Pot may be legal for adults but it’s still dangerous for adolescents

Anyone who’s read my book A Lethal Inheritance knows I’ve consistently and strongly warned against teenagers smoking pot, because their brains have not finished growing, and research clearly shows negative effects when they smoke before 21 or 18. Especially if the young person is vulnerable to mental disorders due to heredity. Today’s NY Times has an excellent article by Tara Parker-Pope on the impact (or potential impact) of marijuana legalization on teen pot use. Please note, neither I nor the article are talking about adult use. This is strictly a maturing brain matter….

Highlights…from Parker-Pope’s article…

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The brain is still wiring itself during adolescence, and marijuana — or any drug use — during this period essentially trains the reward system to embrace a mind-altering chemical.

Studies in New Zealand and Canada have found that marijuana use in the teenage years can result in lost I.Q. points. Mr. Pasierb says the current generation of young people are high achievers and are interested in the scientific evidence about how substance use can affect intelligence.

“You have to focus on brain maturation,” he said. “This generation of kids wants good brains; they want to get into better schools. Talk to a junior or senior about whether marijuana use shaves a couple points off their SATs, and they will listen to you.”

Because early exposure to marijuana can change the trajectory of brain development, even a few years of delaying use in the teen years is better. Research shows that young adults who smoked pot regularly before the age of 16 performed significantly worse on cognitive function tests than those who started smoking in their later teenage years.

Drug educators say that one benefit of the legalization talk is that it may lead to more research on the health effects of marijuana on young people and more funding for antidrug campaigns.

If you want to read the entire article go here: http://well.blogs.nytimes.com/author/tara-parker-pope/

Report: Proper SSRI Antidepressant Starting Dose Minimizes Suicide Risk In Young Adults

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     A large, well-controlled pharmacoepidemiological study shows that three SSRI antidepressants do not increase suicide risk in 10- to 24-year-olds when given at the proper, recommended doses. Higher doses were associated with a 2.2-fold increase in suicide risk. No similar dose effect was seen in those age 25 to 64.   read »

From Forbes.com, the blog of David Kroll, a pharma expert who used to blog for PLOS Blogs, my current employer. I recommend you to read on!

More Americans Understand Mental Illness; Climate Change, Vaccines or the Big Bang…Not So Much

08klass-articleinlineI think my regular readers will find this new poll as interesting as I do! In the table below check out the results of a recent AP survey looking into the confidence Americans have in various concepts which are considered “accepted science.” And while I’m worried by the findings that 51% of those polled don’t think our world started with a Big Bang, and only 53% have confidence in vaccine effectiveness and safety, I find other numbers surprising and even encouraging. For example, 61%, nearly 2/3, are either very or fairly confident that the earth is warming due to human activities. Okay, better than I might have expected. But best of all… 71% say they are extremely or very confident that “a mental illness is a medical condition that affects the brain”.  Another 12% are somewhat confident of this fact, adding up to a whopping 92% who lean favorably towards a scientific understanding of mental disorders. When one considers how much stigma has been driven by an absence of this understanding, we have to be encouraged that things are indeed changing. But then, I am an optimist by nature. What are your thoughts on these questions and answers?

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A Psychiatrist Diagnoses “House of Cards” — Is Claire Underwood a Narcissist?

claire-underwood-blood-300x300I’m sharing the latest blog post from Stanford psychiatrist Shaili Jain, who uses  House of Cards husband and wife team, Frank and Claire Underwood (aka Kevin Spacey and Robin Wright) to teach us about some little understood psychological diagnoses. Here, in its entirety, from “Mind the Brain” on PLOS Blogs Network.

