5 Shortcomings of Young Adult Psychiatric Care

This week, a long-time patient came to see me for her regularly scheduled appointment. After checking-in on her own (now stable) mental health, she wanted to discuss her niece’s recent evaluation by a psychiatrist in another city.

She said, “My niece is nineteen. She went to see a counselor because she was stressed out about college. At the first session, the counselor thought she needed to be taking an antidepressant, and so she sent my niece to a psychiatrist. Her sister took her to the psychiatrists’ office hoping to go in with her, but was told that even with consent by the patient no family members were allowed in the room while the doctor evaluated a patient. After thirty-five minutes speaking to my niece alone, he prescribed an antidepressant and gave her instructions she didn’t really understand. My niece walked out confused, overwhelmed, and feeling all alone. She didn’t know whether to take the medication. Nothing about the situation seems appropriate to me. Do you think this is good medical care?”

Her story was typical of the standard of psychiatric care for young adults with a crisis brought on by stress. I could see a number of problems:

1.     Brief visits. Thirty-five minutes may be enough time to run through short list of medical questions like, “How much alcohol do you drink?” and, “How many hours do you sleep each night?” but it’s certainly not enough time to get to know a person’s normal baseline or to diagnose disease.

When searching for a psychiatric evaluation, it might be important to ask how long an appointment is expected to last. If the visits are routinely short, consider looking for a doctor who spends more time with patients.

2.     Refusal to receive collateral from family members. Mental health professionals can be sticklers for confidentiality rules. Families often complain that they aren’t allowed to express important observations of a loved one’s behavior, or even serious medication reactions, to psychiatrists, even when the patient offers consent.

Contact with family members is not strictly forbidden by privacy rules, but a signed consent form may be required. Common reasons for refusing to include family members in sessions may include misinterpretation of the rules of privacy, or limited time (see item number 1) since additional parties in the room can extend the time required for an evaluation. If having family members involved to share information is important, ask about a doctor’s policy ahead of time.

3.     Refusal to discuss the treatment plan with family members, even when the patient has requested to have someone present.

Whatever the specialty of the doctor, having a family member sit in to the educational portion of the session reduces forgetting and errors. Inquire about the doctor’s policies in advance.

4.     Rush to DSM 5 diagnosis without considering the long-term ramifications. When a young adult receives a new mental illness diagnosis, she may absorb the illness into her sense of self- see it as who she is. But not all young adults with an episode of depression will go on to experience another one.

Patients and families should ask specifically to discuss the doctor’s opinion about the long-term prognosis. After a single episode, even if treatment is required, there is usually no clear indication a person will suffer from lifelong depression.

5.     Rush to prescribing medication. The use of medications for depression is based on research in a broad range of adults, not a group of nineteen year olds. Since young brains are different than mature brains, the effects of medications in young people might be different from the effects in mature research subjects.

Because young brains are different than the average adults who volunteer for research studies, prescription medication should be considered for young adults only after non-medication alternatives have been exhausted. It is unclear why the nineteen year old described above was referred to a psychiatrist so early in her course.

Dr. Deuter is a psychiatrist who specializes in the care of emerging adults. 

5 Things To Discuss Before Your Teen Heads Off To College

Communication between college students and parents is key. Here are five important things to talk about before your teen leaves home:

The Budget

One of the biggest potential sources of family conflict is the college student budget. Whether you are funding your child’s education, or expecting him to come up with the money himself, your child will need to be on the same page. If your financial assistance will be limited, it’s importance to explain what help you can provide and how it will be distributed. Plan to deposit five hundred dollars a month to help out? Say so. Don’t expect your child to intuit your financial plan.

Parents often promise to pay for college in full, but may not define their expectations clearly. Maybe you have been saving since your child was a toddler, but how to you plan to disperse the funds? What if the savings won’t be enough to cover living expenses all four years? Paying for college extends well beyond tuition.

Points to consider:

·      Who will pay living expenses? Will those be paid directly by parents, or will money be deposited in an account for the student to use to pay bills him/herself?

·      How will food, transportation, and clothing be paid for?

·      What about the cell phone?

·      Will parents pay for health care?

·      Who will pay for extras?

