Friday, February 27, 2015

Black History Month – African Americans and Mental Health

Ranna Parekh, MD, MPH


As we celebrate Black History Month, we reflect on African Americans’ place in US history. At the APA, we give thanks to psychiatrists – such as Jeanne Spurlock, MD, Solomon Carter Fuller, MD, Chester Pierce, MD, and a long list of Solomon Carter Fuller Award recipients--whose great contributions continue to influence our medical field.  It is also a time when we are reminded of the unique mental health challenges facing the black community and the importance in working together toward improved access, assessment and treatment.  

The history of African Americans predates slavery; however, its legacy and the ongoing discrimination continue to impact the lives of African Americans today. Emotional strength, strong social connections, and determination have enabled many African Americans to overcome adversity.  Yet African Americans, just like people of all racial/ethnic backgrounds, experience mental illness.

While rates of mental illness in African Americans are similar to those of the general population, African Americans receive less care and poorer quality of care and often lack access to culturally sensitive care. For many reasons, African Americans face particular obstacles in getting help for mental health concerns. Racism, discrimination, cost or lack of health insurance, or distrust of the health care system may prevent some African Americans from getting the help they deserve. Stigma about mental illness can also pose a barrier, and blacks are much less willing than whites to use medicines for a mental illness.




Also, African Americans sometimes express mental illness and emotional distress differently than others.  For example, among people with depression, blacks are more likely than whites to complain of body aches or other physical symptoms. 

Racism and discrimination have multiple effects on mental health.  Victims of discrimination experience feelings of unfairness when dealing with mental illness and those feelings make it difficult for them to do anything about it.  In addition, the anticipation of discrimination, the perception of being in an environment of discrimination, or seeing others being victims can contribute to greater ongoing stress and anxiety.  
Chester M. Pierce, MD, emeritus professor of education and psychiatry at Harvard Medical School and founder of the eponymous Division of Global Psychiatry at the Massachusetts General Hospital is to receive APA’s 2015 Human Rights Award. His life’s work included studying people living in extreme conditions. In 1970, he coined the term microaggessions to help people understand the continuing stain of racism experienced by African Americans. Microaggressions are brief, everyday exchanges that send denigrating messages that are not overt discrimination – the person may not even be aware of the denigrating action. Being continually subjected to these microaggressions takes a toll on physical and mental health. 

This is also compounded by the economic effects—blacks have much higher unemployment and poverty rates than whites.  In January 2015, the unemployment rate for black  men over 20 was more than twice that of white men (11.4% vs 5.2%) and the unemployment rate for black youth age 16-19 was significantly higher than white youth (30% vs 17%). 

Also, African-American men are less likely to seek help for medical problems and mental health concerns often become secondary to any medical concerns. Physical conditions and conditions affecting the mind are connected in many ways--problems that first affect the mind can later increase one’s risk for physical problems, such as diabetes, high blood pressure, or malnutrition. And physical conditions, such as a disease or an accident, can affect the mind (i.e., emotions, thinking, and mood). African Americans have a much higher risk than white Americans for many types of chronic diseases, such as diabetes and heart disease.

The California Mental Health Services Authority has developed a 
video and discussion guide about young black men and mental health. 


Mental disorders are nothing to be ashamed of. They are real medical problems, just like heart disease or diabetes. As with these illnesses, there is help available and much you can do to support or improve your health. Like all people with mental illness, African Americans, do recover and go on to lead productive and fulfilling lives.


Ranna Parekh, MD, MPH, is the director of the Division of Diversity and Health Equity at the American Psychiatric Association


Wednesday, February 25, 2015

A Psychiatrist’s Take on “Fifty Shades”

By Kenneth Paul Rosenberg, MD

I am neither a film critic, nor a sociologist, but to me, “Fifty Shades of Grey” is neither groundbreaking cinema, nor does it herald a new cultural shift in sexual mores. It is, nonetheless, a fascinating narrative for any student of psychology, let alone for a psychiatrist with a specialty in treating sexual disorders. Hence, when asked to write about the movie, it was my pleasure to offer a few thoughts.   

“Fifty Shades” is the story of Christian Grey and college-aged Anastasia Steele, whom he sweeps off her feet and into his den of bondage, whipping and domination. Christian is a concert-level classical pianist and helicopter and glider pilot.  He is ridiculously handsome, under 30 and a billionaire. His Achilles’ heel is that he is the unfortunate victim of childhood physical and sexual abuse at the hands of older women, and, as a consequence, can only connect by inflicting sexual pain on the beautiful virgin, Anastasia. 

For all his power and sadism, Christian is also partly a victim himself. He teaches us about the lingering effects of childhood abuse, and introduces the audience to the practices of bondage, domination, sadism and masochism (BDSM).   Although being a “dominant” is Christian’s ‘thing,’ clinically, one would expect Christian to be a submissive who would seek out reenactments of his abuse at the hands of an older woman. 

