Serious Mental Illness Blog

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For Depression, Prescribing Exercise Before MedicationBy Olga KhazanAerobic activity has shown to be an effective treatment for many forms of depression. So why are so many people still on antidepressants?Joel Ginsberg was a sophomore at a college in Dallas when the social anxiety he had felt throughout his life morphed into an all-consuming hopelessness. He struggled to get out of bed, and even the simplest tasks felt herculean.“The world lost its color,” he told me. “Nothing interested me; I didn’t have any motivation. There was a lot of self-doubt.”He thought getting some exercise might help, but it was hard to motivate himself to go to the campus gym.“So what I did is break it down into mini-steps,” he said. “I would think about just getting to the gym, rather than going for 30 minutes. Once I was at the gym, I would say, ‘I’m just going to get on the treadmill for five minutes.’”Eventually, he found himself reading novels for long stretches at a time while pedaling away on a stationary bike. Soon, his gym visits became daily. If he skipped one day, his mood would plummet the next.“It was kind of like a boost,” he said, recalling how exercise helped him break out of his inertia. “It was a shift in mindset that kind of got me over the hump.”Depression is the most common mental illness—affecting a staggering 25 percent of Americans—but a growing body of research suggests that one of its best cures is cheap and ubiquitous. In 1999, a randomized controlled trial showed that depressed adults who took part in aerobic exercise improved as much as those treated with Zoloft. A 2006 meta-analysis of 11 studies bolstered those findings and recommended that physicians counsel their depressed patients to try it. A 2011 study took this conclusion even further: It looked at 127 depressed people who hadn’t experienced relief from SSRIs, a common type of antidepressant, and found that exercise led 30 percent of them into remission—a result that was as good as, or better than, drugs alone.Though we don’t know exactly how any antidepressant works, we think exercise combats depression by enhancing endorphins: natural chemicals that act like morphine and other painkillers. There’s also a theory that aerobic activity boosts norepinephrine, a neurotransmitter that plays a role in mood. And like antidepressants, exercise helps the brain grow new neurons.But this powerful, non-drug treatment hasn’t yet become a mainstream remedy. In a 2009 study, only 40 percent of depressed patients reported being counseled to try exercise at their last physician visit.Instead, Americans are awash in pills. The use of antidepressants has increased 400 percent between 1988 and 2008. They’re now one of the three most-prescribed categories of drugs, coming in right after painkillers and cholesterol medications.After 15 years of research on the depression-relieving effects of exercise, why are there still so many people on pills? The answer speaks volumes about our mental-health infrastructure and physician reimbursement system, as well as about how difficult it remains to decipher the nature of depression and what patients want from their doctors.Jogging as medicine“I am only a doctor, not a dictator,” insists Madhukar H. Trivedi, a professor of psychiatry at the University of Texas Southwestern Medical Center in Dallas. “I don’t tell patients what to do.”Trivedi is one of the forefathers of the movement to combat melancholy with physical exertion. He’s authored multiple studies on the exercise-depression connection, and workouts are now one of the many weapons in his psychiatric arsenal. But whether any given treatment is right for a particular person is entirely up to that patient, he said.“I talk about the pros and cons about all the treatment options available—exercise, therapy, and pills,” he said. “If a patient says, ‘I’m not really keen on medication and therapy, I want to use exercise,’ then if it’s appropriate, they can try it. But I give them caveats about how they should be monitoring it. I don’t say, ‘Go exercise and call me if it doesn’t work.’”Here’s how he goes about this unconventional type of prescription:“People will take the disease and treatment lightly if they know Paxil is coming.First, Trivedi must gently raise the idea of exercise as a treatment option—patients often don’t know to ask. (There are no televised pharmaceutical ads for running, he notes.) He then tells patients about the studies, the amount of exercise that would be required, and the heart rate they’d need to reach. Based on a recent study by Trivedi and others, he recommends three to five sessions per week. Each one should last 45 to 60 minutes, and patients should reach 50 to 85 percent of their maximum heart rates.He and the patient then blueprint a weekly workout schedule together. Not doing enough sessions, he warns, would be like a diabetic person “using insulin only occasionally.” He encourages patients to use FitBits or other monitoring gadgets to track their progress—and to guilt them off the couch.Trivedi says this approach rests on three key elements. “One, you have to be very clear with patients that just because exercise has been shown to be efficacious, it doesn’t work for everyone. Two, the dose of the treatment is very important; you can’t just go for a stroll in the park. And three, there has to be a constant vigilance about the monitoring of symptoms. If the treatment is not working, you need to do something.”That “something” could be adding antidepressants back into the mix—but only if the workouts have truly failed.“People will take the disease and treatment lightly,” he said, “if they know Paxil is coming.”The insurance challengeWhen it comes to non-drug remedies for depression, exercise is actually just one of several promising options. Over the past few months, research has shown that other common lifestyle adjustments, like meditating or getting more sleep, might also relieve symptoms. Therapy has been shown to work just as well as SSRIs and other medications. In fact, a major JAMA study a few years ago cast doubt on the effectiveness of antidepressants in general, finding that the drugs don’t function any better than placebo pills for people with mild or moderate depression.The half-dozen psychiatrists I interviewed said they’ve started to incorporate non-drug treatments into their plans for depressed patients. But they said they’re only able to do that because they don’t accept insurance. (One of the doctors works for a college system and only sees students.)That’s because insurers still largely reimburse psychiatrists, like all other doctors, for each appointment—whatever that appointment may entail—rather than for curing a given patient. It takes less time to write a prescription for Zoloft than it does to tease out a patient’s options for sleeping better and breaking a sweat. Fewer moments spent mapping out jogging routes or sleep schedules means being able to squeeze in more patients for medications each day.“[Psychiatrists] can probably do four medication-management visits in an hour,” said Chuck Ingoglia, a senior vice president at the National Council for Behavioral Health. “If they were doing therapy, they might see one person for 50 minutes.”An insurance company might pay an internist and a psychiatrist both $100 for an appointment, but a primary care check-up might take 15 minutes while a thorough conversation with a psychiatrist takes 40 or more.Because of these constraints, psychiatrists are among the least likely specialists to accept insurance—only about 55 percent of them do. Henry David Abraham, a psychiatrist in Lexington, Massachusetts, said he stopped accepting insurance once he realized his patient visits were becoming too rushed.“I was seeing patients for 15 minutes each to give them drugs,” he said. “What would my mentors say about that quality of care? They would say, ‘Horrible!’”He now sees patients on a sliding scale, with the wealthy essentially footing the bill for the poor. His sessions include a range of treatment options, including therapy.“One patient lost a husband to cancer, and medication may take the edge off of some of those emotions, but the process she requires is to work through the elements of grief,” he said. “There’s not a pill for that.”Meanwhile, psychiatrists who take insurance are increasingly less likely to offer talk therapy—or longer appointments of any kind—because licensed social workers and psychologists can offer the same types of sessions at lower rates.“If you’re an insurance company, and you can get a social worker to do therapy for $50, that becomes the floor,” Ingoglia said.When Brittany, a woman who lives in northern Virginia, first began experiencing panic attacks a few months ago, she turned to a series of providers in her insurance network. None of the doctors she saw wanted to discuss anything but drug options, she said.“They were all just throwing medication at me,” she said. (She asked that I not use her last name). “I said I don’t want medicine, but they didn’t want to talk about a long-term therapeutic plan.”She went through eight different providers before finally finding a psychiatrist who helped her establish a plan to do yoga several times a week to manage her panic disorder. Those psychiatrist appointments are 90 minutes long.Exacerbating all of this is the fact that there’s a shortage of psychiatrists, and the needs of people with mental health issues are increasingly being addressed by primary-care doctors, who now provide over a third of all mental health-care in the U.S. Sixty-two percent of all antidepressant prescriptions are now written by general practitioners, ob-gyns, and pediatricians.But general practitioners aren’t always as equipped as psychiatrists to diagnose and treat depression. In 2007, 73 percent of patients who were prescribed an antidepressant were not given psychiatric diagnoses. In other cases, primary care doctors may balk at the idea of prescribing any interventions because they don’t feel they know enough about depression.Writing in The New Yorker last year, primary care internist Suzanne Koven said she’s often at a loss when faced with “the lawyer who’s having trouble meeting deadlines and wants medication for attention-deficit disorder. Or the businesswoman whose therapist told her to see me about starting an antidepressant.”She feared she lacked “the time or training to diagnose and manage many psychiatric disorders,” she wrote.Managing life’s roadblocksLet’s say you’re a psychiatrist who has managed to start incorporating sleep, exercise, and other non-drug remedies into a patient’s depression treatment. Congratulations! You now face a patient who is, very possibly, lethargic, unsatisfied, and lying about how many times he or she went running last week.That is, if you can convince the patient to try anything other than drugs in the first place.Julia Samton, a psychiatrist who practices in New York City, said she prescribes medications as a “third-tier resort” after lifestyle changes and therapy have been ruled out. She spends 45 minutes on each appointment, attempting to punch through her patients’ stony Manhattanite exteriors and expose the foundations of their agony.“There are some people who say all they want is medication,” she said. “But they are the ones who are suffering tremendously and have a difficult time accessing their mental life. They want things fixed, and fixed right now.”She said some of her patients are lured by the drug ads they see on TV— charming little spots that make it look like a gloomy day is nothing an SSRI can’t handle.“It’s evocative to see a commercial where your world could change from black and white to color,” she said.Beth Salcedo is a psychiatrist near Washington, D.C. People in this perpetual type-A convention of a town tend to have too much work, too-lofty aspirations, too high a rent, and too little time left before their evening networking event starts.“I think it’s difficult to convince people to spend half an hour a day on exercise when they have kids, a job, and it can take months to see the benefit,” she said.Some patients claim they can’t make time for the gym, or are adamant that they can’t afford to sleep more than six hours each night. And lawyers who work 16-hour days are not going to sit through long counseling appointments no matter how many peer-reviewed studies you wave at them.“What do you do? Do you let them walk around depressed?” Salcedo said. “Or do you offer them a treatment that they’ll accept? Everyone has to do the thing that works for them.”And despite its merits, exercise is not nearly as portable or painless as a tablet.Salcedo had one patient whose mood entirely depended on her workouts. The hitch was that her exercise of choice was swimming—and the only pool she had access to was outdoors. “In the spring, fall, and winter, it wasn’t so easy,” Salcedo said.Depressed patients are also more likely than most to feel unmotivated, so even the best-laid exercise treatment plan can be thwarted by a few days of staying in bed for an extra hour.“Depressed patients have apathy or a lack of energy. Or they have anxiety disorders so they’re not going to go to the gym. Or they’re afraid to be seen jogging across Monument Avenue,” said Joan Plotkin Han, a staff psychiatrist at Virginia Commonwealth University in Richmond. Still, she pushes it with her more intrepid patients. “I don’t want to be that intimidating or threatening, but I’m a nag. And I will nag them.”Of course, sometimes exercise works as a multiplier, augmenting the effectiveness of an existing treatment, including drugs or therapy, or simply by helping the patient regain agency in their lives. Many patients recover from depression faster when the disease is attacked through multiple approaches simultaneously.Ginsberg said exercise didn’t cure him, but it did give him the energy to sort through the origins of his inner turmoil. And Brittany did eventually go on SSRIs to halt her nightly panic attacks—but now that yoga has her anxiety under control, she’s tapering off the drugs once again.Exercise, like any other treatment, won’t work for every depressed patient. But the psychiatrists who incorporate it into their practices are finding that the only way it can work is if it’s treated like real medicine.“The issue is that exercise seems as straightforward and simple as apple pie and your mom,” Trivedi said. “Everybody knows what it is, so it’s misunderstood. It’s important to explain to patients the seriousness of the disease they have and the nuances of the intervention they need.”


For more mental health news, Click Here to access the Serious Mental Illness Blog

For Depression, Prescribing Exercise Before Medication
By Olga Khazan

Aerobic activity has shown to be an effective treatment for many forms of depression. So why are so many people still on antidepressants?

Joel Ginsberg was a sophomore at a college in Dallas when the social anxiety he had felt throughout his life morphed into an all-consuming hopelessness. He struggled to get out of bed, and even the simplest tasks felt herculean.
“The world lost its color,” he told me. “Nothing interested me; I didn’t have any motivation. There was a lot of self-doubt.”
He thought getting some exercise might help, but it was hard to motivate himself to go to the campus gym.
“So what I did is break it down into mini-steps,” he said. “I would think about just getting to the gym, rather than going for 30 minutes. Once I was at the gym, I would say, ‘I’m just going to get on the treadmill for five minutes.’”
Eventually, he found himself reading novels for long stretches at a time while pedaling away on a stationary bike. Soon, his gym visits became daily. If he skipped one day, his mood would plummet the next.
“It was kind of like a boost,” he said, recalling how exercise helped him break out of his inertia. “It was a shift in mindset that kind of got me over the hump.”
Depression is the most common mental illness—affecting a staggering 25 percent of Americans—but a growing body of research suggests that one of its best cures is cheap and ubiquitous. In 1999, a randomized controlled trial showed that depressed adults who took part in aerobic exercise improved as much as those treated with Zoloft. A 2006 meta-analysis of 11 studies bolstered those findings and recommended that physicians counsel their depressed patients to try it. A 2011 study took this conclusion even further: It looked at 127 depressed people who hadn’t experienced relief from SSRIs, a common type of antidepressant, and found that exercise led 30 percent of them into remission—a result that was as good as, or better than, drugs alone.
Though we don’t know exactly how any antidepressant works, we think exercise combats depression by enhancing endorphins: natural chemicals that act like morphine and other painkillers. There’s also a theory that aerobic activity boosts norepinephrine, a neurotransmitter that plays a role in mood. And like antidepressants, exercise helps the brain grow new neurons.
But this powerful, non-drug treatment hasn’t yet become a mainstream remedy. In a 2009 study, only 40 percent of depressed patients reported being counseled to try exercise at their last physician visit.
Instead, Americans are awash in pills. The use of antidepressants has increased 400 percent between 1988 and 2008. They’re now one of the three most-prescribed categories of drugs, coming in right after painkillers and cholesterol medications.
After 15 years of research on the depression-relieving effects of exercise, why are there still so many people on pills? The answer speaks volumes about our mental-health infrastructure and physician reimbursement system, as well as about how difficult it remains to decipher the nature of depression and what patients want from their doctors.

Jogging as medicine
“I am only a doctor, not a dictator,” insists Madhukar H. Trivedi, a professor of psychiatry at the University of Texas Southwestern Medical Center in Dallas. “I don’t tell patients what to do.”
Trivedi is one of the forefathers of the movement to combat melancholy with physical exertion. He’s authored multiple studies on the exercise-depression connection, and workouts are now one of the many weapons in his psychiatric arsenal. But whether any given treatment is right for a particular person is entirely up to that patient, he said.
“I talk about the pros and cons about all the treatment options available—exercise, therapy, and pills,” he said. “If a patient says, ‘I’m not really keen on medication and therapy, I want to use exercise,’ then if it’s appropriate, they can try it. But I give them caveats about how they should be monitoring it. I don’t say, ‘Go exercise and call me if it doesn’t work.’”
Here’s how he goes about this unconventional type of prescription:
“People will take the disease and treatment lightly if they know Paxil is coming.
First, Trivedi must gently raise the idea of exercise as a treatment option—patients often don’t know to ask. (There are no televised pharmaceutical ads for running, he notes.) He then tells patients about the studies, the amount of exercise that would be required, and the heart rate they’d need to reach. Based on a recent study by Trivedi and others, he recommends three to five sessions per week. Each one should last 45 to 60 minutes, and patients should reach 50 to 85 percent of their maximum heart rates.
He and the patient then blueprint a weekly workout schedule together. Not doing enough sessions, he warns, would be like a diabetic person “using insulin only occasionally.” He encourages patients to use FitBits or other monitoring gadgets to track their progress—and to guilt them off the couch.
Trivedi says this approach rests on three key elements. “One, you have to be very clear with patients that just because exercise has been shown to be efficacious, it doesn’t work for everyone. Two, the dose of the treatment is very important; you can’t just go for a stroll in the park. And three, there has to be a constant vigilance about the monitoring of symptoms. If the treatment is not working, you need to do something.”
That “something” could be adding antidepressants back into the mix—but only if the workouts have truly failed.
“People will take the disease and treatment lightly,” he said, “if they know Paxil is coming.”

