Bernards Voices

In the August 25th The New York Times, Pamela Paul reports on preschool depression.

Nothing is fun; I’m bored.  Mickey lies. Dreams don’t come true.

Helen Egger, a Duke University child psychiatrist and epidemiologist, discusses the symptoms.

The misery needs to persist across time, in different settings, with different people. Nor is it enough just to be sad; after all, sadness in the face of unachieved goals or a loss of well-being is normal. But the depressed child apparently has such difficulty resolving the sadness that it becomes pervasive and inhibits his functioning.

Persists. Pervasive.

Among the experts interviewed were:

• Joan Luby is a professor of child psychiatry at Washington University School of Medicine.
• Daniel Klein is a professor of clinical psychology at SUNY Stony Brook.

Preliminary brain scans of Luby’s depressed preschoolers show changes in the shape and size of the hippocampus, an important emotion center in the brain, and in the functional connectivity between different brain regions, similar to changes found in the brains of depressed adults. In a longitudinal study of risk factors for depression, Daniel Klein and his team found that children who were categorized as “temperamentally low in exuberance and enthusiasm” at age 3 had trouble at age 7 summoning positive words that described themselves. By 10, they were more likely to exhibit depressive symptoms. And multiple studies have already linked depression in school-age children to adult depression.

Appropriate Treatment:

For a diagnosis of preschool depression to have any meaningful impact, an appropriate treatment must be found. Talk therapy isn’t practical for children who don’t have the verbal or intellectual sophistication to express and untangle their emotions.

And while practitioners quibble over what to label depression, most agree that for any mood disorder, children this age should not be treated in isolation. “Psychotherapy for depressed preschoolers should always involve the caregiver,” Luby says. “Not because the caregiver is necessarily bad or doing anything wrong, but because the caregiver is an essential part of the child’s psychological apparatus. The child is not an independent entity at this age.”

One established method is called Parent-Child Interaction Therapy, or P.C.I.T. Originally developed in the 1970s to treat disruptive disorders — which typically include violent or aggressive behavior in preschoolers — P.C.I.T. is generally a short-term program, usually 10 to 16 weeks under the supervision of a trained therapist, with ongoing follow-up in the home. Luby adapted the program for depression and began using it in 2007 in an ongoing study on a potential treatment. During each weekly hourlong session, parents are taught to encourage their children to acquire emotion regulation, stress management, guilt reparation and other coping skills. The hope is that children will learn to handle depressive symptoms and parents will reinforce those lessons.

I observed one session in which a therapist deliberately invoked feelings of guilt in the same blond 5-year-old who told the puppets “When bad things happen, I do feel bad.” Seated at a table with his mother, he turned to greet a therapist carrying a tray with two teacups, one elaborately painted. She told him that they were to have a tea party, pointing out her favorite teacup and describing the time it took to decorate it. “I’ll let you use my favorite today,” she beamed. As he gingerly took the rigged cup, its handle snapped off. His face darkened. The therapist lamented the break, ostensibly distraught, and excused herself from the room. The boy’s mother, guided via earset by a therapist watching through a two-way mirror, helped her child work through and resolve his feelings.

“Do you feel like you’re a bad boy?” his mother asked. Most parents want to distract their kids from negative emotions rather than let them process the feelings. “They want to wipe it away and move on,” Luby says. In this session, the mother was instead encouraged to draw the child out.

The boy nodded tearfully. “I feel like I’m going to go into the trash can,” he said.

“Who would put you in the trash can?” his mother asked.

“You would,” he replied in an accusatory voice.

“I would never do that,” she said. “I love you. Accidents happen.” The boy seemed to recover, and they chatted about her earrings, which he flicked playfully with a forefinger. Then his face drooped again.

“Are you mad at me?” he asked, and then added, almost angrily, “I never want to do this activity again.”

“You’re not a bad boy,” she consoled him. Often, parents don’t realize that their children experience guilt or shame, Luby says. “In response to transgression, they tend to punish rather than reassure.”

“I am a bad boy,” the boy said, ducking under the table. “I don’t think you love me now.” He started to moan from the floor, whimpering: “I’m so sad. I’m so sad.”

SUCCESS WITH P.C.I.T. rests heavily on parents, who are essentially tasked with reprogramming their child’s brain to form new, more adaptive habits. Not all parents are equipped to handle the vigilance, the consistency, the sensitivity. But early results look promising.