Ana is essentially a young woman who falls in love with an older, extremely powerful and rich man – a story taken out of the Harlequin romance novels of a previous era. But there is a psychological twist as well. Ana lost her dad when she was young, and her mother appears to be an unrepentant romantic. Mom is so enthralled by handsome men that she smiles when Christian arrives unannounced, even though he is stalking her daughter. Hence, Ana’s psychological backstory is that she is vulnerable to an older, abusive man because of her own losses and trauma. 

There is a debate in the popular media how evil Christian is, and about the degree of abuse that Ana tolerates. Certainly, the fictional relationship between Christian and Ana could hardly be called healthy. Spoiler alert: if it’s any consolation they both leave the relationship with higher levels of insight and knowledge, ending up in better places than they started. (No doubt, their plots will thicken in the sequels!)

It may be pointless to discuss Christian and Ana in psychological terms since they are Hollywood creations. Yet, in the real world, BDSM is a group of accepted sexual practices among consenting adults and common among those seeking BDSM sex workers (or Dominatrices as they are called.) Often BDSM involves more pain than gain – in other words more tying up and humiliation with less emphasis on the sex and orgasm for the seeker or submissive. When occurring with little harm, most psychiatrists see BDSM as a variant of normal. When it consumes the person and prevents intimacy, the practice may rise to the level of a sexual disorder, sexual compulsivity or even addiction.  When the person focuses on a particular inanimate object, like a whip or stiletto heel in lieu of any other sexual or romantic contact, the diagnosis of a fetishitic disorder may apply.  

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), once an unusual sexual practice causes impairment and harm to oneself or others, it is labeled as a paraphilic disorder with subcategories such as sadism and masochism. The American Psychiatric Association has made it clear that non-normative or unusual sexual behaviors are not, in of themselves, signs of mental illness unless the behaviors cause great anguish or real harm to the participants. This distress has to be beyond the guilt and distress that comes from engaging in behaviors that deviate from societal norms. In the case of BDSM, the DSM-5 is careful to discourage labeling atypical behaviors as mental conditions. However, when the behavior rises to the level of causing grief or harm, DSM-5 offers the diagnoses of sexual sadism disorder and sexual masochism disorder.  Psychiatrists can treat these sexual disorders with a variety of modalities ranging from psychotherapy, medication, peer support groups and family counseling with excellent outcomes.  As psychiatrists, we need to make the public aware that when these sexual illnesses occur, real help is available.

Whatever we may think about the sex and stories depicted in “Fifty Shades of Grey,” as psychiatrists, the popularity of the movie provides us with an opportunity to educate the public about the possibilities of improving the lives of those who have serious illnesses and who may suffer in silence and shame.


Kenneth Paul Rosenberg, MD, is Director of Upper East Health (UpperEastHealth.com), a comprehensive practice in Manhattan that focuses on addiction and sexual disorders.  Dr. Rosenberg is also Clinical Associate Professor of Psychiatry at the Cornell Weill Medical Center. 

Eating Disorders Awareness Week 2015: Speak Up and Speak Out

By Deborah R. Glasofer, PhD
Reviewed by B. Timothy Walsh, MD

This week marks Eating Disorders Awareness Week. It is a time to speak up about eating disorders, including anorexia nervosa, bulimia nervosa and binge eating disorder. Many of us fall prey to messages about what is and is not beautiful or healthy. For people with eating disorders, however, the problem extends far beyond any messages heard from the outside world. Individuals with eating disorders struggle – perhaps because of their biology, or as a result of persistent behavioral patterns – with critical messages from within that define health or beauty narrowly or with great distortion.

Eating disorders do not discriminate. They impact women and men of all ages, races, and sizes, although they most often affect girls and women between 12 and 35 years old.

Eating disorders do not tread lightly. These are dangerous illnesses characterized by behaviors (e.g., severely restrictive eating, purging) with potentially life-threatening physical consequences. They can negatively impact psychological health – obsessing about food, eating, or body size, rigidity in thinking, overall anxiety and mood – and carry an increased risk of suicide.

Listen to learn more about the latest breakthroughs in eating disorders understanding and treatment, including cognitive neuroscience and pharmaceutical research. Read up to learn more from the Columbia Center for Eating Disorders, a part of the New York State Psychiatric Institute, about spotting an eating disorder and approaching a child (of any age), a teammate, friend, or loved one about whom you are concerned. Listen in to learn more about who’s who on an eating disorder treatment team, and differences between treatment setting options.


Deborah R. Glasofer, PhD, is a clinical psychologist at the Columbia Center for Eating Disorders and an assistant professor of psychology in the Columbia University Department of Psychiatry.



Friday, February 6, 2015

Wear Red Day: Promoting Healthy Hearts and Healthy Minds 

Erik R. Vanderlip, MD, MPH 


Researchers today are putting together what it means to truly have a “broken heart.” As we adorn our favorite red apparel for “National Wear Red Day” to raise awareness of the untold stories of millions of women experiencing strokes or heart attacks in our country, we must consider the contribution of poor mental health to this burden. 

