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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