Dr. Henry Paul, MD

Psychiatrist, Author and Educator

THE FINAL SHOT – MENTAL ILLNESS

December 11th, 2015

A USA TODAY story out yesterday said, “At a time of heightened concern over police shootings, a new report estimates that people with mental illness are 16 times more likely than others to be killed by police.”

Why is this? The problem is a lack of treatment for those with mental illness, and I also think a lack of training of law enforcement to recognize it. Mental illness is still something that carries a stigma. People, in general, don’t want to talk about it. For years now, the main thing driving the conversation about mental health has been the mass shootings. People are arguing that mental illness is the reason behind the mass shootings.

Now, a new study out from the Virginia-based Treatment Advocacy Center is saying that about one-in-four fatal police encounters involve someone with mental illness. This study is moving beyond saying that not just those who decide to shoot others in a mass shooting have some mental illness, but that many victims of shooting by law enforcement may also have mental health issues that made them do something illegal that got them killed.

I agree, and this is why we need more dialogue and more solutions on how to help those with mental illness. There are over 8 million people in the United States who have a mental disorder that can alter their thinking and perception of the world around them. From paranoid syndromes to fear, loneliness and anger there are plenty of emotions, disturbances of judgement and other issues that are associated with mental illness that can cause a person to act out or sometimes simply not understand laws or social constructs. And, the disorders themselves ranging from bipolar disorder to schizophrenia to various personality and substance abuse disorders that increase vulnerability often go undiagnosed. For many, even if they are diagnosed, some just stop taking their medications and other forms of treatment.

So what’s the answer? Well, I think that Mayor de Blasio and #ThriveNYC is a start. I believe that having a dialogue and trying to develop programs that can help those suffering from mental illness is a good place to start. Look, people with mental illness are no more violent than others. A better understanding by all will help many to seek and get the help they need. America has to embrace this conversation before change can ever really take hold.

Join me on Facebook and let’s have a conversation about this. Ideas and change come from collaborative thinking and open discussion.

LINKS
“I Called the Police for Help, Not to Kill My Son”
Groups call on Congress to reform mental health system

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

THRIVENYC EXPECTED TO TRANSFORM A CITY

December 3rd, 2015

New York City Mayor Bill de Blasio has announced new mental health initiatives for New York City. On November 25, the Mayor and his wife, First Lady Chirlane McCray, appeared on NPR’s Morning Edition to discuss ThriveNYC and how they hope it will transform their city.

De Blasio told host Linda Wertheimer, “We have a fundamental health problem in our city, in our nation, in New York City, as one-in-five New Yorkers are affected by some form of mental illness. And this requires a very comprehensive response, and it begins with making sure people can get access to mental health services.”

An $850 million program, ThriveNYC aims to hire 400 mental health clinicians for high-need communities and provide mental health training to a quarter-million New Yorkers.

The initiative will launch with mental health screenings for postpartum depression. “Despite the great benefit it provides, screening for postpartum depression has not been part of a woman’s routine care,” said McCray in an interview with the Huffington Post last week.

According to the Mayor’s office, the city’s Health and Hospitals, which runs 11 hospitals and Maimonides Medical Center — which together handle a quarter of the city’s births — have pledged to make the depression checks universal for pregnant women and new mothers within two years. It is estimated that one in ten new mothers, meaning 12,000 to 15,000 cases a year in the city, suffers from some sort of post-partum depression. The city’s eventual goal is universal screening.

Homelessness is a big part of this program. “The key is to make sure that people who are suffering – people who have a mental illness – don’t go on the street to begin with – that they are treated.” McCray told Wertheimer.

This is a step in the right direction for New York. I’m sure there will be details to work out as the initiatives unfolds but you have to start somewhere. I think that Mayor de Blasio and his wife are making a great start. Let’s support them.

Get a full copy of the ThriveNYC report (PDF). Understanding New York City’s Mental Health Challenge here. For more details on the initiative visit https://thrivenyc.cityofnewyork.us/.

