Focusing on Mental Health Policy Issues

The recent spate of high-profile mass shootings has inspired yet another “national conversation” about mental illness, with everyone agreeing that the country has a problem. Unfortunately, isolated instances of violence are how the subject typically ends up in the news cycle. But the more mundane social repercussions of mental illness, while perhaps not as headline-worthy, are pervasive and acutely felt nonetheless.

On any given day, one in five people in jail or prison has a severe mental illness. This means that people with serious mental illness are ten times more likely to inhabit a jail cell than a hospital bed. Besides contributing to jail and prison over-crowding, mentally ill people are especially vulnerable to victimization by fellow prisoners, spend more time in solitary confinement, and become suicidal behind bars at higher rates than non-mentally ill inmates. They also cost the correctional system considerably more than otherwise healthy prisoners.

The challenge facing prisons is just one consequence of decades of de-institutionalization policies. From a nationwide peak of around 560,000 psychiatric beds in 1955, the census has been whittled down to about 35,000 today — about half of what experts estimate is actually needed. In the absence of such beds, patients will continue to be warehoused behind bars, lie on emergency-room gurneys for days, and languish in nursing homes. One-third of the nations homeless will still be comprised of the untreated mentally ill, who are at far greater risk of being preyed upon than of harming someone else.

The lesson of downsizing state psychiatric facilities — no less powerful for being familiar — is that good intentions are not enough. Too many sick people are now caught in a pernicious cycle, rotating in and out of emergency rooms, crisis hospitalization, incarceration, homelessness, and back again. Its no wonder some of the strongest supporters of mental-health reform are police, district attorneys, corrections officials, and emergency-room physicians.

These problems afflict roughly 10 million Americans, or just over 4% of the population. Mainly diagnosed with schizophrenia, bipolar (manic-depressive illness), or major depression, such individuals are chronically or periodically unable to care for themselves or are suicidal. At times, they may be dangerous to the public. Relative to other psychiatric patients, those with severe mental illness are far more likely to need medication, intensive supervision, and even involuntary treatment at some point in their lives. But they arent getting the help they need, and the governments good intentions are often the very thing preventing their getting appropriate treatment.

To understand a key source of the problem, we should compare severe mental illness to “mental health.” The Centers for Disease Control describes mental health as a composite of “emotional well-being,” “psychological well-being,” and “social well-being.” According to government statistics, only about 17% of adults are considered to be in a state of optimal mental health — the rest, apparently, need some kind of professional assistance to achieve optimal “wellness.”

Sandwiched between mental health and severe mental illness is a clinical category called mental illness. One recent national survey estimates that nearly 18% of those individuals older than 18, or about 43.7 million people annually, are mentally ill — meaning they fulfill diagnostic criteria for any condition listed in psychiatrys official diagnostic handbook, ranging from attention deficit disorder to panic attacks to anorexia. The severity and chronicity of these conditions varies dramatically, with most conditions resolving on their own, while others are best served with time-limited psychiatric care; some may require hospitalization and long-term medication and therapy.

The distinction between mental health, mental illness, and severe mental illness is crucial, because it leads us to different clinical and policy prescriptions. The vague boundaries of “mental health” enabled a variety of advocates whose true agenda is grievance and social reform to claim that their concerns fell under its rubric, as historian of psychiatry Gerald Grob has observed. As a result, he writes, “persons with serious and persistent mental illnesses…[are] forced to compete, often unsuccessfully, with other groups that now [define] their needs in terms of mental health.”

The problem we have today is that the system is geared more toward mental health than severe mental illness. In fact, the federal governments lead agency on mental health, the Substance Abuse and Mental Health Services Administration, part of the Department of Health and Human Services, has explicitly stated this as its goal. Rather than focusing on reducing homelessness, hospitalization, or incarceration among people with serious mental illness, it concentrates federal and state efforts on delivering amorphous “behavioral health” to everyone else.

This is profoundly misguided. But it may not be surprising after a half-century of inept leadership, Medicaids financial incentives gone awry, and clashing ideas about the nature of the forces (psychological, biological, and social) that lead to psychopathology — and that, in turn, point toward the best possible therapeutic strategies. Ours is a problem-ridden system that could be markedly improved with strong political leadership.

We need a mental-illness system in which care for the sickest of the sick is a priority. If the federal government intends to take mental illness seriously, Congress and the next administration must be keenly responsive to the most vulnerable patients.

a troubled legacy

To understand what should be done, a review of the dynamics that led to the current state of disarray is in order. Four key elements are to blame.

The first emerged in the late 1950s, as officials emptied state hospitals of even the most debilitated patients without adequately planning for their continued treatment. The second contributing factor came with the creation of Medicare and Medicaid in 1965, as new policies limited access to community hospital beds. The third factor is the growing complexity of competing ideas about the causal and remedial factors involved in mental illness, and the resulting complications in policymaking. And fourth is the disproportionate leverage wielded by anti-psychiatry forces in an era of victim politics. This last influence builds upon a longstanding debate regarding the civil liberties of individuals whose capacity to manage their freedom is badly compromised by dysfunction in their brains.

Until half a century ago, the care of people with mental illness had been the responsibility of the states. This changed in 1963 when President John Kennedy ushered in the era of federal support by championing the Mental Retardation Facilities and Community Mental Health Centers Construction Act. The new law mandated the creation of a user-friendly archipelago of 1,500 federally funded community clinics nationwide to supplant the large state asylums and to allow patients to live in their communities while receiving treatment. “When carried out,” Kennedy said of the act, “reliance on the cold mercy of custodial isolation will be supplanted by the open warmth of community concern and capability.” The presidents interest was personal, stemming from the tragic experience of his sister Rosemary, who was born with mild mental retardation and eventually underwent a frontal lobotomy for schizophrenia.

The nation was primed for the change the president sought. Two decades earlier, Life magazine had run “Bedlam 1946,” a searing photo-journalistic exposé of Pennsylvanias Philadelphia State Hospital at Byberry and Ohios Cleveland State Hospital. Books like Albert Deutschs The Shame of the States and popular entertainments like the movie The Snake Pit, both of which appeared in 1948, exposed shocking conditions of filth and abuse in state facilities.

State-initiated efforts improved the conditions at state hospitals in the mid-1950s, and, thanks to the availability of Thorazine, an anti-psychotic medication introduced in 1954, some patients were successfully moved into the community. But with Kennedys community centers under construction in the mid-60s, the campaign to empty out state facilities took on new urgency. Some patients did well upon discharge, but the sickest were caught in a revolving door: Without closely supervised treatment, many failed in the community and went back to whatever institutions were left. Others ended up in a kind of limbo, neither institutionalized nor embedded in a community.

The state-hospital population was further eroded by legal decisions issued in the 1960s and 70s that made it hard for judges to order necessary treatments for patients who were wildly psychotic or immobilized by depression but were refusing care. A convergence of strange bedfellows — fiscally conservative state officials, progressive reformers, former patients, and politically liberal civil-rights lawyers — formed a strong advocacy coalition for deinstitutionalization policies.

In 1965, as the exodus from state hospitals was well underway, Congress passed legislation establishing Medicare and Medicaid. The new law included a provision that unwittingly planted the seeds of the current shortage of public hospital beds. It did so by prohibiting Medicaid from paying for care delivered to patients between the ages of 22 and 64 if that care was provided in an “institution for the treatment of mental diseases,” or IMD. An IMD is defined as a treatment facility with more than 16 beds of which at least half are dedicated to mentally ill patients. The so-called “IMD exclusion” was intended to spur momentum for community treatment by barring the doors to the asylum, which Congress saw more as a warehouse than a treatment facility anyway.

The IMD exclusion did not affect general hospitals and nursing homes. They remained eligible for Medicaid reimbursement. Thus, states had a strong incentive to shift patients from state psychiatric hospitals to Medicaid-eligible institutions, even if those venues were more costly or less effective. With fewer and fewer psychiatric beds available, emergency rooms became holding areas for those who needed inpatient treatment; others spilled out onto the streets and into run-down, questionable boarding houses and jails.

It did not have to be this way, which is clear given how well Medicaid has worked for people with intellectual and developmental disabilities. They, too, could be found living in state hospitals in the mid-20th century, but Medicaid treated them differently. If they still needed residential or intermediate care, Medicaid reimbursed the state for their stay. Then when these patients were discharged into the community, Medicaid covered wraparound services such as vocational assessments, family counseling, medication management, and transportation. Today, these services are provided under a “community options” waiver that “swaps” a Medicaid-covered inpatient bed for a similarly covered, community-based slot.

Unfortunately, no such waiver exists for individuals with serious mental illness, because the IMD exclusion prohibits federal coverage for adults. The ensuing problem of fragmented services is formidable. Between orchestrating disability entitlements, housing, and treatment of medical problems, case management can require organizational skills that are beyond most of us, let alone people who are also overwhelmed by depression, difficulty concentrating, or jumbled thoughts. Even when there are quality services covered by Medicaid, such as nursing-home placement, funds are not always tailored to young or middle-aged able-bodied psychiatric patients. Meanwhile, entire subpopulations of poor, young men are not covered at all in many states.

Thus, as Harold Pollack of the School of Social Service Administration at the University of Chicago explains, “Deinstitutionalization has, on the whole, worked well for the intellectually disabled because they and their supporters could crank the political valves required to make it work. Equally worthy claimants who lacked the same political muscle or public embrace fared much worse. Thats one key lesson of the deinstitutionalization fight.”

