Catch or Release: Gatekeeping in Mental Health

Last week a long time patient asked me about my blog. He had been reading it, but wondered why I focused on writing about teens and young adults. Why not write about some of the issues we were working on for him: relationships, divorce, or PTSD? After all, he said, he is no longer a young adult (he’s 35) and I still treat him. Why not write about midlife?

I considered his question for a long time. Why focus primarily on teens and young adults?

The care of young people, often new to the mental health system, presents special issues. The decisions mental health professionals make regarding these young people have big consequences. On the one hand, if the system can help a kid after he tries heroin the first time, and not wait until his third ICU stay from overdose; or likewise treat a college student with depression when it begins, and not wait ten years until hopelessness has robbed her of the ability to function and left her perpetually wishing for death, offering early treatment can save lives.

Yet it’s not just prevention that makes the care of young people distinctive. Screening folks in or out of care is unique to newcomers into the system. Young people come into mental health care, brought by families, and decisions we make will determine whether they stay in care or move on to have lives free of mental health contact. Young patients may have transient problems or the beginnings of lifelong illnesses. Our assessments and diagnoses, the education we provide families, and the expectations we set as clinicians can influence long-term outcomes profoundly.

Many young people come in to the system due to worried parents and stage of life bumps in the road, and their care must be approached differently. Unfortunately, many professionals are using a cookie cutter approach to all patients who enter the mental health care system. Teens and twenty-somethings are given too much medication, given serious and scary diagnoses and prognoses, and when the treatment is excessive, the patients deteriorate rather than recover. Mental health care involvement for healthy young people is essentially making things worse.

Early detection and early treatment can drastically improve outcomes for those with real illness, but early treatment can worsen outcomes for the bumpy stage of life group. Mental health practitioners and advocates need to re-think an overly inclusive model of mental health care. We need to protect healthy young people from excessive care, and make room in the strapped mental health care system for the people who truly need the vital but limited resources. We need to allocate the resources to the right place.

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

Will Science Unlock the Secrets to Mental Disorders?

Mental health awareness and reducing stigma are in the news at higher rates as the public tries to understand the toll untreated illnesses take. I read a headline yesterday, “Are We Entering A Golden Age of Neuroscience Research?” It would be nice to think so. For me as a psychiatrist, sometimes the options for treating the most complex patients seem bleak. What we can offer now in mental health is simply inadequate. I don’t try to hide that fact from my patients. We work together and do the best we can to alleviate psychic pain and restore well-being, but the treatments we offer fall short of curing suffering in human minds. 

Psychiatric diagnosis, medication, or understanding of disease- these are all not exactly accurate. 

Diagnosis
Mental health diagnosis is still made checking off symptoms from a list. The checklists were developed decades ago to make sure doctors were describing the same illnesses when they used words like “depression” and “schizophrenia.” But it has never been proven that the checklist for depression (or for any other illness) actually captures a single disease. Maybe the symptoms we call “depression” can be produced by seventeen different causes requiring as many different treatments. And maybe the list fails to capture everyone in need of treatment. Even if we identify all the right people, checking off all the items from the list says nothing about why a patient has the symptoms or whether the symptoms can successfully be treated.

Treatments
When patients ask how psychiatric medications work to treat their symptoms, the most honest answer a doctor could give is, “We really don’t know.” Although PET, SPECT, and fMRI scans and chemical tests of brain neurochemistry show us what changes in the brain after taking a medication, we have never proven that the changes we can measure are why the medications help. The same is true for talk therapies and other treatments. Researchers can predict what percentage of patients will improve, but they cannot explain why one person will improve and not another, or whether a given patient will fall in the good-responder or the poor-responder group (or somewhere in between).

Evidence-based care
Throughout the medical field, there is a push for more evidence-based care. Rather than acting on intuition or basing treatments on experience, physicians are urged to study the scientific research and choose treatments based on the evidence. However, in mental health care, there is often not enough evidence to guide physicians. 

Experts within the psychiatric field are divided on the best ways to solve the mental health crisis. Leaders in the field argue how to conduct the research and about the strength of the scientific evidence.