The insurance challenge
When it comes to non-drug remedies for depression, exercise is actually just one of several promising options. Over the past few months, research has shown that other common lifestyle adjustments, like meditating or getting more sleep, might also relieve symptoms. Therapy has been shown to work just as well as SSRIs and other medications. In fact, a major JAMA study a few years ago cast doubt on the effectiveness of antidepressants in general, finding that the drugs don’t function any better than placebo pills for people with mild or moderate depression.
The half-dozen psychiatrists I interviewed said they’ve started to incorporate non-drug treatments into their plans for depressed patients. But they said they’re only able to do that because they don’t accept insurance. (One of the doctors works for a college system and only sees students.)
That’s because insurers still largely reimburse psychiatrists, like all other doctors, for each appointment—whatever that appointment may entail—rather than for curing a given patient. It takes less time to write a prescription for Zoloft than it does to tease out a patient’s options for sleeping better and breaking a sweat. Fewer moments spent mapping out jogging routes or sleep schedules means being able to squeeze in more patients for medications each day.
“[Psychiatrists] can probably do four medication-management visits in an hour,” said Chuck Ingoglia, a senior vice president at the National Council for Behavioral Health. “If they were doing therapy, they might see one person for 50 minutes.”
An insurance company might pay an internist and a psychiatrist both $100 for an appointment, but a primary care check-up might take 15 minutes while a thorough conversation with a psychiatrist takes 40 or more.
Because of these constraints, psychiatrists are among the least likely specialists to accept insurance—only about 55 percent of them do. Henry David Abraham, a psychiatrist in Lexington, Massachusetts, said he stopped accepting insurance once he realized his patient visits were becoming too rushed.
“I was seeing patients for 15 minutes each to give them drugs,” he said. “What would my mentors say about that quality of care? They would say, ‘Horrible!’”
He now sees patients on a sliding scale, with the wealthy essentially footing the bill for the poor. His sessions include a range of treatment options, including therapy.
“One patient lost a husband to cancer, and medication may take the edge off of some of those emotions, but the process she requires is to work through the elements of grief,” he said. “There’s not a pill for that.”
Meanwhile, psychiatrists who take insurance are increasingly less likely to offer talk therapy—or longer appointments of any kind—because licensed social workers and psychologists can offer the same types of sessions at lower rates.
“If you’re an insurance company, and you can get a social worker to do therapy for $50, that becomes the floor,” Ingoglia said.When Brittany, a woman who lives in northern Virginia, first began experiencing panic attacks a few months ago, she turned to a series of providers in her insurance network. None of the doctors she saw wanted to discuss anything but drug options, she said.
“They were all just throwing medication at me,” she said. (She asked that I not use her last name). “I said I don’t want medicine, but they didn’t want to talk about a long-term therapeutic plan.”
She went through eight different providers before finally finding a psychiatrist who helped her establish a plan to do yoga several times a week to manage her panic disorder. Those psychiatrist appointments are 90 minutes long.
Exacerbating all of this is the fact that there’s a shortage of psychiatrists, and the needs of people with mental health issues are increasingly being addressed by primary-care doctors, who now provide over a third of all mental health-care in the U.S. Sixty-two percent of all antidepressant prescriptions are now written by general practitioners, ob-gyns, and pediatricians.
But general practitioners aren’t always as equipped as psychiatrists to diagnose and treat depression. In 2007, 73 percent of patients who were prescribed an antidepressant were not given psychiatric diagnoses. In other cases, primary care doctors may balk at the idea of prescribing any interventions because they don’t feel they know enough about depression.
Writing in The New Yorker last year, primary care internist Suzanne Koven said she’s often at a loss when faced with “the lawyer who’s having trouble meeting deadlines and wants medication for attention-deficit disorder. Or the businesswoman whose therapist told her to see me about starting an antidepressant.”
She feared she lacked “the time or training to diagnose and manage many psychiatric disorders,” she wrote.

Managing life’s roadblocks
Let’s say you’re a psychiatrist who has managed to start incorporating sleep, exercise, and other non-drug remedies into a patient’s depression treatment. Congratulations! You now face a patient who is, very possibly, lethargic, unsatisfied, and lying about how many times he or she went running last week.
That is, if you can convince the patient to try anything other than drugs in the first place.
Julia Samton, a psychiatrist who practices in New York City, said she prescribes medications as a “third-tier resort” after lifestyle changes and therapy have been ruled out. She spends 45 minutes on each appointment, attempting to punch through her patients’ stony Manhattanite exteriors and expose the foundations of their agony.
“There are some people who say all they want is medication,” she said. “But they are the ones who are suffering tremendously and have a difficult time accessing their mental life. They want things fixed, and fixed right now.”
She said some of her patients are lured by the drug ads they see on TV— charming little spots that make it look like a gloomy day is nothing an SSRI can’t handle.
“It’s evocative to see a commercial where your world could change from black and white to color,” she said.
Beth Salcedo is a psychiatrist near Washington, D.C. People in this perpetual type-A convention of a town tend to have too much work, too-lofty aspirations, too high a rent, and too little time left before their evening networking event starts.
“I think it’s difficult to convince people to spend half an hour a day on exercise when they have kids, a job, and it can take months to see the benefit,” she said.
Some patients claim they can’t make time for the gym, or are adamant that they can’t afford to sleep more than six hours each night. And lawyers who work 16-hour days are not going to sit through long counseling appointments no matter how many peer-reviewed studies you wave at them.
“What do you do? Do you let them walk around depressed?” Salcedo said. “Or do you offer them a treatment that they’ll accept? Everyone has to do the thing that works for them.”
And despite its merits, exercise is not nearly as portable or painless as a tablet.
Salcedo had one patient whose mood entirely depended on her workouts. The hitch was that her exercise of choice was swimming—and the only pool she had access to was outdoors. “In the spring, fall, and winter, it wasn’t so easy,” Salcedo said.
Depressed patients are also more likely than most to feel unmotivated, so even the best-laid exercise treatment plan can be thwarted by a few days of staying in bed for an extra hour.
“Depressed patients have apathy or a lack of energy. Or they have anxiety disorders so they’re not going to go to the gym. Or they’re afraid to be seen jogging across Monument Avenue,” said Joan Plotkin Han, a staff psychiatrist at Virginia Commonwealth University in Richmond. Still, she pushes it with her more intrepid patients. “I don’t want to be that intimidating or threatening, but I’m a nag. And I will nag them.”
Of course, sometimes exercise works as a multiplier, augmenting the effectiveness of an existing treatment, including drugs or therapy, or simply by helping the patient regain agency in their lives. Many patients recover from depression faster when the disease is attacked through multiple approaches simultaneously.
Ginsberg said exercise didn’t cure him, but it did give him the energy to sort through the origins of his inner turmoil. And Brittany did eventually go on SSRIs to halt her nightly panic attacks—but now that yoga has her anxiety under control, she’s tapering off the drugs once again.
Exercise, like any other treatment, won’t work for every depressed patient. But the psychiatrists who incorporate it into their practices are finding that the only way it can work is if it’s treated like real medicine.
“The issue is that exercise seems as straightforward and simple as apple pie and your mom,” Trivedi said. “Everybody knows what it is, so it’s misunderstood. It’s important to explain to patients the seriousness of the disease they have and the nuances of the intervention they need.”





For more mental health news, Click Here to access the Serious Mental Illness Blog

Filed under depression depressed major depressive disorder major depression mental illness mental illness mental health health healthy exercise jog jogging run running news science sad sadness seasonal affective disorder disorder diagnosis psychology psychiatry med meds drug drugs treat treatment

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At last, a promising alternative to antipsychotics for schizophreniaBy Daniel and Jason Freeman, the authors of Paranoia: The 21st Century FearFor many, the side-effects of antipsychotics are worse than the symptoms they’re meant to treat. No wonder some people with schizophrenia refuse to take them.Imagine that, after feeling unwell for a while, you visit your GP. “Ah,” says the doctor decisively, "what you need is medication X. It’s often pretty effective, though there can be side-effects. You may gain weight. Or feel drowsy. And you may develop tremors reminiscent of Parkinson’s disease." Warily, you glance at the prescription on the doctor’s desk, but she hasn’t finished. "Some patients find that sex becomes a problem. Diabetes and heart problems are a risk. And in the long term the drug may actually shrink your brain … "
This scenario may sound far-fetched, but it is precisely what faces people diagnosed with schizophrenia. Since the 1950s, the illness has generally been treated using antipsychotic drugs – which, as with so many medications, were discovered by chance. A French surgeon investigating treatments for surgical shock found that one of the drugs he tried – the antihistamine chlorpromazine – produced powerful psychological effects. This prompted the psychiatrist Pierre Deniker to give the drug to some of his most troubled patients. Their symptoms improved dramatically, and a major breakthrough in the treatment of psychosis seemed to have arrived.
Many other antipsychotic drugs have followed in chlorpromazine’s wake and today these medications comprise 10% of total NHS psychiatric prescriptions. They are costly items: the NHS spends more on these medications than it does for any other psychiatric drug, including antidepressants. Globally, around $14.5bn is estimated to be spent on antipsychotics each year.
Since the 1950s the strategy of all too many NHS mental health teams has been a simple one. Assuming that psychosis is primarily a biological brain problem, clinicians prescribe an antipsychotic medication and everyone does their level best to get the patient to take it, often for long periods. There can be little doubt that these drugs make a positive difference, reducing delusions and hallucinations and making relapse less likely – provided, that is, the patient takes their medication.
Unfortunately, dropout rates are high. This is partly because individuals sometimes don’t accept that they are ill. But a major reason is the side-effects. These vary from drug to drug, but they’re common and for many people are worse than the symptoms they are designed to treat.In addition, antipsychotics don’t work for everyone. It is estimated that six months after first being prescribed them, as many as 50% of patients are either taking the drugs haphazardly or not at all.
The conventional treatment for this most severe of psychiatric illnesses, then, is expensive, frequently unpleasant, and not always effective even for those who carry on taking the drugs. But it is what we have relied upon – which helps to explain why the results of a clinical trial, recently published in The Lancet, have generated so much interest and debate.
A team led by Professor Anthony Morrison at the University of Manchester randomly assigned a group of patients, all of whom had opted not to take antipsychotics, to treatment as usual (involving a range of non-pharmaceutical care) or to treatment as usual plus a course of cognitive therapy (CT). Drop-out rates for the cognitive therapy were low, while its efficacy in reducing the symptoms of psychosis was comparable to what medication can achieve.
So what exactly is CT for schizophrenia? At its core is the idea that the patient should be encouraged to talk about their experiences – just as they would for every other psychological condition. Psychosis isn’t viewed as a biological illness that one either has or does not have. Instead, just like every other mental disorder, psychotic experiences are seen as the severest instances of thoughts and feelings – notably delusions and hallucinations – that many of us experience from time to time.
Working together, the patient and therapist develop a model of what’s causing the experiences, and why they’re recurring. These factors will vary from person to person, so what is produced is a bespoke account of the individual’s experience, which is then used to guide treatment. For example, a person so worried by paranoid fears that they won’t set foot outside might be helped to trace the roots of their anxiety to past experiences; to gradually test out their fearful thoughts; and to learn to manage their anxiety while getting on with the activities they enjoy. An individual troubled by hearing voices will be helped to understand what’s triggering these voices, and to develop a more confident, empowering relationship with them.
These are early days. Nevertheless, most of the meta-analyses of CT’s efficacy for psychosis, when added to standard treatment, have indicated definite (albeit modest) benefits for patients, with the latest showing that CT is better than other psychological treatments for reducing delusions and hallucinations. The latest guidelines from the UK’s National Institute for Health and Care Excellence (Nice) recommend it for those at risk of psychosis and, when combined with medication, for people with an ongoing problem.
But not everyone is convinced, and although the research published in The Lancet is encouraging, it was small scale. CT for psychosis is still evolving, and we think that evolution should prioritise three key areas.First, we must focus on understanding and treating individual psychotic experiences. As we’ve reported in a previous post, there is increasing reason to doubt the usefulness of the diagnosis “schizophrenia”. The term has been used as a catch-all for an assortment of unusual thoughts and feelings that often have no intrinsic connections, and aren’t qualitatively different from those experienced by the general population. Each psychotic experience may therefore require a tailored treatment.Second, we must build on the recent transformation in understanding the causes of psychotic experiences, taking one factor at a time (insomnia, say, or worry), developing an intervention to change it, and then observing the effects of that intervention on an individual’s difficulties.And finally, we must listen to what patients want from their treatment – for example, by focusing on improving levels of wellbeing, which tend to be very low among people with schizophrenia.
What about costs compared with drug treatment? A course of CBT is typically just over £1,000, but if it leads to a reduction in the amount of time patients spend in hospital and their use of other services, or a return to work, then it easily pays for itself.
The Nice guidance on psychosis and schizophrenia, updated this year, is unequivocal:"The systematic review of economic evidence showed that provision of CBT to people with schizophrenia in the UK improved clinical outcomes at no additional cost. This finding was supported by economic modelling undertaken for this guideline, which suggested that provision of CBT might result in net cost savings to the NHS, associated with a reduction in future hospitalisation rates."
If the real promise of cognitive therapy can be fulfilled, we may at last have a genuinely effective, relatively cheap, and side-effect-free alternative to antipsychotics for those patients who don’t wish to take them.


For more mental health news, Click Here to access the Serious Mental Illness Blog

At last, a promising alternative to antipsychotics for schizophrenia
By Daniel and Jason Freeman, the authors of Paranoia: The 21st Century Fear

For many, the side-effects of antipsychotics are worse than the symptoms they’re meant to treat. No wonder some people with schizophrenia refuse to take them.

Imagine that, after feeling unwell for a while, you visit your GP. “Ah,” says the doctor decisively, "what you need is medication X. It’s often pretty effective, though there can be side-effects. You may gain weight. Or feel drowsy. And you may develop tremors reminiscent of Parkinson’s disease." Warily, you glance at the prescription on the doctor’s desk, but she hasn’t finished. "Some patients find that sex becomes a problem. Diabetes and heart problems are a risk. And in the long term the drug may actually shrink your brain … "

This scenario may sound far-fetched, but it is precisely what faces people diagnosed with schizophrenia. Since the 1950s, the illness has generally been treated using antipsychotic drugs – which, as with so many medications, were discovered by chance. A French surgeon investigating treatments for surgical shock found that one of the drugs he tried – the antihistamine chlorpromazine – produced powerful psychological effects. This prompted the psychiatrist Pierre Deniker to give the drug to some of his most troubled patients. Their symptoms improved dramatically, and a major breakthrough in the treatment of psychosis seemed to have arrived.

Many other antipsychotic drugs have followed in chlorpromazine’s wake and today these medications comprise 10% of total NHS psychiatric prescriptions. They are costly items: the NHS spends more on these medications than it does for any other psychiatric drug, including antidepressants. Globally, around $14.5bn is estimated to be spent on antipsychotics each year.

Since the 1950s the strategy of all too many NHS mental health teams has been a simple one. Assuming that psychosis is primarily a biological brain problem, clinicians prescribe an antipsychotic medication and everyone does their level best to get the patient to take it, often for long periods. There can be little doubt that these drugs make a positive difference, reducing delusions and hallucinations and making relapse less likely – provided, that is, the patient takes their medication.

Unfortunately, dropout rates are high. This is partly because individuals sometimes don’t accept that they are ill. But a major reason is the side-effects. These vary from drug to drug, but they’re common and for many people are worse than the symptoms they are designed to treat.
In addition, antipsychotics don’t work for everyone. It is estimated that six months after first being prescribed them, as many as 50% of patients are either taking the drugs haphazardly or not at all.

The conventional treatment for this most severe of psychiatric illnesses, then, is expensive, frequently unpleasant, and not always effective even for those who carry on taking the drugs. But it is what we have relied upon – which helps to explain why the results of a clinical trial, recently published in The Lancet, have generated so much interest and debate.

A team led by Professor Anthony Morrison at the University of Manchester randomly assigned a group of patients, all of whom had opted not to take antipsychotics, to treatment as usual (involving a range of non-pharmaceutical care) or to treatment as usual plus a course of cognitive therapy (CT). Drop-out rates for the cognitive therapy were low, while its efficacy in reducing the symptoms of psychosis was comparable to what medication can achieve.

So what exactly is CT for schizophrenia? At its core is the idea that the patient should be encouraged to talk about their experiences – just as they would for every other psychological condition. Psychosis isn’t viewed as a biological illness that one either has or does not have. Instead, just like every other mental disorder, psychotic experiences are seen as the severest instances of thoughts and feelings – notably delusions and hallucinations – that many of us experience from time to time.

Working together, the patient and therapist develop a model of what’s causing the experiences, and why they’re recurring. These factors will vary from person to person, so what is produced is a bespoke account of the individual’s experience, which is then used to guide treatment. For example, a person so worried by paranoid fears that they won’t set foot outside might be helped to trace the roots of their anxiety to past experiences; to gradually test out their fearful thoughts; and to learn to manage their anxiety while getting on with the activities they enjoy. An individual troubled by hearing voices will be helped to understand what’s triggering these voices, and to develop a more confident, empowering relationship with them.

These are early days. Nevertheless, most of the meta-analyses of CT’s efficacy for psychosis, when added to standard treatment, have indicated definite (albeit modest) benefits for patients, with the latest showing that CT is better than other psychological treatments for reducing delusions and hallucinations. The latest guidelines from the UK’s National Institute for Health and Care Excellence (Nice) recommend it for those at risk of psychosis and, when combined with medication, for people with an ongoing problem.