The next major step toward our current dysfunctional approach to treating mental illness seems at first glance to have begun with a semantic, rather than a policy, decision. When Jimmy and Rosalynn Carter entered the White House in 1977, they already had an interest in mental illness. President Carter wasted no time in establishing the Commission on Mental Health. According to historian of psychiatry Gerald Grob, “the [commissions] decision in 1977 to use mental health rather than mental illness…was based on the application of a public health model that emphasized the role of the environment, social services, and prevention rather than the traditional psychiatric focus on the diagnosis and treatment of severe and persistent mental disorders.”

The dubious notion that external influences, such as stress, social problems, traumatic experiences, and even coercive psychiatric care itself are the primary causes of severe mental illness still thrives today in influential quarters, as we will see.

the recovery model

A quarter-century after the Carter commission, in 2002, President George W. Bush revisited the problem of public mental-health care by appointing a commission of his own, called the New Freedom Commission on Mental Health. The commission was charged with conducting a “comprehensive study” of the existing system and advising President Bush on improvements. The 2003 report issued some positive suggestions regarding, for example, the need for an increased number of psychiatric beds and better programs to help disabled patients participate in the workforce. But the Bush commission, like Carters before it, elided the distinction between mental health and mental illness and failed to grapple with approaches to patients with severe mental illness who refused to take medication and had a potential for violence.

Instead, the Bush commission promoted an overly optimistic treatment philosophy that came to be called the “recovery model.” It held that with sufficient therapy, housing options, and employment programs, patients with schizophrenia or manic-depressive illness would be able to take charge of their lives. To be sure, a lot of patients are indeed able to do this, especially young people with recent onset of illness. But the recovery models unrealistic one-size-fits-all approach ignored the toughest cases, which often require heavy doses of paternalism because the patients dont acknowledge their own illness — a symptom of being psychotic in and of itself, in many instances. In an un-medicated state, an individuals symptoms remain unabated, behavior remains menacing or erratic, and the risk of violence, particularly if alcohol or cocaine is involved, is increased.

The recovery agenda was inspired by the patients rights movement of the 1960s. This campaign for enlightened care, which included better quality of treatment, collaboration with physicians, and assurance of privacy of health information, was a sensible reaction to the heavy strain of paternalism that marked the medical field at one time. Psychiatry, in particular, attracted the animus of patients rights activists; after all, it is a field whose very nature requires professionals to make fraught judgments about the normal or abnormal thoughts, behaviors, and identities of their patients. Whats more, for better or worse, psychiatrists may impose tacit or actual control over their patients.

Consequently, the psychiatric patients rights movement took on a radical tenor. Spurred by a 1960s ethos of social justice, activists saw themselves as a class of social dissidents and psychiatry as an agent of social control. The Insane Liberation Front was founded in 1970 in Portland, Oregon. In 1971, the Mental Patients Liberation Project and the Mental Patients Liberation Front appeared in New York and Boston, respectively. The next year, former patients in San Francisco organized the Network Against Psychiatric Assault and the Madness News Network. They have championed the rights of severely ill patients to refuse treatment, representing the expressed wishes of their clients (patients) even when they are delusional, and they have campaigned against involuntary commitment, as well as electroshock therapy, which is one of the safest and most effective treatments for severe depression. So what do these activists prescribe as an alternative? Political empowerment.

By the 1980s, the movement had spawned a new identity known as the “consumer-survivor,” which persists to this day. In this iteration of the psychiatric patients rights movement, dynamics such as identity politics (with the mentally ill playing the role of minority population), disability status, and a sense of entitlement to public services play a larger role than they did in the 60s and 70s. Compared to their earlier counterparts who saw themselves as dissenters, not patients, these consumer-survivors actually do see themselves as ill. “Consumer” is the politically correct word for patient, and “survivor” refers to one who has survived psychiatric care. The most vocal anti-psychiatry consumer-survivor groups are the National Empowerment Center near Boston and the Nation Mental Health Consumers Self-Help Clearinghouse in southeastern Pennsylvania. Funded in part by the federal government and state mental-health agencies, these groups lobby against involuntary treatment and electroconvulsive therapy, and they discourage patients from taking medication.

As with the anti-vaccine movement, such trends always have the capacity to be damaging, but vocal, misguided fringe groups are not a rare occurrence in the United States, especially when it comes to health care. The difference is that these groups have the financial support of the U.S. government; thus, taxpayer money is being used to make things worse.

failing the most vulnerable

The Substance Abuse and Mental Health Services Administration, an agency within the Department of Health and Human Services known by its acronym, SAMHSA, bolsters the consumer-survivor agenda ideologically, programmatically, and financially. It is a striking example of government working at cross-purposes to the best interests of its most desperate constituents.

The agencys entire budget for mental health is around $1.1 billion. (The remainder of its full budget of $3.6 billion is earmarked for prevention and treatment of substance abuse.) Of the $1.1 billion mental-health budget, $482 million goes into block grants to the states for mental-health services, and the remainder goes to other programs for adults and children, the homeless, and Protection and Advocacy (described further below). Given that federal mental-health expenditures total $130 billion annually, mostly in the form of Medicaid, the SAMHSA budget seems modest. But the agency manages to leverage its funds in ways that not only shortchange but actively undermine the welfare of the sickest patients.

For one thing, SAMHSA claims to receive much of its policy input from groups of consumers that it occasionally convenes. These people may have psychiatric problems but generally need only low-levels of support, and many do not take medication. They do not represent the most impaired patients — the ones who are languishing in jails, in emergency rooms, or on the streets. Such people are too lost in their psychosis to show up for a focus group or to embrace the “recovery agenda.” Indeed, approximately half of all untreated people with a psychotic disorder do not acknowledge they are ill, which is itself a neurological condition called anosognosia.

There is a vital role for benign paternalism toward this highly vulnerable set of patients, but the culture of mental health as practiced by SAMHSA effectively denies their existence, let alone their needs. To be sure, the psychiatric profession was once dismissive and too pessimistic about many people who were indeed capable of greater independence, but there is no denying that now a subset of the mentally ill needs much more oversight and, at times, even benign coercion.

SAMHSAs worldview is reflected in the nature of its discretionary grants and programs, some of which completely undermine the best interests of patients with severe mental illness. For example, the agency is a major funder of groups that are overtly opposed to medically accepted psychiatric care. The National Empowerment Center, based in Lawrence, Massachusetts, is one beneficiary of SAMHSA funds. Its mission is “to carry a message of recovery, empowerment, hope and healing to people with lived experience with mental health issues, trauma, and/or extreme states.” The NECs Chief Operating Officer has been a long-time critic of the use of psychiatric medications.

The Washington, D.C.-based National Coalition for Mental Health Recovery is a trade group for recipients of agency largesse. Its mission is to ensure “consumer/survivors have a major voice in…policies at the state and national levels.” The coalition and its smaller, composite organizations oppose the type of services — civil commitment, increased hospital capacity — that target the most impaired. Another example is the Alternatives Conference, which is funded by SAMHSA each year. Among other things, attendees with mental illness are taught how to go off their psychiatric medications. In 2011, SAMHSA gave one of its annual “Voice Awards” to an activist who believes that “[p]sychiatry is not medical because it is not scientific. It does not diagnose or treat actual conditions. It is complete fiction. Voodoo witch doctors have a better cure rate.”

Apart from awarding grants, SAMHSA runs its own programs, perhaps the most painfully misguided of which is the Protection and Advocacy program. Established by Congress, the original, benign intent of the Protection and Advocacy for Individuals with Mental Illness Act of 1986, or P&A, was to investigate allegations of patient abuse, neglect, and rights violations in hospital wards or in residential facilities. Mission creep soon set in, however. As Rael Jean Isaac and Virginia Armat documented in their 1990 book Madness in the Streets, P&A quickly devolved into “playgrounds for anti-psychiatric activists.”

The P&A program operates with $39 million, distributed among the states. The local P&A agencies routinely flout congressional intent by lobbying state legislatures against adopting sensible treatment policies and against strengthening their civil-commitment laws. Making matters worse, they do so at the expense of conducting investigations into the mistreatment of patients. Amanda Peters of South Texas College of Law has closely examined P&A programs, and has found that their lawyers and personnel are so preoccupied with fighting civil-commitment policies and trying to liberate undeniably psychotic patients from hospitals that glaring violations of abuse and neglect go unchecked.

Many P&A lawyers are against hospitalization at any cost, to sometimes tragic result. Consider the story of Joe Bruce of Caratunk, Maine, whose psychotic son is now a murderer because of Maines P&A agency. In 2006, 24-year-old William Bruce was a patient at Riverview Psychiatric Center, where he had been committed after assaulting his father. His parents were afraid of their son and begged the hospital to medicate him with the antipsychotic that had previously quelled his paranoia and aggression. Williams psychiatrists, who had observed him for weeks as an inpatient, fought against Williams pleas for release because he remained paranoid and agitated. Nonetheless, the P&A legal advocates insisted that William was “competent” for discharge and openly coached him — as any lawyer would his client — on how to placate the doctors so theyd let him go. William and his lawyers somehow prevailed over his doctors and parents objections, and Riverview discharged him. Two months later, he killed his mother with a hatchet. The Bruce familys story is one of the most dramatic, but by no means one of the only, examples of the reckless “liberation” of dangerous or debilitated patients at the hands of a P&A agency.

For decades, HHS and SAMHSA have mismanaged the mental-illness resources of the federal government, focusing increasingly on “recovery agendas” instead of on the severely mentally ill. Our most vulnerable citizens are slipping through the cracks. It is long past time for a better, more serious mental-illness agenda.

prescriptions for mental health

Like Presidents Kennedy, Carter, and Bush, the next president could do a great deal to improve the nations mental-health system. The most radical, most effective approach might be to propose legislation to abolish SAMHSA altogether, holding on to those pieces worth saving, such as the collection of statistics, by assigning them to the Centers for Disease Control and Prevention, the National Institutes of Mental Health, or other appropriate government agencies. Charges of abuse (such as excessive use of physical restraints) and neglect could be handled by the Department of Justice. The block grants could be distributed by the Human Resources and Services Administration.

