles with humility and insight.

What we can learn from her story?

To begin with, we can acknowledge that her bout with anorexia has not been easy. She suffered significant depression and even suicidal ideation as she muscled through the course of the illness. This aspect of her history is perhaps the most important take-home message. The work towards recovery from an eating disorder is never straightforward. Each patient finds a unique way to work with his or her treatment team and family to progress towards health. We can also note that Anorexia is a typically insidious and largely unconscious development. As you can hear from Nicole, the syndrome essentially snuck up on her and her family. Continue reading

‘Tis The Season Of Stress: 10 Tips To Help You Cope

Happy Holidays! (Courtesy of Gene Beresin)

Happy Holidays! (Courtesy of Gene Beresin)

By Steve Schlozman, M.D. and Gene Beresin, M.D.
Guest Contributors

Imagine this fairly common holiday scene: You’re driving up and down the aisles in a very busy parking lot. There have been a few near misses, cars pulling out of briefly empty spaces, but there’s always someone waiting for that space, getting there just a second before you. Your car is a cacophony of seasonal torment: The pop music on the radio mercilessly full of holiday cheer, your little one in the car seat with a runny nose, your school-aged kid kicking the back of your seat and your teenager sitting with her legs on the dashboard while she sullenly tunes you out in favor of her iPod and its noise-cancelling earphones.

‘Tis the season…

Study after study shows us that the holidays are stressful for both parents and kids. (Like we needed a study?) People are cranky, irritable, rushed and unruly. All of us await the holidays with great anticipation and high expectations — family, fun, presents, togetherness. And these experiences are reinforced by the multitude of ads we all see on TV. Yet, for most of us, there are immeasurable stresses.

The stress can be about almost anything: the guests, the gifts, the recents divorces or deaths.

And people with psychiatric disorders often have an even harder time. Depression and substance abuse worsen, and suicide attempts appear to increase. Don’t misunderstand — the holidays are also wonderful, but we’d be fooling ourselves if we ignored the yearly misery that the holidays can potentially engender.

So, how do we navigate these frenzied days and stay on an even keel?

It turns out that there are some things we can do to manage the tough times, and though many of these things seem obvious, it’s their very obviousness that often causes us to forget. Here are 10 tips to remember:

1. Pace Yourself (if possible)

Adults and children rarely do well when they’re rushed. Kids detect the panicked demeanor of their parents, and parents then get irritable when their anxious kids act out. So, don’t do everything at once. Continue reading

Persistent Stigma, Skepticism About Mental Illness Causes Real Harm

By Dr. Steve Scholzman
Guest Contributor

Profound misunderstanding about mental illness — its causes, its legitimacy and its treatment — permeate our culture. And the stigma that accompanies this lack of understanding hurts, a lot. Take this example — hardly original or rare.

Imagine a 15-year-old adolescent girl with fairly severe depression. She may be a classmate of your child, or the daughter of a friend. Let’s call her Sally.

Sally’s not so ill that she needs to be in the hospital, but she’s close. Her family and I — her psychiatrist — are doing our best to get her better as quickly as possible so she can get back to school. She’s been out now for about three days. Why? She literally lacks the capacity to think clearly. It’s all she can do to drag herself out of her bed and run a toothbrush across her teeth.

(Michael Summers/Flickr)

(Michael Summers/Flickr)

There’s a big family history of depression so Sally’s parents are both familiar with and frightened by her struggles.

“Can you call the school and ask them to give her more time on some work?” the parents ask.

“Sure,” I say, and I get in touch with the school administrator.

“Well,” I’m told by the very well-meaning administrator, “It IS a tough time of year. The other kids are getting through it somehow. I don’t see why she should get special treatment.”

“Because she has the equivalent of the flu,” I say. I like to use analogies at these crossroads.

“But the flu feels awful. Does she have a fever? Because if she does, she shouldn’t come to school…”

“No, she doesn’t have a fever,” I say. I try another analogy. “What if she had been in a car accident, God forbid?”

“Well, that’s pretty different, isn’t it?”

“How?” I ask.

“She’d be hurt,” I’m told. “This is an entirely different thing. You’ll need to get her pediatrician to call.”

I ask the pediatrician to call, and I can feel his discomfort over the phone. “I’m not very good at making this case,” he acknowledges. “It’s probably better if you just call them back.”

(I have to wonder whether he’d be so uncomfortable if I were a gastroenterologist asking him to call the school about a patient with ulcerative colitis?) Continue reading

Inspired By Family Illness, Philanthropist Gives $650 Million For Psychiatric Research

The Broad Institute of Harvard and MIT  summer student Lydia Emerson and aesearch associate Aldo Amaya. (Courtesy/Kelly Davidson Photography)

Researchers at the Broad Institute plan to use Ted Stanley’s money to catalog all the genetic variations that contribute to severe psychiatric disorders. (Courtesy/Kelly Davidson Photography)

In the largest-ever donation to psychiatric research, Connecticut businessman Ted Stanley is giving $650 million to the Eli and Edythe Broad Institute of MIT and Harvard. The goal — to find and treat the genetic underpinnings of mental illnesses — was inspired by a family experience.

Ted Stanley made his fortune in the collectibles business. He founded The Danbury Mint, a company (later MBI, Inc.) whose first product was a series of medals commemorating the biggest scientific achievement of its time: the moon landing in 1969. While his business grew, his son Jonathan Stanley grew up as a normal Connecticut kid. Until, at age 19, Jonathan came down with bipolar disorder with psychosis, which got worse over the next three years.

“We’ll call it the epiphany from my dad’s standpoint at least,” Jonathan Stanley remembered of the turning point in his illness. “I went three days straight running through the streets of New York, no food, no water, no money, running from secret agents. And not surprisingly, after I stripped naked in a deli, ended up in a psychiatric facility.”

Jonathan was a college junior at the time.

“My dad came to visit, and he got to see his beloved son in a straitjacket,” Jonathan Stanley said.

The Stanleys were lucky. Jonathan responded well to the lithium, then a newly-approved drug. He went on to graduate from college and law school, too. Yet along the way, his father had met other fathers whose sons did not respond to treatment. He met other families who had to keep living with uncontrolled mental illness.

Ted Stanley said that gave him a focus for his philanthropy.

There was something out there that our son could take, and it made the problem go away,” he said. “And I’d like to see that happen for a lot of other people. And that’s why I’m doing what I’m doing.”

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