But not everyone is convinced, and although the research published in The Lancet is encouraging, it was small scale. CT for psychosis is still evolving, and we think that evolution should prioritise three key areas.
First, we must focus on understanding and treating individual psychotic experiences. As we’ve reported in a previous post, there is increasing reason to doubt the usefulness of the diagnosis “schizophrenia”. The term has been used as a catch-all for an assortment of unusual thoughts and feelings that often have no intrinsic connections, and aren’t qualitatively different from those experienced by the general population. Each psychotic experience may therefore require a tailored treatment.
Second, we must build on the recent transformation in understanding the causes of psychotic experiences, taking one factor at a time (insomnia, say, or worry), developing an intervention to change it, and then observing the effects of that intervention on an individual’s difficulties.
And finally, we must listen to what patients want from their treatment – for example, by focusing on improving levels of wellbeing, which tend to be very low among people with schizophrenia.

What about costs compared with drug treatment? A course of CBT is typically just over £1,000, but if it leads to a reduction in the amount of time patients spend in hospital and their use of other services, or a return to work, then it easily pays for itself.

The Nice guidance on psychosis and schizophrenia, updated this year, is unequivocal:
"The systematic review of economic evidence showed that provision of CBT to people with schizophrenia in the UK improved clinical outcomes at no additional cost. This finding was supported by economic modelling undertaken for this guideline, which suggested that provision of CBT might result in net cost savings to the NHS, associated with a reduction in future hospitalisation rates."

If the real promise of cognitive therapy can be fulfilled, we may at last have a genuinely effective, relatively cheap, and side-effect-free alternative to antipsychotics for those patients who don’t wish to take them.



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Parkinsonism a Major Mortality Risk Factor in SchizophreniaBy Daniel M. Keller, PhD
There may be differences between different antipsychotic medications and their possible contribution. ”Specific treatments with clozapine or olanzapine could be related to more comorbidity and mortality,”
Compared with control individuals, patients with schizophrenia have significantly more physical comorbidity, including the novel finding that Parkinsonism is a major risk factor for inhospital mortality in this population, new research shows.A case-control study of general hospital admissions showed that the most common comorbidity among patients with schizophrenia was type 2 diabetes mellitus (T2DM). Twenty more physical diseases were also more prevalent, many of them associated with diabetic complications. Interestingly, Parkinsonism was a major risk factor for inhospital mortality in schizophrenia.The research was a collaboration between investigators in Germany and the United Kingdom. Speaking here at the 22nd European Congress of Psychiatry (EPA), Dieter Schoepf, MD, of the Department of Psychiatry at the University Hospital of Bonn, Germany, said that the study population comprised all admissions to 3 general hospitals in Manchester, United Kingdom (N = 369,488) between January 1, 2000, and June 30, 2012.It included 1418 patients who met diagnostic criteria for schizophrenia at initial admission according to the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Control patients were 14,180 age- and gender-matched hospital patients at initial admission.Five Major FindingsThe study produced 5 major findings related to comorbidities affecting hospitalized patients with schizophrenia. First, they had a nearly 2-fold increased hospital-based mortality rate (18.0%) compared with control patients (9.7%) during the observation period. And the schizophrenic patients died at a younger mean age (64.4 ± 1.0 vs 66.2 ± 0.4 years, respectively).Second, "schizophrenics as compared to controls had a more severe course of illness and a shorter survival after their initial hospitalization," Dr. Schoepf reported. For the entire group of schizophrenic patients, survival averaged 1895 ± 35.1 days vs 2161 ± 11.6 days for all control patients. For deceased patients in each group, survival averaged 951.4 ± 62.9 vs 1030 ± 28.0 days, respectively.Third, patients with schizophrenia had substantially more physical diseases. Among 21 diseases with increased prevalence among the study population compared with control patients, odds ratios (ORs) ranged from 5.3 for fracture of the femur neck to 1.3 for asthma."T2DM was the most common disproportionally increased physical comorbidity," Dr. Schoepf said. Its prevalence among schizophrenic patients was double that of the control patients (17.4% vs 8.5%; OR = 2.3; 95% confidence interval [CI], 2.0 - 2.6).The fourth major finding was that among schizophrenic patients who died, T2DM was the most common physical comorbidity, contributing to about one third (31.4%) of those deaths, compared with 16.9% of deceased control patients.Parkinsonism affected 1.6% of the study group vs 0.4% of control patients (OR = 4.7; 95% CI, 2.8 - 7.7). It was present in 5.5% of deceased study group patients but in only 1.5% of control patients who died.Excluding Parkinsonism, a major risk factor for death among the schizophrenic group, the researchers developed a model that identified 9 other mortality risk factors that “had an equal impact on inhospital death in schizophrenics as compared to controls,” Dr. Schoepf reported.Although the prevalence of these risk factors differed between the 2 groups, their impact on inhospital mortality did not differ when these comorbidities were present in patients in either group. The comorbidities were as follows: T2DM, chronic obstructive pulmonary disease, pneumonia, bronchitis, iron-deficiency anemia, type 1 diabetes, ischemic stroke, nonspecific renal failure, and alcoholic liver disease.Novel ResultSpeaking with Medscape Medical News, session chair Guillermo Lahera Forteza, MD, PhD, professor of psychiatry at the University of Alcalá, Spain, who was not involved in the study, praised it as "impressive…especially the relationship between Parkinsonism and mortality in patients with schizophrenia. I was really shocked about this figure." He added that the relationship between T2DM and mortality has been well known, but the finding about Parkinsonism is something new.Dr. Lahera Forteza said he has questions about the causes of death in cases in which comorbidities exist. There may be differences between different antipsychotic medications and their possible contribution."Specific treatments with clozapine or olanzapine could be related to more comorbidity and mortality," he said, but Dr. Schoepf noted that there are not enough data from this study on this point.Dr. Lahera Forteza advises physicians “to restudy every treatment when the patient has this kind of comorbidity ― to re-evaluate and reassess the pharmacological treatment in every patient.” In addition, physicians should recognize the impact of lifestyle on these patients, who often smoke, drink alcohol, and do not get enough exercise. Negative symptoms, cognitive impairment, and social stigma can all affect lifestyle and contribute to or exacerbate physical comorbidities.Dr. Schoepf and Dr. Lahera Forteza report no relevant financial relationships. The study had no commercial funding.


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Parkinsonism a Major Mortality Risk Factor in Schizophrenia
By Daniel M. Keller, PhD

There may be differences between different antipsychotic medications and their possible contribution. ”Specific treatments with clozapine or olanzapine could be related to more comorbidity and mortality,”

Compared with control individuals, patients with schizophrenia have significantly more physical comorbidity, including the novel finding that Parkinsonism is a major risk factor for inhospital mortality in this population, new research shows.
A case-control study of general hospital admissions showed that the most common comorbidity among patients with schizophrenia was type 2 diabetes mellitus (T2DM). Twenty more physical diseases were also more prevalent, many of them associated with diabetic complications. Interestingly, Parkinsonism was a major risk factor for inhospital mortality in schizophrenia.
The research was a collaboration between investigators in Germany and the United Kingdom. Speaking here at the 22nd European Congress of Psychiatry (EPA), Dieter Schoepf, MD, of the Department of Psychiatry at the University Hospital of Bonn, Germany, said that the study population comprised all admissions to 3 general hospitals in Manchester, United Kingdom (N = 369,488) between January 1, 2000, and June 30, 2012.
It included 1418 patients who met diagnostic criteria for schizophrenia at initial admission according to the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Control patients were 14,180 age- and gender-matched hospital patients at initial admission.

Five Major Findings
The study produced 5 major findings related to comorbidities affecting hospitalized patients with schizophrenia. First, they had a nearly 2-fold increased hospital-based mortality rate (18.0%) compared with control patients (9.7%) during the observation period. And the schizophrenic patients died at a younger mean age (64.4 ± 1.0 vs 66.2 ± 0.4 years, respectively).
Second, "schizophrenics as compared to controls had a more severe course of illness and a shorter survival after their initial hospitalization," Dr. Schoepf reported. For the entire group of schizophrenic patients, survival averaged 1895 ± 35.1 days vs 2161 ± 11.6 days for all control patients. For deceased patients in each group, survival averaged 951.4 ± 62.9 vs 1030 ± 28.0 days, respectively.
Third, patients with schizophrenia had substantially more physical diseases. Among 21 diseases with increased prevalence among the study population compared with control patients, odds ratios (ORs) ranged from 5.3 for fracture of the femur neck to 1.3 for asthma.
"T2DM was the most common disproportionally increased physical comorbidity," Dr. Schoepf said. Its prevalence among schizophrenic patients was double that of the control patients (17.4% vs 8.5%; OR = 2.3; 95% confidence interval [CI], 2.0 - 2.6).
The fourth major finding was that among schizophrenic patients who died, T2DM was the most common physical comorbidity, contributing to about one third (31.4%) of those deaths, compared with 16.9% of deceased control patients.
Parkinsonism affected 1.6% of the study group vs 0.4% of control patients (OR = 4.7; 95% CI, 2.8 - 7.7). It was present in 5.5% of deceased study group patients but in only 1.5% of control patients who died.
Excluding Parkinsonism, a major risk factor for death among the schizophrenic group, the researchers developed a model that identified 9 other mortality risk factors that “had an equal impact on inhospital death in schizophrenics as compared to controls,” Dr. Schoepf reported.
Although the prevalence of these risk factors differed between the 2 groups, their impact on inhospital mortality did not differ when these comorbidities were present in patients in either group. The comorbidities were as follows: T2DM, chronic obstructive pulmonary disease, pneumonia, bronchitis, iron-deficiency anemia, type 1 diabetes, ischemic stroke, nonspecific renal failure, and alcoholic liver disease.

Novel Result
Speaking with Medscape Medical News, session chair Guillermo Lahera Forteza, MD, PhD, professor of psychiatry at the University of Alcalá, Spain, who was not involved in the study, praised it as "impressive…especially the relationship between Parkinsonism and mortality in patients with schizophrenia. I was really shocked about this figure." He added that the relationship between T2DM and mortality has been well known, but the finding about Parkinsonism is something new.
Dr. Lahera Forteza said he has questions about the causes of death in cases in which comorbidities exist. There may be differences between different antipsychotic medications and their possible contribution.
"Specific treatments with clozapine or olanzapine could be related to more comorbidity and mortality," he said, but Dr. Schoepf noted that there are not enough data from this study on this point.
Dr. Lahera Forteza advises physicians “to restudy every treatment when the patient has this kind of comorbidity ― to re-evaluate and reassess the pharmacological treatment in every patient.” In addition, physicians should recognize the impact of lifestyle on these patients, who often smoke, drink alcohol, and do not get enough exercise. Negative symptoms, cognitive impairment, and social stigma can all affect lifestyle and contribute to or exacerbate physical comorbidities.

Dr. Schoepf and Dr. Lahera Forteza report no relevant financial relationships. The study had no commercial funding.



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Utah has highest rate of mental illness in U.S., study saysBy Natalie CroftsUtah has the highest rate of mental illness in the nation, according to a new survey.About 22.4 percent of the adult population in Utah experienced a mental disorder in the past year, according to recently released statistics. Out of those people, 5.14 percent had a severe mental disorder that interfered with their daily activities.
The study was conducted by the Substance Abuse and Mental Health Services Administration, which is an agency within the U.S. Department of Health and Human Services.
The study estimated 42.5 million people over the age of 18 in the U.S. have experienced a mental illness in the past year, at a rate of 18.2 percent. Severe mental illness affected 9.3 million people, at a rate of 4 percent.
"The presence of Severe Mental Illness and Any Mental Illness in every state reinforces that mental illness is a major public health concern in the United States," researchers wrote. "Factors that potentially contribute to the variation are not well understood and need further study."The state with the lowest rate of mental illness was New Jersey, with 3.1 percent of the adult population experiencing a severe mental illness and 14.2 percent experiencing any mental illness.
The statistics were based on findings from the annual National Survey on Drug Use and Health, which is sponsored by SAMHSA. They conducted interviews with a representative sample of 92,400 people aged 18 or older.
States with Highest Rate of Mental Illness:Utah (22.4 percent)Oklahoma (21.9 percent)West Virginia (21.4 percentOregon (20.9 percent)Washington (20.8 percent)States with Lowest Rate of Mental Illness:New Jersey (14.7 percent)Illinois (15.9 percent)Nevada (16.1 percent)Connecticut (16.7 percent)North Carolina (16.8 percent)


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Utah has highest rate of mental illness in U.S., study says
By Natalie Crofts

Utah has the highest rate of mental illness in the nation, according to a new survey.

About 22.4 percent of the adult population in Utah experienced a mental disorder in the past year, according to recently released statistics. Out of those people, 5.14 percent had a severe mental disorder that interfered with their daily activities.

The study was conducted by the Substance Abuse and Mental Health Services Administration, which is an agency within the U.S. Department of Health and Human Services.

The study estimated 42.5 million people over the age of 18 in the U.S. have experienced a mental illness in the past year, at a rate of 18.2 percent. Severe mental illness affected 9.3 million people, at a rate of 4 percent.

"The presence of Severe Mental Illness and Any Mental Illness in every state reinforces that mental illness is a major public health concern in the United States," researchers wrote. "Factors that potentially contribute to the variation are not well understood and need further study."
The state with the lowest rate of mental illness was New Jersey, with 3.1 percent of the adult population experiencing a severe mental illness and 14.2 percent experiencing any mental illness.

The statistics were based on findings from the annual National Survey on Drug Use and Health, which is sponsored by SAMHSA. They conducted interviews with a representative sample of 92,400 people aged 18 or older.

States with Highest Rate of Mental Illness:
Utah (22.4 percent)
Oklahoma (21.9 percent)
West Virginia (21.4 percent
Oregon (20.9 percent)
Washington (20.8 percent)

States with Lowest Rate of Mental Illness:
New Jersey (14.7 percent)
Illinois (15.9 percent)
Nevada (16.1 percent)
Connecticut (16.7 percent)
North Carolina (16.8 percent)



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Factors predicting disengagement from psychosis early intervention identifiedBy Afsaneh Gray, medwireNews ReporterA study of first-episode psychosis patients in Hong Kong has found that those with fewer negative symptoms at presentation and poor medication compliance were more likely than others to disengage from an early intervention program.“We have confirmed reports in previous studies, which were mostly conducted in western populations, that diagnosis of a non-schizophrenia-spectrum psychotic disorder, lower baseline negative symptom severity, poor medication compliance and substance abuse history predicted service disengagement,” write study author Wing Chang (The University of Hong Kong) and colleagues.The team identified 700 patients aged 15 to 25 years who were enrolled in the Early Assessment Service for Young People with Psychosis (EASY) program between 2001 and 2003.Data on each patient were retrieved from clinical records, and the Clinical Global Impressions–Severity Scale was used to determine symptom severity. Information on medication compliance was derived from sources including case management notes, medical records and information from caregivers.Disengagement was defined as missing all outpatient appointments until the end of the 2-year service despite therapeutic need and active follow-up from staff, and occurred in 94 patients.The mean age of participants was 20.65 years and the median duration of untreated psychosis was 91 days. Most (69.14%) patients had a diagnosis of a schizophrenia spectrum disorder (ie, schizophrenia or schizoaffective disorder).Multivariate analysis identified three factors that were independently associated with disengagement. Patients were 56% less likely to disengage if they had schizophrenia-spectrum disorders, rather than other types of psychosis. They were 63% less likely to disengage if they were adherent to their medication, and they were 24% less like to disengage if they had high baseline negative symptom scores (>3).Substance abuse history within the initial 6 months of the program increased the chances of disengagement, but, due to the small number of patients affected, was not included in the final multivariate analysis.The team also found that 63% of disengaged patients were in symptomatic remission during the month in which they left the EASY program.“Early intervention teams should pay attention to factors associated with disengagement, and monitor at risk patients closely to detect signs of non-adherence,” Chang and colleagues conclude in Schizophrenia Research.