Today’s letters to the editor in the New York Times on grief are informative.

Gordon Livingston writes:

To set two weeks as the time allocated to mourning the loss of a loved one before receiving a diagnosis of major depression — as proposed in the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual of Mental Disorders — is ridiculous.

This is illustrative of one type of reaction. But it misses the point. Sadness isn’t depression. Loneliness isn’t depression. Mourning and major depression do not mean the same thing. Conflating the 2, by either side of this argument, is a disservice. Depression, that persists two weeks, diagnosed by a psychiatrist or psychologist, a trained professional, should be treated.

In the original op-ed piece, “Good Grief,” Allen Francis (Francis was chairman of the DSM-IV taskforce.) writes:

Grievers with severe and potentially dangerous symptoms–for example, delusional guilt over things done to or not done for the deceased, suicidal desires to join the lost loved one, morbid preoccupation with worthlessness, restless agitation, drastic weight loss or a complete inability to function. But people with such symptoms are rare, and their condition can be diagnosed using the criteria for major depression provided in the current manual, the D.S.M. IV.

I have sympathy with that point of view–just use major depression as the diagnosis–but I don’t support the earlier parts of his op-ed designed to inflame the debate.

Below is also a common argument for inclusion in the DSM–health insurance, then, has a mechanism to help offset the expense. This is valuable. Elena Lister writes:

It is precisely because of my respect for the necessity of the grieving process that I can support its recognition in the diagnostic manual. The only way that many patients can afford therapy is with insurance — which covers only certain mental health diagnoses, and even then in very limited ways.

This debate is being waged by well-meaning people. And if words like “ridiculous” were left out … it might serve an additional useful purpose of raising awareness.

I’ve posted on the DSM5 debate before. You can access these posts by cliking on DSM5 in the right sidebar under Tags. I really like the (yes it lasts 1 hour) This American Life podcast on the DSM referenced towards the end of this post.

In the August 3, 2010 New York Times, Richard Perez-Pena reports:

Patient advocates filed a federal lawsuit on Tuesday charging that New Jersey psychiatric hospitals routinely medicate patients against their will without a review by an outside arbiter, a practice that is banned in most other states.

Twenty-nine states require a judge’s ruling for involuntary medication, according to the suit, including New York, Connecticut and other large states, like California, Florida and Texas. Five other states leave the decision to an individual or panel outside the hospital. Some states also provide an advocate to represent a patient in a hearing on forced medication.

But in New Jersey, state rules allow a patient in a state hospital to appeal medication decisions only to people in the hospital. The lawsuit contends that the internal appeal process is routinely ignored and that psychiatric patients in private hospitals lack any opportunity to appeal medication regimens at all.

Phil Lubitz, associate director of the National Alliance on Mental Illness of New Jersey, said he did not see forced medication as a major issue, noting that it was extremely difficult to get patients committed in New Jersey, and that most who were presented “a danger to themselves or others.”

But Robert Davison, executive director of the Mental Health Association of Essex County, called New Jersey’s policy “beneath contempt.” “This state is way behind the times,” he said. “It suspends people’s civil rights without due process, and it’s troubled me for years.”

Adjusting for differences between groups, researchers found that depression raised the risk of dementia by 72 percent. And the more severe the depression, the greater the risk of dementia later.

July 19 New York Times, Roni Caryn Rabin.

In the July 19, 2010, The New York Times, Tara Parker-Pope blogs on the impact of ADHD on marriages.

In a marriage, the common symptoms of the disorder — distraction, disorganization, forgetfulness — can easily be misinterpreted as laziness, selfishness, and a lack of love and concern.

Adults with attention disorders often learn coping skills to help them stay organized and focused at work, but experts say many of them struggle at home, where their tendency to become distracted is a constant source of conflict. Some research suggests that these adults are twice as likely to be divorced; another study found high levels of distress in 60 percent of marriages where one spouse had the disorder.

Parker-Pope referred to this www.adhdmarriage.com website.

From the June 28, The New York Times, Seeking to pre-empt marital strife.

One federally financed study is tracking 217 couples taking part in an annual “marriage checkup” that essentially offers preventive care, like an annual physical or a dental exam.

