psychiatry

RECENT POSTS

Commentary: Getting Off Psych Meds Was The ‘Hardest Thing’ She’d Ever Done

By Dr. Annie Brewster

By the time Laura Delano was 25, she was taking five psychiatric drugs: an anti-depressant, an anti-psychotic, two mood stabilizers and an anti-anxiety medication.

But after years entrenched in the mental health system, and defined by her psychiatric diagnoses, Laura finally got off the medications and, as she says, began “recovering from psychiatry.”

For background: Laura grew up in a wealthy Connecticut suburb in a family of high achievers. She was a nationally ranked squash player and student body president. But in her teen years, life got more complicated as she struggled with questions about her own identity.

Laura Delano weaned herself off psychiatric drugs and says she shed her identity as a “professional mental patient.” (Courtesy)

Laura Delano weaned herself off psychiatric drugs and says she shed her identity as a “professional mental patient.” (Courtesy)

She felt burdened by social and academic expectations, and started to act out. She cut herself as a way to “control” her out-of-control world, and was ultimately sent to a psychiatrist by her parents. At 14, she was diagnosed with bipolar disorder and prescribed powerful psychiatric drugs, including the mood stabilizer Depakote and Prozac.

The medication side effects led to additional problems and “symptoms,” which in turn led to more medications, Laura says, and she began to lose herself. She felt defined by the diagnoses she continued to collect: bipolar disorder, borderline personality disorder, substance abuse disorder and binge eating disorder.

Laura’s early 20s were marked by multiple psychiatric hospitalizations and ultimately a suicide attempt. Her only identity was a self-described “professional mental patient.”

But then things began to change.

Over five years ago, Laura weaned herself off psychiatric drugs and shed her diagnostic labels. For her, this has been a spiritual journey involving the cultivation of self-acceptance, self-love and honesty. “It is the hardest thing I have ever done,” says Laura, now 32. But she feels happier, more connected and more engaged in the world. Here’s a bit more from our interview:

“When you are told that your brain is broken — basically the seat of your soul, your mind, the part of you that shapes everything about who you are — when you’re taught to believe that that’s broken, and that you can’t trust yourself, you can’t trust your emotions, you can’t trust your mind, I mean it instills in you just a profound fear. Over all these years I developed this relationship of faith in the mental health system and no faith in myself, and tremendous fear of myself. And so unpacking that has been at the heart of this whole journey, realizing, ‘Wait a minute…If I’m not broken and if the struggles I’ve gone through aren’t symptoms of an illness, what are they? Maybe they are actually important and meaningful…maybe they are telling me something.’ I began to listen to my pain, and to listen to my darkness and it [has]  brought me back to this spiritual journey which I think was beginning way back when I was thirteen… Who am I? How do I fit into this world? What are the stories I have been taught to believe about how you’re meant to live your life, and what it means to be normal and worthy and acceptable…”

Personally, I’m moved by Laura’s story. As a practicing internist, I often rely on psychiatric diagnoses and medications. In my clinical practice, I have seen psychiatric medications reduce suffering and save lives. But it’s been useful to step back and reconsider my filter on these issues.

From day one of medical training, we are taught to fit our patients into neat diagnostic categories whenever possible. The goal of our patient interactions, we learn, is to sift through and distill all that we see and hear in order to home in on a diagnosis. This categorization can be helpful in directing our care, of course, but it can also be limiting, and even dangerous. Rarely does a diagnosis fit perfectly, yet all too often in our culture one’s diagnosis becomes indistinguishable from one’s identity.

Labels have power. With mental illness, diagnostic criteria are particularly difficult to define and identify. Truthfully, our current understanding of the brain and the biochemistry behind mental illness is limited. There are no clear markers to measure and quantify. Instead, we must rely on subjective interpretation of behavior.

And yet, psychiatric labels abound. It is estimated that one in four adults, or approximately 61.5 million individuals, and one in five teens between the ages of 13 and 18, meet criteria for a diagnosis of mental illness within a given year.  Continue reading

Parents’ Depression May Impact Children’s Classroom Performance, Study Finds

A study found that depression in parents may negatively affect their children’s school performance. (Hadley Green for WBUR)

A study found that depression in parents may negatively affect their children’s school performance. (Hadley Green for WBUR)

Joshua Eibelman
CommonHealth Intern

Are your mood swings and depression hurting your children in the classroom?

A new study that followed more than a million Swedish children and their parents suggests the answer may be “yes.”

The Drexel University study, published in the journal JAMA Psychiatry, found that depression in parents may negatively affect their children’s school performance.