By Shaili Jain, MD

Last month I used the character of Frank Underwood as a “case study” to illustrate the misunderstood psychiatric diagnosis of Antisocial Personality Disorder, and many of you asked: Well, what about his wife, Claire? Good question!  You asked, and so today I will do my best to  answer.
SPOILER ALERT: For those of you who have not been on a streaming binge and watched all of Season 2 yet, consider yourself warned. 
Image: Netflix
Clinical lore would certainly support that Claire, herself, must have a personality disorder of some kind – a sort of fatal attraction, where a couple is drawn to each other because there is something in their personality patterns which is complementary and reciprocal. She does appear to have mastered the art of turning a blind eye to Frank’s more antisocial exploits.  She is a highly intelligent woman, and she must have some inkling that her husband may be involved in the death of Zoe Barnes and Peter Russo.  But if she has an inkling, she does not show it.
Claire, from what we know, does not engage in outright antisocial behavior.  Unlike Frank, she has not murdered anyone and we have not seen her engage in very reckless or impulsive outbursts. However, she rarely shows emotion—her smiles seem fake, her laugh empty, and her expressions are bland.  She is more restrained and guarded than Frank, and she does not reveal her inner thoughts to the viewer the way Frank does so it is much harder to know what could be going on in her mind. Still, I think I have seen enough to venture forth with an assertion that she may have a Narcissistic Personality Disorder.
What is Narcissistic Personality Disorder?

A pervasive pattern of grandiosity, need for admiration, and lack of empathy beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of 9 criteria.

Below are the five criteria that I think apply to Claire:

1) Has a sense of entitlement (i.e. unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations) 

 

  Image: NetflixShe expected Galloway to take the blame for the photos that were leaked and eventually claim it was all a “publicity stunt,” thus ruining his own reputation and image.  She expressed no regret that her ex-lover was cornered into having to do this, on her behalf, and no remorse that it almost ruined his life and his relationship with his fiancé. She was entitled to this act because she is “special” and expects that people will “fall on their swords” for her.

2) Is interpersonally exploitative (i.e. takes advantage of others to achieve his or her own ends)

  Claire manipulates the first lady, Tricia Walker, into believing Christina (a White House aide) is interested in the president. She pretends to be a friend, wangles her way into becoming the first lady’s confidant, and persuades her to enter couples therapy with the president.  All of this is actually part of an elaborate plan to help Frank take the President down so that he can become president and she (Claire) can usurp Tricia as first lady. Another example: Claire is pressured by the media into revealing that she once had an abortion, but she lies and states that the unborn child was a result of rape (presumably to save political face).  Again, she shows no remorse about her lie and instead profits from it, gaining much sympathy and public support.

3) Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

This was best seen in the way Claire deals with her former employee Gillian Cole’s threat of a lawsuit –  she pulls a few strings and threatens the life of Gillian’s unborn baby.  In fact, in addition to the obvious lack of empathy was the simmering rage she had toward Gillian for daring to cross her.  Again, entitlement, narcissistic rage, and a lack of empathy would explain that evil threat she made, to Gillian’s face, about the baby.

4) Is often envious of others or believes that others are envious of him or her

I think part of the reason Claire was so angry at Gillian was because, deep down, she was envious of her pregnancy.  We know that, in parallel, Claire is consulting a doctor about becoming pregnant and is told that her chances are slim.  This is such a narcissistic injury to Claire that she directs her rage at Gillian.  I don’t think she was even consciously aware of how envious she is of Gillian for being pregnant. Another example would be the look on her face when Galloway indicates he is madly in love with his fiancé and wishes to make a life with her.  For a second her face darkens – a flash of jealous rage – which then translates to indifference and almost pleasure at his eventual public humiliation.

5) Shows arrogant, haughty behaviors or attitudes 

Image: Netflix

Correct me if I am wrong, but Claire just does not appear to be that warm or genuine and has an almost untouchable air about her. Furthermore, we only ever see her with people who work for her (i.e. have less power than her) or with people more powerful than her (i.e. whose power she wants for herself). Other than Frank, where are her equals? Her oldest friends and colleagues? Her family? People who might not be influenced by her title or power?