Robert Whitaker wrote in his blog (at madinamerica.com) about scientific findings showing that some of our standard practices, defended by medical and psychiatric professionals, don’t really work. He referenced a research study by Wunerink, which found that the accepted practice of leaving schizophrenic patients on medication long term is not effective. Whitaker notes, for psychiatry to truly “follow the evidence,” standard treatment should have changed after that study but it didn’t. Leaders in the field are emerging against the practices as usual- people like Allen Frances and Thomas Insel, but the general practices are not changing even with these “high-ranking voices of dissent.”

Whitaker also raises concerns about inaccurate teachings on “chemical imbalance,” “serotonin deficiency,” “curable illnesses” in mental health, and even the basic ways mental illnesses are diagnosed with checklists of symptoms forming supposed “illnesses.” He notes that these ideas have all been discredited, but are still being practiced routinely. He believes many of the practices are being maintained simply because of tradition or fear of change- or worse, conflicts of interest. 

Joanna Moncrieff wrote in her blog about genetic research in schizophrenia, “We will likely never be able to fully account for why some people experience extreme mental states, but we know that poverty, unemployment, insecure attachments, familial disruption, low self-esteem, abuse etc. play a role for many. We would be better concentrating on how to eliminate these from our society if we really want to reduce the impact of mental disorder, rather that pouring more money into the bottomless pit of genetic research.”

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

Should We Send All Kids to College?

College is increasingly expensive and stressful as kids try to compete with greater numbers of their peers to get into reputable schools, they face mental health problems at alarming rates, graduates face crushing debt, and the job market for college grads is bleak. Why should any of us want our kids to endure college?

Is it even a good investment? College is usually not job training- with notable exceptions like teaching degrees, engineering, and nursing. Studying English or art or math is rarely enough to qualify new graduates for specific careers. And even for those who graduate with credentials qualifying them for jobs, successfully graduating college never guarantees employment. Why bother sending your child for an expensive bachelor’s degree when technical schools train students for careers with less investment of time or money?

In order to weigh to pros and cons, parents need to consider the benefits of a college education beyond career and finances. College may be a step toward your child’s growing maturity. 

Psychological benefits of college:

A place to explore the self
    One of the major tasks of young adulthood is “finding” oneself. But it’s hard to find yourself while steeped in the identity the family assigns. Likewise, it can be difficult to explore self-identity while working at a low paying job and struggling to pay the bills. College provides an opportunity to explore. Attending traditional college can give kids a chance to break away from parents and explore their selves while still benefitting from parental support. Young adults discover their beliefs separate from the family, and then build relationship styles and vocations. They can experience a sense of independence without taking on the full range of pressures of adult responsibility. 

A place to grow before solidly setting down roots for an adult life
    College often serves as a stage in between adolescence of independent adulthood. College students take on some of the responsibilities of independence, like making meals and managing time. But they don’t have to make big life choices, like choosing careers, until later. College provides a phase in between adolescence and adulthood, neatly demarcated by the years in school. By the end of the education, young adults are more ready to face big life decisions.

Learning how to learn, rather than being taught
    In high school, students are often fed information by teachers and then asked to repeat it back for exams. In college, learning is an increasingly solitary activity. Students attend classes and then read and prepare for exams without much guidance. Alone in the library, students learn which information is preferred test material. They structure their study hours without many daily assignments as guideposts. They teach themselves the material.

The opportunity to become a lifetime learner
    As students choose a course of study through the selection of a major, they gain the opportunity to become lifetime learners. Colleges and universities afford students the chance to explore the concepts for which they have an interest or an aptitude rather than requiring every student to learn foundational material. Many students become more engaged and excited learners when they focus in their interests.

Exposure to students from diverse cultural backgrounds
    Colleges and universities draw students from diverse backgrounds. Students come from urban and rural areas near and far, and there commonly students from a variety of foreign lands. Exposure to cultural diversity can enhance tolerance and international cultural awareness, positives for any well-adjusted young adult.

