Study highlights lack of access to mental health care

By Arshya Vahabzadeh,MD 
 @VahabzadehMD

A new study from the CDC’s National Center for Health Statistics once again highlights that too many people living with mental health conditions are not getting needed care.

Study authors Laura A. Pratt, PhD, and Debra J. Brody, MPH, found that nearly 8% of Americans aged 12 and up had depression (moderate or severe depressive symptoms in the past 2 weeks). The rate of depression was twice as high among people living below the poverty level, 15%.

 Far more alarming, the study showed yet again that people with depression are going untreated. While nearly 90% of people with severe depressive symptoms reported difficulty with work, home, or social activities related to their symptoms, only about one-third (35.3%) had seen a mental health professional in the past year, according to the study. Among those with moderate depressive symptoms, only 1 in 5 had seen a mental health professional.

While there are many reasons people don’t get needed mental health care, including mental health stigma and lack of access, discrimination in mental health coverage by insurance companies shouldn’t be among the reasons. Federal law now requires that insurers cover mental health illnesses the same as physical ailments, such as heart disease, diabetes and cancer.


However, many people don’t know their rights when it comes to getting mental health treatment. To address this glaring problem, the American Psychiatric Association has released a new poster --
available to mental health professionals -- that explains in simple terms your rights under the law and what to do if you think your rights are being denied. Download a copy at www.psychiatry.org/parity.

World AIDS Day

By Annelle Primm, MD, MPH

World AIDS Day
December 1, 2014

Focus, Partner, Achieve:  An AIDS-Free Generation

World AIDS Day is a key opportunity to raise awareness and to commemorate those who lost their lives to this often deadly disease. But, today, we can also be hopeful about achieving an AIDS-free generation.  Increased access to treatment, new and better prevention services and care, and advances in treatment are all reasons for hopefulness.  And that amounts to greater peace of mind.

 

An estimated 35 million people worldwide have HIV and more than 39 million people have died from the virus since the first cases in 1981. In the U.S., more than 1.2 million people live with HIV, but nearly 1 in 7 of those don’t know they have the virus.

An estimated 50,000 people in the U.S. are newly infected each year.  It’s why I continue to tell people the importance of getting tested.  There’s no shame, just a need for information.

What is the Connection Between HIV and Mental Health?

Mental and neurological disorders have an intertwined and often complex relationship with HIV and AIDS. Yet mental health issues are often overlooked in HIV interventions and treatment.

• About 60% of people with HIV also have depression.  Sometimes one may be tempted to “blame” depression on their HIV status, but the reality is that depression can happen to anyone and treatment works
• Pre-existing mental disorders (including substance use) can complicate HIV-related illness.  It’s important for physicians to know all they need to know about your health, and for you to be comfortable sharing  
• Nearly 50% of people with HIV experience impaired motor skills, trouble with memory and poor concentration.  If you experience such changes, those are important to inform your doctor about
• Mental illness can make it more difficult for people to adhere to HIV-medication regimens
• New antiretroviral treatments and combination therapies can affect the central nervous system and/or have psychiatric side effects
• Mental illnesses can be especially challenging to recognize and diagnose in people with HIV/AIDS.  That’s why the APA works to educate and provide tools and training to physicians.

Unfortunately, both HIV and mental illness still carry a significant burden of stigma and discrimination.

As HIV/AIDS increasingly becomes a chronic disorder with the improvement of treatments, the need for mental health care and services is rising.  World AIDS Day is also a day to recognize the many psychiatrists and other mental health clinicians working with HIV patients who also have complicated psychiatric or substance use comorbidities.


Looking for ways to take action?  Here are a few simple, powerful, and engaging ways you can take action:

• Know your HIV status. Use and share the HIV Testing Sites & Care Services Locator  
• Share your message on social media using #FacingAIDS or  in the Facing AIDS gallery
• Learn about HIV/AIDS with the HIV/AIDS Basics. Ask questions. Get help.
• Take a quiz:  Are you HIV Aware? 

Annelle Primm, MD, MPH is the Deputy Medical Director of the American Psychiatric Association

Native Americans and Suicide

By Arshya Vahabzadeh, MD & Brad Zehring, DO

 Mental illness does not discriminate - it affects every age, sex, religion, and ethnic group.

The Indian Health Service conducted a study in 2008 that noted that the rate of suicide for American Indians and Alaska Natives is higher than any ethnic group within the United States. The study reported that suicide in these populations is up to 70% higher, especially in ages 10 to 24. Sadly, this statistic is not decreasing. Mental health professionals and society need to recognize the etiology of the despair that leads to suicide so that treatment and appropriate allocation of resources can be made.

