brain

Caregiver’s Guide to Brain Basics

Mental illnesses are brain disorders. Trying to understand the “why” behind an illness or the “how” behind medication requires caregivers to know some detail about how the brain works. For example: What’s a neurotransmitter? What are synapses? And what’s the difference between serotonin and dopamine?

This basic overview, which answers those questions, comes from material on the National Institute of Mental Health’s website. The site contains lots of information to answer your questions about the complexities of mental illness.

NIMH research shows that mental illnesses can be related to changes in the anatomy, physiology and chemistry of the nervous system. When the brain malfunctions, symptoms of mental illness start to appear.

Neurons are the basic working unit of the brain and nervous system, each enclosed by a cell membrane. These highly specialized cells conduct messages. Each neuron has three main parts:

  • A cell body with a nucleus (containing DNA and information the cells needs for growth and repair) and cytoplasm, the substance filling the cell where all the chemicals and small structures named cell organelles reside.
  • Dendrites that branch off from the cell body and are the neuron’s point of contact for receiving chemical and electrical signals (called impulses) from other nearby neurons.
  • Axon that send impulses and extend from the cell body to meet and deliver impulses to another neuron.

Synapses are tiny gaps between neurons where the impulses or messages move from one neuron to the other as chemical or electrical signals.

The brain continues to mature at least until a person is in his 20s. As scientists learn more about brain development, they can see what goes wrong when a person develops a mental illness. One of the mysteries of schizophrenia, for example, is why it often occurs for the first time when a person is in his late teens or early 20s. Many believe scientists will find the secret as they learn more the processes in the brain at that time.

What can go wrong in the brain?

Every cell contains a complete set of DNA, with all the information inherited from our ancestors. As we grow, we create new cells, each with a copy of the DNA. Sometimes the copying process goes wrong, resulting in a gene mutation.

Scientists also study epigenetics, which looks at how environmental factors, such as sleep, diet and stress, can influence our genes. Unlike gene mutations, epigenetic changes don’t change the DNA code. They affect how a gene turns on or off to produce a specific protein.

The role of neurotransmitters

All that we do depends on neurons communicating with each other through electrical impulses and chemical signals. Neurons activate with small differences in electrical charges, called action potentials. The ions (atoms with unbalanced charges) concentrate across the cell membrane and travel very quickly along the axon. (It’s a bit like dominoes falling.)

When the action potential gets to the end of the axon, most neurons release a neurotransmitter, or a chemical message, that crosses the synapse and binds to receptors in the next neuron’s dendrites. So neurotransmitters are key to sending chemical messages between neurons. In mental illness and other conditions like Parkinson’s disease, this process doesn’t work correctly.

Important neurotransmitters include:

  • Serotonin controls functions including mood, appetite and sleep. People with depression usually have lower levels of serotonin. Some medications that treat depression block the recycling, or reuptake, of serotonin by the sending neuron. So more serotonin stays in the synapse for the receiving neuron to obtain. This medication, called selective serotonin reuptake inhibitor (or SSRI) causes more normal mood functioning.
  • Dopamine controls movement and aids the flow of information to the front of the brain, where thought and emotion take place. Low levels of dopamine can result in Parkinson’s disease, which affects the person’s ability to move and causes tremors, shaking and stiffness. Some research suggested that having too little dopamine in the thinking and feelings sections of the brain could play a role in schizophrenia and attention deficit hyperactivity disorder.
  • Glutamate is the most common neurotransmitter. When it is releases, the chances that the neuron will fire increase. So it enhances the electrical flow among brain cells. It also may be involved in learning and memory. Problems in making or using glutamate have been linked in autism, obsessive compulsive disorder, schizophrenia and depression.

Regions of the brain

Many neurons working together form a circuit. And many circuits working together form specialized brain systems. Research into the causes of mental illness tend to focus on these regions:

  • Amygdala activates the “fight-or-flight” response to confront or flee from a situation. Scientists are studying the amygdala’s involvement in anxiety disorders, including post-traumatic stress disorder and phobias.
  • Prefrontal cortex is where the brain’s executive functions are. These include judgment, decision making and problem solving. The prefrontal cortex also works in short-term memory and retrieves long-term memory. It helps to control the amygdala during stressful events. Research shows the people with post-traumatic stress disorder and attention deficit hyperactivity disorder have reduced activity in the prefrontal cortex.
  • Anterior cingulate cortex has many roles, including controlling blood pressure and heart rate. It also helps us respond when we sense a mistake, feel motivated, stay focused on a task and manage emotional reactions. Reduced activity or damage in this area is linked to attention deficit hyperactivity disorder, schizophrenia and depression.
  • Hippocampus helps create and file memories. When it is damaged, the person can’t create new memories. However, the person can still remember past events and learned skills, as well as carry on a conversation, because those activities are in different parts of the brain. The hippocampus may be involved in mood disorders through its control of a major mood circuit called the hypothalamic-pituitary-adrenal axis.

