Bernards Voices

In The New York Times continuing coverage over the Tuscon tragedy, Sulzberger and Gabriel reported yesterday about limits colleges face dealing with mentally troubled students.

In September, Pima suspended Mr. Loughner and told him not to return without a psychologist’s letter certifying that he posed no danger. But it took no steps to mandate that he have a psychiatric evaluation, which in Arizona is easier than in many states.

Laura J. Waterman, the clinical director of the Southern Arizona Mental Health Corporation in Tucson, criticized Pima officials for not seeking an involuntary evaluation. “Where does it reach a level where you say this person shouldn’t be a part of any community and we have a responsibility to do something about that?” she said.

I posted recently on college needs–triggered by another NYT article by Trip Gabriel.

“It is part of our practice to provide students with information of where they can go,” said Charlotte Fugett, an official at the college. “It’s their responsibility to find a practitioner.”

Last year, Pima updated its policies for dealing with disturbed students, as did campuses across the country after several deadly shootings, including the killing of 32 at Virginia Tech. The college created a team of senior officials to identify students who might pose a threat to themselves or others. They began meeting the same month that Mr. Loughner was suspended.

Paradoxically, suspending students like Mr. Loughner may push them over the edge by adding to their grievances and isolating them from people who could monitor them, said experts on campus violence.

A theme of this event, and a theme of all my posts on mental health, is that this is a very difficult issue. But real, live consequences can result. Mental illnesses progress. They take many forms. The science has gaps; is confusing. Yet just like other chronic medical diseases they can worsen over time.

Seek treatment. Ask for help. Get treatment. Ask you friends, family, colleagues to seek help.

Pima had done what most colleges would in placing the responsibility to get a mental health exam on the student, especially since, as the college says, it also delivered the ultimatum to Mr. Loughner’s parents, with whom he lived.

Stella Bay, the police chief for Pima, said the college could initiate an involuntary evaluation only if a student posed “an imminent danger.”

But that assertion seemed to reflect a misunderstanding of the state’s laws regarding involuntary evaluations. Dr. Waterman, of the Southern Arizona Mental Health Corporation, said a mandated evaluation required only some evidence of danger. “It’s a broader standard,” she said. “And it costs nothing to make a phone call and talk about it and consult with a professional.”

I recently posted on the Great Progress HOP and the SHYMCA are making locally on mental health first aid. Expect to hear more soon.

On December 19, 2010, Trip Gabriel reported in the The New York Times that:

Stony Brook is typical of American colleges and universities these days, where national surveys show that nearly half of the students who visit counseling centers are coping with serious mental illness, more than double the rate a decade ago. More students take psychiatric medication, and there are more emergencies requiring immediate action.

Experts say the trend is partly linked to effective psychotropic drugs (Wellbutrin for depression, Adderall for attention disorder, Abilify for bipolar disorder) that have allowed students to attend college who otherwise might not have functioned in a campus setting.

A recent survey by the American College Counseling Association found that a majority of students seek help for normal post-adolescent trouble like romantic heartbreak and identity crises. But 44 percent in counseling have severe psychological disorders, up from 16 percent in 2000, and 24 percent are on psychiatric medication, up from 17 percent a decade ago.

Stony Brook has seen a sharp increase in demand for counseling — 1,311 students began treatment during the past academic year, a rise of 21 percent from a year earlier. At the same time, budget pressures from New York State have forced a 15 percent cut in mental health services over three years.

The article then tells a good day-in-the-life story of the college counselor. The triage they do to make sure the serious cases get dealt with the right way. Many colleges have systems where the campus psych services give a few sessions to the students, but they are designed to refer the students out to a private practioner, just so that there will be enough hours left to deal with all the demand.

On recent day … two dozen volunteers in black T-shirts reading “Chill” stopped passers-by in the Student Activities Center during lunch hour.