LINKS

Huffington Post The Important Thing Hospitals Have Pledged To Do For New Moms

NPR NYC Mayor Unveils Ambitious Plan To Combat Mental Health Illnesses

COPING WITH THE HOLIDAYS

December 29th, 2014

“People with mental problems are our neighbors. They are members of our congregations, members of our families; they are everywhere in this country. If we ignore their cries for help, we will be continuing to participate in the anguish from which those cries for help come. A problem of this magnitude will not go away. Because it will not go away, and because of our spiritual commitments, we are compelled to take action.” Rosalynn Carter

The holidays can be a very fun and joyous time for many, but for others it is stressful and lonely. As we enjoy our holidays, let’s keep in mind those that may find this holiday season a difficult time. Those who are grieving, dealing with divorce or struggling with addiction. Those who have lost their job and are stressed about making ends meet. Those who have loved ones serving overseas and those who are dealing with illness.

NAMI (National Alliance for the Mentally Ill) has some good “tips for dealing with the holidays” that I would like to share with you. These tips are for those dealing with their mental illness and for those who need to be supportive of their loved ones who are dealing with mental illness including family, friends and the religious community. These holidays are steeped in religion and for many this can be a time to reconnect with their faith and spirituality.

If divorce or loss of a loved one has occurred in your family, make sure to make time for your children if they want to talk. It is important to embrace the season together – whatever it may bring.

Wishing you all a safe and happy New Year!

WHAT IS THIS THING CALLED DEPRESSION ANYWAY?

November 18th, 2014

Depression is a scary word to hear, especially from a doctor who is diagnosing you! It is important to remember, when you are diagnosed with depression that you are not alone. Depression affects about 25 million Americans each year. That is about 5-8 percent of adults in the United States. What is startling is that only a fraction of these people receive any treatment.

Depression is a mental disorder. But depressive symptoms present themselves within other mental disorders such as: bipolar disorder, posttraumatic stress disorder PTSD, panic/anxiety disorder, obsessive compulsive disorder (OCD), schizophrenia and borderline personality disorder.

Depression can happen a few times in a lifetime, present with several episodes over a year or have ongoing symptoms that get better and worse. When someone comes in and receives a diagnosis of major depression, it is unknown whether this depression (not associated with mania or hypomania) is a plain unipolar depression or one that is part of bipolar disorder. Bipolar disorder is characterized by episodes of depression and mania/hypomania (like mania but less severe). This is very important because the depression that is part of bipolar disorder, called bipolar depression, is treated differently than simple unipolar depression.

When you first visit your psychiatrist make sure that you can provide a complete history of your mental health. This includes the drugs and treatments you have had over the years, as well as all your symptoms.

Depression symptoms, as listed by the National Alliance on Mental Illness NAMI, include:

Changes in sleep. Some people experience difficulty in falling asleep, waking up during the night or awakening earlier than desired. Other people sleep excessively or much longer than they used to.
Changes in appetite. Weight gain or weight loss demonstrates changes in eating habits and appetite during episodes of depression.
Poor concentration. The inability to concentrate and/or make decisions is a serious aspect of depression. During severe depression, some people find following the thread of a simple newspaper article to be extremely difficult, or making major decisions often impossible.
Loss of energy. The loss of energy and fatigue often affects people living with depression. Mental speed and activity are usually reduced, as is the ability to perform normal daily routines.
Lack of interest. During depression, people feel sad and lose interest in usual activities.
Low self-esteem. During periods of depression, people dwell on memories of losses or failures and feel excessive guilt and helplessness.
Hopelessness or guilt. The symptoms of depression often produce a strong feeling of hopelessness, or a belief that nothing will ever improve. These feelings can lead to thoughts of suicide.
Movement changes. People may literally look “slowed down” or overly activated and agitated.

Your doctor will ask you if you have mania/hypomania to determine if your depression is only depression or if it is bipolar disorder. NAMI also has a good fact sheet with the symptoms of mania. Symptoms of mania/hypomania can include:

Feeling overly happy for an extended period of time.
An abnormally increased level of irritability.
Overconfidence or an extremely inflated self-esteem.
Increased talkativeness.
Decreased amount of sleep.
Engaging in risky behavior, such as spending sprees and impulsive sex.
Racing thoughts, jumping quickly from one idea to another.
Easily distracted.
Feeling agitated or “jumpy.”