The statistics are alarming, but possibly more alarming is the silence around this tragedy. Since suicide is taboo on most reservations - there are reports that a death by suicide often is not reported or legal authorities classify it as an accident. Due to the silence and misrepresentation, the numbers could be even greater.

It is important to break the silence on the troubling trends within Native American reservations. Native Americans must be willing to discuss their stressors and be open to getting education necessary to cope, deal, and treat their stressors. Mental Health professionals must be willing to understand their culture and adapt. Alex Crosby, MD, MPH, medical epidemiologist of the CDC has been recorded as saying that Native American suicide is so prevalent that it has become acceptable practice when tensions build up. Suicide should never be an acceptable option.

Reasons for troubling trends among Native Americans

There are a lot of thoughts on why mental illness and suicide have increased in the Native American population. There has been a lot of discussion of generational trauma due to the disempowerment and oppression of Native Americans and Alaska Natives. It has been discussed that this has caused adverse childhood experiences that lead to high rates of depression and other mental illness that are precursors to suicide.

While disempowerment and oppression could very well be contributing factors - poverty seems to be a growing problem on reservations. Poverty tends to put stress on educational standards decreasing the educational opportunities for those on the reservation – leading to a viscous cycle. There are few jobs on the reservation causing adolescents and young adults to leave their families and move to where there are jobs. However, parents age and get ill causing tension between the traditional Native American family structures where youth takes care of the elderly and providing for the immediate family.

In addition to poverty, substance abuse is a big problem on the reservation. Substance abuse can affect mood, often negatively, which increases the tension and is a risk factor for suicide. Domestic violence and sexual assault are also known problems on the reservation. These stressors have led to unstable environments for children growing up. Add untreated mental illness to the mix and it is easy to see how hopelessness and despair thrive often leading to the belief that suicide is the only way out.

The Way Forward

Recently, the American Foundation for Suicide Prevention joined a Native American Mental Health panel sponsored by Congressional Native American Caucus and Center for Native American Youth. The panel focused on ways of improving mental health resources and suicide prevention. The IHS and the Substance Abuse and Mental Health Services Administration (SAMHSA) collaborated on targeted suicide prevention programs. The IHS established the Suicide Prevention Initiative and SAMHSA provided funding to the IHS to address youth suicide and provide suicide prevention for high-risk populations.

As we move forward as Mental Health professionals, it will be important to continue to collaborate with the Native American population, especially with Mental Health professionals with experience with the population and their culture. Understanding their culture and etiology of stressors will go a long way in providing the appropriate resources and treatment.

Resources for Help
In the US:
·         Suicide help
·         1-800-273-TALK

Outside the US:
·         International Association of Suicide Prevention (IASP)

15 Tips for Talking to Kids about Ebola

By David Fassler, M.D.

Child and adolescent psychiatrist 

Parents and teachers may find themselves faced with the challenge of discussing the evolving Ebola epidemic with children. Although these may be difficult conversations, they are also important. There are no “right” or “wrong” ways to talk with kids about Ebola, but here are some suggestions if you need help. 

1. Provide an open and supportive environment where children know they can ask questions. At the same time, it’s best not to force children to talk about Ebola unless and until they’re ready.

2. Answer questions honestly. Kids will usually know, or eventually find out, if you’re “making things up." It may affect their trust in you or your reassurances in the future.

3. Use words and ideas children can understand. Gear your explanations to the child’s age, language, and developmental level.

4. Help kids find accurate and up to date information. Print out Fact Sheets from the CDC, CNN, WHO and kidshealth.org.

5. Be ready to repeat information and explanations several times. Some information may be hard to accept or understand. Asking the same question over and over may also be a way for a child to ask for reassurance.

6. Acknowledge and validate the child’s thoughts, feelings, and reactions. Let them know that you think their questions and concerns are important and appropriate.

7. Remember that kids often personalize situations. For example, they may worry about their own safety and the safety of family members. They may also worry about friends or relatives who travel or live far away.

8. Be comforting, but don’t make unrealistic promises. It’s fine to let children know that they are safe in their home or at school. But you can’t promise that there will be no cases of Ebola in your state or community.

9. Let kids know that there are lots of people helping the families affected by Ebola. This time is a good opportunity to show children that when something scary or bad happens, there are people to help.

10. Children learn from watching their parents and teachers. They will be very interested in how you react to news about Ebola. They also learn from listening to your conversations with other adults.

11. Don’t let kids watch too much television with frightening images. The repetition of such scenes can be disturbing and confusing.

12. Children who have experienced serious illness, loss, or other traumatic events in the past are particularly vulnerable to graphic news reports or images of death. These children may need extra support and attention.

13. Watch for physical symptoms including headaches and stomachaches. Often times, kids express anxiety through physical aches and pains. An increase in such symptoms without apparent medical cause may be a sign that a child is feeling anxious or overwhelmed.