College is about more than academics, but it still may not be the best route for every young adult. As parents consider whether college a good investment, you may also consider how your young adult child can explore her self-identity, learn to learn independently, and have exposure to cultural diversity through venues other than college. Many young adults mature through other means, such as time in the armed services, living away from parents and working, and learning cultural values from the family.

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

15 Surefire Ways to Brighten Your Mood

It’s your job to regulate your emotions, even under stress. Whether you are starting off for the first time away from home, a parents facing an empty nest the fall, or just looking for new ways to cope with stress, these tips are for you! So how can you re-regulate when you’re feeling lonely, cranky, or down in the dumps?

1. Take a walk
    Walking serves many functions. It can be a distraction, exercise to increase your heart rate and get your blood pumping, or a change of scenery to help you shift your perspective.

2. Spend time in nature
    Take your walk out in the sunshine, or in the rain. Look around at the trees and the birds or the flowers or the cloudy gray sky. Appreciating the vastness of the natural world can leave you in awe and help you replenish your spirit.

3. Pray
    Throughout human history, almost every culture has used prayer in some form. Talking to your higher power, whether you understand Him to be a traditional religious deity you learned about in Sunday school or the unknown forces operating in the universe, provides meaning, clarity, and hope.

4. Meditate
    Meditation is the practice of focusing your mind very intently on something simple, like your breathing or the flame of a candle, and then holding your mind there and/or being patient with yourself while you observe how difficult such a simple task can be. Meditation can be used as a spiritual practice or a way to clear out the constant mental movie of worry and conflict in your mind.

5. Call a friend
    Human beings are social creatures. Seeking out the support of someone who understands your emotions and your experiences is an excellent way to re-group.

6. Read a book
    Ideas in books can open your mind, take you to new worlds, help you see your own struggles played out within the story, or help you step outside your own experiences while you walk in some else’s shoes. Books can teach or entertain and often do both at the same time.

7. Breathe
    Many relaxation techniques use deep breathing. Take a long, slow breath in and count to 10. Then breathe out and count to 10 again. Repeat the process of breathing in and out while counting until you feel the tension in our body and mind relax.

8. Run in place
    Brief bursts of exercise raise your heart rate and increase breathing rate and blood flow, sending a surge of oxygen to your brain. Exercise improves mood and is a great tool even when you have only a few minutes to re-set.

9. Visualize
    Close your eyes and imagine yourself in the most relaxing place you can envision. Imagine all the ways your senses engage with this place. What do you see? Is it a white sandy beach where the waves crash against the shore? Or is it your grandmother’s kitchen with she smell of a freshly baked pie wafting from the oven? Visualize this soothing image. Place yourself there fully. And watch as your tensions are released.

10. Take a nap
    Sometimes the best medicine in this fast paced culture is a nice, quiet time to rest. Lie down. Turn off electronic devices and turn on the nice soothing sound of a fan or soothing music and snuggle up for a cozy nap. You’ll feel better when you’re rested. 

11. Burn a candle or incense
    Calming sensory experiences can help you change your state of mind. Candles, incense, and various essential oils can take you away from your stressors and into the rewarding sensations of aromatherapy.

12. Listen to soothing music 
    Music can shift your brain wave patterns. Fast, loud, aggressive music can put you in the mood for a big presentation or a job interview. Likewise, soft sounds can help you relax and unwind. The trick with music is to choose sounds that evoke the mood you wish to feel, not those that reinforce a mood you’re struggling to change. 

13. Make something- paint, draw, or sew
    Creating an art or craft can busy your hands and mind, and lead to the reward of a completed project to add a little lift to your spirits. If you’re afraid you might not finish, be sure to pick something small to increase your chances of reaping the rewards of completion.

14. Go to a bookstore or public library
    Bookstores and libraries are some of the only places where you can go and be surrounded by people, but not be pressured to make small talk. You can plop down in a comfortable chair and read without having to make a purchase. 

15. Eat
Sometimes your mood is off because you need to eat. Other times, getting a little treat can lift your spirits. Make yourself a healthy treat at the end of a long, hard day and relax. You’ll feel better!

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