DISCLAIMER

Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

SCREENING PRESCHOOLERS FOR DEPRESSION IS A GOOD IDEA

August 22nd, 2014

Depression can strike at any age, even among preschoolers, researchers report. CBS News

A very interesting study came out this month that looked at depression in preschoolers. The study found that preschoolers who are depressed are two and a half times more likely to continue to experience symptoms in elementary and middle school.

The study, published recently in the American Journal of Psychiatry, was done at Washington University by a team headed by Dr. Joan Luby, who directs the university’s Early Emotional Development Program. It included 246 preschool children, ranging from three to five years of age. Luby’s team evaluated the children for depression and other psychiatric conditions over time.

At the onset of the study, 74 of the children were diagnosed with depression. Six years later, 79 of the children met the criteria for clinical depression, including about half of the 74 children diagnosed with depression when the study began. Of the 172 children who were not depressed as preschoolers just 24 percent of them went on to develop depression later.

The study identified a higher risk of depression for children whose mothers had suffered from depression, and those who were diagnosed with a conduct disorder while in preschool.

When I was in training, we were taught that young children could not suffer from depression because they were not old enough to have a superego — a mental structure described by Sigmund Freud that develops at about eight years old. This theory, which denied the obvious, which was that we often saw depressed young children, flew in the face of reality and caused depressed children to be left untreated up until the last few decades.

Today, we know that people of all ages can suffer from depression, especially young children who grow up in stressful circumstances. If untreated, this depression can lead to severe consequences including further depression, educational slowing, behavior disorders and other syndromes.

I agree with the researchers that children as early as three years old should be screened. Childhood depression can be treated, and there are a host of interventions that help including psychotherapy, family therapy, and medication.

OPPOSITIONAL DEFIANT DISORDER AND CONDUCT DISORDER

April 30th, 2014

In the group of disorders called behavior disorders, in addition to Attention Deficit (Hyperactivity) Disorder there are two other conditions: Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD).

Oppositional Defiant Disorder (ODD) is a characterized by:

Negativism
Rebellion
Arguing
Defiance
Anger episodes
Revenge
Resentment
Spite
Annoying others
Blaming others
Irritability
An overall passive aggressive stance (I will show my anger by not doing….”)

Conduct Disorder (CD), an even more serious behavior disorder, often related to the development of Antisocial Personality Disorder in adulthood, is characterized by:

Persistent breaking of rules
Aggression toward other people/animals
Fighting, bullying, cruelty, intimidation
Destruction of property
Fire setting
Lying
Stealing
Other law/rule breaking
Running away
Truancy
Breaking curfew

Both of these serious behavior disorders are difficult to treat, necessitating a multimodal approach and sometimes the use of medication: stimulants in ODD and sometimes antipsychotics in CD.

DISCLAIMER

WHAT ARE THE DRUGS USED TO TREAT TDD & BDD?

April 25th, 2014

Below is a list of the major mood stabilizers. Of all of these, Lithium, Depakote, and Tegretol are the three most commonly used.

Lithium – Approved for children 12 years and older.
Depakote -Approved for children 2 years and older for seizures.
Tegretol – Approved for all ages for seizures.
Gabapentin – Approved for young people 18 and older. Approved only for epilepsy.
Lamictal – Approved for young people 18 and older. Approved for seizures in children.
Topamax – Approved for young people 18 and older and approved for seizures.
Trilpetal – Approved for children 4 and older and approved for seizures.

LITHIUM

The most well-known, well-studied, and longest used drug for BD is Lithium. Despite favorable publicity, the misconception still exists that Lithium is dangerous. The fear springs from the well-publicized stories of the rare Lithium toxicity reaction. I have prescribed Lithium to many hundreds of patients, young and old, and have only witnessed this reaction once. People can and do take Lithium for years with only positive results.