“You don’t wait to see the dentist until something hurts — you go for checkups on a regular basis,” said James V. Córdova, an associate professor of psychology at Clark University in Worcester, Mass., who wrote “The Marriage Checkup” (Jason Aronson, 2009). “That’s the model we’re testing. If people were to bring their marriages in for a checkup on an annual basis, would that provide the same sort of benefit that a physical health checkup would provide?”

From the June 29, Wall Street Journal, Worried About a Moody Team?

Warning signs:

Dr. Diamond says sulks or doldrums that persist for two or more weeks could be a sign of depression and should be taken seriously.

Parents should pay attention to how a teen is functioning in school, sports, favorite activities, a job and with friends.

This article recommends consulting first with the teen’s pediatrician, someone who already has a relationship with the family. (Perhaps killing 2 birds with one stone: your insurance provider may require a referral to a psychiatrist anyway.)

From the July 1, USA Today, Of Medical Specialties, demand for Psychiatrist is Highest.

From April 2009 to March 2010, the company Merritt Hawkins received 179 requests for psychiatrists — a 47% increase from the previous year and 121% increase from the 2006-2007 survey.

The firm, which tracked more than 2,800 physician requests, found that psychiatrists were the third-most-requested physician.

Though demand is growing, fewer medical students are entering careers in psychiatry. Health officials say the field garners little interest because psychiatrists earn less than other specialties, even though they spend the same amount of time in medical training.

Thanks to Lauren for finding these articles.

From The Lancet Mental Health Themed Issue, August 22, 2009:

David Kessler and colleagues evaluate the acceptability and clinical effectiveness of an internet-based psychotherapy programme for depression. Nearly two-thirds of those offered the programme completed five or more therapy sessions, a substantially higher rate than we would expect with in-person therapy. Clinical benefits were larger than generally seen with computerised self-help programmes, and similar to those with traditional in-person psychotherapy.

Listen to the podcast (interview starts at 1:20):

The researcher was asked why they didn’t use video/voice in the internet-delivered therapy and relied on text. He posed a very interesting question in response: what about writing made it so effective? Writing requires pausing/reflection/editing which is different than talking. There is also evidence that writing, as a therapy, helps recovery from trauma. And finally, these questions of “eye contact” and “body language / mood congruency” and “anonymity” … have not been adequately tested yet to demonstrate that a therapist and patient, face to face, is necessarily the best setting for all people, for all therapies.

As discussed in other blogs, the DSM-5 is under review and generates a lot of controversy. This American Life does a great job, using the example of homosexuality, to show how and why definitions of mental disorders change over time. Reflecting not just changes in scientific understanding, but also social, political, and personal pressure. That those pressures exist, and have impact, doesn’t invalidate the DSM.

January 18, 2002 podcast of This American Life. Listen here.

In 1973, the American Psychiatric Association (APA) declared that homosexuality was not a disease simply by changing the 81-word definition of sexual deviance in its own reference manual. It was a change that attracted a lot of attention at the time, but the story of what led up to that change is one that we hear today, from reporter Alix Spiegel. Part one of Alix’s story details the activities of a closeted group of gay psychiatrists within the APA who met in secret and called themselves the GAYPA … and another, even more secret group of gay psychiatrists among the political echelons of the APA. Alix’s own grandfather was among these psychiatrists, and the president-elect of the APA at the time of the change. Alix Spiegel’s story continues, with a man dressed in a Nixon mask called Dr. Anonymous, and a pivotal encounter in a Hawaiian bar.

The 1968 definition at the time was a step forward, defining homosexuality as a disease instead of a moral decision.

The new 1973 definition:

302.0 Sexual orientation disturbance (Homosexuality)
This category is for individuals whose sexual interests are directed primarily toward people of the same sex and who are either disturbed by, in conflict with, or wish to change their sexual orientation. This diagnostic category is distinguished from homosexuality, which by itself does not constitute a psychiatric disorder. Homosexuality per se is one form of sexual behavior and, like other forms of sexual behavior which are not by themselves psychiatric disorders, is not listed in this nomenclature of mental disorders.

If the patient had subjective distress it was a disorder. If it didn’t bother you, you weren’t sick.

The current DSM deletes the definition; it is not a disorder. It is now ethically wrong for psychiatrists or psychologists to treat it as such.