Whether or not SAMHSA is shut down, it is imperative that the next director of federal mental-health initiatives, perhaps working directly out of HHS, be a psychiatrist or psychologist with extensive experience treating and managing systems that target severely and persistently ill patients. (Currently, SAMHSA does not employ a single psychiatrist among its staff of 570, let alone in a leadership or key advisory position.) In 2013, an experienced psychiatrist joined as medical director, but she quit two years later because of what she described as “an open hostility toward psychiatric medicine by those at the helm of the agency. The concept of mental disorders as diseases was rejected.”

A SAMHSA leader who understands the clinical needs of the sickest patients and prioritizes these demands — and who is backed by the secretary of HHS — would instinctively make profound changes. He would cease grant-making to advocacy organizations whose members deliberately undermine the validity of professional help and medications and those who lobby against commitment policies at the state and federal levels. The medical-director slot would be filled by a psychiatrist who endorses mainstream views on the value of medication, the importance of promoting tested programs over a feel-good “wellness” and “empowerment” agenda, and the need for inpatient services. An enlightened agency leader would invest in research aimed at the sickest patients and accept the notion that paternalistic strategies are legitimate and necessary for some of them. Finally, such a leader would contain P&As mission creep and ensure that program funds go solely to the investigation of abuse and neglect, as was the programs original congressional mandate.

Medicaid needs improvements, too. To address the bed shortage, for example, Congress could base eligibility for Medicaid reimbursement solely upon an individuals need for care, rather than upon the location in which it is delivered. Another option is raising the limit on the number of psychiatric beds for which Medicaid will pay, to allow larger facilities already specializing in mental illness to fall outside of the scope of the IMD exclusion. Alternatively, more states could be allowed to use Medicaid Section 1115 waivers — as some already are — to draw down reimbursement for services provided in IMDs. Not surprisingly, some advocates argue against these ideas, concerned that they will re-open the door to institutionalization.

Some policymakers suggest simply expanding the number of psychiatric beds in general hospitals, but economies of scale (a benefit of larger psychiatric institutions) would be lost. Nor would general hospital units be able to reproduce the therapeutic milieu that characterizes a quality inpatient unit. Whats more, general hospitals are reluctant to admit the sickest psychiatric patients, who are often disruptive, sometimes violent, and difficult to treat and require additional nursing.

To inform lawmakers debating this complicated issue, the federal Centers for Medicare & Medicaid Services is funding the Medicaid Emergency Psychiatric Demonstration, mandated by the Affordable Care Act. Eleven states and the District of Columbia are using Medicaid funds to pay for inpatient emergency psychiatric care in psychiatric hospitals for patients aged 21 to 65 without the 16-bed restriction. By focusing on psychiatric emergencies, the three-year demonstration, which began in 2012, also attempts to explore a potential remedy to alleviate burdens placed on general-hospital emergency rooms by psychiatric patients for whom no bed is available.

Medicaid administrators also need more flexibility to cover the unique kinds of help, beyond standard fee-for-service visits for medication and therapy, which enable mentally ill individuals to thrive in the community. These may include Fountain House-type clubhouses (private, non-profit community centers that provide job training, socialization opportunities, and computer access) and various other types of assistance with staying in school or holding down a job. Assertive Community Treatment teams — intensive 24-hour outpatient supervision by clinical teams linking patients to needed medical and social services — would save money and reduce days in the hospital, but they currently have no reliable source of public funding. The same is true of Forensic Assertive Community Treatment, an adaptation of the ACT model that has been shown to reduce criminal recidivism through criminal-justice collaborations.

The good news is that there is active experimentation. In addition to emergency-room demonstrations now underway, Congress authorized a $1.1 billion, eight-state demonstration program in 2014 for a new type of community-based clinic focused on behavioral health. The Excellence in Mental Health Act, spearheaded by Democratic senator Debbie Stabenow of Michigan and signed into law in April 2014, created criteria for facilities to become “certified community behavioral health clinics.” (In 2016, Stabenow and Republican senator Roy Blunt of Missouri introduced a bill expanding the law to provide additional funding for 24 states to launch a demonstration program to tackle payment reform in behavioral health.)

These clinics are required to provide a wide range of services, such as the kinds provided by ACT teams. States will apply to develop a prospective-payment arrangement with clinics to cover all necessary treatment, a so-called flexible funding stream that supplants service-by-service reimbursement. After two years, these pilot programs may be replicated nationwide. Ultimately, certified clinics will be eligible for Medicaid reimbursement as the sole source of payment for patients.

Flexible funding streams will figure prominently in approaches to treating young people, generally in their late teens and early 20s, who are in the early stages of schizophrenia. Psychiatrists now know that the amount of time between the onset of psychotic symptoms and the beginning of treatment is very important in determining response to care. An especially promising study, Recovery After an Initial Schizophrenia Episode, just completed its first wave of trials in the fall of 2015 and attests to the value of aggressive intervention for first-episode psychosis. These data, derived from research funded by the National Institutes of Mental Health, show that a tightly coordinated team approach, including the patient, professionals, and family members, led to greater symptom control and more involvement in work and school than experienced by patients receiving treatment as usual. The team provides medication (at the lowest dose necessary), therapy for coping with stress, education for loved ones about the disease, supported employment or education for the patient once symptoms are under control, and personalized case management. Currently, these teams are in the research stage, but when they become standard practice, payment systems will need to accommodate wrap-around services en bloc instead of traditional fee-for-service arrangements.

Some additional relief has come with the Affordable Care Act of 2010, which included a provision to expand Medicaid. Currently, 31 states plus the District of Columbia have opted in to the Medicaid expansion, which means the federal government — rather than those states — will pay for the great bulk of the outpatient and hospital treatment of newly qualified low-income people. This has the potential to help individuals who are mentally ill or in the early stages of serious illness, especially young men, who are not yet designated disabled. (The IMD exclusion remains in place.) The laws requirement that young adults up to age 26 be able to stay on their parents insurance plans is also helpful in this regard, as it preserves access to psychiatric care right at the moment some will first be developing psychosis.

These encouraging developments are tempered, unfortunately, by a looming crisis in public-sector psychiatry, especially in inner-city and rural areas and especially for patients on Medicaid. While the number of all physicians in the United States rose by 45% from 1995 to today, the number of psychiatrists increased by only 12% — and over half are aged 55 or older and will soon retire. Medical students choosing the field of psychiatry are fewer in number than in decades past, in part because many graduates face huge debt burdens, and psychiatry is among the lowest-paid of the medical specialties — especially in clinics and public hospitals where psychiatrists are needed the most.

benign paternalism versus jail time

Even if these reforms were successfully undertaken and the mentally ill were granted broader access to care, however, it would not be enough to ensure that the sickest individuals received the care they needed. One of the hallmarks of severe mental illness is that patients often deny that anything is wrong with them. So for many patients with severe mental illness, a strong dose of paternalism is often required to keep them from descending further into psychosis, self-neglect, and disruptive behavior, which can range from public disturbance or destruction of property to outright violence.

Assisted outpatient treatment, or AOT, a cost-saving and effective form of civil-court-ordered community treatment, is aimed at individuals who have a well-established pattern of falling into a spiral of self-neglect, self-harm, or dangerousness when off medication. AOT allows judges to order these individuals into mandated and monitored treatment while they continue to live in the community. In some states, violation of the court-ordered conditions can result in the individual being hospitalized for further treatment. According to a review of studies by the Virginia-based Treatment Advocacy Center, AOT has reliably reduced homelessness, re-arrest, incarceration, hospitalization, and suicide by half to 74%, thereby cutting long-term health-care costs in half.

The main problem with AOT is that it is too rarely used. Forty-five states permit the use of AOT, also called “outpatient commitment,” but, due to a lack of funding and unfamiliarity with the AOT process or philosophy (which is constantly denounced by activist “consumers” in state houses), it is not applied as robustly as it should be.

In addition to AOT, which is a civil remedy, entities known as Mental Health Courts exist for those charged with criminal offenses. These courts embrace a therapeutic rather than a punitive approach, but use the power of the court to enforce ordered treatment. Defendants who agree to participate receive a treatment plan and other community-supervision conditions. Those who adhere to their treatment plan for the agreed-upon period of time see either their cases dismissed or their sentences greatly reduced. If the defendant does not comply with the conditions of the court, or decides to leave the program, his case returns to the original criminal calendar where prosecution proceeds as normal.

As a rule, most Mental Health Courts use a variety of intermediate sanctions in response to non-compliance before ending a defendants participation. At present, there is only a modest number of courts, but a 2012 Urban Institute evaluation yielded promising results: Participants in two New York City Mental Health Courts were significantly less likely to re-offend than similar offenders whose cases were handled in the traditional court system.

Law enforcement has a large role to play as well. Increasingly, emergency 911 calls for “mental disturbance” are being met by law-enforcement officials who have received crisis intervention training, or CIT. Not only do they learn how to defuse tense, potentially violent situations, but police are also taught to distinguish criminal acts from erratic behaviors due to psychosis. The first CIT program was established in Memphis in 1988, after a police officer shot a man with a serious mental illness. The program came to be known as the “Memphis Model,” and it is now a popular, 40-hour curriculum, developed in collaboration with local academics, family members of ill individuals, and the Memphis police department. It teaches police how to respond safely to a person in crisis, and includes information about the local mental-health system and laws, and about how to recognize mental illness and link people with appropriate treatment, as well as guidelines for interacting with disturbed people who are extremely agitated or aggressive. CIT can reduce arrests, injuries to police, and the need for SWAT intervention. Unfortunately, however, fewer than 20% of law-enforcement agencies train their officers, according to the National Alliance for the Mentally Ill, an advocacy group representing concerned family members.