No one expects caregivers to become brain scientists, but having a general understanding of the brain will help when learning about medicines and research. The more knowledge we have, the better.

a dead person with a COVID toe tag

Stigma at Its Worst: Schizophrenia and COVID

I am furious about this.

Do you know what the second highest risk factor for dying from COVID is? The highest is old age. The second highest is having a diagnosis of schizophrenia.

This was first reported much earlier in the pandemic. I heard about it. I even mentioned it to an Ohio State University friend who used to head up my city’s health department. But scientists seem to be repeatedly surprised by it. And the government has done basically nothing about it.

Now it’s Year 3, and it’s news on NPR????

If the second highest risk factor for COVID deaths were health disease or lung disease or diabetes, do you think something would have been done to reach out to those folks? Of course. So why was there no effort to help people with schizophrenia?

People with schizophrenia were left off the priority list for help in my state, Ohio, and many others. My loved one with a schizophrenia diagnosis had to wait until people his age were allowed to get vaccines.

NPR interviewed Katlyn Nemani, a neuropsychiatrist and researcher at New York University. She described the initial reaction to the data showing that people with schizophrenia were three times more likely to die from COVID than the general population. It was disbelief.

“They said it must be because people with schizophrenia are already worse off health-wise, or because they have trouble accessing health care,” she said. That turned out to be wrong.

Studies from countries with free universal health care … the United Kingdom, Denmark, Israel, South Korea and so on … came in, also showing that people with schizophrenia were two to five times more likely to die from COVID.

Yet, the CDC didn’t add schizophrenia to the list of high-risk conditions until people began getting booster shots in October 2022. Other countries, like England, Germany and Denmark, put people with schizophrenia on the priority lists for vaccines at the beginning.

Nemani told NPR that this discovery could be good for people with schizophrenia. She said it may mean that the badly understood illness has a component in the immune system or elsewhere in the body. It could lead to new understanding and new treatments … for those with schizophrenia who are still alive, that is.

My own guess? It’s stigma. Far too many people think that the lives of people with schizophrenia do not matter. If they die from COVID, so what?

Schizophrenia is tough enough without the stigma. It affects 24 million people in the world, including 2.8 million in the United States.

This is barbaric. It’s time to fight for people to see the disease as a disease, not a disqualifying condition for living a good life. I am furious. I am sickened. I am sad.

file cabinet folders showing types of mental illness

Mental Illness in the USA: Pandemic Edition

Note: The National Institute of Mental Health, Mental Health America and NAMI have all released statistics about the state of mental health in America. Much reports on the year 2020, the first of the pandemic. Below are highlights from the reports. You can see the full information by clicking on each organization’s link above.

Twenty-one percent of U.S. adults experienced mental illness in 2020. That’s 52.9 million people. The annual prevalence of condition for 2020 is:

  • Anxiety Disorders: 48 million people (19.1% of U.S. population)
  • Major Depression: 21 million (8.4%)
  • Posttraumatic Stress Disorder: 9 million (3.6%)
  • Bipolar Disorder: 7 million (2.8%)
  • Borderline Personality Disorder: 3.5 million (1.4%)
  • Obsessive Compulsive Disorder: 3 million (1.2%)
  • Schizophrenia: 1.5 million (less than 1%)

Fifty percent of all lifetime mental illness begins by age 14 and 75 percent by age 24. About 7.7 million U.S. children ages 6-17 experienced a mental health disorder.

The percentage of people getting treatment continues to be low (46% of adults, 65% of adults with severe mental illness and 50% of youth). The average delay between the onset of mental illness symptoms and treatment is 11 years. And the number of U.S. counties that do not have even one practicing psychiatrist: 55%.