One last comment – in Season 2 Claire certainly comes across as more ruthless and power hungry than the Claire in Season 1—whether she is now showing her true colors and is dropping her facade or just becoming more lost in Frank’s world and hence looking more like him is unclear to me… I suppose we will find out in Season 3!

Meanwhile, if you want to read Shaili’s diagnosis of Frank Underwood, go here.

Creative Commons License This work, unless otherwise expressly stated, is licensed under aCreative Commons Attribution 3.0 Unported License.

Becoming a Digital Media Sensation, While Struggling with Depression — a wise and touching post by Jennifer Pastiloff

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“I’ve carved out a beautiful life and love what I do, but sometimes, especially lately, I feel the old tug of depression, that magnet of sadness which is buried somewhere next to the grief of losing my father at such a young age, but not relegated to that grief. “

This poignant line comes from an article I’d like to recommend by  She’s a young yoga teacher, inspirational speaker, and a digital media sensation (pictured above), who writes about her battle with depression, and how she’s making tough choices like staying on or getting off antidepressants (for her pregnancy and then after) and how (or even if) she can deal openly with her depression with her friends and many fans.  I’ve pasted another favorite piece of her post below followed by a link to the full post on xo jane…

“About a year after I had gone on anti-depressants, I quit the restaurant. I started leading inspirational workshops, which quickly turned into sold-out workshops and retreats all over the world. I developed this huge online following. It all happened very quickly — I went from career waitress to traveling around the world and being on Good Morning America and featured in New York Magazine. And all this success came while I was on meds.

I felt like a fraud. I felt like I should be able to use the tools I was teaching in my workshops and not have to be on anti-depressants. So I went off last summer, and about five minutes later got pregnant….” read the full post here:
 
 
 
 

New analysis of international suicide data repeats 10 year old finding; 85% suffer from a mental illness

Almost startling in its consistency, a new peer-reviewed study published in PLOS ONE (April 2, 2014) , a full decade after the often-cited McGill University metastudy on the relationship between mental illness and suicide risk, produced essentially the same major finding —  within 2%. The Australian and American scientists responsible for the new research paper, titled The Burden Attributable to Mental and Substance Use Disorders as Risk Factors for Suicide: Findings from the Global Burden of Disease Study 2010, compiled worldwide data from the World Health Organization (WHO) to show that 85% of people who die by suicide have a debilitating mental disorder. One difference: this study includes addiction as a major mental disorder, which reflects more recent classifications in the mental health field.

The underlying WHO data doesn’t fully represent mid to lower income countries so even this high a percentage linking suicide and mental illness no doubt underestimates the real numbers of people who die by their own hand in places where national and local health systems simply don’t count them. For better or worse, this research certainly covers most of us living in the US.

Sometimes the numbers provide important nuances to help us understand who, how, where, when and even why…

  • Nearly 1 million people complete suicide every year with over 50% aged between 15 and 44 years [14][15].
  • Over 80% of suicides occur in low to middle income countries and close to 50% occur in India and China alone [15][16].
  • the risk of suicide was 7.5 (6.2–9.0) times higher in males and 11.7 (9.7–14.1) times higher in females with a mental or substance use disorder compared to males and females with no mental health or addiction disorder
  • Suicide from firearms, car exhaust and poisoning are more common in high income countries and suicide from pesticide poisoning, hanging and self-immolation are more common in low to middle income countries [17].

There is also a telling graph of which disorders rank as the most and least dangerous in terms of suicide risk, with major depression leading the way: journal.pone.0091936.g004 Lastly, the authors also looked at prevention strategies, and found that equipping general practitioners to diagnose and treat major depression had the highest value as a strategy, with a few caveats, as usual having to do with the quality of care. ” This was one of the few interventions for which there was good evidence of effectiveness as a suicide prevention strategy in a recent review by Mann and colleagues. That said, ensuring that care from general practitioners is evidence-based requires further consideration, given findings that rates of minimally adequate treatment for depression are lower among patients treated solely by general practitioners or in the general medical care sector, compared to those treated by specialist mental health providers.”