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Factors predicting disengagement from psychosis early intervention identified
By Afsaneh Gray, medwireNews Reporter

A study of first-episode psychosis patients in Hong Kong has found that those with fewer negative symptoms at presentation and poor medication compliance were more likely than others to disengage from an early intervention program.
“We have confirmed reports in previous studies, which were mostly conducted in western populations, that diagnosis of a non-schizophrenia-spectrum psychotic disorder, lower baseline negative symptom severity, poor medication compliance and substance abuse history predicted service disengagement,” write study author Wing Chang (The University of Hong Kong) and colleagues.
The team identified 700 patients aged 15 to 25 years who were enrolled in the Early Assessment Service for Young People with Psychosis (EASY) program between 2001 and 2003.
Data on each patient were retrieved from clinical records, and the Clinical Global Impressions–Severity Scale was used to determine symptom severity. Information on medication compliance was derived from sources including case management notes, medical records and information from caregivers.
Disengagement was defined as missing all outpatient appointments until the end of the 2-year service despite therapeutic need and active follow-up from staff, and occurred in 94 patients.
The mean age of participants was 20.65 years and the median duration of untreated psychosis was 91 days. Most (69.14%) patients had a diagnosis of a schizophrenia spectrum disorder (ie, schizophrenia or schizoaffective disorder).
Multivariate analysis identified three factors that were independently associated with disengagement. Patients were 56% less likely to disengage if they had schizophrenia-spectrum disorders, rather than other types of psychosis. They were 63% less likely to disengage if they were adherent to their medication, and they were 24% less like to disengage if they had high baseline negative symptom scores (>3).
Substance abuse history within the initial 6 months of the program increased the chances of disengagement, but, due to the small number of patients affected, was not included in the final multivariate analysis.
The team also found that 63% of disengaged patients were in symptomatic remission during the month in which they left the EASY program.
“Early intervention teams should pay attention to factors associated with disengagement, and monitor at risk patients closely to detect signs of non-adherence,” Chang and colleagues conclude in Schizophrenia Research.



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New evidence that chronic stress predisposes brain to mental illnessBy Robert SandersBERKELEY - University of California, Berkeley, researchers have shown that chronic stress generates long-term chages in the brain that may explain why people suffering chronic stress are prone to mental problems such as anxiety and mood disorders later in life.Their findings could lead to new therapies to reduce the risk of developing mental illness after stressful events.Doctors know that people with stress-related illnesses, such as post-traumatic stress disorder (PTSD), have abnormalities in the brain, including differences in the amount of gray matter versus white matter. Gray matter consists mostly of cells – neurons, which store and process information, and support cells called glia – while white matter is comprised of axons, which create a network of fibers that interconnect neurons. White matter gets its name from the white, fatty myelin sheath that surrounds the axons and speeds the flow of electrical signals from cell to cell.How chronic stress creates these long-lasting changes in brain structure is a mystery that researchers are only now beginning to unravel.In a series of experiments, Daniela Kaufer, UC Berkeley associate professor of integrative biology, and her colleagues, including graduate students Sundari Chetty and Aaron Freidman, discovered that chronic stress generates more myelin-producing cells and fewer neurons than normal. This results in an excess of myelin – and thus, white matter – in some areas of the brain, which disrupts the delicate balance and timing of communication within the brain.“We studied only one part of the brain, the hippocampus, but our findings could provide insight into how white matter is changing in conditions such as schizophrenia, autism, depression, suicide, ADHD and PTSD,” she said.The hippocampus regulates memory and emotions, and plays a role in various emotional disorders.Kaufer and her colleagues published their findings in the Feb. 11 issue of the journal Molecular Psychiatry.Does stress affect brain connectivity?Kaufer’s findings suggest a mechanism that may explain some changes in brain connectivity in people with PTSD, for example. One can imagine, she said, that PTSD patients could develop a stronger connectivity between the hippocampus and the amygdala – the seat of the brain’s fight or flight response – and lower than normal connectivity between the hippocampus and prefrontal cortex, which moderates our responses.“You can imagine that if your amygdala and hippocampus are better connected, that could mean that your fear responses are much quicker, which is something you see in stress survivors,” he said. “On the other hand, if your connections are not so good to the prefrontal cortex, your ability to shut down responses is impaired. So, when you are in a stressful situation, the inhibitory pathways from the prefrontal cortex telling you not to get stressed don’t work as well as the amygdala shouting to the hippocampus, ‘This is terrible!’ You have a much bigger response than you should.”She is involved in a study to test this hypothesis in PTSD patients, and continues to study brain changes in rodents subjected to chronic stress or to adverse environments in early life.Stress tweaks stem cellsKaufer’s lab, which conducts research on the molecular and cellular effects of acute and chronic stress, focused in this study on neural stem cells in the hippocampus of the brains of adult rats. These stem cells were previously thought to mature only into neurons or a type of glial cell called an astrocyte. The researchers found, however, that chronic stress also made stem cells in the hippocampus mature into another type of glial cell called an oligodendrocyte, which produces the myelin that sheaths nerve cells.The finding, which they demonstrated in rats and cultured rat brain cells, suggests a key role for oligodendrocytes in long-term and perhaps permanent changes in the brain that could set the stage for later mental problems. Oligodendrocytes also help form synapses – sites where one cell talks to another – and help control the growth pathway of axons, which make those synapse connections.The fact that chronic stress also decreases the number of stem cells that mature into neurons could provide an explanation for how chronic stress also affects learning and memory, she said.Kaufer is now conducting experiments to determine how stress in infancy affects the brain’s white matter, and whether chronic early-life stress decreases resilience later in life. She also is looking at the effects of therapies, ranging from exercise to antidepressant drugs, that reduce the impact of stress and stress hormones.

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New evidence that chronic stress predisposes brain to mental illness
By Robert Sanders

BERKELEY - University of California, Berkeley, researchers have shown that chronic stress generates long-term chages in the brain that may explain why people suffering chronic stress are prone to mental problems such as anxiety and mood disorders later in life.
Their findings could lead to new therapies to reduce the risk of developing mental illness after stressful events.
Doctors know that people with stress-related illnesses, such as post-traumatic stress disorder (PTSD), have abnormalities in the brain, including differences in the amount of gray matter versus white matter. Gray matter consists mostly of cells – neurons, which store and process information, and support cells called glia – while white matter is comprised of axons, which create a network of fibers that interconnect neurons. White matter gets its name from the white, fatty myelin sheath that surrounds the axons and speeds the flow of electrical signals from cell to cell.
How chronic stress creates these long-lasting changes in brain structure is a mystery that researchers are only now beginning to unravel.
In a series of experiments, Daniela Kaufer, UC Berkeley associate professor of integrative biology, and her colleagues, including graduate students Sundari Chetty and Aaron Freidman, discovered that chronic stress generates more myelin-producing cells and fewer neurons than normal. This results in an excess of myelin – and thus, white matter – in some areas of the brain, which disrupts the delicate balance and timing of communication within the brain.
“We studied only one part of the brain, the hippocampus, but our findings could provide insight into how white matter is changing in conditions such as schizophrenia, autism, depression, suicide, ADHD and PTSD,” she said.
The hippocampus regulates memory and emotions, and plays a role in various emotional disorders.
Kaufer and her colleagues published their findings in the Feb. 11 issue of the journal Molecular Psychiatry.

Does stress affect brain connectivity?
Kaufer’s findings suggest a mechanism that may explain some changes in brain connectivity in people with PTSD, for example. One can imagine, she said, that PTSD patients could develop a stronger connectivity between the hippocampus and the amygdala – the seat of the brain’s fight or flight response – and lower than normal connectivity between the hippocampus and prefrontal cortex, which moderates our responses.
“You can imagine that if your amygdala and hippocampus are better connected, that could mean that your fear responses are much quicker, which is something you see in stress survivors,” he said. “On the other hand, if your connections are not so good to the prefrontal cortex, your ability to shut down responses is impaired. So, when you are in a stressful situation, the inhibitory pathways from the prefrontal cortex telling you not to get stressed don’t work as well as the amygdala shouting to the hippocampus, ‘This is terrible!’ You have a much bigger response than you should.”
She is involved in a study to test this hypothesis in PTSD patients, and continues to study brain changes in rodents subjected to chronic stress or to adverse environments in early life.

Stress tweaks stem cells
Kaufer’s lab, which conducts research on the molecular and cellular effects of acute and chronic stress, focused in this study on neural stem cells in the hippocampus of the brains of adult rats. These stem cells were previously thought to mature only into neurons or a type of glial cell called an astrocyte. The researchers found, however, that chronic stress also made stem cells in the hippocampus mature into another type of glial cell called an oligodendrocyte, which produces the myelin that sheaths nerve cells.
The finding, which they demonstrated in rats and cultured rat brain cells, suggests a key role for oligodendrocytes in long-term and perhaps permanent changes in the brain that could set the stage for later mental problems. Oligodendrocytes also help form synapses – sites where one cell talks to another – and help control the growth pathway of axons, which make those synapse connections.
The fact that chronic stress also decreases the number of stem cells that mature into neurons could provide an explanation for how chronic stress also affects learning and memory, she said.
Kaufer is now conducting experiments to determine how stress in infancy affects the brain’s white matter, and whether chronic early-life stress decreases resilience later in life. She also is looking at the effects of therapies, ranging from exercise to antidepressant drugs, that reduce the impact of stress and stress hormones.



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[In the News] Study Says Comedians Have Psychotic Personality Traits—Here’s What Some Comedians Have To Say About ThatBy Asawin SuebsaengThe popular belief that creativity is associated with madness has increasingly become the focus of research for many psychologists and psychiatrists. However, despite being prime examples of creative thinking, comedy and humor have been largely neglected. To test the hypothesis that comedians would resemble other creative individuals in showing a higher level of psychotic characteristics related to both schizophrenia and manic depression. A group of comedians (n = 500+) and a control sample of actors (n = 350+) completed an online questionnaire containing the short version of the Oxford–Liverpool Inventory of Feelings and Experiences (O-LIFE), with scales measuring four dimensions of psychotic traits. Scores were compared with general population norms. Comedians scored significantly above O-LIFE norms on all four scales. Actors also differed from the norms but on only three of the scales. Most striking was the comedians’ high score on both introverted anhedonia and extraverted impulsiveness. This unusual personality structure may help to explain the facility for comedic performance.If you’ve ever seen footage of comedian Bill Hicks taking on a heckler, you might have thought to yourself, “Wow, that was pretty psychotic.”Well, according to a recent study published in the British Journal of Psychiatry, you weren’t that far off. For the study, which is titled, “Psychotic traits in comedians,” researchers recruited 523 comedians (404 male and 119 female, most of whom were amateurs) from the United States, Australia, and the United Kingdom. The researchers determined that comedians scored significantly higher on four types of psychotic personality traits compared to a control group of individuals who had non-artistic jobs. The study focuses on two major categories of psychosis—bipolar disorder and schizophrenia—and examines impulsive non-conformity."The results of this study substantially confirmed our expectation that comedians would behave like other creative groups in showing a high level of psychotic personality traits," the authors wrote. “They did so across all the domains sampled by the questionnaire we used, from schizoid and schizophrenic-like characteristics through to manic-depressive features.”The 6-page report also highlights English comedian and actor Stephen Fry, who has been diagnosed with bipolar disorder and attempted suicide in 2012.However, it’s important to point out that the authors of the study aren’t saying all famous or successful comedians are automatically pathologically bipolar or pathologically schizophrenic, or even that they necessarily require treatment. In other words, labeling someone’s personality traits as in the realm of “psychotic” may sound a bit scary—but it doesn’t mean that person is a psychopath or a menace to society.Still, some professional comedians aren’t big fans of this. According to Steve Hofstetter, a former Sports Illustrated columnist and one of most booked comic acts on the American college circuit, a large number of comedians have been taking to social media to share and mock the study in the past couple of days. "The new study claiming comedians have psychotic personality traits was written by a troll who talks to me from inside my butthole," Adam Newman wrote, for instance. Hofstetter has a much harsher take."The idea that it’s a news story that comedians are rebels is the equivalent of saying it’s a news story that people who spend their lives conducting studies never get laid," the Los Angeles-based comedian says. “And if you look at the actual results of the study, it shows that actors were not that far off from comedians at all. So this was clearly a study conducted on the hypothesis that comedians have mental problems.”Rob Delaney, the author and stand-up comedian who was named Mitt Romney’s “Twitter nemesis” during the 2012 election, was similarly critical of the comedians-are-psychotic study—but he was significantly less pissed about it."My honest opinion is that piece really has no effect on me," Delaney wrote in an email. "Plus, [the study] defangs itself when it says, ‘we’re not saying they’re the dangerous kind of psychopath,’ so really I just think it’s an attention-grabber and not actually a substantive piece of information. Do you need a psychological kink of some kind to function as a comedian, particularly one that makes a living at it? Yes. Is that kink psychosis or close to psychosis? I don’t know and I don’t really care. But perhaps that means I’m a psychopath? Maybe. I know I brutally pursue my goals regardless of whatever the hell else is happening in the world and anticipate success in all my endeavors, even when that feeling is unfounded. So that’s what I think.”(Lewis Black, Joan Rivers, and Gallagher did not respond to requests for comment.)So whatever the researchers’ intentions, perhaps their new report hasn’t won them any new friends in the community of stand-up comics. Hell, at least they didn’t author a study telling comedians that they were going to drop dead at a young age.


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[In the News] Study Says Comedians Have Psychotic Personality Traits—Here’s What Some Comedians Have To Say About That
By Asawin Suebsaeng

The popular belief that creativity is associated with madness has increasingly become the focus of research for many psychologists and psychiatrists. However, despite being prime examples of creative thinking, comedy and humor have been largely neglected. To test the hypothesis that comedians would resemble other creative individuals in showing a higher level of psychotic characteristics related to both schizophrenia and manic depression. A group of comedians (n = 500+) and a control sample of actors (n = 350+) completed an online questionnaire containing the short version of the Oxford–Liverpool Inventory of Feelings and Experiences (O-LIFE), with scales measuring four dimensions of psychotic traits. Scores were compared with general population norms. Comedians scored significantly above O-LIFE norms on all four scales. Actors also differed from the norms but on only three of the scales. Most striking was the comedians’ high score on both introverted anhedonia and extraverted impulsiveness. This unusual personality structure may help to explain the facility for comedic performance.

If you’ve ever seen footage of comedian Bill Hicks taking on a heckler, you might have thought to yourself, “Wow, that was pretty psychotic.”
Well, according to a recent study published in the British Journal of Psychiatry, you weren’t that far off. For the study, which is titled, “Psychotic traits in comedians,” researchers recruited 523 comedians (404 male and 119 female, most of whom were amateurs) from the United States, Australia, and the United Kingdom. The researchers determined that comedians scored significantly higher on four types of psychotic personality traits compared to a control group of individuals who had non-artistic jobs. The study focuses on two major categories of psychosis—bipolar disorder and schizophrenia—and examines impulsive non-conformity.
"The results of this study substantially confirmed our expectation that comedians would behave like other creative groups in showing a high level of psychotic personality traits," the authors wrote. “They did so across all the domains sampled by the questionnaire we used, from schizoid and schizophrenic-like characteristics through to manic-depressive features.”
The 6-page report also highlights English comedian and actor Stephen Fry, who has been diagnosed with bipolar disorder and attempted suicide in 2012.
However, it’s important to point out that the authors of the study aren’t saying all famous or successful comedians are automatically pathologically bipolar or pathologically schizophrenic, or even that they necessarily require treatment. In other words, labeling someone’s personality traits as in the realm of “psychotic” may sound a bit scary—but it doesn’t mean that person is a psychopath or a menace to society.
Still, some professional comedians aren’t big fans of this. According to Steve Hofstetter, a former Sports Illustrated columnist and one of most booked comic acts on the American college circuit, a large number of comedians have been taking to social media to share and mock the study in the past couple of days. "The new study claiming comedians have psychotic personality traits was written by a troll who talks to me from inside my butthole," Adam Newman wrote, for instance. Hofstetter has a much harsher take.
"The idea that it’s a news story that comedians are rebels is the equivalent of saying it’s a news story that people who spend their lives conducting studies never get laid," the Los Angeles-based comedian says. “And if you look at the actual results of the study, it shows that actors were not that far off from comedians at all. So this was clearly a study conducted on the hypothesis that comedians have mental problems.”
Rob Delaney, the author and stand-up comedian who was named Mitt Romney’s “Twitter nemesis” during the 2012 election, was similarly critical of the comedians-are-psychotic study—but he was significantly less pissed about it.
"My honest opinion is that piece really has no effect on me," Delaney wrote in an email. "Plus, [the study] defangs itself when it says, ‘we’re not saying they’re the dangerous kind of psychopath,’ so really I just think it’s an attention-grabber and not actually a substantive piece of information. Do you need a psychological kink of some kind to function as a comedian, particularly one that makes a living at it? Yes. Is that kink psychosis or close to psychosis? I don’t know and I don’t really care. But perhaps that means I’m a psychopath? Maybe. I know I brutally pursue my goals regardless of whatever the hell else is happening in the world and anticipate success in all my endeavors, even when that feeling is unfounded. So that’s what I think.”
(Lewis Black, Joan Rivers, and Gallagher did not respond to requests for comment.)
So whatever the researchers’ intentions, perhaps their new report hasn’t won them any new friends in the community of stand-up comics. Hell, at least they didn’t author a study telling comedians that they were going to drop dead at a young age.