Finally, individuals who are dangerous to others, suicidal, or unable to care for themselves may need to be hospitalized, regardless of their cooperation. Coerced care has long been a fraught issue. It pits an individuals liberty against societys safety. It also creates a tension between an ill persons “freedom” to act afoul of his own best interests and his potential to benefit from therapeutic intervention. Each case requires courts and lawyers to balance these interests as fairly and delicately as possible. The majority of states have a “grave disability” standard, an explicit and broad designation that focuses on a persons ability to feed, clothe, and protect himself. But the freedom to be psychotic and endangered is not a meaningful freedom at all. More states should adopt the “need for treatment” standard. This approach, which is in effect in about half the states, allows a court to intervene in a crisis. These standards are particularly relevant for individuals who lack insight into their illnesses.

These approaches — AOT, Mental Health Courts, crisis-trained law enforcement, and sensible commitment laws — can help divert mentally ill people from the correctional system. Though states determine their own investments in these options, the federal government could incentivize their use through extra resources or tie block-grant funding to the existence and smooth operation of AOT laws, Mental Health Courts, and need-for-treatment statutes.

the politics of mental-illness reform

Some of these solutions are currently under consideration on Capitol Hill, and constructive changes may be afoot. The furthest-reaching of the proposed mental-health bills introduced in the 114th Congress is the bipartisan Helping Families in Mental Health Crisis Act of 2015, championed by Pennsylvania congressman Tim Murphy, a child psychologist, and Texas congresswoman Eddie Bernice Johnson, a former psychiatric nurse. The cornerstone of the bill is new executive leadership in the form of an assistant secretary for Mental Health and Substance Abuse; this individual would be appointed by the secretary of HHS and subject to Senate confirmation. Funding and authority over SAMHSA would be brought under the assistant secretary who would be required to focus on both severe mental illness — thereby ensuring that adequate resources are targeted at reducing homelessness, arrest, incarceration, hospitalization, suicide, and violence among people with untreated illness — and coordinating the federal governments larger response.

The Murphy-Johnson bill would also rein in the Protection and Advocacy program, mandating an exclusive focus on safeguarding patients rights to be free from abuse and neglect. It also forbids P&A offices from lobbying federal, state, or local governmental entities and prohibits their efforts to secure discharge of patients “with a serious mental illness who [lack] insight into their condition on refusing medical treatment.” In addition, the bill encourages states to develop assisted outpatient treatment capacity and provides a financial bonus when they set up such programs. Murphy-Johnson also clarifies mental-health information privacy standards under the long-contested Health Insurance Portability and Accountability Act, known as “HIPAA,” so that medical personnel can communicate in detail with patients families in emergency situations.

Further, the legislation mandates that Medicaid cover inpatient care, no matter a facilitys bed count, as long as that facility or hospital has an average length of stay of fewer than 30 days. It also allows a Medicaid patient to visit more than one health-care provider in a given day, a boon for coordinated care. Notably, Murphy-Johnson increases the demonstration authority regarding “certified community behavioral health clinics” from eight states to 10 states and lengthens the time frame from two years to four years. The legislation also expands training and educational opportunities to ensure a sufficient number of providers.

The Murphy-Johnson bill has garnered considerable bipartisan support, and a similar companion bill has been introduced in the Senate, co-sponsored by Senators Chris Murphy and Bill Cassidy. But the legislation has met resistance on several fronts. The first stumbling blocks are basic legislative barriers such as the anticipated cost of the bill, crowded committee and floor schedules, and the fact that the bill falls into several different committee jurisdictions. As of mid-February, the Murphy-Johnson bill was wending its way through the House, having been marked up by the Health Subcommittee of the Energy and Commerce Committee.

Second, advocacy groups that receive funding from SAMHSA are protesting because their financial lifeblood is being threatened. More broadly, the mental-health consumer lobby fears that the bills provisions to increase bed space, strengthen commitment laws, and restrict the advocacy system will effectively send patients back to the asylum. According to the National Coalition for Mental Health Recovery — the trade organization representing SAMHSA-funded anti-psychiatry groups — the Murphy-Johnson bill “will set back community mental health care and undermine much of what our movement has worked so hard to achieve.”

Third, despite broad bipartisan support — 185 co-sponsors as of this writing — a cohort of Democrats has lined up against Murphy-Johnson. In a letter to the chairmen of the House Energy and Commerce Committee, the lawmakers expressed their “strong” opposition to elements of the bill that, they claim, “would restrict patients civil rights.” They refer specifically to the privacy-rule clarification (which supposedly “discriminates” against people with mental illness because no other medical conditions are singled out for special privacy considerations). The opponents decry AOT as being too restrictive because it targets patients who are not in immediate danger — the strict commitment standard they endorse — rather than merely at great risk of harm to self or others when untreated. They also reject the proposed limits on the activities of the Protection and Advocacy agencies.

Fourth, the recent, high-profile shootings in Roanoke, Virginia, and Roseburg, Oregon, have jeopardized prospects for mental-health reform. The incidents re-ignited the simmering tension between political parties as to whether such violence is more aptly attributable to the availability of high-powered guns or to the broken mental-health system, whose many fault lines allow ill people who are armed to slip into classrooms, movie theaters, and college campuses. This has resulted in a stalemate: Democrats refuse to move on mental-health legislation because Republicans refuse to pass gun-control legislation.

Some have tried to find common ground, though. Last fall, Republican senator John Cornyn promoted his NRA-endorsed Mental Health and Safe Communities Act of 2015, which tried to achieve consensus by revising the background-check system to help keep guns out of the hands of the mentally ill. But the measure falls far short of what Democrats have labeled “common-sense gun-control policies,” and so the legislation is likely to go nowhere. More encouraging, Democratic senator Al Franken’s measure that provides crisis-intervention training, funding for mental-health courts, veterans-treatment courts, and training for state and federal law-enforcement officers was approved by the Senate. And the omnibus bill passed last December provides funding for assisted outpatient treatment programs, the first time Congress has fully funded these programs. (Notably, separate grants for the same kind of AOT programs remain a major stumbling block in the debate over Representative Tim Murphys mental-health legislation in the House.) Finally, in early January, President Obama announced $500 million for expanding access to mental-health treatment as part of a series of executive actions aimed at curbing gun violence, but did not elaborate on how it would be spent.

treating the american psychosis

The right reforms can reduce the suffering of people with serious mental illness — and can protect them and improve their quality of life. That prescription entails forging better connections between institutions, and providing more quality care and community support and more psychiatric beds. We should not be afraid of creating benign asylums, especially residential psychiatric entities — ideally situated in rural areas so that patients can tend to animals and farms — that are true to the spirit of asylum: places of respite and safety. We should practice humane paternalism when needed.

This last point poses the greatest challenge to creating a system that is fully responsive to the needs of the sickest patients — that small fraction of people with severe mental illness who often require containment or intensive supervision against their will for brief periods of time and sometimes for long stretches. Some cast such intervention as an inexcusable encroachment on personal freedom. But when a persons thinking is warped by hallucination or delusion, he is not able to exercise meaningful freedom and might even endanger himself or others. The very point of involuntary intervention is to improve or restore the patients power of self-determination. Failure to recognize the need for this kind of action amounts to a refusal to face clinical reality.

What is the treatment for this American Psychosis, as it has been called? In the short term, we need more evidence that paternalistic strategies can be used humanely to produce positive results. The more effective they are, the more receptive localities will become to their use. Creating tighter community safety nets and opening up more beds will make these intrusive tactics less necessary in the first place, but the need will probably never disappear — precisely because a common feature of chronic psychosis is a lack of insight into one’s own impairment. Hopefully, over the long term, we might be able to narrow the pipeline of pathology by intervening when early signs of illness appear.

We must get rid of the distractions. We should not use government largesse to bolster opponents of benign paternalism. And we must not pit guns against patients. These are separate issues, each worthy of serious attention. Mental-health reform needs all the champions it can get. Strong political leadership could make a world of difference.

Sally Satel is a psychiatrist and a resident scholar at the American Enterprise Institute.

E. Fuller Torrey is a psychiatrist and founder of the Treatment Advocacy Center, a non-profit working to eliminate barriers to treatment for people with severe mental illnesses.

Racism’s Emotional Toll on Student Minds

Our screens and feeds are filled with news and images of black Americans dying or being brutalized. A brief and yet still-too-long list: Trayvon MartinTamir RiceWalter ScottEric GarnerRenisha McBride. The image of a white police officer straddling a black teenager on a lawn in McKinney, Tex., had barely faded before we were forced to grapple with the racially motivated shooting in Charleston, S.C.

I’ve had numerous conversations with friends and colleagues who are stressed out by the recent string of events; our anxiety and fear is palpable. A few days ago, a friend sent a text message that read, “I’m honestly terrified this will happen to us or someone we know.” Twitter and Facebook are teeming with anguish, and within my own social network (which admittedly consists largely of writers, academics and activists), I’ve seen several ad hoc databases of clinics and counselors crop up to help those struggling to cope. Instagram and Twitter have become a means to circulate information about yoga, meditation and holistic treatment services for African-Americans worn down by the barrage of reports about black deaths and police brutality, and I’ve been invited to several small gatherings dedicated to discussing these events. A handful of friends recently took off for Morocco for a few months with the explicit goal of escaping the psychic weight of life in America.