14. Children who are consumed with questions or worry about Ebola should be evaluated by a trained and qualified mental health professional. Other signs that a child may need additional care include: ongoing sleep problems, frequent fears about illness or death, or reluctance to leave parents or go to school. If such behaviors continue, ask your child’s pediatrician, family physician, or school counselor to help you contact a mental health professional. 

15. Although parents and teachers may follow the news and the daily updates with interest and attention, most kids just want to be kids. They may not want to think about what’s happening across the country or elsewhere in the world. They’d rather play ball, climb trees, or ride bikes.

Public health emergencies are not easy for anyone to comprehend or accept. Understandably, many young children feel frightened and confused.  As parents, teachers, and caring adults, we can best help by listening and responding honestly and comfortingly. Fortunately, most children, even those who have experienced loss or illness, are quite resilient.  However, by creating an open environment where they feel free to ask questions, we can help them cope with stressful events and experiences.

David Fassler, M.D., is a child and adolescent psychiatrist practicing in Burlington, Vermont. He is also a Clinical Professor of Psychiatry at the University of Vermont.

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Adult Bullying in the Workplace

By Brad Zehring, DO

I would rather be a little nobody, then to be an evil somebody - Abraham Lincoln

Typically, when bullying is talked about it is in the context of children or adolescents during some level of schooling. Rarely do we think about bullying as an adult issue. However, much more attention has been focused on adult bullying – more specifically, adult bullying in the workplace.

According to various sources, citing research and survey’s, it has been reported that as many as 1 in 4 adults will face some form of bullying in their career.  It is important to point out the differences between constructive criticism, workplace conflict, and bullying. Workplace bullying focuses on the person rather than the performance or task being completed by the person. In addition, the person being targeted feels powerless to stop it. Making the situation worse, is when the adult being bullied goes to management to report the offense and the abuse is minimized or discounted altogether. Complicating the issue further is the difficulty verbalizing what is taking place or being unaware that what is occurring is bullying, leading to worsening suffering.

What are some forms of workplace bullying?

As discussed earlier, workplace bullying can be described as an extreme pattern where the person is isolated apart from his/her performance or task. Some examples of workplace bullying are: being left-out of work-related social events, coworkers refusing to help when asked, coworkers leaving the room when you enter or routinely arriving to meetings late that when you call them, being yelled at, put down, or disciplined in front of your coworkers. These are some of the ways that workplace bullying presents, but it is not an exhaustive list.

How workplace bullying is harmful

For individuals who are being bullied in the workplace, their desire to go into work day after day is diminished and their satisfaction in their performance and with their employer decreases.  Many reports discuss the loss of productivity when job satisfaction decreases. Beyond the psychological stress (depression, anxiety, PTSD, etc) – which should not be minimized, stress from bullying can lead to physical illness such as stroke, heart attacks, chronic fatigue or dissatisfaction in an person’s personal life – including leading to suicide. There are many reports documenting poor job satisfaction negatively affecting all areas on one’s life. Feeling accomplished and satisfied in a career can lead to a happier personal life and vice versa.

How to prevent or deal with workplace bullying
While recognizing or speaking up about workplace bullying can be a difficult task - it is important not to be silent about bullying experiences, whether personal attacks or witnessed attacks on colleagues, or isolate from those that may be able to help. Currently, states are working on anti-bullying bills to encourage healthy workplace environments, but fostering a workplace for your coworkers that doesn’t tolerate bullying is key. Many organizations provide or contract with mental health professionals willing to discuss, advise, and help an individual navigate the process. It is important to document your concerns and be specific and concise with the message you are trying to convey if you feel you are being bullied. Despite how difficult it may be, it is important to approach the bully or go to your supervisor with a calm demeanor and discuss your concerns rationally. Lastly, it is important to have an open mind about the situation. Sometimes it may be that the “bully” does not realize how his/her actions have affected you. Approaching them, or the situation, calmly will provide an environment for understanding and increase the probability for change.

How to "Bully-Proof " Kids

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Williams’ death reminds us that a patient’s relief might be a warning sign

By H. Steven Moffic, MD

One of my favorite movie moments is when Robin Williams signs on as an edgy D.J. by exclaiming "Good Morning, Vietnam" from the 1987 movie of the same name. Sometimes, I played the audio over and over, as if it could promise a good day. As he did so often, he found a way to not only lighten the sadness, but to do it in such a way that might be constructively critical.

Surely, the real life mornings were not often happy ones, as so many of our troops died or ended up with post-traumatic stress disorder (PTSD) from that war. It is a lesson we are still learning, so that movie and his role is worth seeing again soon.

Now, after his reported suicide, that good morning seems more like a final good night.