Impact of Mental Illness in 2020

Mental illness and substance use disorders are in involved in one out of 8 emergency room visits (12 million visits). Mood disorders like Bipolar and Major Depression were the most common cause of hospitalization for people under 45, excluding childbirth. People with serious mental illness are:

  • 21% of the homeless
  • 37% of adults in state and federal prisons
  • 44% of adults in local jails
  • 70% of youth in juvenile justice system
  • 15.3% of U.S. veterans

Twenty-five percent of the people shot and killed by police between 2015 and 2020 had a mental illness.

At least 8.4 million Americans provide care to an adult with mental illness. They spend an average of 32 hours per week providing this care, although that seems high to me.

Ranking of States

Mental Health America does an annual ranking of states that show which are doing the best job dealing with mental illness, based on 15 measures. The Top 10 are:

  1. Massachusetts
  2. New Jersey
  3. Pennsylvania
  4. Connecticut
  5. Vermont
  6. New York
  7. Wisconsin
  8. Maine
  9. Maryland
  10. Minnesota

My state, Ohio, fell from No. 11 in the ranking last year to No. 25 because of the large increase in the number of youth who have a mental health diagnosis and are not getting treatment.

988

988 National Suicide Hotline

A new national suicide hotline number will be available in July: 988.

In Ohio, the 988 number will connect to one of 15 designated lifeline call answering points. Trained mental health specialists will answer the calls, providing both counseling and direction to resources for mental health care.

The new number is based on the success of 911, which has been used as an emergency number for all types of crises since 1968. Officials hope that sending suicide calls to 988 will take pressure off the 911 system, which sends police and/or paramedics to a scene.

The 988 calls will connect people immediately to mental health crisis services. It also will improve the information provided. At present, more than 40 percent of Ohio’s suicide prevention calls are answered by people from other states who don’t know the Ohio system and cannot give advice about accessing its resources.

All this will change with 988. In Ohio, the Department of Mental Health and Addiction Services is implementing the new line with federal startup funds of $400 million.

In addition to the designated call line, NAMI Ohio is also asking for the development of a better, more thorough crisis response system, allowing the specialist to help direct people to housing, rehabilitation services and employment services. I agree with this, although I know it will be difficult to get the funding. After all, it doesn’t help much to answer the phone if you can’t direct people to the help they need.

Loving Someone With Mental Illness Support Group

Loving Someone With Mental Illness is a Vineyard Columbus support group that’s open to all. We meet at 7 p.m. Eastern Time on the first and third Thursdays on Zoom. Meetings last about one hour.

We share, have a brief teaching and pray for each other. The conversation is confidential. The teachings include practical information about helping loved ones with mental illness. We also include faith-based teachings on how to walk with Jesus through this difficult situation.

As leaders of the group, my husband and I have loved ones who have diagnosed mental illnesses. The group has been in existence for more than 10 years. You are welcome to attend regularly or whenever you feel the need.

To obtain the Zoom information, feel welcome to email karentwinem@gmail.com

housing

Housing for People with Mental Illnesses

Note: Sources of information for this post are NAMI.org, southeast.org, ood.ohio.gov, “When Someone You Love Has a Mental Illness” by Rebecca Woolis, and my six years working in an organization that provided housing for the mentally ill.

The lack of safe and affordable housing is one of the most powerful barriers to recovery from mental illness. When this basic need isn’t met, people cycle in and out of homelessness, jails, shelters and hospitals.

I agree with a philosophy called Housing First: Having a safe, appropriate place to live can provide stability to allow people with mental illness and/or substance abuse to stabilize and recover. Unfortunately, this housing is relatively rare. It takes organization and effort to get someone into the system.

As we all know, there’s not enough funding to cover the needs of people with mental illness. If the funding existed, case managers, social workers and vocational counselors would be handling housing and money issues for our loved ones. Since there isn’t enough money to go around, families often have to get involved.

Because of this, my No. 1 tip in dealing with the system is to make friends with a social worker. I met social workers at NAMI family support groups and events. This was invaluable in helping me understand how the system REALLY works. I also got excellent advice about where my son should be placed on a waiting list for housing.

What the Law Says

Several pieces of federal legislation prevent discrimination against people with mental illness in employment and housing. The most important in obtaining housing is Title VIII of the Civil Rights Act of 1968 (the Fair Housing Act). For most residential buildings (except some small owner-occupied buildings), this law forbids discrimination, such as refusing to rent or sell, denying that housing is available, and renting or selling on different terms.