The unavoidable point: treatable mental disorders if left untreated put you at a much higher risk for suicide. What else is there to say?

ADHD: a real disorder, denying it hurts children

This is a great article on the website “Real Clear Science” compiling the evidence to respond to those who fall on the overmedication of kids argument to deny the existence of this disorder:

http://www.realclearscience.com/blog/2013/12/should_we_stop_treating_adhd.html

 

 

Let Us Not Forget…Suicide, Even By Celebrities, is Most Often Preceded by Deep, Unrelenting Depression

With a spate of celebrity suicides and overdoses in the news, most recently those of L’Wren Scott and Philip Seymour Hoffman, we can find ourselves sidetracked with sordid details of their deaths, and stories of the fame and fortunes they won or lost. Idle speculation is made about possible motivations; e.g. most annoyingly in the case of Scott, did she fear aging, was it her business debts or did Mick dump her?  With such distractions, we can easily forget that a mountain of research now tells us that most people who take their own lives  (87% in a McGill Metastudy) spent many years before this final act battling a serious psychiatric illness. It is this disorder that undermines their ability to handle any new pressures of the sort  L’Wren Scott or anyone else trying to make a living, find love and raise children encounters today, while most people just slog through life’s ups and downs. Most often the particular disorder that precedes a suicide is unipolar or bipolar depression, or schizophrenia. And far too often one of these disorders is camouflaged by a substance addiction, also known as “self medication.”
          Thinking about all this with a high degree of frustration in recent weeks, I came across this book review I wrote about the memoir “Half in Love” by Linda Gray Sexton — someone who, it occurred to me, knows far more than most of us about celebrity and suicide. The daughter of the iconic Ann Sexton, a Pulitzer-Prize winning poet who famously took her own life in 1974, taking many an English major in her thrall (myself included), Linda inherited her mother’s bipolar disorder and her identity as a writer. In her book, Linda Sexton gives us valuable insights into the magnetic pull suicide can have on someone battling depression — particularly when both the disorder and the act of suicide run in a family. I republish it here in hopes we’ll all be reminded of the all too frequent suffering behind these headlines.

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Linda Sexton’s Memoir Reveals the Dark Truth Behind Her Mother’s Brilliance

A book review by Victoria Costello (originally published on Psychology Today.com, Aug 2011)
 