The Timeline

College isn’t always four years of coursework. Some students extend time in college because their programs last five or more years. Some change majors. Others take it slowly for the first couple of years.

If your plan is to fund college for your child, does your strategy take these things in to account? Is there a time limit to your financial support? How about your patience? Are you prepared to pull the plug if your child is on the seven-year plan? If so, maybe she needs to hear your thoughts ahead of time, so she can find a part time job or pick up the pace.

Crisis Situations

Medical or mental health crisis: Record numbers of college students are seeking mental health support according to recently published studies. Common mental health related causes for leaving college include: depression, anxiety, panic attacks, excessive drinking, and drug use. Are there medical or psychiatric issues that might prevent your college student from completing school uninterrupted? If so, under what circumstances might you need to bring him home? Does he know when to ask for your help?

Academic Crisis: Do you have a plan for failing college grades? Most paying parents won’t want to continue writing checks unless kids are producing passing grades. Have you discussed your views with your soon to be college student?

Breaks From School

Some parents express frustration when kids arrive back home during college breaks, dump their laundry next to the washing machine, and flop down into bed for the duration of the school break. If your son or daughter is home on break, do you expect him or her to help around the house? Work a summer job? Be up and at ‘em by nine every morning and in bed before midnight? Whatever your expectations, be certain to spell them out before the first academic break begins.

Plan B

Recent statistics estimate that almost half of college enrollees drop out before completing a degree. No parent sends a kid to college hoping she’ll drop out, but with estimated dropout rates so high, all parents and new college students should discuss alternative strategies in case college doesn’t work out. 

Dr. Deuter is a psychiatrist who specializes in the care of emerging adults.

Why Is Everyone "For" Or "Against" Treating Mental Disorders?

Everywhere I turn, people are debating mental illness. Not only in the media, but also in my community, the subjects of rising autism rates, ADHD versus bad parenting, mental health funding versus gun control are all being discussed passionately. I scan social media to see that my friends, “friends,” family, and colleagues are sharing posts, updates, and tweets taking a firm stance on some aspect of mental healthcare. I see updates shared by professionals: psychiatrists, psychologists, social workers or others who diagnose and treat people with mental illnesses or addictions. But lay people share content and take positions on mental illness as well, many of them my family and friends. I have observed hundreds (maybe thousands) of social media postings and community discussions about mental health, and regardless of the sharer, opinions seem to only come in two flavors: For and Against. Either the opinion-holder takes a position that mental healthcare is underfunded, stigma must be battled, and awareness must grow so we can expand services (For), or by contrast the opinionated will say mental disorders are overdiagnosed, bad parents let doctors push pills on themselves and their innocent children, and we’ve all been duped by big pharma (Against).

Each time I read a plug for one side of the debate or the other, I hear myself respond the same way: I know which perspective is the truth: Both.

As a practicing clinical psychiatrist, I am giving care for a range of mental health problems. My patients span from the “worried well” to the seriously mentally ill. Anyone on the entirety of the spectrum may walk though my front door. On the one hand, I treat many truly mentally ill people who battle stigma and cannot afford care. They fight shame, worrying about discriminatory treatment in the workplace as well as in social contexts. They struggle to pay for unethically expensive medications. (One example: bipolar patients take an average of three to four medications for the bipolar diagnosis- and some bipolar medications can cost more than five hundred dollars for a month supply of a single med.)

But I also have patients who are not seriously ill. They come seeking answers, and I find that some tend to rely unnecessarily on medical doctors for solutions to life’s problems for themselves and their children. Some are in situational distress due to failing marriages or careers or school failure; others chalk up problem behaviors to biologic disease rather than gaining or teaching self-control. They seek a “magic pill” to solve problems pills cannot solve.

Both extremes exist. Mental illnesses go undertreated, while clinics are overrun with healthier patients over-utilizing mental health care resources. The most severely mentally ill suffer from lifelong psychiatric sicknesses. Some of those sicknesses rob people of their independence and ability to work for income. Chronic diseases burden patients due to high cost and limited access.