“Would you like to take a depression screening?” they asked, offering a clipboard with a one-page form to all who unplugged their ear buds. Students checked boxes if they had difficulty sleeping, felt hopeless or “had feelings of worthlessness.” They were offered a chance to speak privately with a psychologist in a nearby office. Sixteen said yes.

The depression screenings are part of a program to enlist students to monitor the mental health of peers, which is run by the four-year-old Center for Outreach and Prevention.

Students monitoring the mental health of peers. This sounds similar to the Mental Health First Aid program that we’re starting with HOP.

“I don’t have motivation for things anymore,” the student said. “This place just depresses me the whole time.” [The student] had been unaware that students could walk in unannounced to the counseling center. “I thought you had to make an appointment,” she said. “Yes,” she said, “I’ll do that.”

We hear things like this all the time. Help is available. But people, like this student, are unaware just how easy it is to ask for help–if they are willing to ask. We recommend the NJmentalhealthcares helpline for that first call for help. It is staffed by professionals. They assess, and connect, the callers to the right services. And they offer a follow-up call in a week to make sure the connection is made. That is just the surface description of the job, but they become very personally engaged, like the counselors at Stony Brook who are discussed in this article, in making sure the callers get the help they need.

Congratulations to the Ridge High School and William Annin Middle School PTOs, which were awarded a Mini-Grant in the amount of $500 from Building Youth. The groups will use the grant to co-sponsor a parenting presentation on November 10 by Michael J. Bradley, Ed.D. called Yes, Your Teen Is Crazy at Ridge H.S. at 7-8:30 p.m.

Using humor and practical advice, Dr. Bradley uses this information to help parents navigate the sometimes stormy waters of adolescence and emerge with the family intact.

For more information, call Carol Jean Floegel at 766-6761.

Keep Your Family Safe this Holiday Season and Read Our Thanksgiving Safety Tips

– From Bernards Township Board of Health

In today’s New York Times, Pam Belluck reports on a new study from the Archives of General Psychiatry, and efficacy of treatments for adolescent depression.

About half of adolescents who recovered from major depression became depressed again within five years, regardless of what treatment or therapy they received to get over their initial depression

In the study, nearly 200 adolescents, 12 to 17, received 12 weeks of fluoxetine (Prozac), cognitive behavioral therapy, both, or a placebo pill. (Those not receiving cognitive therapy met with a psychiatrist for basic support.) Placebo-takers who did not improve after 12 weeks could choose any of the other treatments.

Researchers had previously found that those receiving the Prozac-and-cognitive-therapy combination recovered faster from the first depression. So they expected those youths to be less prone to another depression.

But that did not happen. After 36 weeks, improvement for everyone was similar, researchers said, and by two years most completely recovered. But by five years, 47 percent suffered another major depression, no matter what treatment had helped them recover.

The researchers also expected that youths who improved almost fully during the 12 weeks would have less chance of recurrence. They did not, although those showing no improvement at all at 12 weeks were more prone to another depression after recovery than those who showed at least some progress during the 12 weeks. Teenagers who also suffered from anxiety were more likely to become depressed again.

I’ve posted (eg. in March) here many times before on depression: it is progressive, it is chronic, it needs to be attacked aggressively. In my family’s own personal experience it is devastating if not treated.

Dr. Curry said one limitation to the study was that researchers did not look at specific events in the youths’ lives to see if some encountered more stress than others.

I’ve also posted recently (and in August) that having the parents involved in therapy helps. That doesn’t appear to have been considered in this study. My personal theory is that the parents could use the therapy just as much as the kids. We learn so little about how to parent. We do it seat of the pants. And of course we parents may have issues all of our own.

In The New York Times, October 18th, Roni Caryn Rabin reports on the success of “Bringing in the Family to Fight Anorexia.”