Researchers used Sweden’s computerized health and population records, allowing them to analyze parents’ inpatient medical records from 1969 onward and outpatient records from 2001 onward, as well as education records for all children born in Sweden between 1984 to 1994.

Led by Hanyang Shen, a Drexel alumna, the study looked at how depression in parents at various stages of their children’s lives — before birth, after birth, at ages 1-5, 6-10 and 11-16 years, and anytime before the final year of school at age 16 — was connected to school performance.

The study’s conclusion? Both “maternal depression and paternal depression at any time before the final compulsory school year were associated with worse school performance,” researchers wrote.

Specifically, depression in mothers was found to be linked to a 4.5 percent decrease in grades  while paternal depression resulted in a 4 percent decrease, compared with children without depressed parents.

Worryingly, maternal depression was more strongly associated with worse school performance for children than lower family income, which was linked to a grade decrease of 3.6 percent, researchers wrote.

Continue reading

Panel Recommends Depression Screening For Women During And After Pregnancy

(Chris Martino/Flickr)

(Chris Martino/Flickr)

On Tuesday the U.S. Preventive Services Task Force released new recommendations on screening for depression in adults, notably calling for depression screening in women both during and after pregnancy.

The recommendations, published in the Journal of the American Medical Association, suggest: “All adults older than 18 years should be routinely screened for depression. This includes pregnant women and new mothers as well as elderly adults.”

Why?

“Depression is among the leading causes of disability in persons 15 years and older,” the task force statement said. “It affects individuals, families, businesses, and society and is common in patients seeking care in the primary care setting. Depression is also common in postpartum and pregnant women and affects not only the woman but her child as well. …The [task force] found convincing evidence that screening improves the accurate identification of adult patients with depression in primary care settings, including pregnant and postpartum women.”

The government-appointed panel found that the harms from such screening are “small to none,” though it did cite potential harm related to drugs frequently prescribed for depression:

The USPSTF found that second-generation antidepressants (mostly selective serotonin reuptake inhibitors [SSRIs]) are associated with some harms, such as an increase in suicidal behaviors in adults aged 18 to 29 years and an increased risk of upper gastrointestinal bleeding in adults older than 70 years, with risk increasing with age; however, the magnitude of these risks is, on average, small. The USPSTF found evidence of potential serious fetal harms from pharmacologic treatment of depression in pregnant women, but the likelihood of these serious harms is low. Therefore, the USPSTF concludes that the overall magnitude of harms is small to moderate.

Nancy Byatt, medical director at the Massachusetts Child Psychiatry Access Project for Moms (MCPAP for Moms) and an assistant professor of psychiatry and obstetrics and gynecology at UMass Medical School, said the new recommendations “are an incredibly important step to have depression care become a routine part of obstetrical care.”

She added: “Depression in pregnancy is twice as common as diabetes in pregnancy and obstetric providers always screen for diabetes and they have a clear treatment plan. The goal [here] is that women are screened for depression [during pregnancy and postpartum] and they are assessed and treated and this becomes a routine part of care just like diabetes.”

Dr. Ruta Nonacs, who’s in the psychiatry department at Massachusetts General Hospital and editor-in-chief at the MGH Center for Women’s Mental Health, sent her thoughts via email:

In that the USPSTF recommendation recognizes pregnant and postpartum women as a group at high risk for depression, this represents a step in the right direction in terms of ensuring that psychiatric illness in this vulnerable population is identified and appropriately treated. However, there remain significant obstacles to overcome. Research and clinical experience indicate that while pregnant and postpartum women with mood and anxiety disorders can be identified through screening, many women identified in this manner do not seek or are not able to find treatment.

While screening is important, we must also make sure we tend to the construction of a system that provides appropriate follow-up and treatment. Because stigma continues to be significant with regard to mental health issues in mothers and mothers-to-be and because there are concerns regarding the use of medication in pregnant and nursing women, we must make sure that after screening, we help women to access appropriate resources and treaters who have expertise in the treatment of women during pregnancy and the postpartum period.

Continue reading

Related:

Opinion: When The Doctor Must Choose Between Her Patients And Her Notes

By Dr. Mary C. Zeng
Guest Contributor

It’s been a long day in the psychiatry clinic.

Seeing patients is never dull, and each interaction is meaningful in its own way. From the moment they walk into my office to the moment they leave, I try my best to be fully present with the patients sitting in front of me. That means listening to every word, watching every nuance of body language, hearing every concern — both spoken and unspoken. It means bearing their grief as they tell me about the father they’re losing to cancer, their pain as they suffer through profound bouts of depression and their agony as they recall their nightmares of childhood trauma.