Although he is probably best known for his manic comedy, he also played many serious roles. Most ironically now, he won an academy award in 1997 for playing an empathic therapist in the film “Good Will Hunting.”
Indeed, beloved entertainers like Robin Williams have a therapeutic role of sorts for society in the sense that they provide some relief—even if briefly—for the grief and stress of everyday life. For playing that societal role, such people become a repository for our hopes, dreams and demons. As we know for so many famous entertainers, it is not easy for them to have a successful private life—a private life that the public also tries to invade, as if they were related to us.

What we do know publicly is that Williams suffered from chronic depression and intermittent substance abuse. It is reported that he received treatment, including entering rehab just last month. Obviously, money to get the best treatment was not an issue, though how good the treatment was will remain unknown. We do know, however, that wealthy VIPs often receive treatment just as poor as low-income folks without resources. We also know that occasionally depression is a terminal illness, though that ending is not predictable.

Beyond the public information, and despite the understandable curiosity, this is not the time, nor should it ever be the time, to speculate about his diagnosis and reasons for committing suicide. In fact, the so-called "Goldwater Rule," called that for the inappropriate professional speculation about presidential candidate Barry Goldwater, ethically prohibits such speculations on the part of psychiatrists like myself.

Given this professional ethical principle, as well as the family's request for privacy, is there anything we can still learn from this apparent tragedy? The most intriguing detail that caught my attention was his last tweet and Instagram on July 31. Reportedly, he had wished his daughter a happy 25th birthday.

Why might this positive communication be of importance to us?

It reminded me of the only patient I ever had who committed suicide, long ago, when I was a resident in training. In the second session, the depression of this elderly man seemed to be less severe, but after that session he walked into Lake Michigan and drown. In the psychological autopsy, I never forgot the warning that when a depressed patient starts to seem better, they actually can be at higher risk for suicide.

Risky time

Why is that time of apparent improvement a risky time? The person can have more energy, then plan and complete a suicide. They may also feel relief at their decision, causing others to paradoxically feel relief. That is one of the reasons why it is so common to hear of the genuine surprise that the suicide occurred, as the person seemed to be happier.

What this means, not only for professionals, but for the public, is not to take at face value if a depressed person seems better. Be sure there is a sound explanation for the apparent improvement. 

Our only consolation must be that entertainers like Robin Williams keep on living in the form of their life’s work, like the movie “Good Morning, Vietnam,” that is so ubiquitously available nowadays. Even so, it would not be surprising if at the times we laugh once again at Robin William's humor, that the laughter will also be accompanied by some tears of grief.

Bio

H. Steven Moffic, MD, is a Life Fellow of the APA. Currently, he blogs regularly for Psychiatric Times, Behavioral Healthcare, and The Hastings Center's Over 65.

This blog was originally published in Behavioral Healthcare. Tweet

Spreading Hope!

By Matt Goldenberg D.O.
@docgoldenberg 
“You treat a disease, you win, you lose. You treat a person, I guarantee you, you'll win, no matter what the outcome.” 

I whole-heartedly agree with that statement. However, I cannot take credit for those words. Those are the words of Robin Williams, or more specifically, the words of his character in Patch Adams.

I want to discuss the disease called depression. I will start by first discussing the diagnosis and the signs and symptoms of depression. I will then follow up with my thoughts on the various treatment options for depression and the strategies I employ with my patients to improve their outcomes. None of my thoughts and suggestions should serve in place of a formal consultation with a mental healthcare provider. However, I hope shedding light on mental health diagnoses like depression will lift the veil and social stigma on these chronic diseases that impact so many people.

Psychiatry has come a long way in the last decade. This is a time of continued discovery and increasing public awareness. The leaders of our professional organization, the American Psychiatric Association (APA), have suggested that we as mental health professionals are under a microscope. I agree that we are and I also strongly believe that we are up for the challenge. School shootings and celebrity suicides and overdoses have increasingly put a focus on mental health. Psychiatry has significantly improved the outcomes, treatment options and the prognosis of patients with mental illness. However, we still are unable to decrease the prevalence of the diseases we treat or prevent them. We know that the brain changes during an episode of depression and our treatments help it to return to normal (see the image below). Although we are getting closer, we still currently do not have widely accessible blood or imaging tests that can confirm our diagnosis or localize the area of disease.

I can say with certainty, however, we are able to accurately diagnose patients. We are able to identify medications, psychotherapies and other treatments that patients with a specific diagnosis or cluster of signs and symptoms often benefit from. There is strong evidence that our treatments decrease symptomatology and disability and improve quality of life, clinical outcomes and a patient’s prognosis.