          As someone who’s battled life-long major depression, I thought I knew enough about the depths of despair to which this illness can send you. And then I read Linda Sexton’s painfully explicit, at times claustrophobic, yet surefooted and ultimately redemptive memoir Half in Love, Surviving the Legacy of Suicide. When I put down Sexton’s book, I had a profound new understanding of the extent to which unipolar depression, my diagnosis, is the milder second cousin to the bipolar variety. This memoir leaves no doubt of the extreme danger conferred by the massive mood swings of bipolar disorder, particularly the high risk of suicide. It’s one thing to know it, it’s quite another to see it through Linda Sexton’s eyes as the child of a bipolar mother for whom death was both a demanding creative muse and Linda’s main rival for her mother’s attention.
          Interestingly, Anne Sexton managed to include young Linda in her creative writing process, going so far as to arrange poetry writing lessons for her daughter. But the pull of death was something else entirely, first for the mother, and then, in a near repeat of the same tragedy, for the daughter who emulated everything about her. Linda Sexton begins her story on the evening of her first suicide attempt, when she takes narcotic pills and slits her wrists in the bath tub of her family home while her husband is away on business and her teenage sons sleep in their rooms down the hall. As she sinks into unconsciousness, Linda remembers the promise she made to her boys that she would never do to them what her mother had done to her, and then proceeds to nearly do it. The author describes her loss of resolve with heartbreaking honesty. “I was ready, at last, to cheat on love. Ready to renege on assurances that now felt as if they had been too easily given to everyone-children, husband, sister, father, friends. Immersed in communing with my mother, I became a small child that night, a vulnerable daughter. She seemed right then to hover in the room, guiding me. I knew that when I finished, she would be waiting to fold me into her arms, and I would go home with her one more time.”
          The next scene, appropriately, brings us back to the morning in 1974, when, as a 21 year old college senior, Linda learns that her mother, by then a Pulitzer Prize winning cultural darling, has finally, after innumerable attempts, succeeded in killing herself by carbon monoxide poisoning in the family garage. Over the next several chapters, Linda recounts her later childhood and teen years at the hands of this often loving, but wildly inconsistent mother. By the time the author returns to the night of her own suicide attempt, she is forty-five years old, and we are not a bit surprised to learn that she has reached the same age as Anne Sexton when she took her life…so strongly has Linda brought us into her visceral experience of being the adoring, insecure daughter who identifies completely with a beautiful, vivacious, but helplessly narcissistic parent.
download The fact that it is Anne Sexton’s bipolar disorder–never properly diagnosed or treated–producing this deranged parenting is never far from the reader’s consciousness. The daughter well understands her mother’s feelings of hopelessness; within months Linda receives the same diagnosis. Linda Sexton’s journey to recovery is well worth reading for itself. But because of  her mother’s cultural significance, Linda’s story offers us other insights. After reading Half in Love, I re-read some of Anne Sexton’s poetry, and watched some videos of her readings from the 1960s, performances that are now easily accessible on You-Tube.
          I also read with dismay the review given Half in Love in the New York Times in February of this year. While it is mostly positive, the reviewer ends bizarrely by lamenting that Linda Gray Sexton is not a carbon copy of her mother, writing: “There is, however, no getting around the fact that Sexton never becomes as compelling a character as her mother was… Even when she was sickest, Anne Sexton managed to create a vibrant world around herself, never losing her status as a figure to be reckoned with.” About Linda Sexton’s book this critic writes, “There is a surprising blandness to her sensibility, and her cause isn’t helped by overwrought language and hackneyed therapy-speak.” Well, gee, I thought, should we really be surprised that the story of someone in recovery isn’t nearly as “compelling” as that of someone who never leaves the path of self destruction; abandoning her children while self-medicating and, driven by her mania, giving riveting performances of suicidal poetry all over the world?
          The poetry of Anne Sexton is startling and beautiful; just as she was. But what Linda’s story finally makes clear is that her mother could barely get to her desk, let alone write something beautiful when she was in one of her long stretches of depression, which would frequently go on for months. I couldn’t help but wonder…aren’t we beyond the idiocy that says mental illness and great art somehow need each other? There are numerous studies showing that although the mood swings of bipolar and the cliff-edged near psychotic thinking of schizophrenia can bring extra-ordinary creative insights, everything else about these diseases can extinguish the same insights There’s still the odor of romanticization here.
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          I highly recommend Half in Love, Surviving the Legacy of Suicide. The good news Linda Gray Sexton offers in her final chapter is the arrival of her own hard won stability. And then, in a touching and beautifully rendered scene, she shares the conversation she has with her two now grown sons, in which she asks their forgiveness and speaks openly about the illness for which they too are at high risk. The fact that this conversation happens at all offers real hope that the legacy of suicide will, at least in this family, finally be halted.

Book Review: By All Means…Where Mindfulness Meets Mental Health

By Edward Brown   Illustrations: Margot Koch

Missing Links Press  Reviewed Jan/2014 (Releasing April 2014)

To Buy on Amazonbook cover

A few pages into this “Zen cautionary tale,”, the dramatic stakes are set high and our attention is arrested when its main character, Edward, barely manages to extricate a piggy hand-puppet from the jaws of a neighborhood feline – just as the interloping cat tries to slink out Edward’s side door.

We soon learn that Edward is a revered, Northern California spiritual master and teacher who, on this day, is preparing to drive a few hours south to give a talk.

In “real life” he is known as Edward Brown, the equally revered Zen Buddhist teacher and author of the beloved Tassajara cook books.