Lithium can be harmful to the thyroid and to the kidneys over the long term. It is essential that kidney and thyroid function tests be done regularly when taking this drug. Before starting Lithium, your child should have a complete blood count, an ECG, and thyroid and kidney tests.

TEGRETOL

Tegretol (Carbamazine) is an antiepileptic drug used commonly for BD in adults and young people. It is not approved for use in BD and is given off-label. It is approved for use in epilepsy for children as well as adults. Despite this off label use, it has been reported as quite successful in some of the few trials reported. The dosage recommended for young people is up to 300 mgs a day.

Before prescribing Tegretol a complete history and physical examination is necessary. There should be a complete examination of the skin as well as a complete blood count and other blood tests to be sure of the level of liver function.

DEPAKOTE

Depakote, as it is most well-known, is another anti-epileptic medication used as a mood stabilizer. Like with other antiepileptic medication this is used off-label in young people. But it is widely used and considered almost as good as Lithium for BD. It is specifically used quite a bit in teenagers with BD with good results. It is sometimes used as a first line monotherapy like Lithium or in combination with other drugs.

Before starting this drug a complete medical history and physical exam is necessary. There should also be a complete blood count, clotting tests, tests of kidney function, urine analysis, and a pregnancy test for girls. Caution should be taken and full disclosure about PCOS (polycystic ovaries) and pregnancy issues should be made.

DISCLAIMER

HOW DO WE TREAT BD AND TDD?

April 24th, 2014

The treatment of BD in children is similar to that of adult BD. First, we treat whatever the episode that is being experienced – acute phase treatment – and when things get better we focus on preventing future episodes – maintenance phase treatment. Most of the medications for both phases are the same. One must also keep in mind that BD children often have comorbid (additional) diagnoses which might need treatment, as well.

Acute Phase Treatment

The acute phase of treatment of BD means medicating a child who is either manic or depressed (but depressed with a history of mania or hypomania) or one who has TDD.

The initial acute phase treatment for mania without psychotic features (hallucinations and delusions), or TDD starts with monotherapy treatment with one drug. The one drug is either a mood stabilizer such as Lithium, Depakote, or Tegretol, or less commonly Gabapentin, Trileptal, or Topamax, or an antipsychotic drug such as Risperdal, Seroquel or Zyprexa, or less commonly Abilify or Geodon. If a child only partially responds than an augmenting agent is often tried in conjunction with the first medication. Usually this consists of adding an antipsychotic to a mood stabilizer or conversely a mood stabilizer to an antipsychotic. Alternatively, if the child does not respond to monotherapy the psychiatrist sometimes skips the augmentation phase and just switches to another of the original choices of monotherapy listed above. Again, there is still an opportunity to add an augmenter. If the child still fails to respond than differing combinations of mood stabilizers and antipsychotics are often tried. On the whole most children do respond to one or more of the more common first line drugs (Lithium, Tegretol, Depakote or Risperdal, Seroquel or Zyprexa).

For BD children with psychotic features, it is common to start with a combination of a mood stabilizer and an antipsychotic drug. If this fails the psychiatrist can switch the combination of these drugs, and then add another antipsychotic medication or add another mood stabilizer. Finally, if all combinations of the common mood stabilizers and antipsychotics are exhausted, less effective mood stabilizers in conjunction with different antipsychotic medications may be prescribed.

Maintenance Phase Treatment

The maintenance phase of drug therapy is aimed at preventing recurrence of episodes of BD. Interestingly the maintenance drugs are the same ones used in the acute phase of treatment. There is little evidence that these drugs work as well in preventing relapses in young people as they do in adults. The maintenance phase usually lasts from one to two years and depends, to a degree, on the level of impairment, the chronicity of the condition, the number of episodes of bipolarity, and the level of stability reached by the youth and the environment in which she lives. While most young patients are able to get off these medications, there will be times that this will prove impossible. Sometimes relapse follows quickly upon stopping the medications. As with some adults, a decision will be made that drug therapy will be maintained indefinitely to help the child or adolescent progress in life, socially, educationally, and vocationally without the risk of further decompensation.