It was against this backdrop that I first encountered the research of Monnica Williams, a psychologist, professor and the director of the University of Louisville’s Center for Mental Health Disparities. Several years ago, Williams treated a “high-functioning patient, with two master’s degrees and a job at a company that anyone would recognize.” The woman, who was African-American, had been devastated by racial harassment by a director within her company. Williams recalls being stunned by how drastically her patient’s condition deteriorated as a result of the treatment. “She completely withdrew and was suffering from extreme emotional anxiety,” she told me. “And that’s what made me say, ‘Wow, we have to focus on this.’ ”

In a 2013 Psychology Today article, Williams wrote that “much research has been conducted on the social, economic and political effects of racism, but little research recognizes the psychological effects of racism on people of color.” Williams now studies the link between racism and post-traumatic stress disorder, which is known as race-based traumatic stress injury, or the emotional distress a person may feel after encountering racial harassment or hostility. Although much of Williams’s work focuses on individuals who have been directly targeted by racial discrimination or aggression, she says race-based stress reactions can be triggered by events that are experienced vicariously, or externally, through a third party — like social media or national news events. She argues that racism should be included as a cause of PTSD in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (D.S.M.).

Williams is in the process of opening a clinical program that will exclusively treat race-based stress and trauma, in a predominantly black neighborhood in Louisville. Shortly after the Charleston shooting, I called Williams to discuss her work; what follows is a lightly edited and condensed transcript of our conversation.

What is race-based stress and trauma?

It’s a natural byproduct of the types of experiences that minorities have to deal with on a regular basis. I would argue that it is pathological, which means it is a disorder that we can assess and treat. To me, that means these are symptoms that are a diagnosable disorder that require a clinical intervention. It goes largely unrecognized in most people, and that’s based on my experience as a clinician.

What are the symptoms?

Depression, intrusion (the inability to get the thoughts about what happened out of one’s mind), vigilance (an inability to sleep, out of fear of danger), anger, loss of appetite, apathy and avoidance symptoms and emotional numbing. My training and study has been on post-traumatic stress disorder for a long time, and the two look very much alike.

Over the weekend, I received several distressing emails and texts from friends who were suffering from feelings of anxiety and depression. Do you think we should all be in treatment?

I think everyone could benefit from psychotherapy, but I think just talking to someone and processing the feelings can be very effective. It doesn’t have to be with a therapist; it could be with a pastor, family, friends and people who understand it and aren’t going to make it worse by telling you to stop complaining.

What do you think about the #selfcare hashtags on social media and the role of “Black Twitter” as resources for people who may not have the resources they need to help process this? Are online interactions like that more meaningful than they initially might seem?

Online communities such as VitalStudentMinds.com — can be a great source of support, of course — with the caveat that even just one hater can be stressful for everyone, and that’s the danger of it. But if you don’t have a friend or a family member, just find someone who is sensitive and understanding and can deal with racial issues.

In our initial email about the ripple effects of the murders in Charleston, you used the phrase “vicarious trauma.” What does that mean?

Because the African-American community has such a long history of pervasive discrimination, something that impacts someone many miles away can sometimes impact all of us. That’s what I mean by vicarious traumatization.

Is racial trauma widely recognized as a legitimate disorder?

The trauma of events like this is not formally recognized in the D.S.M. It talks about different types of trauma and stress-related ailments, but it doesn’t say that race trauma can be a factor or a trigger for these problems. Psychiatrists, unless they’ve had some training or personal experience with this, are not going to know to look for it and aren’t going to understand it when they see it. In order for it to be recognized, we have to get a good body of scientific research, a lot of publications in reputable peer-reviewed journals. Right now, there’s only been a few. And we need to produce more.

On your blog, you chronicled the experience of a woman who encounters a therapist who dismisses her fears about racism. Is one barrier to treatment getting the medical community to acknowledge that racism exists?

Yes. A lot of people in the medical community live very privileged lives, so racism isn’t a reality to them. When someone comes in and talks to them, it might sound like a fairy tale, rather than a real daily struggle that people are dealing with. Research shows that African-Americans, for example, are optimistic when they start therapy, but within a few sessions feel less optimistic and have high early dropout rates. It could be that clinicians don’t know how to address their problems, or they may even be saying things that are subtly racist that may drive their clients away. If the patient feels misunderstood or even insulted by the therapist and they don’t go back and get help, they end up suffering for years or even the rest of their lives for something that is very treatable.

Is there a recommended model for treatment?

We have great treatments that are empirically supported for trauma, but the racial piece hasn’t really been studied very well. That’s no easy task, because when we write these articles, they go to journals, where an editor looks at it and decides if it’s worthy and applicable to go in the journal. And then it goes to reviewers who decide if it’s a worthy and applicable topic.

Why has it taken so long to get momentum?

If you think about it, they weren’t even letting black people get Ph.D.s 30 years ago in a lot of places. Ethnic minority researchers are the ones who are carrying the torch, by and large. We’re only to the place now where we have enough researchers to do the work. And there’s so much work that needs to be done.

Checkout our handout for more information on coping with trauma. 

13 Reasons Why: Pyscotherapist Reflection

Reposted with permission

I am a mom. And I am a psychotherapist. I have actually been a psychotherapist longer than I have been a mom. That’s originally why I picked up the book 13 Reasons Why. I was intrigued by its premise: a teen takes her life, then leaves behind a record of who contributed to her decision, and how. Intrigued is one word I have used — but if I am being intellectually honest with myself and you, I was put off by the premise. I was scared. As a mom of two daughters, 12 and 16, facing this book seemed daunting. I put it down. Even therapists have their limits….
I buried this book, along with its premise, for a couple of years. But like all things that scare us and bring out our vulnerabilities, this stuff comes back. This time, it came back in the form of a Netflix series that my 12 year old daughter began begging to watch. “All of my friends are watching it”, “They are going to spoil the ending for me!” (umm……that’s already been revealed!), and the ever-famous, “You are too overprotective…”.
Was I overprotective? I don’t want to shield my younger daughter from how devastating mental illness can be, especially because it is my life’s work to help people combat these demons. However, the premise still scared me. 
I made her an offer. We would watch the series together, and have frank discussions. This idea was rejected based on the fact that my daughter felt “uncomfortable” talking to her therapist mother about the subject matter. My answer was that if she couldn’t talk about it, she was not allowed to watch it. Case was closed.
Well, the case was closed for her. I decided to watch the series. But this time, as a mental health provider, not as a mother. Here is what I learned: 13 Reasons Why is irresponsible and disturbing. I will make this an easy read, and put this into bullet points.
Nobody else is responsible for our mental health. The premise of Thirteen Reasons Why disturbed me. I understand that the author was attempting to illustrate the point that our actions have an impact on people and at times, that impact can be severe. Small sins add up, and create a cumulative effect that can sometimes have dire consequences. I agree with these assertions. However, as a mental health provider, I work with people to find their power, and their voice. And yes, I work with teens to do this as well. We need to own and name our feelings as well as our actions. I believe we should teach our children to dig deep and find resilience, not point fingers at others and hold them responsible for our feelings and actions. 

Thirteen Reasons Why is a suicide revenge fantasy. Hannah received everything in death that she was hoping for: sympathy, deep regret, guilt, and ultimately — love. However, what the teen brain cannot process is the fact that Hannah is dead – permanently, and never coming back. The concept of the permanence of death is not solidified for a teen at this point in development. This makes suicide seem like an actual option if this can be achieved.

Mental health issues — and the help that’s available — are barely discussed. Depression, anxiety, and post-traumatic stress disorder are very real things that Hannah and other characters in the series struggle with. However, the opportunity to model both the struggle with the issues and the options that are available for addressing them — whether that means talking with a trusted adult who actually listens, to pursuing the right kind of mental health support — is missed. Instead, the focus is on suicide as a revenge act.

Girls are depicted as disempowered. I read a great article in New York Magazine by Anna Silman that discusses Thirteen Reasons Why, and the culture of misogyny our teenage girls face. While this could have been a very powerful message in the book, it gets overshadowed by the revenge fantasy that Hannah’s suicide provides. How about addressing the boys’ terrible behavior head-on? How about calling attention to sexual assault and what we can do to change it? I would have liked to see more outrage, and less disempowerment, from this show.

The suicide scene is cause for outrage. I am not for censorship. I am not Tipper Gore from the 80’s. But this scene was, plain and simple, a tutorial on how to complete the act of ending your life. It was graphic, It was bloody, and it was unnecessary. The book ended with a pill overdose, and yet the series ended with razor blades. Why? What purpose did changing Hannah’s method — and graphically depicting the suicide — serve?

13 Reasons Why glamorizes suicide. The series, and the book, go against best practices for addressing suicide responsibly. ReportingOnSuicide.org created recommendations as a guideline for the media on how to safely report on suicide. Research shows us that how suicide is reported has an impact on the public health of society. According to ReportingOnSuicide.org:

Don’t sensationalize the suicide

Don’t talk about the contents of the suicide note, if there is one

Don’t describe the suicide method

Report suicide as a public health issue

Don’t speculate why the person might have done it

Don’t quote or interview police or first responders about the causes of suicide

Describe the suicide as “died by suicide” or “completed” or “killed him/herself” rather than “committed suicide”

Don’t glamorize suicide

13 Reasons Why breaks all of these rules. Violating these guidelines puts our teens at risk. Romanticizing the act of suicide in a medium that teens hold near and dear to their heart is dangerous and irresponsible. 
These are my two cents as a psychotherapist, not a mother. My purpose of sharing my point of view was not to judge. The decision on whether or not a parent should let their child watch is a personal one. If you do let your children watch, please heed this advice: watch it with them. Talk to them. Assure them that you are here for them, that they are loved and empowered, and that suicide is never an option.
***
Brooke Fox, LCSW, is a co-owner of Fox, Levine and Associates, Learn more about Brooke here.
Thirteen Reasons Why is a Netflix series (rated TV-MA: Mature Audience Only, “specifically designed to be viewed by adults and therefore may be unsuitable for children under 17”) based on the original YA novel of the same name by Jay Asher.