Psychiatrists are trained to view the patient as a “whole person”. Psychiatry is a field of medicine whose assessment by definition includes all of the biological, psychological and social aspects of a patient’s life. We listen for the psychological and social factors that can contribute to disease. Oftentimes, the “whole story” can be more telling than only focusing on specific symptoms of a given disease. There is a saying, throughout all fields of medicine, that “most patients have not read the textbook.” In other words, patients usually do not present exactly as the textbook says they should. Stress and psychological factors can mimic chest pain, shortness of breath, gastrointestinal problems and a whole host of other diseases. If we do not step back and get the whole story, we can miss the root cause or the exacerbating factors of many manageable diseases which are of the mind.

Many of the diseases we treat, such as depression, are chronic illnesses which require lifelong treatment. Our treatments can improve a patient’s mental health and coping skills and decrease their symptomatology and substance use. We know through decades of research that these are modifiable risk factors for suicide. Therefore, Psychiatrists have the training and tools necessary to decrease a patient’s risk of attempting suicide. Our treatments have the potential to not only significantly improve the lives of our patients, but also the lives of their families and everyone who comes into contact with them. Anyone who tells you otherwise is misleading, misinformed or both.

I hope this information and the blogs to follow will give you hope. Mental illness can include symptoms which can be devastating and complications which can be life-threatening. However, it is important to state again, these are treatable diseases. If you or someone you know, would like to talk to someone, call your primary care doctor or your insurance company for a referral to a Psychiatrist. A true multi-disciplinary team also includes therapists, psychologists, nurses and social workers. You are never alone. You can call the national suicide helpline 24 hours a day, seven days a week (1-800-273-TALK (8255) or visit www.suicidepreventionlifeline.org). There are also local crisis lines likely available in your area and are an internet search away. If you are ever feeling unsafe, or fearing for the safety of a loved one, you can call 911 or go to the nearest emergency department.

It is time for everyone to understand that there is no shame in getting help for depression, much as there is no shame in getting help with diabetes or high cholesterol. Even if you have never suffered from depression, there is a lot you can learn.

Together we can raise awareness and spread truth and hope. I know that if we spread knowledge, and ignore the misinformation, we will overcome the complacency and ignorance that is so pervasive today. That is how we can best honor those we have lost. That is how we can best prevent the next death from mental illness and addiction.

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How does your primary care doctor coordinate with your psychiatrist?

By Pierre Gingerich-Boberg, Medical Student
Reviewed by Claudia Reardon, MD

I’m stuck in behaviors that are making me unhealthy.  My smoking makes my asthma worse, and I don’t want to end up with emphysema like my dad.  I smoke when I’m anxious, and my finances, my teenager, my boss, and my increasing weight all make me anxious.  Now to top it off, my chronic headaches are getting worse.  My problems are physical, but I know they’re also mental.  But the idea of seeing a psychiatrist makes me even more anxious!  What should I do?

Patients need primary care doctors who can comprehensively address the varied aspects of their physical and mental health. Health systems are starting to recognize that multi-disciplinary teams (sometimes called patient-centered medical homes) can be an effective way to provide integrated care.  How might this look for our example patient?

First, it’s worth noting that traditional primary care doctors already spend a lot of effort helping patients with a wide spectrum of behavior issues.  We saw this for our example patient.  Her anxiety is an example of a classic mental health problem—others might be depression, panic attacks, and addictions. Primary care docs refer some of these patients to psychiatrists, but primary care docs are treating the majority directly.  Our patient’s headaches are likely a functional ailment. Like irritable bowel syndrome and general aches and pains, headaches are real problems that often defy simple solutions.  Standard treatments focus on limiting symptoms while helping patients cope with the stressors and psychological distress that often contribute.  Finally, our patient faces problems with health-related behaviors including tobacco use, diet, and stress management.  These and other common behaviors are hugely important for the development of chronic diseases.  

Our patient’s picture might seem complex, but primary care doctors face such complexity (and more) every day! Frankly, patients often are dealing with too much for their doctors to address optimally in a 15-20 minute time slot. One approach is to triage—to ask what’s treatable and doable, and what can wait until the next appointment. The limited time available for counseling tends to push primary care doctors toward relying on treatment with psych meds. A second approach is to refer the patient to a psychiatrist.  But psychiatrists in many communities are spread too thin, so patients often wait weeks or months for an appointment. Then there’s stigma--our example patient’s anxiety around psychiatric care is actually pretty typical.  This helps push up no-show rates for first visits with a psychiatrist to 30 or 40%.  It’s no wonder that careful studies show that only a fraction of the mental health problems in our communities are ever diagnosed, and fewer still are adequately treated.

