mental illness

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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 They have been replaced by a legal process called civil commitment that firmly puts patients’ rights first.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

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

Chris/flickr

Chris/flickr

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.”

Continue reading

5 Ways The Brain Stymies Scientists And 5 New Tools To Crack It

Dr. Steven Hyman (Maria Nemchuk/Broad Institute)

Dr. Steven Hyman (Maria Nemchuk/Broad Institute)

In past lives, Dr. Steven Hyman has been the director of the National Institute of Mental Health and the provost of Harvard. He’s currently the president-elect of the Society for Neuroscience, and he directs the Stanley Center for Psychiatric Research at the Broad Institute in Cambridge, where we spoke, and where he demonstrated a preternatural professorial ability to speak off-the-cuff in structured outlines. Our conversation, lightly edited and broken down into what seemed to be its natural numbering scheme:

The Obama BRAIN initiative. We’ve had a ‘decade of the brain’ before, in the 1990s —

It accomplished nothing. Because it was a media blitz, it wasn’t based on new science.

So — Why this? Why now? What’s different?

Part of the growing public interest in the brain, and certainly much media attention, is a little bit unfortunate because it focuses on people applying tools, such as brain imaging, in ways that are untutored and underpowered but yield interesting — if not really scientifically valid — ideas about say, why a certain person is liberal or conservative, or why a certain person takes risks or is very self-protective. A subset of those may be scientifically addressable questions, but we’re a long way from understanding them deeply. Nonetheless they’re irresistible to the public and then of course it’s given rise to a new generation of debunkers — fair enough. So maybe we can set aside this false interest, this prurient interest in the brain and focus on the serious matters at hand.

In terms of political will, the question is not why now but why so late?

The bottom line is the brain is well recognized to be the linchpin of being human in the sense that it is the substrate of thought, emotion, control of behavior, and therefore, undergirds our life trajectories, our actions, our morality. And when the brain gets sick in any way we realize that it exacts an extraordinarily severe toll on the sufferer, on families, on society. Just think about Alzheimer’s disease, heroin addiction, major depression, schizophrenia, autism, intellectual disability — these are common conditions in which people can no longer exert reliable, effective agency on their own behalf and therefore society often has to step in for them at great cost and often really great pain.

Tragically, for the longest time there wasn’t so much we could do about it. Using medications that were really discovered by luck, by prepared serendipity; using, in more recent years, the few psychotherapies, especially Cognitive Behavioral Therapies, which have been empirically tested, we have been able to help a lot of people manage their symptoms, in some cases to become better stoics. With imaging technologies we began some decades ago — though at really still very relatively poor resolution — to get spatial maps of what’s happening in the brain. But we were really stymied in terms of getting a deeper understanding, a better picture, for several reasons:

1. The brain is new

The first, which is really important, is that the human brain is evolutionarily very recent in terms of many of its higher functions. What this means is that although we can learn an enormous amount from studying animals the way we do in the rest of biology and medicine, animal models are ultimately limited. Anything that requires language, just to take one example, we can’t model in animals. I think I understand my dog, but I wouldn’t publish it. There are really very many important functions — language, morality, certain kinds of creativity, the arts, humor, not to mention human mental illnesses, that really have not been well modeled in animals.

Continue reading

Empathy Lessons: Training Police To Understand People With Mental Illness

In a training exercise, Somerville Police Officer Eli Kim, left, tries to book Somerville Officer Samir Messaoudi -- playing the role of a man with schizophrenia -- while Cambridge Police Officer Fred Cabral does the sound effects of voices in Messaoudi's head. (Cambridge Police Department)

In a training exercise, Somerville Police Officer Eli Kim, left, tries to book Somerville Officer Samir Messaoudi — playing the role of a man with schizophrenia — while Cambridge Police Officer Fred Cabral does the sound effects of voices in Messaoudi’s head. (Cambridge Police Department)

Earlier this month, Somerville Police Officers Alan Monaco and Timothy Sullivan responded to a call about a fight between two young men. They found one of them, Mike, in an agitated state.