That said, a history of arson and/or sexual assault usually keeps individuals out of housing for people with mental illness. Housing for people with mental illness is usually called housing for the disabled, in part to keep the neighbors from fighting it. People who are currently homeless usually get more help from organizations than those who are not.

Obtaining Housing

Many people with a serious mental illness live on Supplemental Security Income (SSI), which averages just 18% of the median income and can make finding an affordable home near impossible.

Housing options range from completely independent living to 24/7 care. The type of housing that is right for your loved one can depend on whether they need assistance paying bills, cleaning and making appointments or require no assistance at all. Here’s a look at some of the housing available.

Supervised Group Housing: Trained staff members are present 24/7 to provide care and assistance with things like medication, daily living skills, meals, paying bills, transportation and treatment management. These group homes provide their residents with their own beds, dressers and closet space, and shared bathrooms and common areas. This is the best type of housing for people experiencing a serious mental illness which may affect their ability to perform their daily tasks.  There’s virtually none of this in my part of the country, central Ohio.

Partially Supervised Group Housing: Some support is provided for the residents, but staff isn’t there 24 hours a day. The residents can be left alone for several hours and are able to call for help if needed. People who choose to stay in these group homes can perform their daily living tasks independently or semi-independently, help with cooking and cleaning and may even hold a part-time job or participate in a day program.

Permanent Supportive Housing: Supportive housing provides very limited assistance. The residents of these homes live almost independently and are visited by staff members infrequently. Community mental health center and social workers on site to help. Health care comes in.

Rental Housing:  Rent can be paid for in full by the individual or subsidized by a third party, such as the government or a non-profit agency. Someone who chooses this type of housing can take care of all their basic needs like cooking, cleaning, paying bills and managing their medication. They also may have a job and have or be seeking custody of children. If this is the right type of housing for your loved one, then they will still most likely work with a caseworker to manage their recovery.

Affordable Senior Housing: When your loved one becomes 55 or older, they usually qualify for affordable senior housing, such as offered by National Church Residences in 25 states. This housing for low-income seniors has no supportive services.

Ways to pay

Section 8: The United States Department of Housing and Urban Development (HUD) provides a number of housing assistance and counseling programs. The Housing Choice Voucher Program (Section 8) is the federal government’s program for assisting low-income families, the elderly and the disabled. HUD also helps apartment renters by offering reduced rents to low-income residents. Under this program, a renter pays 30 percent of their gross adjusted income for housing and utilities. The landlord then receives a voucher from the federal government which covers the remainder of the rent.

Section 811: The Supportive Housing for People with Disabilities Program (Section 811) is a federal program dedicated to developing and subsidizing rental housing for very or extremely low income adults with disabilities, like a chronic mental illness. The biggest difference between this program and similar ones is that it provides housing specifically for the disabled and ensures that all housing has access to appropriate supportive services like case management and employment assistance.

Applying for housing

If you can get a social worker or case manager to help fill out applications for jobs and housing, do so. You can practice any interview with your loved one. Interview tips include:

  • Don’t volunteer information about medical history.
  • Do not lie about job history, including positions held or lengths of time worked.
  • If asked about gaps in employment history, you can say “I was recovering from an illness,” “I was participating in a vocational rehab program” or “I was taking some classes.”
  • If there’s concern about ability to pay rent, you can say, “I have a guaranteed disabilities payment.”

Co-signing a lease makes you legally responsible for making sure the rent is paid during the period of the lease. Before you decide to do this, assume that you will pay all the rent and look at how that will impact you. Make your decision based on that. You also may become responsible for damages to the apartment, so be aware of that as well.

Housing in Columbus Metro Area

To apply for Community Housing Network housing, please call the Community Housing Network Intake Department at 614-487-6700. CHN has developed and manages more than 1,200 apartments. CHN provides rent subsidies to an additional 400 residents renting from private landlords. CHN also provides all customary property management.

National Church Residences takes its residents through Community Shelter Board, so call there.

To apply for Unified Supportive Housing System, apply for Alcohol, Drug and Mental Health Board of Franklin County housing, go to the Community Housing Network website, complete the CHN USHS Housing Request and submit to the CHN Intake Department.