From the June 17, 2010, NYT article by Mireya Navarro.

“It’s the fear of losing everything,” said Representative Anh Cao, a Republican from New Orleans who has assembled a response team to travel along the Gulf Coast to assess constituents’ needs. Mr. Cao said he had met two fishermen in Plaquemines Parish who told him they were contemplating suicide. While those cases are “extreme,” Mr. Cao said, they reflect how some people “are approaching a point of despair.”

Officials with the Louisiana Department of Health and Hospitals said staff members had counseled 749 people in the last week of May and the first week of June to “mitigate” symptoms that could lead to destructive behavior.

This is one of those articles that in the past, I would have read, then dismissed the mental health impact as no news, totally understandable.

Researchers who studied the aftermath of the 1989 Exxon Valdez spill said coastal residents of Alaska saw a higher incidence of suicide, divorce, domestic violence and substance abuse. To this day, many are still dealing with the effects of the environmental damage, economic losses and lawsuits.

Crises like the BP oil spill are inevitable in life, and often totally beyond our ability to influence or control. If we saw a therapist as often as we see a dentist, then in times of crisis, we will already have a relationship with someone we trust, who can help.

Roni Caryn Rabin reports in The New York Times June 10, 2010, on a study that analyzed data from the Scottish Health Survey of 1998 and 2003.

Smokers are known to suffer from high rates of depression and other mental health problems, and now a study reports that even people exposed to secondhand smoke are at significantly increased risk — and more likely to be hospitalized for mental illness.

The study analyzed … a nationally representative sample of about 5,560 nonsmoking adults and 2,595 smokers. Nonsmokers exposed to secondhand smoke were 1.5 times as likely to suffer from symptoms of psychological distress as unexposed nonsmokers, the study found.

While Rabin’s article is just a summary, the referenced study is easy to find and moderately easy to read.

The study talks about evidence that tobacco can induce a negative mood.

It also poses the chicken and egg question: are people with mental illnesses more likely to be in an environment with second hand smoke?

As I read the article I look for answers regarding heritability. A nervous parent, that self-medicates with tobacco, could genetically pass on a susceptibility to nervousness for example. But also the way a nervous parent acts around their infant and young child, is going to teach that child a lot about nervousness, and the child is going to develop unhealthy coping skills, for example. Does the study eliminate children of smokers from the study?  Should it?

Another question: is mental health contagious (post partum depression in fathers, Dr. Holland on Science Friday)?  I’ve read that one or two mentally ill apples can spoil a bunch.  You’ve probably seen evidence of this at the office or in your family–when there is one or two people that are negative, or perhaps overly emotional, does that “infect” the behavior of the other people in the group?  Second hand smokers are physically in the same group as smokers.

Another thing I wonder about is socio-economic questions. Do smokers have less money? Are they under stress to make their monthly house payment, rent, grocery bill? We are full of stereotypes about smokers. Are they lonely? Do they drink too much?

All these questions are a trap. If you’ve read this far in the post, I want to make a point that was true in my personal experience, and it may be yours. I do all this analyzing to understand why the person might be depressed–search for the cause. I find a plausible theory that explains it (genetics, low income …) and I ignore the most important fact–the depression (or anxiety) is real and needs to be addressed.

Here is a quote from the study:

The fact that the results of the age-adjusted and fully adjusted models were similar suggests that the associations were not accounted for by measured covariates. Although CIs were relatively large in some analyses, the effect sizes were substantial.

CI stands for Cotinine Level. “Exposure to Second Hand Smoke was assessed using the salivary cotinine level, which is a reliable and valid circulating biochemical marker of nicotine exposure.” The co-variates were “age, sex, social status, BMI (body mass index), chronic illness, psychological distress at baseline, physical activity, and alcohol intake.”

More quotes from the Comment section at end of study that touch on my questions above. (The Comment section is the easiest part to understand.)

In a cohort of Swedish participants, heavy smoking was associated with increased risk of suicide over 26 years of follow-up, but the excess risk of suicide among smokers was almost entirely explained by an increased prevalence of heavy alcohol consumption and low mental well-being among the smokers.

In addition, the dopaminergic system may play a role. Smokers who are genetically predisposed to low resting intrasynaptic dopamine levels have heightened smoking-induced dopamine release, which has been associated with greater depression and anxiety. Thus, this genetic predisposition may also operate in relation to SHS exposure.