It also means putting aside my personal agenda to focus wholly on them, which includes resisting my urge to take notes during the patient interview so that I can save time later, with fewer notes to complete after the patient leaves.

It is a common complaint that doctors look at their computer screens and type on their keyboards more than they listen to their patients. But consider this reality: From the doctor’s perspective, every moment she spends focusing on you, the patient, rather than on the “note” she needs to write up about your appointment, is a debt that must be repaid later in the day. If the doctor can’t complete your note during the 15 minutes you spend with her, then she must add another 15 minutes to the end of her workday in order to finish that note. Multiply that 15 minutes by the 10-15 patients she sees in a day and all of a sudden she has missed the family dinner and the kids are already asleep by the time she comes home.

Continue reading

Child Psychiatrists Suggest Resolution For 2016: ‘Let’s Parent Ourselves This Year’

The authors propose framing resolutions in an entirely new way. (PROfrankieleon/Flickr)

The authors propose framing resolutions in an entirely new way. (PROfrankieleon/Flickr)

By Drs. Gene Beresin and Steve Schlozman

There’s this guy, Sisyphus.

I feel like he invented the New Year’s resolution.

You know Sisyphus — he’s the guy who works so hard to push that stupid boulder up the hill, only to have it roll down again at the end of his hard work. You’d think he (and we) would have learned after all these years, but there he is, at the bottom of the hill, trying again and again.

It’s a lot like so many of us. “Today,” you may be saying with resolve, “will be different.” “Today I will get that boulder to the top of the hill.” Or: “This year I’ll lose weight. Drink less. Exercise more.” Fill in the blank.

But how many times do we fail in these New Year’s resolutions?

Researchers note that New Year’s resolutions are typically grounded in motivations to change our perceived vices: our addictions, our “bad” behaviors, our so-called “destructive flaws.” We know what’s good for us, we just can’t get it right.

Luckily for us, we do a little better than Sisyphus. It turns out that almost half of us succeed in our goals. We don’t hear about those successes so much but it’s true: We manage to keep about 50 percent of our self-improvement mandates. Of course that means that about 50 percent of the time we lose our momentum before the year is over. Hence, those same darn resolutions return to us each December.

This exercise in at least partial futility begs a fundamental question: Why is “bad” behavior so hard to change? We try to raise our kids to correct misbehavior; why can’t we do it ourselves?

This query is, understandably, the focus of a lot of research. We harbor false or exaggerated predictions. We assume (and we all know the dangers of assumptions) that change will be easier this year, or more predictable this year, or that we’ll somehow have changed enough that the resolution will finally be within our grasp.

Here’s the kicker, though, and it’s an important one: We truly believe that we’ll succeed. We’re not actively lying to ourselves.

Psychologists Janet Polivy and Peter Herman call this a “false-hope syndrome,” an exaggeration of our expectations for change, inevitably followed by the forlorn shutting down of our previously high aspirations. Continue reading

How Trauma Brings Fear, Yes, But Also More Nuanced Reactions

A woman breaks down while paying her respects at a makeshift memorial near the Inland Regional Center Friday in San Bernardino, California, where several people were shot and killed by two shooters on Dec. 2. (Jae C. Hong/AP)

A woman breaks down while paying her respects at a makeshift memorial near the Inland Regional Center Friday in San Bernardino, California, where several people were shot and killed by two shooters on Dec. 2. (Jae C. Hong/AP)

By Mary C. Zeng, MD
Guest Contributor

November and December have been months of trauma.

The Paris terror attacks and the American shootings in San Bernardino and Colorado Springs have taken a heavy toll on both survivors and witnesses. Media coverage depicting scene after scene of carnage has also generated painful and lingering emotional reactions by secondhand exposure. A recent New York Times article describes “a creeping fear of being caught in a mass rampage has unmistakably settled itself firmly in the American consciousness.”

It’s true that trauma breeds fear. Those who were directly victimized in the attacks are, of course, likely to develop both short- and long-term fear reactions. But even indirect victimization, such as through the media, can be psychologically damaging. One study of New Yorkers after Sept. 11 found that people who watched more news coverage were over three times more likely to develop post-traumatic stress disorder (PTSD), a hallmark disease of fear.

However, if we are to truly understand and appreciate each other’s emotions during these troubling times, we must talk beyond fear. Failure to do so would be a disservice to those who are suffering.

A variety of responses is expected, and normal, in the aftermath of trauma. Fear is only one of several emotions that may arise — one of a cluster of experiences collectively known as peri-traumatic distress. Other feelings in this cluster include helplessness, sadness, grief, guilt, shame, anger and horror. Certain cognitive responses, such as a worry about fainting or dying, are also common, as are physical sensations such as loss of bowel or bladder control and shaking, sweating or a racing heart.