Housing providers include:Alvis, Equitas, Community Housing Network, Maryhaven, National Church Residences, Volunteers of America of Greater Ohio, YMCA, and YWCA. These organizations usually take the homeless first. Ways to be homeless can vary, including couch surfing, or staying for one friend after another.

Next time we will talk about processes for getting a job when your loved one is recovering.

tired black woman touching head and looking down

Relapse Prevention: Know the Warning Signs

This month is Mental Health Awareness Month. Some of us are aware of mental illness every waking hour because we have a loved one dealing with it. We dread relapses. To help, I’ve collected information from NAMI, Mental Health America and my own reading/experience.

Recognizing the Early Warning Signs

Mental illness, especially bipolar disorder, schizophrenia and clinical depression, is usually episodic. The symptoms vary over time. When your loved one experiences another episode, it is commonly called a relapse.

Please note: Persistent symptoms that continue despite the stabilization of the illness are not signs of a relapse, but are treatment-resistant symptoms.  If the symptoms get worse, it’s a relapse.

Before the relapse, people often experience changes in their feelings, thoughts and behaviors. These are early warning signs. Studies indicate between 50% and 70% of people experience early warning signs over a period of one to four weeks before a relapse.

Looking for early warning signs allows you to start working with your loved one and his treatment providers to minimize the setback. Because you are the most frequent contact with your loved one, you are the one who sees the warning signs. The ill person will not be able to see them.  This blog post explains why.

Common Warning Signs

Each person has their own specific signs or “relapse signature.” But some warning signs are common, including:

  • Feelings of tension, anxiousness or worries.
  • More irritability.
  • Increased sleep disturbance (hearing them up in the night).
  • Depression.
  • Social withdrawal (more extreme, not even leaving his room to eat).
  • Concentration problems (taking longer to do tasks, having trouble finishing tasks, having trouble following a conversation or TV show).
  • Decreasing or stopping medication or treatment (refusing to go to the case manager or doctor, skipping the vocational program).
  • Eating less or eating more.
  • Excessively high or low energy.
  • Loss of interest in doing things.
  • Loss of interest in the way he or she looks / poor hygiene.
  • Being afraid of “going crazy.”
  • Becoming excessive in religious practices.
  • Feeling bothered by thoughts that will not go away.
  • Feeling overwhelmed by demands.
  • Expressing worries about physical problems.

Most common relapse indicators for schizophrenia:

  • Restless or unsettled sleep.
  • Nervousness or tension.
  • Having a hard time concentrating.
  • Isolation.
  • Feeling irritable.
  • Having trouble taking care of routine things.
  • A lack of energy.
  • Feeling sad or depressed.
  • Feeling confused.
  • A change in appetite.

Most common relapse indicators for bipolar disorder:

  • Disturbed or lack of sleep.
  • Talking quickly and more often than usual.
  • Acting reckless.
  • Feeling very tired.
  • Feeling very depressed.

An Off Day or the Start of a Relapse?

Everyone can have an off day. You can feel down in the dumps, with no energy. Or you can seem a little manic.  If a person has had mental health problems, it’s important to consider whether they are having an off day or starting a relapse.

Early warning signs are:

  • A cluster of changes.
  • Happening together.
  • Lasting over a period of time.
  • Gradually getting worse.
  • Following the same pattern as before.

Your Loved One’s Relapse Signature

Think about the last time your loved one got worse. If you keep a journal, look at what you wrote. It helps to think about:

  • What was the time of year?
  • Did your loved one say how they were feeling physically?
  • How was the mood?  The level of concentration?
  • Did any unusual changes in behavior take place in the weeks before the last relapse?
  • Did your relative do things that seemed “out of character” before the last relapse?
  • Have the same behaviors preceded other relapses?

Thinking about what was happening in the person’s life when you start to notice these changes can help too. 

Next time we’ll talk about what to do when your loved one shows signs of relapse.

hand coming up from water

Dealing With Depression

Depression and anxiety are now wide-spread problems stemming from the coronavirus pandemic. But caregivers of people with mental illness have often suffered from these issues.

On February 21, 2021, the New York Times published an American Psychological Association poll that said 74 percent of psychologists are seeing more patients with anxiety disorders than before pandemic. Sixty percent were seeing more people with depression. Time Magazine also published this on the increase in depression.

First the good news.

Almost all depression and anxiety conditions are treatable.  But there is no magic fix. These are very complex conditions.  Depression and increased anxiety also can be signs that a person with a more severe diagnosis, such as bipolar disorder or schizophrenia, is heading into an episode. Let’s take a look at depression first.