DISCLAIMER

CHILDREN WITH TDD ARE OFTEN MISDIAGNOSED

April 24th, 2014

Children with Temper Dysregulation Disorder with Dysphoria (TDD) are often misdiagnosed with Bipolar Disorder (BD). Why? Because there is confusion regarding the symptoms. Symptoms that include chronically aggressive, irritable unhappy children with frequent temper tantrums have often been diagnosed as having BD, when actually they should have been diagnosed with TDD.

TDD is a fairly new syndrome that has been known to many of us in the mental health community for years. It is a classification that has been suggested to replace the diagnoses of bipolar children in cases where symptoms include:

Having frequent tantrums in response to stress
Acting with rage and aggression out of proportion to whatever the cause
Having behavior that makes them appear younger than they really are
Experiencing these episodes at least several times a week
Feeling a lot of irritability, anger, and sadness (dysphoria) in between tantrums
Having tantrums that appear in more than one setting (home and school) and that start before a child is ten years old and no earlier than six years old

These symptoms appear quite frequently and they generally have to last a year to officially be called TDD. These children also share other characteristics:

They do not have mania.
They share a similarity to children with Oppositional Defiant Disorder.
They rarely develop BD but are more likely to become depressed as they get older if not treated. I have often seen depressed adults who describe their behaviors as children that sound like TDD.

Medications for BD, TDD, and Accompanying Conditions

Children younger than mid-adolescence rarely present with classically described BD. Therefore, the available treatments are those used for adults, but given to children “off-label”. The medical establishment calls the group of medications “Mood Stabilizers”. Other than Lithium, the most well-known of the group, most of the mood stabilizers were used originally by neurologists to treat epilepsy and are called anti-epileptic medications. These medications are often used in conjunction with antipsychotic medications for children with BD and TDD. Although, formal studies are somewhat lacking, it does seem that these drugs help. For the sake of discussion we will address the BD child as one who either presents as having classic BD (rare) or TDD.

DISCLAIMER

RECOGNIZING BIPOLAR IN CHILDREN AND ADOLESCENTS

April 21st, 2014

The adult presentation of Bipolar Disorder (BD), as it is historically known, begins to appear in mid to late adolescence. In younger children, classical BD is extremely rare. In dealing with literally thousands of children, I have come across only a handful of cases of classic BD. The upsurge in diagnoses has occurred in younger children because these children present with behavior disorders associated with mood changes that are hard to classify using the present diagnostic parameters. However, including them in the BD category might not be the solution. For example:

In childhood one rarely encounters the above mood episodes (mania/hypomania and depression) as separate, distinct entities. In other words, it is difficult to identify discreet episodes of elevated or irritable mood episodes, intervening normal periods, and than discreet episodes of depression. Thus in children who have mood variability with characteristics of bipolar episodes there is usually no cycling as there is with adults and the course is much more variable. In fact, it is rare to see full blown mania in young children. Keep in mind that there are normal times when children seem to feel great or even overly exuberant as a regularly occurring reaction to an external event or personal achievement.
Since in adulthood irritability frequently presents as part of a manic episode, the psychiatric community decided to put children with excessive irritability alternating with other mood variations in the category of BD. But this seems more like convenience for the diagnostician than truth. If all these children were, in fact, presenting with some form of BD than they would eventually develop true BD, which they do not.
Many children classified as Childhood BD really suffer from ADHD, a disruptive behavior disorder other than ADHD, Post Traumatic Stress Disorder (PTSD) with a behavioral disorder, or plain severe anxiety. Even youngsters with hypersexuality (typical of mania) often are sexually abused children acting out.
It appears to me that behavior disordered children who don’t quite fit the ADHD, Oppositional Defiant Disorder or Conduct Disorder entities have been deposited in the BD category for lack of a better fit. And since some of the medications used for BD help with excessive behaviors, the diagnosis is made.

In summary, truly bipolar children are a rarity in clinical psychiatry, although, on occasion, one does see such a child. More likely, your child who has a severe behavioral disorder, great variation in mood, resistance to medications for ADHD, or anxiety is suffering from a mixed disorder which defies strict diagnosis at this time. The good news is that there is treatment for these children.

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