Clinical depression has repeatedly been linked with accelerating the onset of heart attacks and strokes and severely complicating recovery. People with depression often lack the concentration and energy to effectively exercise, eat healthfully, and engage in rehabilitation to optimize recovery. Several studies 1,2 have suggested significant reductions in heart attacks and improved rehabilitation after stroke with proper depression treatment, yet these practices are not yet standard care. Proactively managing our moods and emotions should be granted the same time and effort as lowering our cholesterol, losing weight or dieting. From taking a daily aspirin to taking a walk, keeping tabs on our emotions and addressing them head-on should be an essential part of heart and brain health. 

There are a number of reasons this hasn’t caught on. Cardiologists and primary care physicians are happy to roll up their sleeves to manage cholesterol and lower blood pressure, but when it comes to emotions, many lack the training and expertise to feel confident in diagnosing mental illness, much less manage it. Mental illness is often seen as very subjective, making it challenging to measure or assess. 


Furthermore, mental illness is too often stigmatizing, and many people are embarrassed to admit they’re struggling to cope. Or they may feel as if the overwhelming hopelessness they’re feeling is a natural consequence of having a heart attack or stroke. While it may be common, we know it’s not healthy. Solid, effective treatments exist that we know can help improve our quality of life as well as, perhaps, extend longevity. 


We’re not scared to talk to our doctors about high blood pressure or aspirin, and we shouldn’t be scared to talk to them about our mood. It may be one of the only ways we can begin to mend our broken hearts. 

More information from the American Heart Association:


References: 
1. Jorge RE, Acion L, Moser D, Adams HP, Robinson RG. Escitalopram and enhancement of cognitive recovery following stroke. Arch Gen Psychiatry. 2010;67(2):187-96. doi:10.1001/archgenpsychiatry.2009.185.
2. Stewart JC, Perkins AJ, Callahan CM. Effect of Collaborative Care for Depression on Risk of Cardiovascular Events: Data From the IMPACT Randomized Controlled Trial. Psychosom Med. 2014;76(1):29-37. doi:10.1097/PSY.0000000000000022.

Friday, January 23, 2015

You want to do what?!?! The importance of informed consent in treatment


By Gail  A. Edelsohn, MD, MSPH

We come across ads in print, on television and on the Internet for medications and therapies that promise to make your child do his homework without a screaming match, behave better and generally restore harmony to home life. Not so easy, taking a medication raises a host of questions:  How long does the therapy take? Should I as the parent sign off on this? What about the possible serious side effects, such as significant weight gain, thoughts about suicide, risk of diabetes or a life-threatening condition?



Parents and legal guardians make decisions about psychosocial therapy and medication treatment for children and adolescents every day. But who should give permission and sign informed consent?  What should parents, advocates, guardians be looking for or consider before signing informed consent? Is signing a form enough?  What about the child or teen - do they have a voice regarding their own treatment?
What is Informed Consent?
Psychiatric informed consent involves a parent or legal guardian giving permission for his/her child to undergo evaluation and treatment.  It is a process which partly involves receiving sufficient relevant information about the condition, prognosis, risks and benefits of treatment to be given and other types of treatment available. Informed consent is NOT simply a signed and dated form. Parents and guardian should expect informed consent to include:

  The purpose of the treatment
  • To address a specific condition or diagnosis?
  • To lessen symptoms?
  •  To change behaviors?
  The effects of treatment
  • How will you know if it is working?
  •  How long till you see an effect?
  Risks of treatment
  • Side effects of medications
  • Consequences of psychosocial treatment (e.g., therapy can be emotionally difficult)
  Risks of NO treatment
  • Will symptoms improve over time without treatment?
  • Will things get worse or lead to other consequences? (e.g., Untreated individuals are more likely to use substances, get into legal trouble)
  What alternative treatments are available?
  

For medication
  • Is it FDA approved for this age and condition? (i.e., prescribed FDA on label)
  • If it is prescribed off-label, why?
  • Are there any FDA warnings about the medication and what do they mean?
  • What is the plan for stopping or phasing out the medication?
     Parents and legal guardians are asked to give legal permission or informed consent for treatment.  If a child is in foster care, it may be the parent or it may be child welfare service or court that can give consent.   Where a child is living (home, out of home placement) does not tell you who the legal guardian is.  In some states an adolescent may give informed consent for psychiatric treatment depending on the state’s legislation about mental health procedures. Ideally the parents/guardians and the child should be involved in treatment decision making.

Children also have a voice in this process.  Children and youth should be involved in giving assent.  Assent involves providing the child or teen with information about the therapy or medication in terms appropriate to their age and stage of development. The assent process should include opportunities for the child/adolescent to ask questions and have their concerns addressed.


Gail A. Edelsohn, MD, MSPH, is senior medical officer with Community Care Behavioral Health, clinical professor of psychiatry and human behavior,  Jefferson Medical College, and clinical professor of psychiatry and behavioral science, Temple University School of Medicine.