Depression … what it is and who gets it

Depression can result from a combination of genetic, biological, environmental, and psychological factors, the Veterans Administration website reports. Trauma, loss of a loved one, a difficult relationship, or any stressful situation may trigger depression, but depression can also occur without an obvious trigger.

According to the National Alliance on Mental Illness, an estimated 16 million American adults—almost 7% of the population—had at least one major depressive episode in a non-pandemic year. Women are 70% more likely than men to experience depression. And young adults aged 18–25 are 60% more likely to have depression than people aged 50 or older.

Depression is frequently under-diagnosed, however. Psychologists estimate that only about one-third (35%) of people with depression ever see a mental health professional.

The Veterans Administration reports that military personnel are prone to depression, at least partially as a result of exposure to traumatic experiences, including witnessing combat and separation from family during deployment or military trainings. Data shows it is five time higher among active duty soldiers and even higher among the previously deployed solders.

Some will only experience one depressive episode in a lifetime, but for most, depressive disorder recurs.

Without treatment, episodes may last a few months to several years.

Symptoms of Depression

Depression can present different symptoms, depending on the person. But for most people, depressive disorder changes how they function day-to-day, and typically for more than two weeks. Common symptoms include:

  • Changes in sleep
  • Changes in appetite
  • Lack of concentration
  • Loss of energy
  • Lack of interest in activities
  • Hopelessness or guilty thoughts
  • Changes in movement (less activity or agitation)
  • Physical aches and pains
  • Suicidal thoughts

We are not capable of diagnosing depression, but we can use the SIGECAPS diagnostic tool to determine whether someone should see a doctor. If a person has five or more of these 8 symptoms every day for two weeks, they are likely struggling with a major depression.

SIGECAPS Diagnostic Tool

  • SADNESS / SLEEP INTERRUPTION
  • INTERESTS … lost interest in things that used to enjoy
  • GUILT … ruminating over past perceived failures, character flaws, mistakes
  • ENERGY … noticeable lack of it
  • CONCENTRATION … inability to
  • APPETITE … could be eating more or eating less
  • PSYCHOMOTOR ABNORMALITIES … retardation (slowed speech, slowed movement, shuffling gait, collapsed posture, low voice volume, monotone speech, lack of facial expressions) or agitation (pacing, wringing hands, removing and putting on clothing over and over,
  • SUICIDAL … actively (with a plan), passively (stopped caring whether they live or die) and para (cutting or overdoses that the person knows won’t kill them … a cry for help)

Causes of Depression

Depression does not have a single cause. It can be triggered by a life crisis, physical illness or something else. But it can also occur spontaneously. Scientists believe several factors can contribute to depression:

  • Trauma. When people experience trauma at an early age, it can cause long-term changes in how their brains respond to fear and stress. These changes may lead to depression.
  • Genetics. Mood disorders, such as depression, tend to run in families.
  • Life circumstances. Marital status, relationship changes, financial standing and where a person lives influence whether a person develops depression.
  • Brain changes. Imaging studies have shown that the frontal lobe of the brain becomes less active when a person is depressed. Depression is also associated with changes in how the pituitary gland and hypothalamus respond to hormone stimulation.
  • Other medical conditions. People who have a history of sleep disturbances, medical illness, chronic pain, anxiety and attention-deficit hyperactivity disorder (ADHD) are more likely to develop depression. Some medical syndromes (like hypothyroidism) can mimic depressive disorder. Some medications can also cause symptoms of depression.
  • Drug and alcohol abuse.  About one-third of people with substance abuse problems also have depression. This requires coordinated treatment for both conditions, as alcohol can worsen symptoms.