For more mental health news, Click Here to access the Serious Mental Illness Blog

Filed under news new science scientific research psychology psychologist psychological psychiatry psychiatrist comedian comic actor actors psychotic psychosis schizo psych psycho schizoprenia schizoprenic personality person treat treatment creativity creative performer sketch stand up

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[In the News] A.D.H.D. Experts Re-evaluate Study’s Zeal for DrugsBy Alan schwartz
"Another co-author, Dr. Lily Hechtman of McGill University in Montreal, added: “I hope it didn’t do irreparable damage. The people who pay the price in the end is the kids. That’s the biggest tragedy in all of this.”Twenty years ago, more than a dozen leaders in child psychiatry received $11 million from the National Institute of Mental Health to study an important question facing families with children with attention deficit hyperactivity disorder: Is the best long-term treatment medication, behavioral therapy or both? The widely publicized result was not only that medication like Ritalin or Adderall trounced behavioral therapy, but also that combining the two did little beyond what medication could do alone. The finding has become a pillar of pharmaceutical companies’ campaigns to market A.D.H.D. drugs, and is used by insurance companies and school systems to argue against therapies that are usually more expensive than pills.But in retrospect, even some authors of the study — widely considered the most influential study ever on A.D.H.D. — worry that the results oversold the benefits of drugs, discouraging important home- and school-focused therapy and ultimately distorting the debate over the most effective (and cost-effective) treatments.The study was structured to emphasize the reduction of impulsivity and inattention symptoms, for which medication is designed to deliver quick results, several of the researchers said in recent interviews. Less emphasis was placed on improving children’s longer-term academic and social skills, which behavioral therapy addresses by teaching children, parents and teachers to create less distracting and more organized learning environments.Recent papers have also cast doubt on whether medication’s benefits last as long as those from therapy.“There was lost opportunity to give kids the advantage of both and develop more resources in schools to support the child — that value was dismissed,” said Dr. Gene Arnold, a child psychiatrist and professor at Ohio State University and one of the principal researchers on the study, known as the Multimodal Treatment Study of Children With A.D.H.D.Another co-author, Dr. Lily Hechtman of McGill University in Montreal, added: “I hope it didn’t do irreparable damage. The people who pay the price in the end is the kids. That’s the biggest tragedy in all of this.”A.D.H.D. narrowly trails asthma as the most frequent long-term medical diagnosis in children. More than 1 in 7 children in the United States receive a diagnosis of the disorder by the time they turn 18, according to the Centers for Disease Control and Prevention. At least 70 percent of those are prescribed stimulant medication like Adderall or Concerta because, despite potential side effects like insomnia and appetite suppression, it can quickly mollify symptoms and can cost an insured family less than $200 a year.Comprehensive behavioral (also called psychosocial) therapy is used far less often to treat children with the disorder largely because it is more time-consuming and expensive. Cost-conscious schools have few aides to help teachers assist the expanding population of children with the diagnosis, which in some communities reaches 20 percent of students. Many insurance plans inadequately cover private or group therapy for families, which can cost $1,000 a year or more.“Medication helps a person be receptive to learning new skills and behaviors,” said Ruth Hughes, a psychologist and the chief executive of the advocacy group Children and Adults With Attention-Deficit/Hyperactivity Disorder. “But those skills and behaviors don’t magically appear. They have to be taught.”Accepting no support from the pharmaceutical industry — “to keep it clean,” Dr. Arnold said — the National Institute of Mental Health gathered more than a dozen top experts on A.D.H.D. in the mid-1990s to try to identify the best approach. Over 14 months, almost 600 children with the disorder ages 7 to 9 across the United States and Canada received one of four treatments: medication alone, behavioral therapy alone, the combination, or nothing beyond whatever treatments they were already receiving.The study’s primary paper, published in 1999, concluded that medication “was superior to behavioral treatment” by a considerable margin — the first time a major independent study had reached that conclusion. Combining the two, it said, “did not yield significantly greater benefits than medication” alone for symptoms of the disorder.In what became a simple horse race, medication was ushered into the winner’s circle.“Behavioral therapy alone is not as effective as drugs,” ABC’s “World News Now” reported. One medical publication said, “Psychosocial interventions of no benefit even when used with medication.”Looking back, some study researchers say several factors in the study’s design and presentation to the public disguised the performance of psychosocial therapy, which has allowed many doctors, drug companies and schools to discourage its use. First, the fact that many of the 19 categories measured classic symptoms like forgetfulness and fidgeting — over academic achievement and family and peer interactions — hampered therapy’s performance from the start, several of the study’s co-authors said. A subsequent paper by one of those, Keith Conners, a psychologist and professor emeritus at Duke University, showed that using only one all-inclusive measurement — “treating the child as a whole,” he said — revealed that combination therapy was significantly better than medication alone. Behavioral therapy emerged as a viable alternative to medication as well. But his paper has received little attention.“When you asked families what they really liked, they liked combined treatment,” said Dr. Peter Jensen, who oversaw the study on behalf of the mental health institute. “They didn’t not like medicine, but they valued skill training. What doctors think are the best outcomes and what families think are the best outcomes aren’t always the same thing.”Just as new products like Concerta and extended-release Adderall were entering the market, a 2001 paper by several of the study’s researchers gave pharmaceutical companies tailor-made marketing material. For the first time, the researchers released data showing just how often each approach had moderated A.D.H.D. symptoms: Combination therapy did so in 68 percent of children, followed by medication alone (56 percent) and behavioral therapy alone (34 percent). Although combination therapy won by 12 percentage points, the paper’s authors described that as “small by conventional standards” and largely driven by medication.Drug companies ever since have reprinted that scorecard and interpretation in dozens of marketing materials and PowerPoint presentations. They became the lesson in doctor-education classes worldwide.“The only thing we heard was the first finding — that medication is the answer,” said Laura Batstra, a psychologist at the University of Groningen in the Netherlands.Using an additional $10 million in government support to follow the children in the study until young adulthood, researchers have seen some of their original conclusions muddied further. Many experts interpret these more recent findings as showing the dissipation of medication’s effects; others counter that going off the medication, as many children did, would naturally dampen continuing positive effects.Most recently, a paper from the study said flatly that using any treatment “does not predict functioning six to eight years later,” leaving the study’s original question — which treatment does the most good long-term? — largely unanswered.“My belief based on the science is that symptom reduction is a good thing, but adding skill-building is a better thing,” said Stephen Hinshaw, a psychologist at the University of California, Berkeley, and one of the study researchers. “If you don’t provide skills-based training, you’re doing the kid a disservice. I wish we had had a fairer test.”





For more mental health news, Click Here to access the Serious Mental Illness Blog

[In the News] A.D.H.D. Experts Re-evaluate Study’s Zeal for Drugs
By Alan schwartz

"Another co-author, Dr. Lily Hechtman of McGill University in Montreal, added: “I hope it didn’t do irreparable damage. The people who pay the price in the end is the kids. That’s the biggest tragedy in all of this.”

Twenty years ago, more than a dozen leaders in child psychiatry received $11 million from the National Institute of Mental Health to study an important question facing families with children with attention deficit hyperactivity disorder: Is the best long-term treatment medication, behavioral therapy or both?
The widely publicized result was not only that medication like Ritalin or Adderall trounced behavioral therapy, but also that combining the two did little beyond what medication could do alone. The finding has become a pillar of pharmaceutical companies’ campaigns to market A.D.H.D. drugs, and is used by insurance companies and school systems to argue against therapies that are usually more expensive than pills.
But in retrospect, even some authors of the study — widely considered the most influential study ever on A.D.H.D. — worry that the results oversold the benefits of drugs, discouraging important home- and school-focused therapy and ultimately distorting the debate over the most effective (and cost-effective) treatments.
The study was structured to emphasize the reduction of impulsivity and inattention symptoms, for which medication is designed to deliver quick results, several of the researchers said in recent interviews. Less emphasis was placed on improving children’s longer-term academic and social skills, which behavioral therapy addresses by teaching children, parents and teachers to create less distracting and more organized learning environments.
Recent papers have also cast doubt on whether medication’s benefits last as long as those from therapy.
There was lost opportunity to give kids the advantage of both and develop more resources in schools to support the child — that value was dismissed,” said Dr. Gene Arnold, a child psychiatrist and professor at Ohio State University and one of the principal researchers on the study, known as the Multimodal Treatment Study of Children With A.D.H.D.
Another co-author, Dr. Lily Hechtman of McGill University in Montreal, added: “I hope it didn’t do irreparable damage. The people who pay the price in the end is the kids. That’s the biggest tragedy in all of this.”
A.D.H.D. narrowly trails asthma as the most frequent long-term medical diagnosis in children. More than 1 in 7 children in the United States receive a diagnosis of the disorder by the time they turn 18, according to the Centers for Disease Control and Prevention. At least 70 percent of those are prescribed stimulant medication like Adderall or Concerta because, despite potential side effects like insomnia and appetite suppression, it can quickly mollify symptoms and can cost an insured family less than $200 a year.
Comprehensive behavioral (also called psychosocial) therapy is used far less often to treat children with the disorder largely because it is more time-consuming and expensive. Cost-conscious schools have few aides to help teachers assist the expanding population of children with the diagnosis, which in some communities reaches 20 percent of students. Many insurance plans inadequately cover private or group therapy for families, which can cost $1,000 a year or more.
“Medication helps a person be receptive to learning new skills and behaviors,” said Ruth Hughes, a psychologist and the chief executive of the advocacy group Children and Adults With Attention-Deficit/Hyperactivity Disorder. “But those skills and behaviors don’t magically appear. They have to be taught.”
Accepting no support from the pharmaceutical industry — “to keep it clean,” Dr. Arnold said — the National Institute of Mental Health gathered more than a dozen top experts on A.D.H.D. in the mid-1990s to try to identify the best approach. Over 14 months, almost 600 children with the disorder ages 7 to 9 across the United States and Canada received one of four treatments: medication alone, behavioral therapy alone, the combination, or nothing beyond whatever treatments they were already receiving.
The study’s primary paper, published in 1999, concluded that medication “was superior to behavioral treatment” by a considerable margin — the first time a major independent study had reached that conclusion. Combining the two, it said, “did not yield significantly greater benefits than medication” alone for symptoms of the disorder.
In what became a simple horse race, medication was ushered into the winner’s circle.
“Behavioral therapy alone is not as effective as drugs,” ABC’s “World News Now” reported. One medical publication said, “Psychosocial interventions of no benefit even when used with medication.”
Looking back, some study researchers say several factors in the study’s design and presentation to the public disguised the performance of psychosocial therapy, which has allowed many doctors, drug companies and schools to discourage its use.
First, the fact that many of the 19 categories measured classic symptoms like forgetfulness and fidgeting — over academic achievement and family and peer interactions — hampered therapy’s performance from the start, several of the study’s co-authors said.
A subsequent paper by one of those, Keith Conners, a psychologist and professor emeritus at Duke University, showed that using only one all-inclusive measurement — “treating the child as a whole,” he said — revealed that combination therapy was significantly better than medication alone. Behavioral therapy emerged as a viable alternative to medication as well. But his paper has received little attention.
“When you asked families what they really liked, they liked combined treatment,” said Dr. Peter Jensen, who oversaw the study on behalf of the mental health institute. “They didn’t not like medicine, but they valued skill training. What doctors think are the best outcomes and what families think are the best outcomes aren’t always the same thing.”
Just as new products like Concerta and extended-release Adderall were entering the market, a 2001 paper by several of the study’s researchers gave pharmaceutical companies tailor-made marketing material. For the first time, the researchers released data showing just how often each approach had moderated A.D.H.D. symptoms: Combination therapy did so in 68 percent of children, followed by medication alone (56 percent) and behavioral therapy alone (34 percent). Although combination therapy won by 12 percentage points, the paper’s authors described that as “small by conventional standards” and largely driven by medication.
Drug companies ever since have reprinted that scorecard and interpretation in dozens of marketing materials and PowerPoint presentations. They became the lesson in doctor-education classes worldwide.
“The only thing we heard was the first finding — that medication is the answer,” said Laura Batstra, a psychologist at the University of Groningen in the Netherlands.
Using an additional $10 million in government support to follow the children in the study until young adulthood, researchers have seen some of their original conclusions muddied further. Many experts interpret these more recent findings as showing the dissipation of medication’s effects; others counter that going off the medication, as many children did, would naturally dampen continuing positive effects.
Most recently, a paper from the study said flatly that using any treatment “does not predict functioning six to eight years later,” leaving the study’s original question — which treatment does the most good long-term? — largely unanswered.
“My belief based on the science is that symptom reduction is a good thing, but adding skill-building is a better thing,” said Stephen Hinshaw, a psychologist at the University of California, Berkeley, and one of the study researchers. “If you don’t provide skills-based training, you’re doing the kid a disservice. I wish we had had a fairer test.”



For more mental health news, Click Here to access the Serious Mental Illness Blog

(Source: The New York Times)

Filed under adhd a.d.h.d science news new ney york times nyt expert experts research researcher kid kids child children young psychiatry psychiatrist psychiatric psychology psychologist psychological damage health illness mental health mental illness mental crazy mad

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A psychiatrist thinks some patients are better off without antipsychotic drugsBy Matt McClainWhat does it mean that the man who killed 12 people at the Washington Naval Yard had told people that he was “hearing voices”?I have spent 30 years as a psychiatrist treating people who are psychotic. Almost every day I meet with individuals who hear voices that no one else hears, are sure the TV or radio is talking to them or have such confused thinking that it is hard to understand what they are trying to tell me.Sometimes these patients lead quiet lives. But not uncommonly these voices get them into trouble. I’ve had patients who call the police repeatedly, demanding that they stop bugging their phone. And others who stay up all night talking back at the voices. Some accuse family members of being involved in the torment.In many cases, this is a frightening experience — for the people I see and those who love them. And the labels we use — “schizophrenia,” “bipolar disorder,” “psychosis” — only crudely capture these experiences.About 60 years ago, a group of drugs was discovered that appeared to quiet the voices, improve the clarity of thought and lessen the preoccupation with delusion beliefs. Originally called major tranquilizers and later renamed antipsychotic drugs, these have been considered essential for the treatment of people with schizophrenia.Once it was clear that these drugs were helpful in the short term, questions arose over how long people should remain on them. Studies done in the 1970s and 1980s looked at people who were stabilized after being treated with antipsychotic drugs for several months and then followed them for up to two years. Some continued on the drugs, while others stopped taking them. The relapse rate was much higher in the group that stopped the medications. Based on these studies, treatment guidelines now state that people should stay on anti-psychotics indefinitely.The problem with “indefinitely” is that antipsychotic drugs have many troubling side effects. They can cause muscle stiffness, tremor and something called tardive dyskinesia, where muscles in the face or limbs move uncontrollably. But the belief — my belief — was that this was the unfortunate price paid to help people who were suffering.Many people do not want to take these drugs because of the side effects or because they do not think of themselves as ill. After all, if the government is using telemetry to transmit messages into your brain, the solution is to turn off the source of the transmission, not to take a pill. I considered myself a successful psychiatrist when I was able to use my powers of persuasion to convince a reluctant patient to stay on the drugs.Yet, over the past 15 years, my attitude has shifted. I have become deeply disturbed by the marketing practices that many pharmaceutical companies began to use in the 1990s to push their new medications.Like many of my colleagues, I awaited the new drugs with enthusiasm, hoping that they would have fewer terrible side effects. Leading psychiatrists who had worked on the development of the drugs also said that they not only were less likely to cause neurological problems but also were more effective.Quickly, though, I started to think that their benefits were being inflated and their side effects minimized. With one drug in particular, it was clear after a year that my patients were gaining weight at alarming rates: 20, 30, even 100 pounds in a matter of months, a real threat to their health.Researchers test such new drugs on people for years before they reached the market, but little attention was focused on this issue and only then in the context of a product war — i.e., whether one drug caused more weight gain than others. Only a decade after they were released to the market was it widely acknowledged that severe weight gain was common with many of the newer anti-psychotics, increasing the risk of diabetes. Given that people may take these drugs for decades, the health consequences are serious.Yet until 21 / 2 years ago, I still thought that prescribing antipsychotic drugs was necessary. After all, a good number of my patients ended up in the hospital or, worse, the police station, when they stopped taking their medications. I did not think I had any other option than to continue to employ my now well-honed powers of persuasion to convince them to stay on their drugs.And then I read Robert Whitaker’s “Anatomy of an Epidemic,” in which he wondered why, if these new drugs were so great, we were seeing increasing numbers of people on disability for psychiatric conditions. He looked at the studies of long-term outcomes, and what he found surprised me and many of my colleagues: Although it is very hard to do a definitive study that follows people for many years, the research suggested that, over time, the people who remain on these drugs do worse than those who stop using them.Those who remained on the drug were less likely to return to work or develop meaningful relationships. Of equal concern, it appeared that brain shrinkage — thought initially to be due to the illness itself — was in fact caused by the drugs. Even when monkeys took these drugs for a period of months, their brains shrank.If Whitaker was right, everything I had been doing for 20 years was wrong. Many psychiatrists have accused him of cherry-picking the data or distorting the findings of the studies. I have spent much of my time rereading the articles and studies he cites, looking for others, talking to colleagues and reading as much criticism of his work as I can find.And what I concluded is that Whitaker is probably right.The dilemmaThis created a dilemma for me: If the drugs that are helpful in the short run may be harmful over time, what do I do for the person who is unable to have a conversation because the voices in his head are so loud?If the medications stop the voices, do I suggest he come off the drugs and risk relapse? Or do I suggest he stay on them and reduce his chances for a full recovery? If I suggest that he stop the drugs and then something bad happens, I may be blamed for his relapse, while I am unlikely to be blamed 30 years from now when he has diabetes.Doctors are held to a standard of “accepted community practice.” What if my own research has led me to a conclusion that is at odds with accepted community practice? What if accepted community practice is so distorted by pharmaceutical advertising in favor of these drugs that it is suspect and unreliable?Two years ago, I decided to invite my patients into this conversation. I explain to them what I have read and what conclusions I have drawn, as well as the conflicting views of other psychiatrists.I have been monitoring those who have chosen to wean themselves from the antipsychotic drugs they have been taking, in some cases for 20 years or more. What has been most striking is that my patients make careful and deliberate decisions. Many psychiatrists fear that having this conversation will lead to massive dropping of the drugs, but this has not been my experience. Some do — most often, the ones who have stopped them multiple times in the past — but most are cautious. Of the 64 people I have tracked, 40 decided to try a dose reduction, 22 chose to remain in their current dose and only four abruptly stopped taking their medications.Some might think my approach cavalier. When we read about Aaron Alexis, who heard voices and shot 12 people before being killed at the Washington Navy Yard, it raises our fears. However, it is important to keep in mind that the problems I describe are common and that the vast majority of people who experience psychosis are not likely to be violent toward others. One study found an increased risk of violence only among those with mental illness who also abuse drugs or are young men. Such risk factors and an individual’s history would, of course, be a part of any decision about whether to wean someone off medication.In this context, a blog post by Thomas Insel, the director of the National Institute of Mental Health, received much attention this year. Insel described a Dutch study involving 103 people treated for schizophrenia and related disorders. The participants were randomly assigned to one of two groups: Half remained on drugs continuously; the others stopped taking drugs when they became well but restarted them if symptoms emerged. After seven years, the researchers found that those who were not continuously on drugs had a much greater likelihood of getting a job and resuming their regular life activities than those who remained on medications. Remember that people who stop drugs have a higher rate of relapse? It turns out that over the seven years, those who remained on the drugs relapsed as often as the others.“For some people, remaining on medication long-term might impede a full return to wellness,” Insel wrote. “For others, discontinuing medication can be disastrous.”The problem is that we do not know who is in which group.A slow reductionA man I have known for many years has had some serious bouts with psychosis. He has been hospitalized multiple times, and his thoughts have put him — though not others — at personal risk. However, the medications have also put him at risk. He is now overweight and has diabetes and his kidneys are not working well. He spends a good part of his day sleeping and the rest watching TV.We have tried in the past to reduce his dose, but these efforts have never gone well. Within days he would be hallucinating and delusional. However, recently we found that with a very slight reduction in dose, he would relapse for about a month but then improve. Perhaps it was his age or greater experience, but he was able to get through the bad days without getting into trouble, and once things quieted down in his mind he felt better. We have agreed to slowly proceed.His family supports his choice. We all understand the risk of dose reduction, but we see it in the context of all of the risks. Maintaining his current dose is not without consequence. I have known him for a long time, but the problems of schizophrenia tend to start early and he is still a young man. Even if it takes five years to get him on a significantly lower dose, we have the opportunity to improve the long-term quality of his life.The Dutch study shifted the focus away from the belief that we need to eradicate all symptoms of schizophrenia to a focus on improving the quality of patients’ lives and health, the relationships they have, the work they do. Some people can learn to live with voices. Some people find that the voices have a significant meaning for them and that communicating with them is what is most important. Some people can learn to talk themselves down from delusional thoughts. And some people might choose hearing voices over being 30 pounds overweight and tired all of the time. The point is that this is not a choice I should be making for my patients; it is a choice I need to make with them.