A third option returns us to the medical home concept.  At the VA and increasingly in federally qualified health centers (FQHCs), mental health services are being brought into the primary care setting.  Here, behavioral health consultants (BHCs) share space with primary care doctors.  These are generally psychologists or social workers, that is, non-physicians. BHCs’ schedules are intentionally left mostly open, so that they’re available to see patients immediately after a non-threatening ‘warm handoff’ from the primary care doc.  The BHC can offer expert counseling for the patient, and advise the primary care provider on diagnosis and treatment.  BHCs arrange for a small subset of their patients to get a subsequent visit with a psychiatrist (a specialist physician), who is also in-house.   All the BHC patients get systematic evaluation and follow-up by phone or with visits to make sure their needs don’t fall through the cracks.

When a behavioral health consultation system is in place, problems of waiting times, missed appointments, and incomplete records are eliminated for most behavioral health visits.  Primary care docs have more time to focus on medical issues, while getting the expert consultation they need to optimize behavioral health care for their patients. Finally, because most behavioral issues can be addressed efficiently by BHCs, specialty psychiatrists are not so swamped, and waiting times can be greatly shortened for the small group of patients needing psychiatric care beyond what can be managed in the primary care setting. Tweet

Diversity Mental Health Month: Why It is Needed and How It Came to Be

By Steve Koh, MD, MPH, MBA

July of 2014 is the very first APA Diversity Mental Health Month. This emphasis on mental health needs of diverse populations is much needed. While we have diversity oriented month observances for specific population groups like the Black History Month (February), National Women’s History Month (March), Asian Pacific American Heritage Month (May), Gay and Lesbian Pride Month (June), American Indian Heritage Month (August), and Hispanic Heritage Month (September), we have not had a dedicated month more broadly addressing diverse populations and mental health issues.

I cannot overemphasize the importance of this month. For the first time, together, we will bring attention to the unique and challenging needs of the diverse populations with mental illness and substance use disorders, work to decrease mental health disparities, and engage with diverse populations to help promote and grow future mental health champions in the communities.

The concept for Diversity Mental Health Month came from a group of participants in APA’s Minority Fellowship program.  The program’s goal is to eliminate racial and ethnic disparities in mental health and substance abuse care by providing specialized training and mentorship. The fellowship fosters those with diverse backgrounds who have chosen to become physicians specializing in mental health and to do this work with the diverse populations.  

But what happens when we go home? What then? We felt that it was easy to get lost when we left our APA meetings in Washington DC. How do we galvanize our colleagues at home to look at the importance of minority mental health issues? To recognize the stigma of being an ethnic and cultural minority and also suffering mental illness? To understand that many minority students do not consider going into field of medicine let alone mental health profession? To appreciate the importance of cultural competency and humility in working with diverse patient population?

Without involvement a coordinated effort by the APA, it was our belief that while we personally benefited from the fellowship experience, our impact would be limited. There needed to be a designated time for all of APA to bring attention to this important patient population.  So the idea was born to create a Diversity Mental Health Month. The APA Assembly asked APA staff to help create a month designated to minority mental health issues and for the APA to actively promote the month.

I hope that others are excited about this new endeavor of the APA as I am. The challenges are great but together we can bring the needed attention to this area of our profession.

Many resources, including an infographic with basic data on mental health disparities, and brochures and fact sheets on specific populations, suggested activities, video messages, and more, are available at www.psychiatry.org/diversity-month.

Depression & Cancer

By Brad Zehring, DO @DrZehringDO

“Cancer can take away all of my physical abilities. It cannot touch my mind, it cannot touch my heart, and it cannot touch my soul”  - Jim Valvano

But, what happens when it does?

Depression is a multifactorial disorder that requires acknowledgement of the biological, psychological, and social aspects of a person’s life. Professionals in the mental health community describe this as the biopsychosocial model. It provides an understanding of the factors influencing a person’s mental and physical state of being.

When mental health professionals talk about depression they often do so in regards to Major Depressive Disorder (MDD). According to DSM 5 (Diagnostic and Statistical Manual of Mental Disorders), 5 out of 9 criteria are needed to diagnose MDD. It requires a depressed mood or anhedonia (lack of enjoying what was previously enjoyed) for greater than 2 weeks including: disturbances in sleep, guilty/hopeless/worthless feelings, poor concentration, low energy, changes in appetite (weight loss or weight gain), psychomotor agitation or retardation, and suicidal ideation.

Depression affects your entire body. But, the physical aspects of depression are often overlooked. It is common for people with depression to experience weight changes, digestive problems, headaches, back pain, muscle and joint pain, and disruptions in sleep cycle. Many symptoms that are present in cancer.

Depression has been linked with many health problems, including cancer. Cancer is a heavy word. The enormity of the word brings many images to the forefront of our imagination: radiation, chemotherapy, losing hair, sickness, weakness, and death - among others. There is so much symptom overlap between cancer and depression it can be hard to recognize the etiology of the symptoms.