Treatments for Depression

After an assessment rules out medical and other possible causes, a patient-centered treatment plans can include any or a combination of the following:

  • Psychotherapy including cognitive behavioral therapy, family-focused therapy and interpersonal therapy.
    • Cognitive behavioral therapy (CBT) has a strong research base to show it helps with symptoms of depression. This therapy helps assess and change negative thinking patterns associated with depression. The goal of this structured therapy is to recognize negative thoughts and to teach coping strategies. CBT is often time-limited and may be limited to 8–16 sessions in some instances. 
    • Interpersonal therapy (IPT) focuses on improving problems in personal relationships and other changes in life that may be contributing to depressive disorder. Therapists teach individuals to evaluate their interactions and to improve how they relate to others. IPT is often time-limited like CBT.
    • Psychodynamic therapy is a therapeutic approach rooted in recognizing and understanding negative patterns of behavior and feelings that are rooted in past experiences and working to resolve them. Looking at a person’s unconscious processes is another component of this psychotherapy. It can be done in short-term or longer-term modes. 
  • Medications including antidepressants, mood stabilizers and antipsychotic medications.
  • Exercise can help with prevention and mild-to-moderate symptoms.
  • Psychoeducation and support groups
  • Brain stimulation therapies can be tried if psychotherapy and/or medication are not effective. These include electroconvulsive therapy (ECT) for depressive disorder with psychosis or repetitive transcranial magnetic stimulation (rTMS) for severe depression.
    • Electroconvulsive Therapy (ECT) involves transmitting short electrical impulses into the brain. ECT does cause some side effects, including memory loss. Individuals should understand the risks and benefits of this intervention before beginning a treatment trial.
    • Repetitive Transcranial Magnetic Stimulation (rTMS) is a relatively new type of brain stimulation that uses a magnet instead of an electrical current to activate the brain. It is not effective as a maintenance treatment.
  • Light therapy, which uses a light box to expose a person to full spectrum light in an effort to regulate the hormone melatonin.
  • Alternative approaches including acupuncture, meditation and nutrition can be part of a comprehensive treatment plan, but do not yet have strong scientific backing.

Major Depressive Disorder with a Seasonal Pattern

Major Depressive Disorder with a Seasonal Pattern (formerly known as seasonal affective disorder, or SAD) is characterized by recurrent episodes of depression in late fall and winter, alternating with periods of normal mood the rest of the year.

Researchers at the National Institute of Mental Health were the first to suggest this condition was a response to decreased light and experimented with the use of bright light to address the symptoms. Scientists have identified that the neurotransmitter serotonin may not be working optimally in many people who experience this disorder.

The prevalence of this condition appears to vary with latitude, age and sex:

  • Prevalence increases among people living in higher/northern latitudes.
  • Younger persons are at higher risk.
  • Women are more likely than men to experience this condition.

Symptoms

This disorder’s most common presentation is of an atypical depression. With classic depression, people tend to lose weight and sleep less. This condition is the kind of atypical depression often seen in bipolar disorder—people tend to gain weight and sleep more.

Although not everyone experiences all the following symptoms, the classic characteristics of Major Depressive Disorder with a Seasonal Pattern include:

  • Hypersomnia (or oversleeping)
  • Daytime fatigue
  • Overeating
  • Weight gain
  • Craving carbohydrates

Many people may experience other symptoms as well, including:

  • Decreased sexual interest
  • Lethargy
  • Hopelessness
  • Suicidal thoughts
  • Lack of interest in usual activities and decreased socialization

Diagnosis

The key to an accurate diagnose of this condition is recognizing its pattern. Symptoms usually begin in October/November and subside in March/April. Some people begin to experience a “slump” as early as August, while others remain well until January. Regardless of the time of onset, most people don’t feel fully “back to normal” until early May.

For a diagnosis to be made, this pattern of onset and remission must have occurred during at least a two-year period, without the occurrence of any non-seasonal episodes during that same period.

This means you will not receive this diagnosis the first time you experience symptoms. If you believe you may have a seasonal depressive pattern, it’s important to pay attention to the pattern. Track your symptoms, noting when they begin and when they subside. This self-awareness can help. Mental health professionals will ask you about your observations and also your family history since mood disorders tend to run in families.

Treatment

As with most depressive disorders, the best treatment includes a combination of antidepressant medications, cognitive behavioral therapy and exercise. Unlike other depressive disorders, this condition can also be treated with light therapy. Light therapy consists of regular, daily exposure to a “light box,” which artificially simulates high-intensity sunlight.

If you know you have a seasonal pattern, ask yourself “How can I plan for this?” Because this disorder has a specific pattern, those who experience it can prepare for its arrival in the following ways, for example:

  • Exercise more toward the end of summer
  • Get into therapy around September
  • Start your lightbox in October
  • Plan a vacation to a sunny spot in January

When They Don’t Think They Are Mentally Ill

One symptom of having a mental illness is … not knowing that you have a mental illness. Really.

