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.

Depression Diagnosis in Teens: Is Decreasing Stigma Putting Normal Teens at Risk?

National campaigns to reduce mental health stigma and raise awareness have been in full swing for years. Awareness is needed. Equal treatment for mental health illnesses is paramount. Mental illnesses are real, devastating, and may be poorly understood.

But what happens when we mix in normal, healthy individuals with the truly ill? What happens when we treat people who don’t actually suffer from the illness in question? Who is at risk for unnecessary treatment? What harm can come of it?

NIH reports that 11% of kids will suffer from depression between the ages of 11 and 18. Illness rates are available on the NIH website and www.nih.gov.

From Web MD:

What Are the Symptoms of Depression?

For major depression, you may experience five or more of the following symptoms for at least a two-week period:

Persistent sadness, pessimism

Feelings of guilt, worthlessness, helplessness, or hopelessness

Loss of interest or pleasure in usual activities, including sex

Difficulty concentrating and complaints of poor memory

Worsening of co-existing chronic disease, such as rheumatoid arthritis or diabetes

Insomnia or oversleeping

Weight gain or loss

Fatigue, lack of energy

Anxiety, agitation, irritability

Thoughts of suicide or death

Slow speech; slow movements

Headache, stomachache, and digestive problems

Now consider the average teen:

Normal teens may be moody, sad, pessimistic, disinterested, or irritable. Normal teens often oversleep, complain of poor memory, may grapple with their worthiness, and have changes in weight. How many of these criteria might a healthy teen meet? The diagnosis only requires checking off five from the list.

These questions leave me wondering if psychiatry needs to re-write the criteria for depression in children and adolescents. Shouldn’t the criteria be limited to only the extremes, those outside the range of “normal” for the developmental stage of adolescence? Do these criteria limit, or capture too broad a group?

Kids who are diagnosed with depression will not follow the same long-term course as adults with the same diagnosis. Kids may outgrow mental health problems, or their problems may morph into a different diagnosis in adulthood. For example, childhood bipolar disorder raises the risks for adult depression and anxiety disorders, but less often results in adult bipolar disorder. (In the new criteria released in 2013, childhood bipolar disorder was renamed to decrease misperceptions about the adulthood risks).

Suicide: The Case for Treatment

Depression is one of many psychiatric disorders that can increase suicide risk. Many have argued for treatment of teen depression to prevent suicide. Suicide is terrible, and we all want to prevent it if possible. But the jury is still out on whether treatment for teen depression actually reduces suicide risk, and some studies raise concerns about depression treatments actually increasing suicidality in teens and young adults (those were the studies which sparked the black box warning for antidepressants).

So, if preventing suicide is not a clear reason to treat iffy teens, why risk it? Consider the following:

If we use limited mental health services on the wrong folks, what’s left for the truly ill?

Unnecessary treatments can be expensive and harmful. Antidepressants carry a black box warning in teens: they can make things worse.

Former child patients who feel they were inappropriately treated become some of the strongest voices in the anti-mental health organizations. Anti-mental health advocacy threatens to deprive patients in need of the psychiatry and psychotherapy services necessary to control their illnesses.

Expanded efforts to raise awareness and offer treatment may inadvertently raise the rate of false positives. We need to capture the truly depressed kids, but somehow avoid treating kids who don’t have the illness.

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

Parents: First-Line Healthcare Advocates

I awoke this morning to find my middle-schooler pasty-pale, feverish, and gaunt. I called the doctor’s office, and will head over to have him seen in a couple of hours.

Today, I am reminded of what it feels like to be a healthcare consumer, rather than my usual role as a physician—being the patient, or parent of the patient in this case, is not very fun. In fact, being the healthcare consumer is scary. I feel vulnerable. I don’t want my child to be sick, and I don’t want to rely on an expert (our doctor is wonderful, by the way!) to assess the situation and provide us with a plan. But today I have to trust and rely.

He probably has an acute illness, something short-term. I can already anticipate how the visit will go. Either he will need a week of antibiotics, or we will be asked to watch and wait. Most of my patients are not so lucky. In mental health, I rarely see a teen for a one-time, sick visit resulting a weeklong treatment or supportive care. The vulnerability parents must feel walking into my office is difficult to comprehend.

Increasingly, I read reports of a growing deficit of Americans’ trust in our healthcare system. Waning trust is attributed to many factors: the growing bureaucracy in medical care, a lack of a long-term personal relationship with our doctors, physician conflicts of interest, privacy concerns, seven minute visits… many among us fear we can no longer trust the professionals who deliver our care. But none of my anxiety about the visit today is due to any of these concerns. Even though I trust the doctor and know she will listen and give us the time we need today, my fear is more basic: “What if she doesn’t understand what’s wrong with him? What if our concerns cannot be addressed?”

Those reports I read come from professional medical journals and monographs, written by leaders in the field, all trying to address the quality of healthcare through changes in policy and education. But none of those reports contain anything that helps me today. Today’s clinic visit is not about policy.

As a parent, maintaining trust in my doctor means taking a few simple steps to make myself part of the healthcare team. It usually starts with a theory of the illness that I develop before I walk into the clinic. I might pull out a medical book, talk to a friend, or search the internet for information. Armed with information, I can ask intelligent questions.

And I will make a list. (As a doctor, I always appreciate when patients come in with a list. Lists are the best way to prevent the hand-on-the-door rememberings of important details we needed to address earlier, or the dreaded telephone message afterward noting, “I forgot to tell the doctor…”)

Finally, I will take a few notes when the doctor gives her opinions and instructions. These can guide me after we leave the office, in case I have trouble recalling directions.

We have a long-term relationship with our doctor, an invaluable commodity in healthcare. She knows our histories and she listens. But if I were in the unfortunate position of seeing a new doctor today, I would have a few more steps to take at this visit: I would need to decide whether this person could meet our needs as a family, be ready with a plan if the clinician might not work out, and advocate for the proper system of care to address my child’s specific medical care requirements. My questions might extend, not just to today’s needs, but to the greater spectrum of medical care needs my child has now and will have in the future.

In healthcare situations, the parent’s role is much like his/her role as advocate and overseer with a caring teacher who might not understand a child’s learning issues, or an aggressive gymnastics coach whose style is troublesome. We step in and take action when our experts fail us. We clear up misunderstandings and facilitate communication; we empower our kids to speak up for themselves; we pull them out of situations that can’t be repaired. We are their advocates in every way.

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