So begins Brown’s intimate, revelatory and often LOL funny novella, which is enhanced by the knowing illustrations of Margot Koch and released this month by San Francisco’s Missing Links Press.

Readers are as grateful as the piggy puppet, named Ponce, when Edward keeps him at his side for the rest of this gently taut adventure tale, complete with a mid-life love story, a near-tragic climax and an emotionally and spiritually rich dénouement. The book’s heart center belongs to the rescued pig puppet. As narrator, Ponce adeptly moves between the voice of Ed’s wounded child-self to that of the grown up Edward – who in turn shows up alternately as Edward the venerable Zen master or “Eddiebear” (Ed’s childhood nickname) — the flawed human being for whom centeredness or masteries of any kind are moving targets.

When Ponce speaks as the young Edward, whose abandonment issues stem from having lost his mother at the tender age of three, Brown makes us feel how that loss formed him and still fuels the 60-something’s foibles and frustrations, as in this scene when Ponce expresses Ed’s satisfaction when Margot compliments his cooking:

This pleased Edward quite a bit because if she liked his cooking enough Edward supposed that she wouldn’t leave, and that would be a good thing not to be abandoned, though, of course, he’d have to keep on cooking.

Brown uses this juicy biographical material to dole out more than pop psych. Ponce’s insights run deep and wide, too, as when he muses on the challenge Zen Ed faces “teaching enlightenment to people not especially interested in waking up”

Even in relationship it seemed that people often aimed to not relate. They’d say, “I like your act, do you like mine, too? You do your act with me, and I’ll do my act with you. Okay? Is it a deal?” Let’s get together and not actually meet, shall we?”

Oh my, I thought, as I brought the book into my lap for a moment of uncomfortable self-reflection.

To provide comic relief from such truth-telling, narrator Ponce is also charged with regularly tossing Ed off his pedestal. Here, in preparation for the appearance in Santa Cruz, Ponce watches impatiently as “the master” carefully selects, folds and packs his proper Zen wardrobe, including the mandatory “white jiban, beige komono, dark brown obi, and a handsome stick,” noting:

Check, check check, if you were going to be a Zen person, it was important to be masterful and nothing says masterful like fine robes. Unfortunately Edwards’ were getting to be threadbare, especially if you looked closely, so everyone knew that he was over the hill just like his robes, a teacher that some conceded, ‘might be good for beginners.’

For me, there was identification and surprise in Ed’s Woody Allen-esque “meltdown” as he multitasks himself into distraction on his way out the door. As I try to insert meditation into my morning routine – before the coffee, Tweets, and Facebook postings that typically launch me into the work day — I have flashed more than once on one of the book’s most reassuring messages:  that we are all beginners.

For Edward, the character, a lack of mindfulness could take a serious toll as he begins the drive to Santa Cruz. A jammed Marin commute brings about a chain of events that force him to confront his own mortality, and highlight his shortcomings as a friend and protector to Ponce (who is, after all, the abandoned Eddiebear).

And yet, all may not be lost. Despite Ponce’s immediate, terrifying predicament, seemingly abandoned by Edward and stuck in a dark, cold place, our piggy puppet discovers that by changing his perspective, by looking “from the center of the sparkle,” there is a glimmer of light and promise of another, perhaps more enduring rescue.

Mindfulness and Mental Health

I recommend Ed Brown’s By All Means to anyone – teens and up — seeking inspiration for a more mindful, less stressful life.

More germane to the mental health community, I believe By All Means can provide valuable comfort and support to anyone struggling with a mental disorder — in themselves and/or a loved one. Writing from the perspective of someone with lifelong depression, and as a parent to an adult child with depression, I can attest that those of us who are dealing with the symptoms of a mental disorder face one daily, constant, and fundamental task: to manage our minds; and, when pulled away by scary, negative thoughts, to step back from the precipice of hopelessness and despair that can engulf us.