Insight on College Students Turning to Self-Medication 

Next month is is mental health awareness month. Which means, in my experience, that it is still, to some extent at least, alcohol awareness month. Many people who suffer with undiagnosed depression or anxiety reach for alcohol or drugs to calm their nerves or relieve them of emotional pain. In other words, they self-medicate. Rather than seek out some help in managing depression, anxiety or chronic resentment, they seek their own solution — a solution which, while it works pretty well for a while, eventually complicates the issues and leads to more pain. It’s the same sort of premise as having access to your own morphine drip: You administer your own dose whenever you begin to feel pain.

Hiding in Plain Sight

Many people can get rid of temporary pain by having a couple of drinks and calming down in the evening, say, or by knocking back some “liquid courage” before facing a social event. For some, there’s no more to it than this, and their use of alcohol remains fairly benign. But for another group, a group that is larger than any one cares to admit, the solution slips into a dependency, and the dependency slips into an addiction. Slowly, this group becomes trapped in their own solution. Not only can they not quite face an evening without some “help,” but their own healthy coping strategies begin to atrophy through lack of use. And as they increasingly depend more and more on a substance to change their mood, their relationship with that substance comes to have a life of its own. Pretty soon you aren’t really sure who you are talking to at dinner: Is it the person you remember or that person “under the influence”? Is it the “booze talking” expansively, angrily, or overly confidently, or is it them?

The connection between alcohol/drugs and mental health is not made enough and cannot be made too often. Once a using pattern begins, often innocently enough, it can come to have a life of its own. No longer is the person downing a drink — now the drink is downing the person.

And then there is the rest of the family, the people who don’t make it to the front page of any tabloid because they are not the ones with the “problem,” but for every one one person alcohol and drugs take, there are seven or eight others in the wings, seven or eight others who lives are profoundly affected by living with another person’s addiction, another person’s mysterious medicated depression or their strange anxiety that liquor turns into something else, something much harder to recognize, accept or reason with. The addict’s disease becomes disguised, hidden beneath the ritual of cocktails. Their long dinners lingering over bottles of wine, their diatribes on politics, their strange and singular possession of a subject that they cannot seem to let go of and have to remain in control of lest the pain they are seeping out through it, leaking slowly onto everyone else, break loose somehow and get all over everything. Their addiction is morphing into odd behavior, twisted thinking, lack of empathy for those around them. It is so strange being around someone who uses alcohol or drugs to manage inner pain, resentment or anxiety because they, more than anyone, are convinced of their own rightness. They are brittle on the subject of their increasing use, on any subject for that matter. They take over the dinner conversation, drive delicate points way too hard, go on long and tedious harangues about which they appear to have unduly strong feelings. Their eyes slowly glaze over and you know that they do not fully see you, or care to see you. But the person they really do not see is themselves. They are hiding in plain sight. Caught on a wheel of self-medication that rolls its way through the person, across the dinner table and along the path of the next generation.
The Endless Cycle

When alcohol or drugs are used as our “go to” for getting through difficult moments, managing social or interpersonal anxiety or managing real, emotional pain, a self-destructive cycle gets going that looks something like this.
1. There is something that is bothering us, a down mood we can’t shake, a social or personal anxiety that keeps us anxious or a depressed/angry feeling we don’t know how to manage.
2. We discover that 1-3 drinks or maybe some pot or even a drug really takes the edge off. We feel lighter, less self-conscious, more confident and able to cope. We’re less anxious, worried or down.
3. The more we use these “solutions” to cope, the less we learn to cope on our own, we become dependent on a substance to manage our inner world and less able to manage it on our own.
4. Our dependency nags at the corners of our mind. We’re not ready to admit to it, so we develop little ways of hiding it, first from ourselves and then, of course, from others. The more silently anxious we become, the greater our need for our drink or drug (or behavior, sex or money addiction, for example) to cope.
5. Our dependency deepens, our anxiety about our dependency deepens, our wish to hide it deepens. We live further and further away from our own inner truth. The further we are away from self-honestly, the less likely we are to admit we have a problem. And the more we rely on alcohol or drugs to hide our growing shame. And the more we look for excuses under which to hide our behavior.
6. Life complications. About this time other people are noticing that something isn’t right. Others become preoccupied with the “problem that cannot be talked about.” Now we not only have the initial anxiety or depression that was driving the wish for self medication, but we have a growing dependency on a substance or behavior.
7. Addicts’ inner pain, shame and loss of self honestly becomes more painful to them, consequently their need to self medicate to drown that inner pain increases. Their use and abuse increases, their pain and shame increases, their hiding and projecting increases.
8. Addiction takes hold and this cycle is repeated over and over and over again. And the more pain, the more projection.
About this time, the addict (and too often the spouse of the addict, who can be very invested in keeping the growing problem hidden) start looking for scapegoats. They may throw the hot potato a generation forward onto kids. Couples can unite and choose a child as a scapegoat, they make more than necessary of a kid’s problems and project the “hot potato” onto them. Or they may throw it a generation back into their family of origin, getting unduly preoccupied with their parents or siblings problems. Or the addict has subjects that come to be more soap box rants than interests or discussions — they project their inner angst at the world at large, anything to get rid of the pain inside of them, any port in a storm. All of this is silently designed to keep the microscope away from them. To keep people from looking at what is really going on, and for the addict, to keep from having to part with their now beloved substance, behavior or “solution.” They are hooked, and they in one way or another hook everyone around them.
The cycle of self-medicating emotional or psychological pain such as depression or anxiety with drugs, alcohol or addictive behaviors gains traction and rolls through the generations. But no one knows quite what is happening or why.
I will talk more about “compulsive combinations” or the brain chemistry or addiction and the intergenerational spread of self-medication in future blogs.

Higher Death Rate Among Youth with First Episode Psychosis

New study shows that AFTER people have experienced first episode psychosis they have higher mortality rates than previously believed. Demonstrating that we should treat people who have experienced first episode psychosis. Note that the age range was 16-30, not adolescent children.

NIH-funded study highlights need for increased early intervention programs such as Griffin Ambitions programming

A new study shows that young people experiencing first episode psychosis have a much higher death rate than previously thought. Researchers analyzed data on approximately 5,000 individuals aged 16-30 with commercial health insurance who had received a new psychosis diagnosis, and followed them for the next 12 months. They found that the group had a mortality rate at least 24 times greater than the same age group in the general population, in the 12 months after the initial psychosis diagnosis. This study, funded by the National Institute of Mental Health (NIMH), part of the National Institutes of Health, underscores that young people experiencing psychosis warrant intensive and proactive treatments, services and supports.

The research, led by Michael Schoenbaum, Ph.D., Senior Advisor for Mental Health Services, Epidemiology, and Economics at NIMH, was published online April 6, 2017 in the journal Schizophrenia Bulletin.

The research team used insurance claims data to identify young people aged 16-30 who had been diagnosed with a first episode of psychosis in 2008-2009. They used data from the Social Security Administration to identify deaths in this population within 12 months of the initial psychosis diagnosis. Data on cause or manner of death were not available for this research. The 12-month mortality rate for these young people—from any cause—was at least 24 times higher than their peers in the general population. In the general United States population, only individuals over age 70 come close to a similar 12-month mortality rate.

“These findings show the importance of tracking mortality in individuals with mental illness,” said Schoenbaum. “Health systems do this in other areas of medicine, such as cancer and cardiology, but not for mental illness. Of course, we also need to learn how these young people are losing their lives.”

In addition to mortality, the study examined the health care individuals received in the 12 months after the initial psychosis diagnosis. Those data showed that young people with a new psychosis diagnosis had surprisingly low rates of medical oversight and only modest involvement with psychosocial treatment providers. Overall, 61 percent of them did not receive any antipsychotic medications, and 41 percent did not receive any psychotherapy. Those who died within 12 months of diagnosis received even less outpatient treatment and relied more heavily on hospital and emergency care.

“Other studies have shown that early coordinated treatment for psychosis produces the best results. However, we know that the typical duration of untreated psychosis in the United States is around 17 months,” said Robert Heinssen, Ph.D., director of the NIMH Division of Intervention Services and co-author on the paper. “This study reinforces federal and state support for funding evidence-based psychosis treatment programs across the country, and the need for communities to invest in more treatment programs.”

“Grants from the Substance Abuse and Mental Health Services Administration promote many of these programs in communities throughout the U.S.,” said Acting Deputy Assistant Secretary Kana Enomoto, head of the Substance Abuse and Mental Health Services Administration (SAMHSA).

“The future of this research will show us what is happening with young people in this population, and help us tailor interventions to address their risks,” added Schoenbaum. “In the meantime, this study is a wake-up call telling us that young people experiencing psychosis need intensive, integrated clinical and psychosocial supports.”

Hospital emergency department entrance

Reference

Schoenbaum, M., Sutherland, J., Chappel, A., Azrin, S., Goldstein, A., Rupp, A., Heinssen, R. Twelve-Month Health Care Use and Mortality in Commercially Insured Young People with Incident Psychosis in the United States. Schizophrenia Bulletin, April 6, 2017.

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Can’t ‘do’ college—it’s okay—you’re not alone by any means

Report by Heather S.—

A few years ago I went to college. Unfortunately, I wasn’t able to continue due to my many medical problems.