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A psychiatrist thinks some patients are better off without antipsychotic drugs
By Matt McClain

What does it mean that the man who killed 12 people at the Washington Naval Yard had told people that he was “hearing voices”?
I have spent 30 years as a psychiatrist treating people who are psychotic. Almost every day I meet with individuals who hear voices that no one else hears, are sure the TV or radio is talking to them or have such confused thinking that it is hard to understand what they are trying to tell me.
Sometimes these patients lead quiet lives. But not uncommonly these voices get them into trouble. I’ve had patients who call the police repeatedly, demanding that they stop bugging their phone. And others who stay up all night talking back at the voices. Some accuse family members of being involved in the torment.
In many cases, this is a frightening experience — for the people I see and those who love them. And the labels we use — “schizophrenia,” “bipolar disorder,” “psychosis” — only crudely capture these experiences.
About 60 years ago, a group of drugs was discovered that appeared to quiet the voices, improve the clarity of thought and lessen the preoccupation with delusion beliefs. Originally called major tranquilizers and later renamed antipsychotic drugs, these have been considered essential for the treatment of people with schizophrenia.
Once it was clear that these drugs were helpful in the short term, questions arose over how long people should remain on them. Studies done in the 1970s and 1980s looked at people who were stabilized after being treated with antipsychotic drugs for several months and then followed them for up to two years. Some continued on the drugs, while others stopped taking them. The relapse rate was much higher in the group that stopped the medications. Based on these studies, treatment guidelines now state that people should stay on anti-psychotics indefinitely.
The problem with “indefinitely” is that antipsychotic drugs have many troubling side effects. They can cause muscle stiffness, tremor and something called tardive dyskinesia, where muscles in the face or limbs move uncontrollably. But the belief — my belief — was that this was the unfortunate price paid to help people who were suffering.
Many people do not want to take these drugs because of the side effects or because they do not think of themselves as ill. After all, if the government is using telemetry to transmit messages into your brain, the solution is to turn off the source of the transmission, not to take a pill. I considered myself a successful psychiatrist when I was able to use my powers of persuasion to convince a reluctant patient to stay on the drugs.
Yet, over the past 15 years, my attitude has shifted. I have become deeply disturbed by the marketing practices that many pharmaceutical companies began to use in the 1990s to push their new medications.
Like many of my colleagues, I awaited the new drugs with enthusiasm, hoping that they would have fewer terrible side effects. Leading psychiatrists who had worked on the development of the drugs also said that they not only were less likely to cause neurological problems but also were more effective.
Quickly, though, I started to think that their benefits were being inflated and their side effects minimized. With one drug in particular, it was clear after a year that my patients were gaining weight at alarming rates: 20, 30, even 100 pounds in a matter of months, a real threat to their health.
Researchers test such new drugs on people for years before they reached the market, but little attention was focused on this issue and only then in the context of a product war — i.e., whether one drug caused more weight gain than others. Only a decade after they were released to the market was it widely acknowledged that severe weight gain was common with many of the newer anti-psychotics, increasing the risk of diabetes. Given that people may take these drugs for decades, the health consequences are serious.
Yet until 21 / 2 years ago, I still thought that prescribing antipsychotic drugs was necessary. After all, a good number of my patients ended up in the hospital or, worse, the police station, when they stopped taking their medications. I did not think I had any other option than to continue to employ my now well-honed powers of persuasion to convince them to stay on their drugs.
And then I read Robert Whitaker’s “Anatomy of an Epidemic,” in which he wondered why, if these new drugs were so great, we were seeing increasing numbers of people on disability for psychiatric conditions. He looked at the studies of long-term outcomes, and what he found surprised me and many of my colleagues: Although it is very hard to do a definitive study that follows people for many years, the research suggested that, over time, the people who remain on these drugs do worse than those who stop using them.
Those who remained on the drug were less likely to return to work or develop meaningful relationships. Of equal concern, it appeared that brain shrinkage — thought initially to be due to the illness itself — was in fact caused by the drugs. Even when monkeys took these drugs for a period of months, their brains shrank.
If Whitaker was right, everything I had been doing for 20 years was wrong. Many psychiatrists have accused him of cherry-picking the data or distorting the findings of the studies. I have spent much of my time rereading the articles and studies he cites, looking for others, talking to colleagues and reading as much criticism of his work as I can find.
And what I concluded is that Whitaker is probably right.

The dilemma
This created a dilemma for me: If the drugs that are helpful in the short run may be harmful over time, what do I do for the person who is unable to have a conversation because the voices in his head are so loud?
If the medications stop the voices, do I suggest he come off the drugs and risk relapse? Or do I suggest he stay on them and reduce his chances for a full recovery? If I suggest that he stop the drugs and then something bad happens, I may be blamed for his relapse, while I am unlikely to be blamed 30 years from now when he has diabetes.
Doctors are held to a standard of “accepted community practice.” What if my own research has led me to a conclusion that is at odds with accepted community practice? What if accepted community practice is so distorted by pharmaceutical advertising in favor of these drugs that it is suspect and unreliable?
Two years ago, I decided to invite my patients into this conversation. I explain to them what I have read and what conclusions I have drawn, as well as the conflicting views of other psychiatrists.
I have been monitoring those who have chosen to wean themselves from the antipsychotic drugs they have been taking, in some cases for 20 years or more. What has been most striking is that my patients make careful and deliberate decisions. Many psychiatrists fear that having this conversation will lead to massive dropping of the drugs, but this has not been my experience. Some do — most often, the ones who have stopped them multiple times in the past — but most are cautious. Of the 64 people I have tracked, 40 decided to try a dose reduction, 22 chose to remain in their current dose and only four abruptly stopped taking their medications.
Some might think my approach cavalier. When we read about Aaron Alexis, who heard voices and shot 12 people before being killed at the Washington Navy Yard, it raises our fears. However, it is important to keep in mind that the problems I describe are common and that the vast majority of people who experience psychosis are not likely to be violent toward others. One study found an increased risk of violence only among those with mental illness who also abuse drugs or are young men. Such risk factors and an individual’s history would, of course, be a part of any decision about whether to wean someone off medication.
In this context, a blog post by Thomas Insel, the director of the National Institute of Mental Health, received much attention this year. Insel described a Dutch study involving 103 people treated for schizophrenia and related disorders. The participants were randomly assigned to one of two groups: Half remained on drugs continuously; the others stopped taking drugs when they became well but restarted them if symptoms emerged. After seven years, the researchers found that those who were not continuously on drugs had a much greater likelihood of getting a job and resuming their regular life activities than those who remained on medications. Remember that people who stop drugs have a higher rate of relapse? It turns out that over the seven years, those who remained on the drugs relapsed as often as the others.
“For some people, remaining on medication long-term might impede a full return to wellness,” Insel wrote. “For others, discontinuing medication can be disastrous.”
The problem is that we do not know who is in which group.

A slow reduction
A man I have known for many years has had some serious bouts with psychosis. He has been hospitalized multiple times, and his thoughts have put him — though not others — at personal risk. However, the medications have also put him at risk. He is now overweight and has diabetes and his kidneys are not working well. He spends a good part of his day sleeping and the rest watching TV.
We have tried in the past to reduce his dose, but these efforts have never gone well. Within days he would be hallucinating and delusional. However, recently we found that with a very slight reduction in dose, he would relapse for about a month but then improve. Perhaps it was his age or greater experience, but he was able to get through the bad days without getting into trouble, and once things quieted down in his mind he felt better. We have agreed to slowly proceed.
His family supports his choice. We all understand the risk of dose reduction, but we see it in the context of all of the risks. Maintaining his current dose is not without consequence. I have known him for a long time, but the problems of schizophrenia tend to start early and he is still a young man. Even if it takes five years to get him on a significantly lower dose, we have the opportunity to improve the long-term quality of his life.
The Dutch study shifted the focus away from the belief that we need to eradicate all symptoms of schizophrenia to a focus on improving the quality of patients’ lives and health, the relationships they have, the work they do. Some people can learn to live with voices. Some people find that the voices have a significant meaning for them and that communicating with them is what is most important. Some people can learn to talk themselves down from delusional thoughts. And some people might choose hearing voices over being 30 pounds overweight and tired all of the time. The point is that this is not a choice I should be making for my patients; it is a choice I need to make with them.



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Stigma of Mental Illness: Families Are Often Embarrassed By Mentally Ill Relatives, Says New StudyBy Kendra Pierre-Louis
Family support is widely discussed as a beneficial factor in helping people with illnesses cope and even recover from serious illnesses. However, a recent study carried out by Spanish researchers has revealed that when it comes to illnesses, some types of illnesses are less likely to evoke empathy and more likely to evoke shame than others. Specifically, the research suggests that mental health conditions such as alcoholism and depression are more likely to be accompanied not by familial support but by family shame and embarrassment.
The study, which was published in Psychological Medicine, is based on mental health surveys conducted by the World Health Organization, which assessed attitudes regarding illness in more than 16 countries including Spain. The study estimates the degree to which a family member might feel embarrassed when a close relative is suffering from a general medical health condition versus their level of embarrassment when a close relative is suffering from alcoholism, drug addiction, or a mental health condition.
The study found that both mental and physical illnesses take a toll on a family, but that mental illness was significantly more likely to feel a stigma associated with their family member’s illness. The study is unique in that most previous studies have focused on how the sick individual felt, or the overall society’s attitude towards illness. This is the first study of its kind to look at attitudes on the family level.
The authors say that based on the study’s conclusions — which take into account the cultural context of each country surveyed — that anti-stigma campaigns around mental illnesses should include relatives within their target audience.


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Stigma of Mental Illness: Families Are Often Embarrassed By Mentally Ill Relatives, Says New Study
By Kendra Pierre-Louis

Family support is widely discussed as a beneficial factor in helping people with illnesses cope and even recover from serious illnesses. However, a recent study carried out by Spanish researchers has revealed that when it comes to illnesses, some types of illnesses are less likely to evoke empathy and more likely to evoke shame than others. Specifically, the research suggests that mental health conditions such as alcoholism and depression are more likely to be accompanied not by familial support but by family shame and embarrassment.

The study, which was published in Psychological Medicine, is based on mental health surveys conducted by the World Health Organization, which assessed attitudes regarding illness in more than 16 countries including Spain. The study estimates the degree to which a family member might feel embarrassed when a close relative is suffering from a general medical health condition versus their level of embarrassment when a close relative is suffering from alcoholism, drug addiction, or a mental health condition.

The study found that both mental and physical illnesses take a toll on a family, but that mental illness was significantly more likely to feel a stigma associated with their family member’s illness. The study is unique in that most previous studies have focused on how the sick individual felt, or the overall society’s attitude towards illness. This is the first study of its kind to look at attitudes on the family level.

The authors say that based on the study’s conclusions — which take into account the cultural context of each country surveyed — that anti-stigma campaigns around mental illnesses should include relatives within their target audience.