Now a new study by Dr. Le Grange, of the University of Chicago, reports that the family approach, called the Maudsley method after the London hospital where it was developed, not only is more effective than individual therapy but also keeps working even after the treatment ends. The study, published this month in Archives of General Psychiatry, is one of just a handful of clinical trials that have evaluated treatments for anorexia nervosa in adolescents. Researchers randomly assigned 121 patients ages 12 to 18, mostly girls, to a year of either family or individual therapy at the University of Chicago and at Stanford — 24 hours in all.

Impressive results:

Twelve months after the treatment had ended, 49 percent of those who had been in family therapy were in full remission, more than double the 23 percent of those who had been in individual therapy. And among patients who were in remission at the end of the treatment itself, only 10 percent of the family-therapy group had relapsed a year later, compared with 40 percent of those who had individual therapy.

[One] therapist told her that parents should not be the “food police,” and that therapy had to get to the root causes of the problem before her daughter would resume eating.

“It doesn’t work that way,” Ms. Brown said in an interview. “You need the physical recovery first, and then the cognitive recovery. The patient is racked with guilt, anxiety, feeling she’s fat and loathsome if she eats — it was our job to be louder and drown out those voices in her head.”

In September 2, The New York Times’s Duff Wilson reports on prescribing psychotropic drugs on children.

The boy’s daily pill regimen multiplied: the antipsychotic Risperdal, the antidepressant Prozac, two sleeping medicines and one for attention-deficit disorder. All by the time he was 3.

More than 500,000 children and adolescents in America are now taking antipsychotic drugs, according to a September 2009 report by the Food and Drug Administration. Their use is growing not only among older teenagers, when schizophrenia is believed to emerge, but also among tens of thousands of preschoolers.

“Psychotherapy is the key to the treatment of preschool children with severe mental disorders, and antipsychotics are adjunctive therapy — not the other way around,” [Dr. Lawrence L. Greenhill, president of the American Academy of Child and Adolescent Psychiatry,] said. But it is cheaper to medicate children than to pay for family counseling, a fact highlighted by a Rutgers University study last year that found children from low-income families, like Kyle, were four times as likely as the privately insured to receive antipsychotic medicines.

In addition, foster care children seem to be medicated more often, prompting a Senate panel in June to ask the Government Accountability Office to investigate such practices.

Ms. Warren conceded that she resorted to medicating Kyle because she was unprepared for parenthood at age 22, living in difficult circumstances, sometimes distracted.

Letters to editor on above article.

In the August 25th The New York Times, Pamela Paul reports on preschool depression.

Nothing is fun; I’m bored.  Mickey lies. Dreams don’t come true.

Helen Egger, a Duke University child psychiatrist and epidemiologist, discusses the symptoms.

The misery needs to persist across time, in different settings, with different people. Nor is it enough just to be sad; after all, sadness in the face of unachieved goals or a loss of well-being is normal. But the depressed child apparently has such difficulty resolving the sadness that it becomes pervasive and inhibits his functioning.

Persists. Pervasive.

Among the experts interviewed were:

• Joan Luby is a professor of child psychiatry at Washington University School of Medicine.
• Daniel Klein is a professor of clinical psychology at SUNY Stony Brook.

Preliminary brain scans of Luby’s depressed preschoolers show changes in the shape and size of the hippocampus, an important emotion center in the brain, and in the functional connectivity between different brain regions, similar to changes found in the brains of depressed adults. In a longitudinal study of risk factors for depression, Daniel Klein and his team found that children who were categorized as “temperamentally low in exuberance and enthusiasm” at age 3 had trouble at age 7 summoning positive words that described themselves. By 10, they were more likely to exhibit depressive symptoms. And multiple studies have already linked depression in school-age children to adult depression.

Appropriate Treatment:

For a diagnosis of preschool depression to have any meaningful impact, an appropriate treatment must be found. Talk therapy isn’t practical for children who don’t have the verbal or intellectual sophistication to express and untangle their emotions.