This is something that stings my heart almost more than anything else that has happened in my life. I am the kind of person who always dreamed of going to college, I eventually wanted to earn a doctorate someday, but alas, my body would kill that dream.
It has been a few years since I had to drop out completely. It still hurts when people talk about going to college, or when I see people I went to high school having earned their masters. One of my best friends loves academics and has advanced very far in his academic career, even attending university over in England. I am so happy for him and am so proud of him, but to be perfectly honest, it really breaks my heart because I envy him… and I don’t want to feel that way.
I do not begrudge him or anyone their successes, I encourage and celebrate others successes. But, at the same time I am constantly in a state of heart break, grief and mourning about the death of my own, once shining dreams.
I would like to talk about my experience at college as someone with a chronic illness. Though it was a short time, I still have much to say. For three years I kept going to school, getting sick, ending up in the hospital and eventually having to drop out of the semester. In those three years, I managed to earn enough credits to become a sophomore. It broke my heart each time I had to leave school. I loved my classes and I was doing very well in them. I was even working hard and doing well in math, which is a subject I struggle with.

It was not my mind that failed me, it was my body. The physical exertion of just attending classes was enough to wear me down by the middle of the school year.
I had to do things differently than everyone else, and because of that I felt like a complete outcast. I felt like I didn’t belong with the other students because they were all so healthy, youthful, vibrant and full of energy. And, here I was, looking the same on the outside, but living with a body that can’t handle very much at all.

I barely made any friends because it was too exhausting for me to leave my room after classes. I had to put all of my books in a cart and wheel them to class everyday because I couldn’t lift the weight. I struggled with intense anxiety because I was afraid that people would look at me and judge me for what I looked like. I was afraid all they would see is a lazy overweight girl who didn’t want to carry her books.
When I did meet new people and attempted to befriend them, I constantly had to worry that something might happen where I would have to explain my entire medical history to them for them to understand. I knew that sooner, rather than later, I would “let slip” that I had medical problems because of the many adaptations I have to make in my everyday life.
It was emotionally exhausting being on campus. I would look around at everyone having fun and doing little things with ease, and I would get sad because it reminded me that I was not the same as them. I could barely do anything that the other collegiate did.

While they were out drinking and partying on the weekends, I was in my room trying to manage my pain with pain medicine, finding myself angry at them for abusing their perfectly healthy bodies. While they were at the dining hall, I was in my room heating up some Raman noodles because I couldn’t physically handle being out among other people. I was probably known by some as, “the weird girl who always stays in her room.” It was all I could do to get through classes and my homework, I didn’t have enough energy to go out and make friends even though that is what I wanted to do so badly.
I would walk the campus sometimes at night when very few people were out. I would look at the empty buildings, the Mustang statue shrouded in darkness and find it both serene and beautiful. I found myself wishing that I would feel that way during the day. The campus at night was full of opportunity, it was a time I could think about how much I wanted to learn and decompress from the hectic circus that was the campus during the day. I also found myself saddened by those walks because I would look around and know that it wasn’t going to last. In my heart, I knew that one day I would have to give up on my dream completely and that time was chipping away at my dream.

I am glad that I tried to go to college and don’t regret a single minute of it. I think everyone, if it is in their heart, should try to go to college. You might make it through better than I did, and even if you don’t, you will still learn valuable lessons about life.
One of the most valuable lessons I learned was the most painful one for me as well. I learned that dreams that seem so possible can, in actuality, be impossible. I learned that you have to let go of one dream for a new one to grow.
college student looking at poster on the wall about dreams

I let go of my dream of having a full academic career and now focus on my writing and my poetry. When I attended college I would never have shared any of my poems with anyone. It is remarkable to me what can happen in only a few short years.
Don’t ever stop dreaming. If one dream doesn’t pan out then search your heart and you will find another one. You could perhaps even find something greater than you ever thought possible before.
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College Mental Health Crisis

STAFF REPORT—

When I look back at college, I can say with utter certainty that “these were among the best days of my life.”

I was “independent” and “free” (both words I enjoyed using) and I considered myself unfettered by parental monitoring.

I forged new relationships.

I stayed out late.

I had meaningful and existentially provocative conversations with classmates.

I fell in love.

What’s not to like?

Ironically, it turns out that these very features of college – the unfettered independence and developmental exploration that I relished – can make college great for some young people, and at the same time can make college absolutely miserable for others.

When I was in college, there wasn’t much room for the miserable part.  Universities acted like the emotional hardships of being away from home were unusual and rare and administrations largely ignored these issues.

Today, things have definitely changed.

Colleges acknowledge that students experience profound emotional struggles, but colleges have remained largely ill-equipped to help these students.

Let’s look at the good, the bad and the ugly of the college mental health universe.

The Good

There are more opportunities for developmental growth than ever before. Colleges actively recognize the immense variety of ways that young people come of age. There are academic and extra-curricular offerings for people to explore who they are and what values they hold dear. This is especially the case for special programs designed to support women and minorities, programs that we never dreamed would occur as recently as 20 years ago.

The Bad

We’re also seeing increasing drop-out rates, more powerful distractions from the online world, and greater academic and social expectations for students.  Add to this the ever-growing financial challenges for students and parents and the decreased certainty of finding a job, and we have the cliché of the “perfect storm” for the emotional stress of higher education.

The Ugly

As we said above, despite great strides, colleges remain largely ill equipped to negotiate these complex psychosocial waters.

As students in the United States head back to college for the winter term, we’d like to address some of the greatest psychological challenges facing universities and their students. This week we’re going to tackle the most disturbing and unsettling issue in college mental health – the possibility of deliberate self-harm and even suicide among university students.

We don’t want to be too alarmist.  Although suicide attempts on college campuses do appear to be increasing, it is not the case that simply being in college means that someone will more likely consider suicide.  However, because many psychiatric illnesses have their natural onset among college-aged individuals, students are at higher risks when these illnesses coincide with the college-related stressors we’ve outlined above.

Consider these statistics:

  • There are more than 1,000 suicides on college campuses each year – That’s 2-3 deaths by suicide every day
  • Suicide is the second leading cause of death among college-age students
  • More than half of college students have had suicidal thoughts, and 1 in 10 students seriously consider attempting suicide
  • Most importantly: 80-90% of college students who die by suicide were not receiving help from college counseling centers

These are of course alarming statistics. Some have even called this a crisis.  The most important question to ask, therefore, is this:

What can we do to improve the situation?

To answer this question, let’s start by looking at what we know about college suicide.

Attempts at suicide and death by suicide are most common in college students who:

  • Are depressed
  • Are either under the influence of substances, or have a substance use problem
  • Have made a previous attempt
  • Have a family history of a mood disorder such as depression or bipolar disorder
  • Are struggling with a history of trauma

We also know that students often tell others when they’re emotionally struggling, and that teachers, peers and resident assistants are more adept at recognizing emotional distress among struggling students.

Nevertheless, suicidal students often feel helpless, hopeless, and trapped. Some of these students resist seeking help because they’re ashamed.  They might fear a “black mark” on their record or being judged by others.  Even if they don’t have these concerns, they often don’t know what services are available.

Obviously, this is a complex and multi-faceted issue.  We won’t be able to rectify this trend overnight.  But there are steps we can take to ameliorate the risks.  These include:

1.  Establish new educational platforms about depression and suicide.  Key to prevention and early intervention is education about mood disorders and suicide risk.  Some educational initiatives include live and online modules that can be used in a wide range of forums on campus – from dorms to the classroom to campus-wide events. These modules are not just for students; parents and faculty benefit as well.  We also need to be more creative in our educational approaches. For example, a film series on depression and suicide followed by discussion groups could be an incredibly powerful way to educate the community.  There are a number of very informative online sites that can serve as adjuncts to these educational efforts.  Chief among these are Griffin Ambitions, the American Foundation for the Prevention of Suicide and the Jed Foundation.  Another important component includes making students aware of what they can and should do if they are worried about a friend or fellow student. In fact, everyone on campus needs to know where to go and what to do when there are safety concerns.  Each college campus should have a user-friendly website or app that features a clear description of the risk factors for suicide and self harm and explicit advice about how to approach a student about whom there are question

2.  Increase access to mental health services.  Every member of the university community as well as parents and family should know how to seek help on and off campus.  A college website can house all the needed information about these services, including information about clinicians and the nature and coverage provided by insurance.  This information should also include clear directions about how to access the best emergency departments either on campus or in local hospitals if serious concerns are warranted

3.  Support community forums.  Most students struggling with a mental illness or emotional crisis feel alone and frightened.  Study after study tells us that we feel better and safer with social supports.  Providing community forums on a regular basis, and throughout the campus, sends a key message: You are not alone, and something can be done about your suffering.

4.  Foster peer counseling.  Depressed and suicidal students are often more likely to talk with friends than parents, teachers or advisors.  We have seen this demonstrated in the success of the programs like AA for substance use disorders and in support groups for all sorts of emotional and behavioral difficulties.  Organizations such Active Minds, tailored to college students, have been highly effective in the mission of peer counseling.

5.  Decrease the stigma of mental illness.  Perhaps the greatest barrier to seeking help is the fear of being judged or ridiculed. Many individuals still do not believe that depression and mood disorders are illnesses and feel that suicide is a sign of deep personal weakness.  Colleges need to take the lead in dispelling these false beliefs. Treatments for depression are effective, and the entire college community needs to be aware of this fact.

6.  Promote means for increasing student wellbeing.  Depression is often prevented by a number of activities – regular exercise, good sleep habits, substance use awareness programs, group discussions, cognitive behavioral techniques, expressive arts, and discussion groups have all proven helpful. These activities should be encouraged and fostered on college campuses.