Another common response immediately following a trauma is peri-traumatic dissociation: a state of disconnectedness from oneself or from reality, memory loss, reduced awareness or time distortion that is triggered by a traumatic event.

Both of these sets of responses are normal short-term reactions to trauma. They may be experienced with varying levels of intensity, depending on how directly or indirectly someone was exposed to the trauma. They are expected to phase out, or extinguish, for many people over a course of weeks after the traumatic event.

It is when these reactions do not extinguish that the long-term and potentially crippling effects of trauma begin to show in individuals with a genetic predisposition. Peri-traumatic responses then turn into PTSD, a psychiatric illness affecting 7-8 percent of all Americans over their lifetimes. The classic signs of PTSD, aside from exposure to a traumatic event, include intrusive memories of the event; avoidance of people, places and situations associated with the event; negative mood and cognitions; and hypervigilance and hyperarousal.

In the same way that a veteran who saw IEDs in Iraq now sees IEDs everywhere, the mass shooting survivor forgets how to feel safe even on the home front. The world turns into a permanently dangerous, uncontrollable place.

Besides peri-traumatic distress, peri-traumatic dissociation and PTSD, which are widely researched because they can lead to psychological disability down the line, a whole range of emotions is possible in light of the recent tragedies. Numbness, bewilderment, resignation — there is no one right way to react to trauma. Traumatized individuals are also at higher risk of developing psychiatric disorders other than PTSD, such as major depression and substance abuse.

But positive adaptations to trauma have also started to receive research attention. Continue reading

Am I Safe? Psychiatrist’s Tips For Talking To Kids About The Paris Attacks

A victim outside the Bataclan theater in Paris (Jerome Delay/AP)

A victim outside the Bataclan theater in Paris (Jerome Delay/AP)

Advice columnist Steve Almond has a typically provocative piece on WBUR’s Cognoscenti today: “Why I’m Not Talking To My Kids About The Paris Attacks.” He and his wife decided, he writes, that “we have absolutely no interest in exposing our kids to the sort of panic-stricken coverage whose central aim is the profitable stoking of anxiety.”

But for parents whose children have been exposed to the news from Paris, here are some extensive and sage tips, broken down by age group, from child psychiatrist Gene Beresin, director of The Clay Center for Young Healthy Minds at Massachusetts General Hospital, re-posted with permission from The Clay Center’s website.

By Dr. Gene Beresin

Our hearts go out to the families of those who lost their lives or were injured in the recent terrorist acts in Paris.

At times like these, amid our shock, grief and fear, we need to be particularly attuned to the impact such events have on our children. Kids of all ages have questions and various emotional reactions — compounded all the more by the footage and commentary they may be seeing and experiencing. It is abundantly clear from sound research that children and teens can develop significant stress responses to what they are exposed to in the media.

While we want to shield our kids from the horrific images and stories of the terrorist attacks, it is increasingly hard to create an impervious shield. Full protection is impossible, and we should instead be prepared to help them in the wake of yet another mass killing.

While the world may feel to us increasingly unsafe, it’s our obligations as parents and caregivers to provide comfort, reassurance and guidance to our kids.

Here are some tips for all of us as we navigate this tragic time.

For Parents And Caregivers

Let’s face it: We’re all scared. These terrorist acts leave us feeling afraid, angry and insecure. However, we as adults need to find our own way of coping; after all, the more secure we feel, the better we are able to help our kids.

• We need, in times like these, to engage with others. Adults as well as kids require a sense of community to help us feel connected and protected. So, don’t worry alone; talk about what you are feeling with your partner, spouse and friends. It’s our relationships that hold us safely in this world.

• Make time for self-care through relaxing activities such as reading, listening to music or exercising.

• Pace yourself in terms of the amount of information you choose to consume. Sometimes, it’s best to just disconnect completely.

• If you have specific questions about your kids, call your pediatrician, primary care provider or mental health professional for advice.

Universal Impact On Children Of All Ages

Children need answers to three fundamental questions:

• Am I safe?

• Are you, the people who take care of me, safe?

• How will these events affect my daily life?

Parents should expect to answer these questions over and over again. For those with toddlers and preschool children who may not yet be able to express their concerns in words, it’s still important to reassure them that everyone is safe, and that life will continue in a normal fashion. Continue reading

Related:

Majority Of Young People With Depression Don’t Get Treatment, Report Finds

A new national snapshot of the state of mental health across America is, frankly, a little discouraging, especially when it comes to young people.