Like Eddiebear and Ponce, we each carry emotional wounds into adulthood – wounds that can make dealing with difficult symptoms, and thoughts, all the tougher. But, like the characters in this honest and insight-packed book, we absolutely can acquire and commit to a set of practices – call them spiritual or therapeutic, it doesn’t really matter – that will help us find a way out.

As a beginning student of mindfulness and meditation, I am struck by the similarities between the techniques I’m learning to gently tell my mind “get back to you later” while attempting to focus simply on my breath, and those I’ve been given in cognitive behavioral therapy to manage negative self-messages and obsessive thoughts. In both cases, the primary technique used is to observe without making negative self-judgments; in other words, to practice kindness with ourselves.

So I recommend this book as one way to gain new perspective and help that process. . As always, I also suggest you talk to a friend or a mental health practitioner if you are having a tough time.

“3 Lessons from the Gus Deeds’ Story” – A Psychiatrist Takes on America’s Failed Mental Healthcare Delivery System

By Shaili Jain, MD
Posted: February 6, 2014 on PLOS BLOGS, Mind the Brain 

From “60 Minutes,” CBS Television, January 26th, 2014

Creigh Deeds: There’s just a lack of equity in the way we as a society, and certainly as a government and insurance industry, medical industry, with the way we look at mental health issues.

Scott Pelley: Don’t want to fund it. Don’t want to talk about it. Don’t want to see it.

Sen Creigh Deeds on 60 Minutes

Creigh Deeds: Absolutely. That– that’s exactly right. But the reality is, it’s everywhere.

If inadequate access to mental healthcare in the US is a disease, and I would argue that it can certainly be seen that way in terms of the toll it has taken on American society, then medical school did next to nothing to prepare me to understand its causes; or, to deal with them. After 15 years of treating thousands of patients with psychiatric disorders, I have long struggled to concisely understand and articulate the confluence of factors that determine why my patients do (or do not) have access to mental healthcare.

Recently, whilst watching 60 minutes all that changed. From the story of a young man named Gus Deeds, a clear and concise picture emerged of cause and effect, depicting the factors that largely determine whether a patient in need of mental health care is likely to receive that care. 

In this segment, Scott Pelley interviewed Virginia State Senator, Creigh Deeds, about his son Gus, who was 24 years old and had been living with serious mental illness.  His struggle culminated, last November, in a tragic ending. The Deeds’ predicament with their son was echoed by other family members of mentally ill children and adults who were also interviewed for this segment.

I was deeply saddened and perturbed by the story and although I had never met any of the people involved and had no inside knowledge of the situation, Senator Deed’s narrative was all too familiar to my ears as a litany of causes for an avoidable tragedy : inadequate mental health resources; resistance to care by the patient; additional obstacles presented by insurance companies, and fragmented treatment options.

Watching the interview, my head reverberated with all the questions I had asked myself when attempting to provide care for patients with serious mental illness.

These were the types of questions that plagued me during the earlier days of my career.  Why am I not able to stop them falling through the cracks in the system? Why do I have to spend so much time persuading insurance companies to pay for their basic care? What am I doing wrong? What can I do better?  Why does the opinion of their loved ones not seem to count?

The causes behind inadequate access to mental health care in the US must be described with a terminology not taught in medical school. They hail from different worlds than the one in which I was trained: the worlds of law, healthcare policy, sociology and the insurance industry.

Gus Deeds and Craig Deeds, 2009

Gus Deeds and Craig Deeds, 2009

If this situation is going to change, the Gus Deeds story provides a tragic, teachable moment for all Americans.

Here are 3 key lessons we can all learn from what happened to the Deeds family.