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After Mental Illness, an Up and Down LifeBy Lee GutkindTEMPE, Ariz. — IN 2005, a distraught mother rushed her 13-year-old son to the emergency room for a psychiatric evaluation. The boy was overwrought, consumed by anxiety. The physicians asked the standard questions: Did he want to kill or hurt himself or others? No, was his answer.The boy’s name was Adam Lanza. In the years between that hospital visit and the day, last December, when he shot to death 26 people at a Connecticut elementary school, there is reason to believe he had guidance from well-meaning therapists, parents and teachers. These efforts were obviously ineffective. What went wrong?Twenty years ago, I wrote a book about childhood mental illness that focused on the experiences of two struggling young people in Pittsburgh, Daniel and Meggan. At the time, this is what struck me most about the treatment of children and adolescents with mental health problems: Social workers and psychiatrists mostly tried their best but didn’t know what they were doing, really. The science was imprecise and the system was fractured.Two decades later, we are now able to see inside the brain with startling precision, thanks to sophisticated imaging techniques. And we know a lot more about brain biology. But we have been unable to transform much of that knowledge into definitive treatments.Caring for the mentally ill adult is challenging. Children are considerably more complicated, because they are constantly changing and developing. Adam Lanza may have been a totally different human being in 2005 from the one he was in 2012. Or he may have been the same person, displaying symptoms the experts did not then acknowledge or understand.Recently, I’ve been thinking about Daniel and Meggan, and wondering what happened to them. Had they ended up hurting themselves or others? Had they been able to live productive and satisfying lives?When I met Daniel, he was a scrawny 10-year-old with tight curly hair. He had a scar on his forehead, where a ceiling had collapsed on him during a fire in a rooming house where his family had stashed, ignored and frequently abused him. Daniel was suffering from post-traumatic shock syndrome and schizophrenia and, after being removed from his family, was staying at a residential treatment center — one of 13 places he lived before turning 18.In contrast, Meggan came from an upper-middle-class background, but she, too, suffered through a series of placements. Her parents shuttled her from therapists to hospitals to special schools, seeking help for and insight into her unpredictable behavior. Exhausted and nearly bankrupt, they eventually gave up, voluntarily relinquishing custody of their daughter to the state. This was then a frequent choice for many desperate families.A reversal of approach has taken place since Daniel’s and Meggan’s therapeutic gantlet, when nearly three-fourths of all mental health dollars for adolescents were devoted to institutional care. Today, mental health professionals are more focused on keeping families together. In some states, intervention teams are available to respond to children in crisis, at home or at school. Drop-in centers have been established to provide families a therapeutic timeout. But these and other Band-Aid approaches are employed sporadically, and often, according to the United States Government Accountability Office, they are administered by undertrained personnel. The system, to put it bluntly, is a mess.Funding, obviously, is part of the problem. Fifteen million children in the United States now suffer from some mental health disorder, and the Centers for Disease Control and Prevention reports that their numbers have been rising since at least the mid-1990s. But at the same time, spending on mental health treatment as a share of overall health spending declined from more than 9 percent in the mid-1980s to 7.4 percent in 2004, where it remained through recent years.Resources aren’t the only problem. Psychologists and psychiatrists are still befuddled by basic challenges, beginning with diagnoses, which, for children, can change as they develop. In the 1990s, Meggan was told she was bipolar, then, 10 years later, that she was a high-functioning autistic and, more recently, according to her mother, a borderline personality. She has given up listening to doctors. “I am myself,” she insists, “my own unique flavor of mental health — ‘Meggan’s Syndrome’ — which is pretty awesome!”After diagnoses, there’s the problem of medication. Certainly the advent of anti-psychotic medications has helped improve the treatment of the mentally ill, but dosages are still largely based on trial and error. Many of these drugs lack a Food and Drug Administration recommendation for children and adolescents — but that doesn’t mean they aren’t given to them. Meggan and Daniel were both prescribed a cocktail of drugs as children, one of the first being the mood stabilizer Lithium. According to a 2012 study in JAMA Psychiatry, the rate of antipsychotic drugs administered to children between 1993 and 2009 — Abilify, Geodon, Seroquel and others — has increased by a factor of nearly eight (for adults, the rate has only doubled). And, according to the G.A.O., foster children receive these medications up to four times more often than kids in the general population.Studies have demonstrated that talk therapy or talk therapy combined with medication is more effective than meds alone. But there aren’t enough qualified psychiatrists and psychologists to provide that therapy. Today there are around 7,400 child psychiatrists practicing in the United States (roughly one for every 2,000 patients), compared with 4,600 in 1992. By 2020 there will be around a thousand more, though the American Academy of Child and Adolescent Psychiatry estimates that we will need double the current number by then.I hadn’t communicated with Meggan since the book was published, so this summer I set up an appointment to talk. Now 38, she is the same vivacious and manic Meggan, laughing, crying and contradicting herself. We talked in a conference room at the medical center where she now works — and where she was once an inpatient.She’s had an “up and down” life, she told me. On the plus side, she’s a college graduate with a degree in biology and three children. But she feels lonely and isolated. She is going through a divorce, and about three years ago was cited for marijuana possession, the use of which prompted her parents to seek custody of her children. She stopped cold turkey, and the suit was settled privately. She often works seven days a week, but her parents continue to supplement her income.Daniel and I had kept in touch sporadically. I knew he had been in jail a couple of times for petty crimes and that he had relocated to another state. He married and legally changed his first and last names, thinking that a new name would help him escape the trauma of his past. But painful memories plague him. Now 37, he weighs 267 pounds, at 5-foot-3, and is suffering from congestive heart failure.Meggan and Daniel have demonstrated their ability to survive and their will to persevere. After much effort, Daniel taught himself to read on a basic level, by studying websites and sounding out and memorizing words. And he never relented in his efforts to find work. He is now employed as a part-time cashier at a Ponderosa Steakhouse, his first paying job. He and his wife continue to rely on disability payments, however.Meggan has had setbacks and made harmful choices, but she is now a responsible mother and a breadwinner.Just think what they could have achieved, had they not been held captive by a dysfunctional system. We must work harder to understand mental illness and to provide the resources that social-service professionals need, to ensure that lost children like Meggan and Daniel can achieve their full potential.


For more mental health news, Click Here to access the Serious Mental Illness Blog

After Mental Illness, an Up and Down Life
By Lee Gutkind

TEMPE, Ariz. — IN 2005, a distraught mother rushed her 13-year-old son to the emergency room for a psychiatric evaluation. The boy was overwrought, consumed by anxiety. The physicians asked the standard questions: Did he want to kill or hurt himself or others? No, was his answer.
The boy’s name was Adam Lanza. In the years between that hospital visit and the day, last December, when he shot to death 26 people at a Connecticut elementary school, there is reason to believe he had guidance from well-meaning therapists, parents and teachers. These efforts were obviously ineffective. What went wrong?
Twenty years ago, I wrote a book about childhood mental illness that focused on the experiences of two struggling young people in Pittsburgh, Daniel and Meggan. At the time, this is what struck me most about the treatment of children and adolescents with mental health problems: Social workers and psychiatrists mostly tried their best but didn’t know what they were doing, really. The science was imprecise and the system was fractured.
Two decades later, we are now able to see inside the brain with startling precision, thanks to sophisticated imaging techniques. And we know a lot more about brain biology. But we have been unable to transform much of that knowledge into definitive treatments.
Caring for the mentally ill adult is challenging. Children are considerably more complicated, because they are constantly changing and developing. Adam Lanza may have been a totally different human being in 2005 from the one he was in 2012. Or he may have been the same person, displaying symptoms the experts did not then acknowledge or understand.
Recently, I’ve been thinking about Daniel and Meggan, and wondering what happened to them. Had they ended up hurting themselves or others? Had they been able to live productive and satisfying lives?
When I met Daniel, he was a scrawny 10-year-old with tight curly hair. He had a scar on his forehead, where a ceiling had collapsed on him during a fire in a rooming house where his family had stashed, ignored and frequently abused him. Daniel was suffering from post-traumatic shock syndrome and schizophrenia and, after being removed from his family, was staying at a residential treatment center — one of 13 places he lived before turning 18.
In contrast, Meggan came from an upper-middle-class background, but she, too, suffered through a series of placements. Her parents shuttled her from therapists to hospitals to special schools, seeking help for and insight into her unpredictable behavior. Exhausted and nearly bankrupt, they eventually gave up, voluntarily relinquishing custody of their daughter to the state. This was then a frequent choice for many desperate families.
A reversal of approach has taken place since Daniel’s and Meggan’s therapeutic gantlet, when nearly three-fourths of all mental health dollars for adolescents were devoted to institutional care. Today, mental health professionals are more focused on keeping families together. In some states, intervention teams are available to respond to children in crisis, at home or at school. Drop-in centers have been established to provide families a therapeutic timeout. But these and other Band-Aid approaches are employed sporadically, and often, according to the United States Government Accountability Office, they are administered by undertrained personnel. The system, to put it bluntly, is a mess.
Funding, obviously, is part of the problem. Fifteen million children in the United States now suffer from some mental health disorder, and the Centers for Disease Control and Prevention reports that their numbers have been rising since at least the mid-1990s. But at the same time, spending on mental health treatment as a share of overall health spending declined from more than 9 percent in the mid-1980s to 7.4 percent in 2004, where it remained through recent years.
Resources aren’t the only problem. Psychologists and psychiatrists are still befuddled by basic challenges, beginning with diagnoses, which, for children, can change as they develop. In the 1990s, Meggan was told she was bipolar, then, 10 years later, that she was a high-functioning autistic and, more recently, according to her mother, a borderline personality. She has given up listening to doctors. “I am myself,” she insists, “my own unique flavor of mental health — ‘Meggan’s Syndrome’ — which is pretty awesome!”
After diagnoses, there’s the problem of medication. Certainly the advent of anti-psychotic medications has helped improve the treatment of the mentally ill, but dosages are still largely based on trial and error. Many of these drugs lack a Food and Drug Administration recommendation for children and adolescents — but that doesn’t mean they aren’t given to them. Meggan and Daniel were both prescribed a cocktail of drugs as children, one of the first being the mood stabilizer Lithium. According to a 2012 study in JAMA Psychiatry, the rate of antipsychotic drugs administered to children between 1993 and 2009 — Abilify, Geodon, Seroquel and others — has increased by a factor of nearly eight (for adults, the rate has only doubled). And, according to the G.A.O., foster children receive these medications up to four times more often than kids in the general population.
Studies have demonstrated that talk therapy or talk therapy combined with medication is more effective than meds alone. But there aren’t enough qualified psychiatrists and psychologists to provide that therapy. Today there are around 7,400 child psychiatrists practicing in the United States (roughly one for every 2,000 patients), compared with 4,600 in 1992. By 2020 there will be around a thousand more, though the American Academy of Child and Adolescent Psychiatry estimates that we will need double the current number by then.
I hadn’t communicated with Meggan since the book was published, so this summer I set up an appointment to talk. Now 38, she is the same vivacious and manic Meggan, laughing, crying and contradicting herself. We talked in a conference room at the medical center where she now works — and where she was once an inpatient.
She’s had an “up and down” life, she told me. On the plus side, she’s a college graduate with a degree in biology and three children. But she feels lonely and isolated. She is going through a divorce, and about three years ago was cited for marijuana possession, the use of which prompted her parents to seek custody of her children. She stopped cold turkey, and the suit was settled privately. She often works seven days a week, but her parents continue to supplement her income.
Daniel and I had kept in touch sporadically. I knew he had been in jail a couple of times for petty crimes and that he had relocated to another state. He married and legally changed his first and last names, thinking that a new name would help him escape the trauma of his past. But painful memories plague him. Now 37, he weighs 267 pounds, at 5-foot-3, and is suffering from congestive heart failure.
Meggan and Daniel have demonstrated their ability to survive and their will to persevere. After much effort, Daniel taught himself to read on a basic level, by studying websites and sounding out and memorizing words. And he never relented in his efforts to find work. He is now employed as a part-time cashier at a Ponderosa Steakhouse, his first paying job. He and his wife continue to rely on disability payments, however.
Meggan has had setbacks and made harmful choices, but she is now a responsible mother and a breadwinner.
Just think what they could have achieved, had they not been held captive by a dysfunctional system. We must work harder to understand mental illness and to provide the resources that social-service professionals need, to ensure that lost children like Meggan and Daniel can achieve their full potential.



For more mental health news, Click Here to access the Serious Mental Illness Blog

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[In the News] The Violence in Our Heads
By T. M. Luhrmann
Stanford, California. — The specter of violence caused by mental illness keeps raising its head. The Newtown, Conn., school killer may have suffered from the tormenting voices characteristic of schizophrenia; it’s possible that he killed his mother after she was spooked by his strange behavior and tried to institutionalize him. We now know that Aaron Alexis, who killed 12 people at the Washington Navy Yard on Monday, heard voices; many observers assume that he, too, struggled with schizophrenia.
To be clear: a vast majority of people with schizophrenia — a disease we popularly associate with violence — never commit violent acts. They are far more likely to be the victims of violence than perpetrators of it. But research shows us that the risk of violence from people with schizophrenia is real — significantly greater than it is in the broader population — and that the risk increases sharply when people have disturbing hallucinations and use street drugs. We also know that many people with schizophrenia hear voices only they can hear. Those voices feel real, spoken by an external, commanding authority. They are often mean and violent.
An unsettling question is whether the violent commands from these voices reflect our culture as much as they result from the disease process of the illness. In the past few years I have been working with some colleagues at the Schizophrenia Research Foundation in Chennai, India, to compare the voice-hearing experience of people with schizophrenia in the United States and India.
The two groups of patients have much in common. Neither particularly likes hearing voices. Both report hearing mean and sometimes violent commands. But in our sample of 20 comparable cases from each country, the voices heard by patients in Chennai are considerably less violent than those heard by patients in San Mateo, Calif.
Describing his own voices, an American matter-of-factly explained, “Usually it’s like torturing people to take their eyes out with a fork, or cut off someone’s head and drink the blood, that kind of stuff.” Other Americans spoke of “war,” as in, “They want to take me to war with them,” or their “suicide voice” asking, “Why don’t you end your life?”
In Chennai, the commanding voices often instructed people to do domestic chores — to cook, clean, eat, bathe, to “go to the kitchen, prepare food.” To be sure, some Chennai patients reported disgusting commands — in one case, a woman heard the god Hanuman insist that she drink out of a toilet bowl. But in Chennai, the horrible voices people reported seemed more focused on sex. Another woman said: “Male voice, very vulgar words, and raw. I would cry.”
These observations suggest that local culture may shape the way people with schizophrenia pay attention to the complex auditory phenomena generated by the disorder and so shift what the voices say and how they say it. Indeed, that is the premise of a new patient-driven movement, more active in Europe than in the United States, which argues that if you treat unsettling voices with dignity and respect, you can change them.
The Hearing Voices movement encourages people who hear distressing voices to identify them, to learn about them, and then to negotiate with them. It is an approach that flies in the face of much clinical practice in the United States, where psychiatrists tend to assume that treating such voices as meaningful encourages those who hear them to give them more authority and to follow their commands.
Yet while there is no judgment from the scientific jury at this point, there is evidence that at least some people find that when they use the Hearing Voices approach, their voices diminish, become kinder and sometimes disappear altogether — independent of any use of drugs.
This evidence is strengthened by a recent study in London that taught people with schizophrenia to create a computer-animated avatar for their voices and to converse with it. Patients chose a face for a digitally produced voice similar to the one they were hearing. They then practiced speaking to the avatar — they were encouraged to challenge it — and their therapist responded, using the avatar’s voice, in such a way that the avatar’s voice shifted from persecuting to supporting them.
All of the 16 patients who received a six-week trial of that therapy found that their hallucinations became less frequent, less intense and less disturbing. Most remarkably, three patients stopped hearing hallucinated voices altogether, even three months after the trial. One of those three patients had heard voices incessantly for the prior 16 years.
The more we know about the auditory hallucinations of schizophrenia, the more complex voice-hearing seems and the more heterogeneous the voice-hearing population becomes. Not everyone will benefit from the new approaches. Still, they offer hope for those struggling with a grim disease.
Meanwhile, it is a sobering thought that the greater violence in the voices of Americans with schizophrenia may have something to do with those of us without schizophrenia. I suspect that the root of the differences may be related to the greater sense of assault that people who hear voices feel in a social world where minds are so private and (for the most part) spirits do not speak.
We Americans live in a society in which, when people feel threatened, they think about guns. The same cultural patterns that make it difficult to get gun violence under control may also be responsible for making these terrible auditory commands that much harsher.


For more mental health news, Click Here to access the Serious Mental Illness Blog

[In the News] The Violence in Our Heads

By T. M. Luhrmann

Stanford, California. — The specter of violence caused by mental illness keeps raising its head. The Newtown, Conn., school killer may have suffered from the tormenting voices characteristic of schizophrenia; it’s possible that he killed his mother after she was spooked by his strange behavior and tried to institutionalize him. We now know that Aaron Alexis, who killed 12 people at the Washington Navy Yard on Monday, heard voices; many observers assume that he, too, struggled with schizophrenia.

To be clear: a vast majority of people with schizophrenia — a disease we popularly associate with violence — never commit violent acts. They are far more likely to be the victims of violence than perpetrators of it. But research shows us that the risk of violence from people with schizophrenia is real — significantly greater than it is in the broader population — and that the risk increases sharply when people have disturbing hallucinations and use street drugs. We also know that many people with schizophrenia hear voices only they can hear. Those voices feel real, spoken by an external, commanding authority. They are often mean and violent.

An unsettling question is whether the violent commands from these voices reflect our culture as much as they result from the disease process of the illness. In the past few years I have been working with some colleagues at the Schizophrenia Research Foundation in Chennai, India, to compare the voice-hearing experience of people with schizophrenia in the United States and India.

The two groups of patients have much in common. Neither particularly likes hearing voices. Both report hearing mean and sometimes violent commands. But in our sample of 20 comparable cases from each country, the voices heard by patients in Chennai are considerably less violent than those heard by patients in San Mateo, Calif.

Describing his own voices, an American matter-of-factly explained, “Usually it’s like torturing people to take their eyes out with a fork, or cut off someone’s head and drink the blood, that kind of stuff.” Other Americans spoke of “war,” as in, “They want to take me to war with them,” or their “suicide voice” asking, “Why don’t you end your life?”

In Chennai, the commanding voices often instructed people to do domestic chores — to cook, clean, eat, bathe, to “go to the kitchen, prepare food.” To be sure, some Chennai patients reported disgusting commands — in one case, a woman heard the god Hanuman insist that she drink out of a toilet bowl. But in Chennai, the horrible voices people reported seemed more focused on sex. Another woman said: “Male voice, very vulgar words, and raw. I would cry.”

These observations suggest that local culture may shape the way people with schizophrenia pay attention to the complex auditory phenomena generated by the disorder and so shift what the voices say and how they say it. Indeed, that is the premise of a new patient-driven movement, more active in Europe than in the United States, which argues that if you treat unsettling voices with dignity and respect, you can change them.

The Hearing Voices movement encourages people who hear distressing voices to identify them, to learn about them, and then to negotiate with them. It is an approach that flies in the face of much clinical practice in the United States, where psychiatrists tend to assume that treating such voices as meaningful encourages those who hear them to give them more authority and to follow their commands.