This symptom is anosognosia … pronounced uh-no-sog-NOH-zee-uh.  It means being unaware of one’s disease, disability or defect. This is common, as many who have tried to help a loved one can tell you.

Some people who have brain-based or “mental” illness have insight.  They know they have a mental disturbance that could be an illness. They recognize they have  experiences, including beliefs and perceptions, that don’t match reality.  Because they can see this, they are much more likely to accept treatment.

People with anosognosia often don’t accept treatment simply because they don’t think they are sick.

Anosognosia affects 50 percent of people with schizophrenia and 40 percent of people with bipolar disorder.  It also can be a symptom of major depression with psychotic features.

What Causes This?

The symptom can vary over time. Sometimes people understand they are ill, and sometimes they don’t. They are not being stubborn or difficult. The same brain dysfunction that causes hallucinations and voices also causes anosognosia.

People constantly update their own mental images of themselves.  You remember that you have a sunburn or a bruise or a runny nose, so you are not surprised when you see it again. The updating process takes place in the frontal lobe.

Unfortunately schizophrenia, bipolar disorder and dementia damage the frontal lobe.  So our loved ones can lose the ability to update their self-images.

Without an update, they have an old self-image from before the illness. Since our perceptions feel accurate, they believe they are well.  They decide that our families are lying or making a mistake.  When families insist that they are right, the person with the illness may get frustrated or angry.  They may begin to avoid family and friends.

Why Is Insight Important?

Lack of insight not only causes conflict. It usually causes a person to avoid treatment. It is also the most common reason that people with mental illness stop taking their medications.  When combined with psychosis or mania, lack of insight can cause dangerous behavior.

How Can You Tell If It’s Anosognosia or Denial?

It’s likely to be anosognosia if:

  • The lack of insight is severe and persistent (lasting for months or years).
  • The beliefs (I am not sick, etc.) are fixed. They don’t change when you confront the person with overwhelming evidence.
  • You hear illogical explanations or elaborate statements that attempt to explain away the evidence of the illness.

How Can You Help Your Loved One?

Anosognosia is a delusion. We can’t talk people out of delusions.  (That’s what a delusion is: a belief in the face of contrary evidence.) So stop arguing about it.

The alternative that experts stress is listening to the person.  The LEAP method, developed by Dr. Xavier Amador, has proven quite effective in research in helping people to accept that need for treatment.

In summary, the LEAP method is:

  • Listen to your loved one. If they don’t think they are sick, find out what problems they think they do have.  Lack of sleep, for example.
  • Empathize. Let them know you understand how difficult things are.
  • Agree with the loved one on some point. Example:  Lack of sleep makes things hard.
  • Partner with the loved one, starting with solving the problem that they recognize.

The method is detailed in Dr. Amador’s book, “I’m Not Sick. I Don’t Need Help.”  Details on also available in the videos here.  They are worth watching.

 

It’s National Minority Mental Health Awareness Month

The pandemic and systemic racism has caused so much angst this summer.  So it’s important to talk about National Minority Mental Health Awareness Month.

The House of Representatives started this annual observation in 2008 in honor of mental health advocate and writer Bebe Moore Campbell.

The Department of Health and Human Services is highlighting its free and accredited e-learning program: Improving Cultural Competency for Behavioral Health Professionals. This program is part of the Office of Mental Health’s Think Cultural Health E-learning courses.

Despite advances in health equity, disparities in mental health care persist. The Agency for Healthcare Research and Quality reports that racial and ethnic minority groups in the United States are:

  • Less likely to have access to mental health services.
  • Less likely to use community mental health services.
  • More likely to use emergency departments.
  • More likely to receive lower quality care.

All this adds up to poor mental health outcomes, including suicide. According to the Substance Abuse and Mental Health Services Administration (SAMHSA) and the CDC:

  • In 2017, 10.5% (3.5 million) of young adults age 18 to 25 had serious thoughts of suicide including 8.3% of non-Hispanic blacks and 9.2% of Hispanics.
  • In 2017, 7.5% (2.5 million) of young adults age 18 to 25 had a serious mental illness including 7.6% of non-Hispanic Asians, 5.7% of Hispanics and 4.6% of non-Hispanic blacks.
  • Feelings of anxiety and other signs of stress may become more pronounced during a global pandemic.
  • People in some racial and ethnic minority groups may respond more strongly to the stress of a pandemic or crisis.