It is important that health care professionals, family members, and other caretakers are vigilant with a person’s mental well being after they are diagnosed with cancer. Even if a person has never experienced depression previously, their risk of depression is increased when they find out they have cancer. Research shows that the incidence of depression increases proportionately with the cancer’s progression. It is believed those with depression have increased likelihood of depression because of increased immune response (cytokines) within the body.

It is important not to assume that someone with cancer has an appropriate depressed mood due to his or her circumstances.  This is why it is important to screen for depression in those diagnosed with cancer. Screening for depression can help “tease out” symptoms related to depression and symptoms related to the cancer. Treating depression in patients with cancer can help them focus on their treatment and have the motivation to do everything needed to possibly achieve remission. Proper treatment gives them the ability to focus on their future. Cancer alone is enough, but when combined with untreated depression the results can be deadly.

After recognizing depression in someone with cancer, there are ways to treat depression in parallel with cancer treatment. There are two forms of treatment. One involves medication and the other involves psychotherapy, or talk therapy. The typical medications for depression are antidepressants like Selective Serotonin Reuptake Inhibitors (SSRI) and Serotonin and Norepinephrine Reuptake Inhibitors (SNRI). These medications have been around for a long time and are generally well tolerated. They take anywhere from 2-6 weeks for clinical efficacy. These medications should be monitored with cancer treatment, as there can be drug interactions and side effects that may not be present in someone taking these medications without cancer. In addition to medications, psychotherapy can be effective. More specifically, Cognitive Behavioral Therapy (CBT) can help people change their negative thoughts about cancer and their future. For the most efficacious treatment a combination of both should be implemented.

Cancer is a serious illness and a well-developed multi-disciplinary approach is necessary to best treat the patient. Cancer can cause a lot of different disturbances in physical and mental health. It is important to have health professionals, like psychiatrists and psychologists, part of the treatment team to ensure proper treatment of the whole patient.

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Telemedicine, Here I Come!

By Hind Benjelloun, MD @hbenjelloun 

My decision to pursue a career in telemedicine was a long process. I had a comfortable, stable clinical position at a highly regarded academic center in a lively city. But I kept wondering if my career needed a boost. I found myself thinking, career development takes risk. Medicine is an ever-changing and growing field. I felt that I had to embrace some changes myself if I wanted to keep up.

Telemedicine is a relatively new discipline. The idea of incorporating health care with technology, specifically the web, may have some rolling their eyes or shaking their heads. But, simply put, it is the future of healthcare; and it is certainly getting the buzz these days.

The American Telemedicine Association is rapidly growing and developing its services and its role in healthcare. Many medical and scientific organizations are recognizing the importance of the discipline as well. You can see it reflected in the number of publications, conference seminars, and available CME. Tech gurus are predicting that the recent acquisition of Oculus by Facebook will be a game changer in the tech industry and will further grow telemedicine’s influence.

So I took the plunge into a field in its infancy. I went for it.  Telepsychiatry! After almost ten years at Georgetown University Medical Center, I drastically shifted gears to pursue a full time career in crisis telepsychiatry.

In this career change, I have been labeled a pioneer among colleagues and friends. It feels wonderful to immerse myself in such an innovative healthcare movement. My healthy narcissism embraces it and it strengthens my confidence in what some may call a risky career decision. Today, telepsychiatry is revolutionary in the way it enhances access to care. And although right now telepsychiatry is primarily seen as a means of engaging the rural patient population, it will progress in the medical community as a future medical norm. The evidence is growing and continues to demonstrate the boom of telemedicine and its success.

Still, taking the leap into telepsychiatry had its downsides.

Because of its youth, telemedicine lacks a number of accessible mentors who can guide the process. There are few clinicians who have an “institutional” knowledge of telemedicine to share. This means that other than the anecdotal accounts that you may read in a journal or blog post about what it’s like to venture into the world of telemedicine as a provider, there aren’t many reputable sources to turn to.  I had trouble knowing what to expect.

I started working with InSight, a national telepsychiatry provider company earlier this year. As a crisis telepsychiatrist with InSight, I have the ability to seamlessly transition between seeing patients at multiple hospitals in multiple states back to back. Today, I love my job. But the legislative hurdles I had to jump through to get going were a major headache.

I was completely committed to offering services right away when I made the decision to start practicing telepsychiatry. I was ready to go. But I had no idea what kind of challenges I would encounter as I attempted to receive licensing from medical boards that all work independently of each other.

After the first hurdle of becoming licensed, I thought I had passed the finish line. But to my surprise, I was back to waiting on privileges from hospitals that were scrutinizing my immunization records and testing my knowledge of their fire code. This all seems so frivolous and a waste of time, effort and money. Didn’t they understand that I would be seeing patients remotely?

When I finally began working with a regular schedule, I found myself asking, why did it take so long for me to be able to actually see patients and provide care?