Meanwhile, clinics are overflowing with less serious patients. The healthier patients may not need care, or may need only short term treatment. Those with transient, stressor-induced symptoms may continue to receive care far too long. Most episodes of mental distress are destined to come, and then go, as stressors abate. Unfortunately, patients with short term, symptom-inducing mental distress may mistakenly believe they suffer from chronic psychiatric illness. As our profession tries to expand access to care and raise awareness, we seem to be catching too many healthy people in our nets.

The origins of these problems are complex. For one, mental health criteria are vague, leaving far too much room for subjective interpretation. Doctors, trained to diagnose disease and prescribe treatment, stretch these vague criteria to explain patients’ symptoms and rarely turn away anyone asking for care. Doctors diagnose and prescribe even when reassurance or support might have been more appropriate. Patients want answers- easy ones if possible. Payers want diagnoses and scientifically validated medical treatments, labeling with “normal stressors” and treating with “reassurance” can be expensive for patients when payers refuse to cover them.

One of the biggest burdens on our current medical care system is the treatment of mental illnesses. Presently, the approach is messy and inefficient. Both over-diagnosis and under-diagnosis run rampant. Educate yourself. Take charge of your healthcare. Advocate for change. Do something. But please don’t take a simple stand For or Against.

Dr. Deuter is a psychiatrist who specializes in the care of emerging adults.

Twenty-Something’s at Work: Bridging the Gap

If you are an adult over thirty-five, chances are you have found yourself wondering what is with the newest “crop” of adults who are entering adulthood roles. Everywhere I look, there are news articles about “millennials” struggling in the workplace and the current generation of “narcissistic” twenty-somethings. One perspective on millennials is that they were raised in an era of “everyone gets a trophy,” and as a result they all think they are above average. Another view holds that as digital natives with constant access to video games and text messaging, young adults are awkward, socially anxious, and overwhelmed by the greater world. It appears millennials are viewed as a product of parenting and cultural mistakes over the past twenty years.

One such twenty-something, Tara, has been coming to see me for anxiety since she was a teen. She is a clever, practical young woman who has been working and supporting herself for the last two years. Tara works for a small insurance agency. She started off working in a crowded office. She commuted in to the city every morning, settled in to her uncomfortable office chair, and logged-on to a desktop computer. Five days a week, she served out her nine hour sentence. She entered data into spreadsheets while distracted by office gossip and a constant clash of office personalities around her. Tara felt her work was inefficient. She was unhappy. So, she put in a request to begin working from home.

Initially, her request to work remotely was met with confusion and disdain by fellow professionals. She was seen as spoiled, demanding, and entitled. Senior team members, many in their sixties, equated “working from home” with getting paid for laying on the couch. Tara was confused. Her desire was to become a more effective employee, not to slack-off. But after the work-at-home request was granted and Tara stopped commuting to the office, her colleagues were pleasantly surprised. Tara finished projects in record time, and even took on additional responsibilities.

Tara’s perspective on workplace efficiency and her co-workers’ misinterpretation of her intentions are fairly typical workplace dynamics for millennials. They are often seen as selfish, demanding, or difficult. If you work with twenty-somethings, bear in mind the following:

            - They are young and inexperienced. A social faux pas that drives co-workers and supervisors mad may simply occur because twenty-somethings are still learning. What appears grandiose, narcissistic, and self-important may be a naïve attempt to be assertive or confident.

            - Their parents may have sheltered them. Millennials have been known to take their parents with them to job interviews. I recently read a news story about a company sending out performance “report cards” to parents of workers in their early to mid twenties. One of the most common complaints about the current crop of new adults is their tendency to seek handholding from supervisors. But if close supervision is all they’ve known, of course they need a little reassurance at first. Take the opportunity to become a mentor.

            - Millennials typically care a lot about efficiency and work-life balance, and less about wealth and status. To attract young workers, companies are increasingly offering shorter hours, work-at-home options, and a more comfortable work environment.

            - They want to make a difference, not just collect a paycheck. Young adults are major participants in any opportunity to stay connected to the community- like company wide service projects.

            - As with any demographic group, there is more variation within a group of twenty-somethings than you might think. Resist the urge to stereotype and get to know your young colleagues as individuals.

Dr. Deuter is a psychiatrist who specializes in the care of emerging adults.