Why I Want to Hear From Your Mom

Jim comes into the clinic waiting room and plops down with his mom seated next to him. She nervously clutches her handbag, a look of worry evident in her eyes. When I call him into the interview room, his mother’s eyes dart from me to him and back. Does she have something she wants to tell me?

“Why don’t you come back with him, just for a few moments,” I say to the mom. Jim huffs at her. I smile cautiously at him and wait for his mom to follow.

Inside the room, door closed, I ask Jim if it was his idea to come for the evaluation, or someone else’s. He tilts his head toward his mother and rolls his eyes. He says, “I’ve been a little bit anxious with school and everything, that’s all. I’m fine. I went to a holistic herbal shop and got some new supplements. I don’t need to be here. She’s just hysterical, as usual.

I turn to address Jim’s mom. “Can you tell me why you wanted him to come for the evaluation?”

She glances over at Jim from the corner of her eye to see him lean back in his chair and look up at the ceiling. “Jim hasn’t slept in several days. We hear him upstairs during the night, in and out of closets and boxes. I don’t know what he is doing up there, but he seems agitated at night and moody all day. He peels out of the driveway recklessly when he leaves the house. Jim has always been calm, quiet, and easy going. He has always slept 10-12 hours a night. He has never been like this before.”

---

People seek psychiatric evaluation for any number of reasons: anxiety, depression, inability to sleep, changes in behavior, substance use. They sit down in a chair, answering questions about their inner experiences and trying to explain a hidden problem. They offer a peek inside their minds and hearts.

But I always want to hear from their families, too.

In healthcare, we refer to the information obtained from significant others “collateral reports.” I want to hear as many collateral reporters as I can find. Not all healthcare professionals agree with this view. They worry that involving family members can bias the clinical picture, or that somehow privacy will be breached by asking questions of the wrong family member. Still, I am adamant about the value of an outsider point of view to make things clearer.

Maybe you are a healthcare professional, or maybe a patient reading these words, and perhaps the idea that family should be directly involved in your healthcare evaluations seems to cross the line. If so, hear me out.

Psychiatry is the medical discipline that treats mental health problems, or lately referred to as “behavioral health” problems. “Mental” and “behavioral” health are the purview of my field of medicine. “Mental” = internal, thoughts and feelings hidden out of view, on the inside. “Behavioral” = external action, on display for others to view.

·      Only the patient himself can tell me his mental state.

·      And I can rarely rely on a patient himself to accurately describe his own behavior problems.

The patient describes his first person perspective on how he feels and thinks. Families give information about what happens on the outside, the changes in behavior visible from their perspectives.

In mental health, we have to hear from Jim’s mom. Otherwise, we will be operating with bad information, treating the wrong problem.

Posted on April 24, 2017 by Melissa Deuter.

The Secrets Inside Someone Else’s House

You never know what goes on inside someone else’s house. Maybe you think you know, but you don’t. Nowhere is this a more evident truth that working as a mental health professional. Even those of us who don’t make literal house calls are invited into the private lives, the secrets, into the hidden shameful corners of people’s lives.

 

Those beautiful, well-dressed, smiling people may go home and close out the world, and inside suffer unthinkable abuse, addiction, or illness. Those neatly groomed children may be sleeping on bare mattresses on the floor, hardly scraping together the resources to put forth an acceptable level of personal grooming to hide their poverty and slip under the radar of watchful others who might realize the truth.

 

People are hiding their secrets

Hiding depression and paralyzing panic

Hiding an eating disorder

Hiding poverty

Hiding physical, sexual, or emotional abuse

Hiding alcoholism and prescription pill addiction

Hiding pain.

 

In those dark corners people are sad and scared and real and raw. Sometimes I wish I could live in a world where all those dark corners could be brought into the light, and we could all be honest and open. If we dared to tell the truth (and hear the truth), how different would the world be?

Posted on April 10, 2017 by Melissa Deuter.

Yes, Antidepressants Work Differently in Teen Brains

Do antidepressants work differently in teen brains?

We know teen brains are different, that has be proven time and again through neuroresearch. In fact, brains are different until they fully “mature” at around age 25 years.

I have been working with teenagers my whole career, and I started out following the standards of psychiatry without much questioning: put teens on the same medications you might prescribe adults, and dose them similarly. But it didn’t take long before I grew to question standard practice. I was prescribing antidepressants to teens, and too many of them would get better for a couple of weeks, and then spiral into a crisis. Not only would they spiral, but they would all go into basically the same type of spiral, a spiral full of pent up energy bursting to come out as troubled behavior. The pent-up-badness would burst out as aggression toward the parents, drug experimentation, lying, running away in the middle of the night, or in kids who were too cooperative and well-behaved for any of the behaviors above, the behavior bursting forth would be self-harm or a suicide attempt.

At first, I decided I must be seeing a large number of Bipolar teens. The symptoms above are often side effects of antidepressants in Bipolar spectrum illness. But that didn’t make sense. Bipolar Disorders exist at rates in the low single digits (less than 5%), and almost every teen was reacting badly to antidepressants.

I started to veer away from using antidepressants in teens, at the least the standard ones. I tried non-serotonin alternatives like bupropion (Wellbutrin) wherever I could, and treated anxiety with drugs like buspirone and hydroxyzine. I was offering individual and family therapy as an alternative to medications for every patient family who was willing to try it. I was making fewer referrals to the hospital, and trying to find answers in the medical literature to explain what I was seeing, but I didn’t find clear answers, only occasional competing theories that needed to be investigated further.

And then something very important happened in my practice. My youngest child got injured, and I was suddenly away from practice for almost 6 weeks. My psychiatric colleagues generously covered my practice without question; they took over and treated my patients for me while I sat in the ICU with my child and I was unable to offer any insights to the practice. My colleagues must have stared at my handwritten chart notes in confusion, wondering why these patients weren’t receiving the antidepressants they so desperately deserved. The doctor colleagues changed my patients’ care plans, and one by one prescribed the teens antidepressants.

Even though I was on leave, I hadn’t inactivated my emergency call service. I had a pretty stable group of patients, and I didn’t receive frequent enough calls to worry about it. I remember when the calls started coming in: a teen found unresponsive, another had made a serious attempt on her life, another had run away. These were teens I knew well, and their crisis behaviors were a shocking break from normal.

Having already struggled with questions about antidepressants in teens, this 6-week window functioned as a small-scale experiment. I was convinced that antidepressants were acting differently in teen brains. I spoke with colleagues who mostly shrugged and said, “I haven’t seen that.” Only one, Dr. Randall Sellers, a psychiatrist who also treated mostly teens and young adults, passionately agreed. He thought we needed to conduct a research study, but before we put together that study, Dr. Sellers died suddenly from metastatic melanoma.

In the intervening years, research is catching up. Black box warnings for suicidal ideations have been issued for all antidepressants used in teens, and increasingly research articles are recommending cautiously low dosing of antidepressants in teen and young adult brains. Unfortunately, the wheels of change turn slowly, and while we wait for change, another teen was admitted to the hospital yesterday for downing a bottle of pills prescribed by her primary care physician.

Maybe this piece will start a conversation, spark a closer look, or persuade a parent to request caution from a doctor. Antidepressants are often predictable in their effects on adult brains, but teen brains are different and so are their responses to these medications.

Posted on March 27, 2017 by Melissa Deuter.