One startling finding from the annual report produced by the nonprofit Mental Health America: “[S]ixty-four percent of youth with depression do not receive any treatment.”

In addition, the report found:

Even among those with severe depression, 63 percent do not receive any outpatient services. Only 22 percent of youth with severe depression receive any kind of consistent outpatient treatment (7-25+ visits in a year).

I asked one of our frequent contributors, child psychiatrist Dr. Eugene Beresin, executive director of the Massachusetts General Hospital Clay Center for Young Healthy Minds and professor of psychiatry at Harvard Medical School, for his thoughts on the report.

Here, lightly edited, is his response:

First, I am not surprised. There are a number of issues not emphasized by this summary:

1. There is a huge shortage of child and adolescent psychiatrists in the U.S. Currently there are about about 7,000.

So while many parents seek help, the access to care is severely limited. Primary care pediatricians are inadequately trained in psychiatry and this has been addressed by the American Academy of Pediatrics. Their graduate training requires only two months in developmental behavioral pediatrics and few have any significant training in psychiatry. They are desperate to make referrals and often are at a loss to find qualified clinicians. Some states such as Massachusetts and New York have statewide efforts to assist them through consultation and education in psychiatry, but this only scratches the surface. Continue reading

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.

Continue reading

Related:

CDC: One-Third Of Children With ADHD Diagnosed With The Disorder Before Age 6

(Vivian Chen/Flickr)

(Vivian Chen/Flickr)

One-third of children diagnosed with ADHD were diagnosed young — before the age of 6 — according to a new national survey from the U.S. Centers for Disease Control and Prevention.

Earlier, the CDC found that based on parental reports, 1 in 10 school-aged children, or 6.4 million kids in the U.S., have received a diagnosis of ADHD, a condition marked by symptoms including difficulty staying focused and paying attention, out of control behavior and over-activity or impulsivity.

The percentage of children diagnosed with ADHD has increased steadily since the late 1990s and jumped 42 percent from 2003-2004 to 2011-2012, the CDC says. Last year, concerns flared when a report found that thousands of toddlers are being medicated for ADHD outside of established pediatric practice guidelines.

In the current analysis, also based on parental reporting, and using data drawn from the 2014 National Survey of the Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder and Tourette Syndrome, the CDC also found:

•The median age at which children with ADHD were first diagnosed with the disorder was 7 years old

•The majority of children (53.1%) were first diagnosed by a primary care physician

•Children diagnosed before age 6 were more likely to have been diagnosed by a psychiatrist

•Children diagnosed at age 6 or older were more likely to have been diagnosed by a psychologist

•Among children diagnosed with ADHD, the initial concern about a child’s behavior was most commonly expressed by a family member (64.7%)

•Someone from school or daycare first expressed concern for about one-third of children later diagnosed with ADHD (30.1%)

•For approximately one out of five children (18.1%), only family members provided information to the child’s doctor during the ADHD assessment

What are we — parents, educators, doctors — to make of all this? In particular, what does it mean that so many very young kids are being diagnosed with an attention disorder? (Has anyone ever encountered a 4- or 5-year-old child who is not hyperactive, impulsive and inattentive??)

I asked two doctors — a pediatrician and a psychiatrist — for their impressions of the CDC report. Both agreed that we seem to have two problems when it comes to ADHD: over-diagnosing and under-diagnosing. Here, lightly edited, are their responses.

First, the pediatrician:

James M. Perrin, MD, is a professor of pediatrics at Harvard Medical School and associate chair of MassGeneral Hospital for Children. Dr. Perrin is also the immediate past president of the American Academy of Pediatrics and chaired the 1990s committee that wrote the first practice guidelines for ADHD (and he was on the committee for the 2011 revision).

RZ: How difficult is it to diagnose ADHD in children under 6 years old?

JP: In the pediatric community, we have worked over last 15 years to train general pediatricians to make diagnoses of ADHD reliably and follow very clear, specific guidelines on how to do so. In 2011, the AAP revised its practice guidelines for ADHD and included the opportunity to diagnose children ages 4 and 5 years old.

At the same time we recognize it’s very hard to do that well in that age group…because a lot of children are inattentive at 4 — you don’t expect them to work hard and read a Hardy boys book for an hour and half. Five is often impulsive, active, so it’s not unusual to have symptoms that children with ADHD would also have at age 4, 5. So, it’s not easy.

We did say [in the guidelines] pretty clearly that you shouldn’t make the diagnoses without significant impairment of normal behavior. What we mean by that is a child whose symptoms impair her ability to play with other children, or whose behavior is so out of control that it’s dangerous, for instance she runs out in front of cars, or has many accidents, that’s when the symptoms become impairing. Continue reading