#1 Despite reforms, mental health care services are inadequate or nonexistent to large segments of American Society

 Access to mental healthcare starts with the premise that, if services are available and there is an adequate supply of services, then the opportunity to obtain health care exists, and a population may ‘have access’ to services. Unfortunately, this assumption of adequate supply cannot be made with regards to services provided by mental health professionals.  There is a shortage of mental health professionals in the United States, And the situation is particularly dire in rural and underserved parts of the Nation.  Add to this the fact thatfunding for community resources such as inpatient psychiatric beds and long-term behavioral health facilities has been shrinking for decades and it is not hard to imagine why the issue of access has become problematic for many who are in urgent need of psychiatric attention.

# 2. Because of stigma and denial surrounding mental illness, patients who most need care don’t always seek it

Stigma can be societal and manifest as discrimination towards people with mental health problems. A response from one of the other parents interviewed by Pelley, says it all: When Pelley asked her what the difference between being the mother of a child who has mental illness and the mother of a child who might have heart disease or cancer was, she answered with one word. Sympathy.Predisposing factors such as patient race, age, and health beliefs also influence an individual’s decision to access mental healthcare. Specifically, in the case of those living with serious mental illness, it is not uncommon for the patient to deny that he/she is ill and, therefore, think that they do not need help or medical treatment, i.e. they choose not to access mental healthcare. This denial brings with it a layer of complexity to interactions between mental health professionals and the patients they serve for, unlike many other illnesses, our patients may hide or not fully disclose essential aspects of his/her symptoms for fear of the consequences of such disclosures.

Another layer of complication is that federal and state laws, surrounding the involuntary hospitalization of individuals with mental illness, whilst designed to protect patient’s rights, often leave loved ones and mental health professionals who understand the patient and their illness with no voice, and minimal sway and influence over decisions that get made in courts. This situation emphasizes why it is so important that mental health professionals have the necessary time to carefully evaluate patients; be able to provide them with the continuity of care they need so that they can, eventually, develop a trusting relationship with their patient.  Often, it is through this trust that some aspects of denial can be challenged to ensure a better outcome for the patient. And this brings us to the next lesson

#3. Current insurance policies create barriers to patient access and encourage providers to offer reductionist mental health care services

The issues surrounding access to mental healthcare are further compounded by discriminatory, and often illegal, barriers to mental health and addiction services imposed by the health insurance industry. One of the most consistentdebates that have raged in the psychiatric community, since the advent of managed care, has surrounded such insurance company policies and procedures.

Professional organizations have argued (successfully) that such policies appear to be designed to encourage psychiatrists to provide services that are reductionistic (as they are less time consuming and hence less expensive) and discourage approaches or treatments that: take more time; preserve continuity of care and build trust between patient and the professional caring for them. Americans with mental health disorders have been routinely discriminated against when they are required to pay higher copayments, allowed fewer doctor visits or days in the hospital, or made to pay higher deductibles than those that apply to other medical illnesses.

Whilst the signing of the 2008 Paul Wellstone and Pete Domenici Mental Health Parity Act has been viewed as breakthrough legislation to combat this discrimination it is important to note that the Act does not require employers to offer mental health or substance use disorder benefits, only that IF they are offered they must be offered on par with medical/surgical benefits. From 2014, under the Affordable Care Act, new individual and small group plans in and outside of the mandated insurances will be required to offer coverage. Barriers to the effective implementation of such requirements remain to be seen.

If a picture (in this case a 20 minute segment of TV news reporting) is worth a 1,000 words (in this case a 5,000 research or sober policy document) then this 60 minutes segment is that picture. I would encourage anyone with an interest in mental healthcare to watch it.

http://www.cbsnews.com/news/mentally-ill-youth-in-crisis/

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About Shaili Jain, MD

Shaili Jain, MD serves as a psychiatrist at the Veterans Affairs Palo Alto Health Care System, is a researcher affiliated with the National Center for Posttraumatic Stress Disorder and a Clinical Assistant Professor affiliated with the Department of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine. Her medical essays and commentary have appeared in the New England Journal of Medicine, the Journal of the American Medical Association, public radio and elsewhere. The views expressed are those of the author and do not necessarily reflect the official policy or position of the Department of Veterans Affairs or the United States Government.