And while practitioners quibble over what to label depression, most agree that for any mood disorder, children this age should not be treated in isolation. “Psychotherapy for depressed preschoolers should always involve the caregiver,” Luby says. “Not because the caregiver is necessarily bad or doing anything wrong, but because the caregiver is an essential part of the child’s psychological apparatus. The child is not an independent entity at this age.”

One established method is called Parent-Child Interaction Therapy, or P.C.I.T. Originally developed in the 1970s to treat disruptive disorders — which typically include violent or aggressive behavior in preschoolers — P.C.I.T. is generally a short-term program, usually 10 to 16 weeks under the supervision of a trained therapist, with ongoing follow-up in the home. Luby adapted the program for depression and began using it in 2007 in an ongoing study on a potential treatment. During each weekly hourlong session, parents are taught to encourage their children to acquire emotion regulation, stress management, guilt reparation and other coping skills. The hope is that children will learn to handle depressive symptoms and parents will reinforce those lessons.

I observed one session in which a therapist deliberately invoked feelings of guilt in the same blond 5-year-old who told the puppets “When bad things happen, I do feel bad.” Seated at a table with his mother, he turned to greet a therapist carrying a tray with two teacups, one elaborately painted. She told him that they were to have a tea party, pointing out her favorite teacup and describing the time it took to decorate it. “I’ll let you use my favorite today,” she beamed. As he gingerly took the rigged cup, its handle snapped off. His face darkened. The therapist lamented the break, ostensibly distraught, and excused herself from the room. The boy’s mother, guided via earset by a therapist watching through a two-way mirror, helped her child work through and resolve his feelings.

“Do you feel like you’re a bad boy?” his mother asked. Most parents want to distract their kids from negative emotions rather than let them process the feelings. “They want to wipe it away and move on,” Luby says. In this session, the mother was instead encouraged to draw the child out.

The boy nodded tearfully. “I feel like I’m going to go into the trash can,” he said.

“Who would put you in the trash can?” his mother asked.

“You would,” he replied in an accusatory voice.

“I would never do that,” she said. “I love you. Accidents happen.” The boy seemed to recover, and they chatted about her earrings, which he flicked playfully with a forefinger. Then his face drooped again.

“Are you mad at me?” he asked, and then added, almost angrily, “I never want to do this activity again.”

“You’re not a bad boy,” she consoled him. Often, parents don’t realize that their children experience guilt or shame, Luby says. “In response to transgression, they tend to punish rather than reassure.”

“I am a bad boy,” the boy said, ducking under the table. “I don’t think you love me now.” He started to moan from the floor, whimpering: “I’m so sad. I’m so sad.”

SUCCESS WITH P.C.I.T. rests heavily on parents, who are essentially tasked with reprogramming their child’s brain to form new, more adaptive habits. Not all parents are equipped to handle the vigilance, the consistency, the sensitivity. But early results look promising.

From the June 28, The New York Times, Seeking to pre-empt marital strife.

One federally financed study is tracking 217 couples taking part in an annual “marriage checkup” that essentially offers preventive care, like an annual physical or a dental exam.

“You don’t wait to see the dentist until something hurts — you go for checkups on a regular basis,” said James V. Córdova, an associate professor of psychology at Clark University in Worcester, Mass., who wrote “The Marriage Checkup” (Jason Aronson, 2009). “That’s the model we’re testing. If people were to bring their marriages in for a checkup on an annual basis, would that provide the same sort of benefit that a physical health checkup would provide?”

From the June 29, Wall Street Journal, Worried About a Moody Team?

Warning signs:

Dr. Diamond says sulks or doldrums that persist for two or more weeks could be a sign of depression and should be taken seriously.

Parents should pay attention to how a teen is functioning in school, sports, favorite activities, a job and with friends.

This article recommends consulting first with the teen’s pediatrician, someone who already has a relationship with the family. (Perhaps killing 2 birds with one stone: your insurance provider may require a referral to a psychiatrist anyway.)

From the July 1, USA Today, Of Medical Specialties, demand for Psychiatrist is Highest.