“He started flipping out — get your effing hands off me, don’t touch me!” Monaco recalled. “He was up and down, he would be screaming and yelling one minute, nice and talking and smoking cigarettes the next. We talked about what the issue is; he said the other kid said something detrimental about his mother, and his mother’s sick, and he spit in his face.”

Coincidentally, the two Somerville officers had just been in a training session on mental disorders — including Asperger’s, one of Mike’s diagnoses. So they knew people with Asperger’s can be hyper-sensitive about being touched and insensitive about how close to get to other people. Like Mike, who got far too close to the officers when he talked to them, right up into their faces.

“Normally for a police officer, if you invade our space, we have a safety zone where we don’t want people close to us,” Monaco said. “I would have pushed him away. I would have physically pushed him off me.”

But the officers thought pushing Mike back with their hands — their natural reaction — would backfire.

“I think in this case Mike would have reacted adversely,” Monaco said, “and he would have ended up in jail, where he didn’t need to be.”

“It also seemed to de-escalate Mike in a sense,” Officer Sullivan said. “He got to vent and calm down and talk to us in I guess what would be a normal voice for Mike, and it worked. … The class actually helped us a lot.”

The class they took was part of 40 hours of training to create “Crisis Intervention Teams” that serve as a police department’s go-to group for mental health crises.

With a state Department of Mental Health grant of $168,000, the Massachusetts chapter of the National Alliance on Mental Illness is working to help bring that advanced training to more police departments around the state.

Crisis teams have been catching on around the country; earlier this month, the Connecticut Legislature passed a bill to ensure that all the state’s police officers get such training. The need has been rising: Cuts in mental health services over recent years mean that police are called upon to deal with growing numbers of people with severe mental illness, who often end up in jail instead of treatment.

“What we know is that at least 10 percent of all calls to 911 involve people having a psychiatric crisis,” said June Binney, director of the Criminal Justice Project at NAMI Mass., who oversees the training. “What we think anecdotally, from what we hear from police departments, is that number is really more in the range of 25-35 percent of all 911 calls related to people in a psychiatric crisis.”

State government figures show Massachusetts spends relatively little on police training compared to other states, Binney noted. And when it comes to mental illness, a lack of police training can pose real risks, she said.

“The consequences at worst can be very dire,” she said. “They could be people dying, they could be a person with a mental health problem who is fighting back and strong and may get hurt, and police officers are at a huge risk of getting injured in some of these encounters. So the skill set is really critical to keep the situation calm and keep the situation safe, first and foremost, and to avoid unnecessary arrests and get people the treatment they need.”

The training isn’t just classroom lectures. It’s acting out explosive situations in a simulation room with a giant interactive screen. It’s role-playing and practicing “de-escalation” of fraught encounters, responding calmly even when faced with yelling and aggression. Continue reading

The OCD In Us All: Study Finds Almost Everyone Has Intrusive Thoughts

Some people with OCD wash their hands compulsively. (Wikimedia Commons)

Some people with OCD wash their hands compulsively. (Wikimedia Commons)

Confession: Every time I flush the toilet, I have to be out of the bathroom before the last of the water goes down the pipe. If I’m not — well, I don’t know. Something bad will happen. And when I’m choosing a spoon for breakfast — only breakfast, not later meals — sometimes I’m seized by the feeling that I’ve chosen the wrong spoon. If I use it, I doom the day. I put it back into the silverware tray and choose another.

I knew that I was far from alone — that Obsessive-Compulsive Disorder-type thoughts and behaviors are extremely widespread. But not this widespread. A study just out in the Journal of Obsessive-Compulsive and Related Disorders suggests to me that if you don’t have any of these thoughts and behaviors, you’re the weird one.

The study looked at 777 university students in 13 countries, including Canada, Israel, Iran and the United States. From the press release:

International study finds that 94 percent of people experience unwanted, intrusive thoughts

Montreal, April 8, 2014 — People who check whether their hands are clean or imagine their house might be on fire are not alone. New research from Concordia University and 15 other universities worldwide shows that 94 per cent of people experience unwanted, intrusive thoughts, images and/or impulses. Continue reading