Yet while there is no judgment from the scientific jury at this point, there is evidence that at least some people find that when they use the Hearing Voices approach, their voices diminish, become kinder and sometimes disappear altogether — independent of any use of drugs.

This evidence is strengthened by a recent study in London that taught people with schizophrenia to create a computer-animated avatar for their voices and to converse with it. Patients chose a face for a digitally produced voice similar to the one they were hearing. They then practiced speaking to the avatar — they were encouraged to challenge it — and their therapist responded, using the avatar’s voice, in such a way that the avatar’s voice shifted from persecuting to supporting them.

All of the 16 patients who received a six-week trial of that therapy found that their hallucinations became less frequent, less intense and less disturbing. Most remarkably, three patients stopped hearing hallucinated voices altogether, even three months after the trial. One of those three patients had heard voices incessantly for the prior 16 years.

The more we know about the auditory hallucinations of schizophrenia, the more complex voice-hearing seems and the more heterogeneous the voice-hearing population becomes. Not everyone will benefit from the new approaches. Still, they offer hope for those struggling with a grim disease.

Meanwhile, it is a sobering thought that the greater violence in the voices of Americans with schizophrenia may have something to do with those of us without schizophrenia. I suspect that the root of the differences may be related to the greater sense of assault that people who hear voices feel in a social world where minds are so private and (for the most part) spirits do not speak.

We Americans live in a society in which, when people feel threatened, they think about guns. The same cultural patterns that make it difficult to get gun violence under control may also be responsible for making these terrible auditory commands that much harsher.



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[IN THE NEWS] Services for the Underserved Addresses Mental Illness Among Young Adults Under New Citywide Initiative
By Staff WriterBehavioral Health News
Many youth are hit suddenly with mental illness during their teens and early adulthood. For some, it may be as many as seven years between their “first break” and the first time they formally receive treatment. This results in many of them lagging behind their peers as they transition to adulthood. Working in partnership with the New York City Department of Health and Mental Hygiene (DOHMH), Services for the UnderServed (SUS) aims to change that trajectory.  
With funding from the Centers for Medicare and Medicaid Services, DOHMH has launched Parachute NYC, a new citywide pilot, which provides options for people experiencing emotional and mental health problems. When youth grow older and fall into an adult age bracket for treatment—often leading to institutionalization—they are stigmatized and marginalized by society. This strips them of hope for the future and disconnects them from their communities.  
Instead of going to a hospital, Parachute NYC offers a “soft landing” into mental health care and support for people in crisis. The project offers an alternative to traditional emergency room and inpatient care, through which young adults are diverted from institutional settings, and are able to avoid a revolving door of repeat hospitalization.  
As part of Parachute NYC, SUS and several other New York City-based organizations were selected to create an integrated series of interventions for these individuals. SUS is the only agency chosen to serve young adults 18-30 years old with mental illness—those with little or no experience with the institutional mental health system, and those needing respite from their current living environments. SUS’ Parachute Project, a Crisis Respite Center (CRC) in Brooklyn, is as much a respite for these young adults as it is a prevention program. It offers them temporary residential care for up to two weeks, in a safe and supportive home-like environment, helping to prevent chronicity of mental illness.  
During their voluntary stay, Parachute “guests” are taught recovery and relapse prevention skills with the 24-hour support of peers in conjunction with the clinical support of the Woodhull Hospital Mobile Crisis Team. Project staff work with the young adults and their families, where indicated, to develop a recovery plan that focuses on their immediate wellness goals in preparation for their return home, to school and to work. The Project is intended to help these young adults get their lives back on track as quickly as possible and restore their wellness by providing immediate and continuous care. This model is designed to ensure better continuity of care and recovery outcomes for these young adults and will reduce their use of emergency and inpatient care during psychiatric emergencies.  
SUS’ effort in this space carves a new niche for the agency in the health care landscape by pioneering a new approach to treatment for this population, which is often overlooked in the mental health field. SUS is proud to be a partner in this new initiative, which empowers young adults in managing their own recovery from mental illness. 

For more mental health news, Click Here to access the Serious Mental Illness Blog

[IN THE NEWS] Services for the Underserved Addresses Mental Illness Among Young Adults Under New Citywide Initiative

By Staff Writer
Behavioral Health News

Many youth are hit suddenly with mental illness during their teens and early adulthood. For some, it may be as many as seven years between their “first break” and the first time they formally receive treatment. This results in many of them lagging behind their peers as they transition to adulthood. Working in partnership with the New York City Department of Health and Mental Hygiene (DOHMH), Services for the UnderServed (SUS) aims to change that trajectory.  

With funding from the Centers for Medicare and Medicaid Services, DOHMH has launched Parachute NYC, a new citywide pilot, which provides options for people experiencing emotional and mental health problems. When youth grow older and fall into an adult age bracket for treatment—often leading to institutionalization—they are stigmatized and marginalized by society. This strips them of hope for the future and disconnects them from their communities.  

Instead of going to a hospital, Parachute NYC offers a “soft landing” into mental health care and support for people in crisis. The project offers an alternative to traditional emergency room and inpatient care, through which young adults are diverted from institutional settings, and are able to avoid a revolving door of repeat hospitalization.  

As part of Parachute NYC, SUS and several other New York City-based organizations were selected to create an integrated series of interventions for these individuals. SUS is the only agency chosen to serve young adults 18-30 years old with mental illness—those with little or no experience with the institutional mental health system, and those needing respite from their current living environments. SUS’ Parachute Project, a Crisis Respite Center (CRC) in Brooklyn, is as much a respite for these young adults as it is a prevention program. It offers them temporary residential care for up to two weeks, in a safe and supportive home-like environment, helping to prevent chronicity of mental illness.  

During their voluntary stay, Parachute “guests” are taught recovery and relapse prevention skills with the 24-hour support of peers in conjunction with the clinical support of the Woodhull Hospital Mobile Crisis Team. Project staff work with the young adults and their families, where indicated, to develop a recovery plan that focuses on their immediate wellness goals in preparation for their return home, to school and to work. The Project is intended to help these young adults get their lives back on track as quickly as possible and restore their wellness by providing immediate and continuous care. This model is designed to ensure better continuity of care and recovery outcomes for these young adults and will reduce their use of emergency and inpatient care during psychiatric emergencies.  

SUS’ effort in this space carves a new niche for the agency in the health care landscape by pioneering a new approach to treatment for this population, which is often overlooked in the mental health field. SUS is proud to be a partner in this new initiative, which empowers young adults in managing their own recovery from mental illness. 




For more mental health news, 
Click Here to access the Serious Mental Illness Blog

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Mobile mental health care pilot kicks off in JakartaHumanitarian news and analysis - A service of the UN Office for the Coordination of Humanitarian Affairs
JAKARTA, 30 August 2013 (IRIN) - Viviana Sari, an Indonesian high school student, was at a loss for words when psychiatrist Tiur Sihombing asked her to define the word “depression”. 
“Stressed?” the 17-year-old said hesitantly. Viviana was among more than two dozen students at Jakarta’s state-run High School No. 70 taking part in a recent counselling session conducted by a team from the Mobile Mental Health Service, a joint government and NGO initiative aimed at improving mental health in the country. 
Strengthening community mental health systems is one of the government’s goals in improving access to health care, an area often neglected and poorly-funded in this largely rural nation of more than 250 million. 
Launched in July, two blue buses emblazoned with the sign Mobile Mental Health Service now ply the streets of the capital Jakarta three days a week, making stops in schools and other public places to provide free mental health services, including counselling, treatment and education. 
Each mobile clinic is staffed by a psychiatrist, a general practitioner, two psychologists and a nurse. 
The pilot project - the brainchild of the Indonesian Health Ministry, the Metaforma Institute, a local NGO, and the Jakarta Health Department - aims to promote mental health care amid widespread ignorance about the scourge. 
“The prevalence of mental health problems is among the highest in Jakarta, but many people are not aware,” Marleni Desnita, head of the counselling division at the Health Ministry’s directorate of mental health, told IRIN. 
“With this project we hope to disseminate information about mental health, that mental health problems are treatable and those with the problems don’t need to be isolated, shackled or cast away,” she said. 
Under-diagnosed and untreated 
According to the Ministry of Health, some 19 million Indonesians have some form of mental health disorder, including anxiety and depression, while at least one million have severe psychoses. 
This in a country where about 18,000 people - mostly in rural areas and bereft of any mental health services - continue to be chained or shackled because of mental illness, while large pockets of the country still cite magic spells as the cause. 
In Indonesia, up to 80 percent of people consult traditional healers as a first resort even if medical services are available, which accounts for why formal medical services are not often used, according to a recent policy paper. 
The mobile clinic project would be evaluated in three months and could be expanded to other provinces if deemed successful. So far, it has been well-received by the public, Desnita said. 
“People have been very enthusiastic. They talk about it to their relatives and neighbors. It’s good because it means there’s less stigma attached to mental disorders,” she said. 
Latest government statistics show the prevalence of anxiety and depression in Jakarta stands at 14 percent, higher than the national average, while the prevalence of serious of mental illness such as schizophrenia is around 2 percent. 
Moving forward 
As part of its overall health strategy, the government plans to provide 30 percent of the country’s 9,000 community health clinics and 1,700 general hospitals with new and redistributed staff to provide basic mental health care by 2014. 
Currently, 33 specialized mental health hospitals and 600 psychiatrists offer public mental health care across the sprawling archipelago, according to the Health Ministry. 
Indonesia has fewer than 0.05 psychiatrists per 10,000 inhabitants, compared to 0.3 in neighbouring Singapore and 1.3 in Australia, the World Health Organization reported in 2013. 
Sihombing, one of the psychiatrists on board the mobile clinic, said many of the patients who consulted her spoke of symptoms of serious mental disorders. 
“It’s encouraging that more and more people are aware of the need to consult health professionals for their mental health issues,” Sihombing said. 
The introduction of a universal health scheme in the capital in 2012 by Governor Joko Widodo, known as Jakarta Health Care, has also prompted more people to seek treatment. 
“Before the introduction of the Jakarta Health Care, the Duren Sawit Mental Hospital where I practise received about 30-40 mental health patients a day, but now the number has doubled,” she said. 
Viviana said she learned so much from the interaction with mobile clinic’s team. 
“Now I know what depression is; how to deal with it and prevent it. As teenagers we have a lot of problems, but I hope I will never have to visit a psychiatrist.” 

For more mental health news, Click Here to access the Serious Mental Illness Blog

Mobile mental health care pilot kicks off in Jakarta
Humanitarian news and analysis - A service of the UN Office for the Coordination of Humanitarian Affairs

JAKARTA, 30 August 2013 (IRIN) - Viviana Sari, an Indonesian high school student, was at a loss for words when psychiatrist Tiur Sihombing asked her to define the word “depression”. 

“Stressed?” the 17-year-old said hesitantly. Viviana was among more than two dozen students at Jakarta’s state-run High School No. 70 taking part in a recent counselling session conducted by a team from the Mobile Mental Health Service, a joint government and NGO initiative aimed at improving mental health in the country. 

Strengthening community mental health systems is one of the government’s goals in improving access to health care, an area often neglected and poorly-funded in this largely rural nation of more than 250 million. 

Launched in July, two blue buses emblazoned with the sign Mobile Mental Health Service now ply the streets of the capital Jakarta three days a week, making stops in schools and other public places to provide free mental health services, including counselling, treatment and education. 

Each mobile clinic is staffed by a psychiatrist, a general practitioner, two psychologists and a nurse. 

The pilot project - the brainchild of the Indonesian Health Ministry, the Metaforma Institute, a local NGO, and the Jakarta Health Department - aims to promote mental health care amid widespread ignorance about the scourge. 

The prevalence of mental health problems is among the highest in Jakarta, but many people are not aware,” Marleni Desnita, head of the counselling division at the Health Ministry’s directorate of mental health, told IRIN. 

“With this project we hope to disseminate information about mental health, that mental health problems are treatable and those with the problems don’t need to be isolated, shackled or cast away,” she said. 

Under-diagnosed and untreated 

According to the Ministry of Health, some 19 million Indonesians have some form of mental health disorder, including anxiety and depression, while at least one million have severe psychoses

This in a country where about 18,000 people - mostly in rural areas and bereft of any mental health services - continue to be chained or shackled because of mental illness, while large pockets of the country still cite magic spells as the cause

In Indonesia, up to 80 percent of people consult traditional healers as a first resort even if medical services are available, which accounts for why formal medical services are not often used, according to a recent policy paper. 

The mobile clinic project would be evaluated in three months and could be expanded to other provinces if deemed successful. So far, it has been well-received by the public, Desnita said. 

People have been very enthusiastic. They talk about it to their relatives and neighbors. It’s good because it means there’s less stigma attached to mental disorders,” she said. 

Latest government statistics show the prevalence of anxiety and depression in Jakarta stands at 14 percent, higher than the national average, while the prevalence of serious of mental illness such as schizophrenia is around 2 percent. 

Moving forward 

As part of its overall health strategy, the government plans to provide 30 percent of the country’s 9,000 community health clinics and 1,700 general hospitals with new and redistributed staff to provide basic mental health care by 2014. 

Currently, 33 specialized mental health hospitals and 600 psychiatrists offer public mental health care across the sprawling archipelago, according to the Health Ministry. 

Indonesia has fewer than 0.05 psychiatrists per 10,000 inhabitants, compared to 0.3 in neighbouring Singapore and 1.3 in Australia, the World Health Organization reported in 2013. 

Sihombing, one of the psychiatrists on board the mobile clinic, said many of the patients who consulted her spoke of symptoms of serious mental disorders. 

“It’s encouraging that more and more people are aware of the need to consult health professionals for their mental health issues,” Sihombing said. 

The introduction of a universal health scheme in the capital in 2012 by Governor Joko Widodo, known as Jakarta Health Care, has also prompted more people to seek treatment. 

“Before the introduction of the Jakarta Health Care, the Duren Sawit Mental Hospital where I practise received about 30-40 mental health patients a day, but now the number has doubled,” she said. 

Viviana said she learned so much from the interaction with mobile clinic’s team. 

Now I know what depression is; how to deal with it and prevent it. As teenagers we have a lot of problems, but I hope I will never have to visit a psychiatrist.” 




For more mental health news, 
Click Here to access the Serious Mental Illness Blog

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20 notes

[Article of Interest] Effect of Diagnostic Labeling
New study by Lorenza Magliano, John Read et al, in Psychiatry Research, (in press, 2013)
This study examines whether medical students’ views of treatments for ‘schizophrenia’ and of patients’ rights to be informed about their condition and their medication were influenced by diagnostic labeling and causal explanations and whether they differed over medical training.
Three hundred and eighty one Italian students attending their first or fifth/sixth year of medical studies read a vignette portraying someone who met diagnostic criteria for ‘schizophrenia’ and completed a self-report questionnaire.
The study found that labeling the case as ‘schizophrenia’ and naming heredity among its causes were associated with confidence in psychiatrists and psychiatric drugs. Naming psychological traumas among the causes was associated with confidence in psychologists and greater acknowledgment of users’ right to be informed about drugs.
Compared to first year students, those at their fifth/sixth-year of studies more strongly endorsed drugs, had less confidence in psychologists and family support, and were less keen to share information on drugs with patients.
These findings highlight that students’ beliefs vary during training and are significantly related to diagnostic labeling and belief in a biogenetic causal model.
Psychiatric curricula for medical students should include greater integration of psychological and medical aspects in clinical management of ‘schizophrenia’; more information on the psychosocial causes of mental health problems.

For more mental health news, Click Here to access the Serious Mental Illness Blog

[Article of Interest] Effect of Diagnostic Labeling

New study by Lorenza Magliano, John Read et al, in Psychiatry Research, (in press, 2013)

This study examines whether medical students’ views of treatments for ‘schizophrenia’ and of patients’ rights to be informed about their condition and their medication were influenced by diagnostic labeling and causal explanations and whether they differed over medical training.

Three hundred and eighty one Italian students attending their first or fifth/sixth year of medical studies read a vignette portraying someone who met diagnostic criteria for ‘schizophrenia’ and completed a self-report questionnaire.

The study found that labeling the case as ‘schizophrenia’ and naming heredity among its causes were associated with confidence in psychiatrists and psychiatric drugs. Naming psychological traumas among the causes was associated with confidence in psychologists and greater acknowledgment of users’ right to be informed about drugs.

Compared to first year students, those at their fifth/sixth-year of studies more strongly endorsed drugs, had less confidence in psychologists and family support, and were less keen to share information on drugs with patients.

These findings highlight that students’ beliefs vary during training and are significantly related to diagnostic labeling and belief in a biogenetic causal model.

Psychiatric curricula for medical students should include greater integration of psychological and medical aspects in clinical management of ‘schizophrenia’; more information on the psychosocial causes of mental health problems.




For more mental health news, 
Click Here to access the Serious Mental Illness Blog

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