From April 2009 to March 2010, the company Merritt Hawkins received 179 requests for psychiatrists — a 47% increase from the previous year and 121% increase from the 2006-2007 survey.

The firm, which tracked more than 2,800 physician requests, found that psychiatrists were the third-most-requested physician.

Though demand is growing, fewer medical students are entering careers in psychiatry. Health officials say the field garners little interest because psychiatrists earn less than other specialties, even though they spend the same amount of time in medical training.

Thanks to Lauren for finding these articles.

From The Lancet Mental Health Themed Issue, August 22, 2009:

David Kessler and colleagues evaluate the acceptability and clinical effectiveness of an internet-based psychotherapy programme for depression. Nearly two-thirds of those offered the programme completed five or more therapy sessions, a substantially higher rate than we would expect with in-person therapy. Clinical benefits were larger than generally seen with computerised self-help programmes, and similar to those with traditional in-person psychotherapy.

Listen to the podcast (interview starts at 1:20):

The researcher was asked why they didn’t use video/voice in the internet-delivered therapy and relied on text. He posed a very interesting question in response: what about writing made it so effective? Writing requires pausing/reflection/editing which is different than talking. There is also evidence that writing, as a therapy, helps recovery from trauma. And finally, these questions of “eye contact” and “body language / mood congruency” and “anonymity” … have not been adequately tested yet to demonstrate that a therapist and patient, face to face, is necessarily the best setting for all people, for all therapies.

As discussed in other blogs, the DSM-5 is under review and generates a lot of controversy. This American Life does a great job, using the example of homosexuality, to show how and why definitions of mental disorders change over time. Reflecting not just changes in scientific understanding, but also social, political, and personal pressure. That those pressures exist, and have impact, doesn’t invalidate the DSM.

January 18, 2002 podcast of This American Life. Listen here.

In 1973, the American Psychiatric Association (APA) declared that homosexuality was not a disease simply by changing the 81-word definition of sexual deviance in its own reference manual. It was a change that attracted a lot of attention at the time, but the story of what led up to that change is one that we hear today, from reporter Alix Spiegel. Part one of Alix’s story details the activities of a closeted group of gay psychiatrists within the APA who met in secret and called themselves the GAYPA … and another, even more secret group of gay psychiatrists among the political echelons of the APA. Alix’s own grandfather was among these psychiatrists, and the president-elect of the APA at the time of the change. Alix Spiegel’s story continues, with a man dressed in a Nixon mask called Dr. Anonymous, and a pivotal encounter in a Hawaiian bar.

The 1968 definition at the time was a step forward, defining homosexuality as a disease instead of a moral decision.

The new 1973 definition:

302.0 Sexual orientation disturbance (Homosexuality)
This category is for individuals whose sexual interests are directed primarily toward people of the same sex and who are either disturbed by, in conflict with, or wish to change their sexual orientation. This diagnostic category is distinguished from homosexuality, which by itself does not constitute a psychiatric disorder. Homosexuality per se is one form of sexual behavior and, like other forms of sexual behavior which are not by themselves psychiatric disorders, is not listed in this nomenclature of mental disorders.

If the patient had subjective distress it was a disorder. If it didn’t bother you, you weren’t sick.

The current DSM deletes the definition; it is not a disorder. It is now ethically wrong for psychiatrists or psychologists to treat it as such.

Monday’s New York Times reports that 1 in 10 fathers is affected by prenatal or postpartum depression.

“It may be Mom’s depression leading the way; it may be Dad’s depression leading the way; it may have to do with the child’s temperament,” said Dr. James F. Paulson.

American fathers were at greater risk for depression than fathers in other countries, with rates of 14.1 percent compared with 8.2 percent elsewhere. Dr. Paulson said the disparity might be because of cultural differences, along with more liberal paternity-leave policies in other countries.

Here is a link to the study’s abstract in JAMA.