The limitations of the study should also be recognized. We did not have sufficient suicide deaths to facilitate a meaningful analysis. Given that much psychiatric illness is managed in primary care or in outpatient clinics, in our prospective analyses we only captured cases severe enough to warrant hospital admission.

Recently, when the YMCA here in Bernards Township hosted its Mental Health Awareness Week, I was asked if I wanted to share some of my thoughts on this topic through this forum.  So far, I haven’t done so, but I’ll start today.

It is slightly difficult for me to know where to begin because of the stigma associated with mental illness.  But, really is any illness something you wish for or can even control?  Just as with other illnesses, with mental illness there is often a biological root which cannot be avoided.  We have compassion on those with cancer, but somehow mental illness is a taboo subject.  In my opinion, this should not be the case.

So, I guess I’ll start with honesty, because without honesty, I don’t think we can move forward as a society on this issue.  I am someone who has struggled and is struggling with a mental illness.  For a long time, I thought it was something I had done wrong, something I could fix on my own.  It’s not.  My illness has its root in my biological makeup and I need medication to function in society.  Does that mean the stigma is gone?  Nope.  There is a certain level of vulnerability that comes even with posting this.  I can’t control what people think or say about me.  But again, just as with cancer, it’s not really something I have any control over.

My motive for even posting is that perhaps you too are struggling.  It could be depression or anxiety, schizophrenia or bipolar disorder, anything really.  I want you to know there are other people out there.  People willing to take the illness on and ride it out.  There are ups and downs.  I don’t always have a great day.  But with the help of medication, I can generally function.

Dealing with mental illness does mean you have to be willing to acknowledge something is wrong.  This can be hard because of the stigma and lack of awareness associated with mental illness.  It’s interesting that people often care more for the body than the mind.  If you notice something wrong with your body, you get it checked out.  If you notice you’re feeling down all the time, or are having panic attacks, you may not. I would encourage you to find help for these issues because getting help for your mind is just as important as getting help for your body.

May I post a hypothesis?  I think we’re afraid.  Afraid of being found lacking.  Our society pushes us to be perfect.  We’re afraid that somehow we’re not the supermen we pretend to be when we have a problem.  I’ll be the first to confess I’m not a superwoman.  I’ve tried it, and it’s not all it pretends to be.

I’ll end this with a plea.  Please, if you think you might be struggling with a mental illness seek out help.  You may be surprised in finding more compassion than you anticipated.  I did.

The Dec 16, 2006 Lancet podcast on Generalized Anxiety Disorder addresses the question: how should our medical system detect and treat anxiety?

GAD is defined by exclusion.   It is not a panic disorder—which is a sudden, severe, episode or attack, of anxiety.   GAD is not post traumatic stress disorder—which also has clearly defined source.  GAD, Professor Peter Tyrer says, effects 10 to 12% of the population at any one time.   It is chronic.  It persists.  It is described as free floating.  Everything a person does or thinks is tinged with anxiety.   Psychological symptoms include: tension, worry, inability to concentrate. The physical symptoms are a consequence of continuous autonomic arousal: palpitations, trouble breathing, chest pains, tingling, and feelings of unreality, depersonalization.

Depression and anxiety often overlap—in fact that combination is the most common mental illness a primary care physician would see.   And it isn’t that a primary care physical would be blind to anxiety—it is so common that they know it when they see it—but what is more rare is the decision to treat it, because they, like the general public, see it as a symptom and they look past it, wanting to get to the underlying problem.

But GAD treatment exists.   Not only are there drugs (sedatives, tranquilizers, anti-depressants) but also cognitive behavioral therapies that help the patient identify their distorted cognitions and conclusions they have about their symptoms.

Since anxiety is such a common ailment, economic and social concerns demand it be dealt with in primary care.  The big challenge facing the UK national health service is to:

… make the psychological treatments available, because these are the ones that are wanted by patients, and the evidence base suggests, because of the dependence problems with drug treatments, and these occur with all types of psychiatric drugs for treatment of anxieties, nothing really which is effective in treating anxiety has no problems at all when you stop taking it, but this doesn’t apply to the psychological treatments …

The psychological treatments are successful and their effects persist.   The drugs stop being effective when the patient stops taking them.