The answer lies in legislation. The laws and regulations in place for telemedicine are significantly outdated. Why is my medical license in one state insufficient in another? Big changes are needed to reflect the advent of technology’s integration into medicine. And when it comes down to it, it’s the patients who suffer from these outdated practices the most.

The shortage of psychiatric prescribers, as well as other types of providers in the United States is a growing problem. Telemedicine is an important way of addressing that shortage with the providers we already have.

Thankfully, there is yet hope. The Federation of State Medical Boards (FSMB) has recognized this unnecessary obstacle to patient care and the strain inflicted on telemedicine as an industry.  At its annual meeting at the end of April, the FSBM will vote on adopting the federation’s Interstate Medical Licensure Compact, a licensing option that would allow qualified physicians to expedite licensure in all states who participate in the Compact. Telemedicine as a field of practice would be transformed dramatically with the adoption of the Compact. Fingers crossed.

I am enthusiastic about potential for growth of telepsychiatry and telemedicine. But I believe providers must take an active role in pioneering this new form of care, and pushing for its successful implementation for the people who need it—our patients.

Bottom line—we are in this for our patients, and it is our patients who will benefit the most from telemedicine and a successful reevaluation of the legislation that regulates it.

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How Psychotherapy Changes the Brain

By Serina Deen, MDMPH

When I first see patients for evaluation, they often tell me that they’ve debated starting a “biological” treatment such as medication, versus a “psychological” treatment such as psychotherapy. I’m happy to report that as brain imaging technology advances, we’re finding that this distinction may be obsolete. 

Psychotherapy is also “biological” in that it can lead to real functional and structural changes in the brain.   In fact, sometimes psychotherapy and medication produce surprisingly similar changes in the brain.  We still have a lot to learn about the topic, but below are some examples of what researchers have been finding so far.

Functional Changes in the Brain:
In one study, researchers at UCLA found that people who suffered from depression had abnormally high activity in an area of the brain called the prefrontal cortex.  Those who got better after they were treated with a type of therapy called interpersonal therapy (IPT) showed a decrease in activity in the prefrontal cortex after treatment.  In other words, IPT seemed to “normalize” brain activity in this hyperactive region.

Another study looked at people who have obsessive compulsive disorder (OCD), who tend to have an overactive area of the brain called the caudate nucleus.  Treatment with a type of therapy called cognitive behavior therapy (CBT) was associated with a decrease in the hyperactivity of the caudate nucleus, and the effect was most evident in people who had a good response to CBT.  In other words, the better the therapy seemed to work, the more the brain activity changed.

Changes in Brain Volume:

People with chronic fatigue syndrome (CFS) suffer from debilitating fatigue.  People with CFS tend to have a decrease in a type of brain tissue called grey matter in the prefrontal cortex of the brain.  Researchers in the Netherlands gave people with CFS 16 sessions of CBT, and found significant increases in gray matter volume in the prefrontal cortex.  This seems to suggest that the CFS patients were able to “recover” some gray matter volume after CBT.

Similarities and Differences to Medications

Psychotherapy sometimes seems to work in similar ways as medications, and other times appears to have different mechanisms of action.

In the study mentioned previously about people with depression, both IPT and the antidepressant paroxetine (Paxil) showed a decrease in prefrontal cortex activity.  And with OCD patients, both CBT and the antidepressant fluoxetine (Prozac) produced similar decreases in activity in the caudate nucleus. 

However in a different study, the antidepressant Venlafaxine (Effexor) produced changes in different parts of the brain than IPT in depressed patients.  This shows that there is variability in how different treatments work in the brain.

How Psychotherapy Produces Brain Change

We now know that the brain keeps changing, even after we become adults.  Learning leads to the production of new proteins, which in turn can change connectivity in our brains in a process called neuroplasticity.   Indeed, researchers in Germany showed that certain neurochemicals involved in neuroplasticity increased in depressed patients who got better after a course of interpersonal therapy. 

Picking a Treatment that Works Best for You
Even though we know that both medication and psychotherapy can change our brain, we still have a long way to go in learning exactly how that happens and when to use what treatment. Given a specific mental illness, sometimes medications work best, sometimes psychotherapies are the best option, and sometimes it’s a combination of the two.  In addition, there are different types of psychotherapies that work for different illnesses, just as there are many different types of medications.  If you’re considering seeking help for mental illness, it would be helpful to talk with a trained professional about what would work best for you. 

Read tips on what to expect during your first visit with a psychiatrist  

"Let's Talk Facts" brochure on Psychotherapy

Brain Awareness blog post from NIMH Director Tom Insel, MD

APA Releases List of Five Uses of Psychiatric Medication to Question

Six tips for talking to your doctor about medication

For more information about psychotherapy

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