The closest I can find to an apples/apples comparison with frequency in women, was this quote in mesdscape from the authors:

Although past studies have shown incidence rates of 10% to 30% for maternal depression, which can often lead to negative family and child development outcomes, studies focusing on paternal depression are troubled by “clinical heterogeneity and prevalence estimates that vary considerably,” the investigators write.

Sciencedaily also covered the article.

The correlation between paternal and maternal depression also suggests a screening rubric — depression in one parent should prompt clinical attention to the other. Likewise, prevention and intervention efforts for depression in parents might be focused on the couple and family rather than the individual,” the authors write.

This is another example that our mental health–for the good or for the bad–is contagious.

Drifting off topic …

I was talking to a buddy of mine today while getting my haircut. One of the things we’ll be thinking about for next year’s mental health week, is how to attract a male audience. My friend suggested a talk on anger. He also agreed that an audience that was exclusively or predominantly male would attract other men.

Guys that are out of work; guys that have a health problem; or an addiction (alcohol, gambling) problem … these are candidates for topics, but I’ve got two issues with that:

1. I’m looking increasing general awareness–lower obstacles for asking for help when you or your family face that eventual crisis.  The problem with tackling a specific topic (like post partum in this article, or layoffs, or home foreclosures, or a drinking problem) is that when we are, seduced really, by our understanding of the source of the problem it actually gives us a way to avoid facing it.  Oh … well when my child (and wife) start sleeping through the night, my depression will go away.  Or when I find work, my depression will go away. But let’s think about just simply treating the depression now.  Take advil or tylenol for that fever.  Treat it!
2. Similarly, if the guy says to himself, Hey I have a job.  Hey, I haven’t been laid off–my salary isn’t at risk.  I bike 50 miles week.  I’m fit.  Work out.  I don’t kick the dog.  So I don’t need help.  I’m tough enough just to get thru these feelings of depression myself.  If I had a public excuse like a layoff, then maybe I’d be willing to ask for help. Good luck with that.

Dr. Brad Sachs spoke tonight at Bernards High School on Raising Teens With Love And Acceptance (Despite How Impossible They Can Be).  He clearly has a lot of wisdom, experience, and practical advice for parents.  I can’t do justice to his whole talk here, but others who saw it may want to chime in with their thoughts.

About 100 people attended. During the performance I got one email from a parent that had to stay home with their teen–we know sometimes parenting does get in the way of a good night out. But Dr. Sachs gave us a good night out.

I’m going to focus on 2 slides of the 30 or 40 he showed.

Slide 5 is just 3 points: The Fantasy Teen, The Actual Teen, and The Good Enough Teen.  The fantasy teen is the one the parent starts with in his or her mind.  This teen exists before your child is even born.  It may exist before you even get married.  It is the fantasy child that has the best of all your strengths, and is also strong where you are weak.  The fantasy child is happy, well-adjusted, has great friends.  Is successful on the field and in the classroom, etc.  When the actual child comes along, he or she will dance on the grave of your fantasy child.  This may happen in the first weeks after birth, maybe when the baby doesn’t take to nursing well.  Or it may happen in early adolescence.  But it will happen.  It has to happen.  Then begins the process–the work that the parent and the adolescent do to shape the fantasy child and actual child into the good enough teen.

Slide 7 and the next couple of slides are about grieving.  The adolescent is grieving the loss of their childhood.  All the symptoms of grief (which Dr. Giacalone talked about Tuesday morning) apply.  You don’t get to adulthood without saying goodbye to childhood.  It is a necessary thing.  A healthy thing.  A painful thing.  When the adolescent says “I’m such a loser,” they’re literally saying they’ve lost their childhood.

The parent is also grieving.  The parent is grieving at least for the looming empty nest.

Here is Dr. Sachs presentation.

Dr. Sachs wrapped up on slide 30 with key advice, that we’re hearing in all the talks: LISTEN! Listen to your child.

Other talks asked us to: Listen to our spouse. Listen to ourself.