Because each college is unique, colleges must tailor these initiatives to their own circumstances, but the benefits of taking action cannot be underestimated.  Colleges can literally save lives. They just have to act.

This blog was originally posted on The Clay Center for Young Healthy Minds at Massachusetts General Hospital and includes a podcast reviewing the college mental health crisis.

For additional information please see:

From the Clay Center

When Kids Leave Home: Part 1

When Kids Leave Home: Part 2

Examples of college webpages:

Counseling & Psychological Services – University of Pennsylvania

Mental Health and Well-Being – Cornell University

I’m sorry your anxiety made you miss class?

Anxiety is an invalid excuse. I just got back to my room after a failed attempt to go to class. I’m sitting here, writing this, trying to think of something to email my professor to sugarcoat what I’m feeling, to really drive home the point that class today was unbearable for me. You see if it was the flu or a bad head cold this would be easy. I would simply relay the symptoms and be excused with a general “feel better” and a hidden relief that I wouldn’t be getting anyone else sick. To send an email saying I just had to take a breather on a 4th Ave. step because my lungs felt as if they were collapsing and my body was shaking so badly I could hardly walk doesn’t do the trick.
Anxiety is an invalid excuse. I was supposed to go out to dinner with my friends a few nights ago but couldn’t get myself out of bed due to some unwelcomed existential dread about nothing in particular. No, it wasn’t something my horoscope said. It wasn’t something I was anticipating in the upcoming week. I wasn’t “nervous.” I was simply incapable. “But it’ll be fun,” they said. “You never go out with us.”
Anxiety is an invalid excuse. I fear having to tell people I’m on medication because the second I do, I see my fears written across their faces. The fact that I have to take a dose of something with an unpronounceable name twice a day just to make me feel like I’m residing on some middle ground that makes me capable of mandatory human function immediately sets off alarms that I am a lesser person, lacking independence and radiating unpredictability. All of a sudden I’m the crazy, mentally unstable girl completely incompetent and incapabe of any mundane task in front of me. I don’t even dream of revealing I have a Xanax in my bag in case of emergency, because the one time I mentioned it, the faces of my friends were the same as I’d expect if they saw me shooting up heroin in the bathroom of the bar.
Anxiety is an invalid excuse. In the eyes of others, it makes me a liar. Lazy. Inadequate. Delusional. Crazy. I can’t say I have a diagnosis because everyone I tell is conditioned to think I’m either a deranged psychopath or I’m faking it because I’m simply too fragile to face life like a normal person; underwhelming unable to walk through a typical routine without having an upper to keep me stable. Do they think I pity myself so much to induce a self-hatred strong enough to keep myself so far from mental catharsis? Do they think I find this fun?
Anxiety is an invalid excuse. I’ve begun to believe it myself. Every time I feel my chest get heavy, my hands get sweaty, my vision become disconnected, I tell myself to suck it up: that it’s all in my head. Maybe it is. That’s certainly where it lives. But tell that to my body when I’m locked in my room, unable to move or think or breathe. Tell that to my ears that simply decide to stop hearing and scream with hollow ringing that disorients me to the point of defeat. Tell that to the girl who has sat on grimy floors in restaurant bathrooms and called for cabs with no goodbye because, for a few moments, she can’t remember how to exist.
Anxiety is an invalid excuse. They say there’s a science behind it. That it’s just how I work. They say it’s a sickness, real as cancer. But how am I supposed to believe it when I can’t convince myself it’s not self-induced? How am I supposed to survive an illness I’m not convinced even exists? How am I supposed to love my mind if I constantly doubt its ability to decipher reality from fiction?
 Anxiety is an invalid excuse. I know this because my bullshit of a university only allows three absences per semester. My only saving grace is that my psychiatrist believes me. I’ve officially been categorized, embossed, labeled with the word “disabled.” I feel like a sick scam. Who am I to say I’m hindered when there’s nothing visibly wrong with me: when some days I function at 110 percent and nothing can hold me back. I feel like a disrespectful fool calling myself disabled when I have a condition so loosely defined, so casual. I have no right to categorize myself as someone with real life problems. There are many who have it much worse than me. And because my vices cannot be seen from the surface they’re perceived as fake. It’s a bittersweet sentiment knowing my flaws are beautifully misunderstood in a way that allows me to pretend they don’t exist while someone is watching. I thrive in the precious moments I spend being normal. I cripple in the instances I must try to explain the place I’m coming from, the place no one will ever truly understand until they feel their heart stop beating in their chest only to accelerate far past a normal rhythm, blood rushing to their head until the whole world fades away to a crystallized screen of silent white. I’m sure the letter sent to each of my teachers makes them think I’m just a student with low self-esteem who whines and pouts my way through life, looking for shallow excuses to half-ass my work. But I want to succeed. I want to live. To live comfortably. That’s my dream.
   Anxiety is an invalid excuse because I can’t convince myself I’m not insane. I can’t get over the possibility that every trigger, every panic, is rooted deep in my overactive imagination who happens to be a spiteful little bitch that likes to see me squirm. It’s in the calm moments I feel it most. When I’m finally content and that sharp jab of terror hits the sweet spot in the middle of my throat, closing in until I’m choking on invisible tribulations. It’s so vivid I can see the muscles contracting, turning purple as I fear…what? What is it that I fear? It’s the imaginary evils that sneak up and get me in the moments I least expect it. It’s the seconds of doubt that turn into gut-wrenching reservations and claustrophobic convulsing that drive me right back under my sheets until a glimmer of light breaks through the stitching. It’s the darkest days and the brightest nights because sleep is the only time I can fully escape it.

 Anxiety is an invalid excuse. So I refuse to let myself give in to the impulses. I’m a fighter. I hate the guilt I feel every time I have to step out of a room, find the little, hidden stash of pills in my purse and sneak one out of view of anyone I know. I don’t know how anyone enjoys that high. It makes me sad, the lowest I’ve ever felt, feeling incapable of performing in my day-to-day life without an artificial aid. But I’ve come to terms with the idea that sometimes there is no other option. I hope one day I’ll be okay with that.

5 Things You Should Know About STRESS

Everyone feels stressed from time to time.

But what is stress? How does it affect your health? And what can you do about it?


Stress is how the brain and body respond to any demand. Every type of demand or stressor—such as exercise, work, school, major life changes, or traumatic events—can be stressful. Stress can affect your health. It is important to pay attention to how you deal with minor and major stress events so that you know when to seek help. Here are five things you should know about stress: 1 Stress affects everyone. Everyone feels stressed from time to time. Some people may cope with stress more effectively or recover from stressful events more quickly than others. There are different types of stress—all of which carry physical and mental health risks.A stressor may be a one time or short term occurrence, or it can be an occurrence that keeps happening over a long period of time.
Examples of stress include:
◉ Routine stress related to the pressures of work, school, family, and other daily responsibilities
◉ Stress brought about by a sudden negative change, such as losing a job, divorce, or illness
◉ Traumatic stress experienced in an event like a major accident, war, assault, or a natural disaster where people may be in danger of being seriously hurt or killed. People who experience traumatic stress often experience temporary symptoms of mental illness, but most recover naturally soon after.

2 Not all stress is bad. Stress can motivate people to prepare or perform, like when they need to take a test or interview for a new job. Stress can even be life-saving in some situations. In response to danger, your body prepares to face a threat or flee to safety. In these situations, your pulse quickens, you breathe faster, your muscles tense, your brain uses more oxygen and increases activity—all functions aimed at survival.

3 Long-term stress can harm your health. Health problems can occur if the stress response goes on for too long or becomes chronic, such as when the source of stress is constant, or if the response continues after the danger has subsided. With chronic stress, those same life-saving responses in your body can suppress immune, digestive, sleep, and reproductive systems, which may cause them to stop working normally. Different people may feel stress in different ways. For example, some people experience mainly digestive symptoms, while others may have headaches, sleeplessness, sadness, anger or irritability. People under chronic stress are prone to more frequent and severe viral infections, such as the flu or common cold. Routine stress may be the hardest type of stress to notice at first. Because the source of stress tends to be more constant than in cases of acute or traumatic stress, the body gets no clear signal to return to normal functioning. Over time, continued strain on your body from routine stress may contribute to serious health problems, such as heart disease, high blood pressure, diabetes, and other illnesses, as well as mental health problems like depression or anxiety.

4 There are ways to manage stress. The effects of stress tend to build up over time.Taking practical steps to manage your stress can reduce or prevent these effects.The following are some tips that may help you to cope with stress:
◉ Recognize the Signs of your body’s response to stress, such as difficulty sleeping, increased alcohol and other substance use, being easily angered, feeling depressed, and having low energy.
◉ Talk to Your Doctor or Health Care Provider. Get proper health care for existing or new health problems.
◉ Get Regular Exercise. Just 30 minutes per day of walking can help boost your mood and reduce stress.
◉ Try a Relaxing Activity.
Explore stress coping programs, which may incorporate meditation, yoga, tai chi, or other gentle exercises. For some stress-related conditions, these approaches are used in addition to other forms of treatment. Schedule regular times for these and other healthy and relaxing activities. Learn more about these techniques on the National Center for Complementary and Integrative Health (NCCIH) website at (www.nccih.nih.gov/health/stress).
◉ Set Goals and Priorities. Decide what must get done and what can wait, and learn to say no to new tasks if they are putting you into overload. Note what you have accomplished at the end of the day, not what you have been unable to do.
◉ Stay Connected with people who can provide emotional and other support.To reduce stress, ask for help from friends, family, and community or religious organizations.
◉ Consider a Clinical Trial. Researchers at the National Institute of Mental Health (NIMH), NCCIH, and other research facilities across the country are studying the causes and effects of psychological stress, and stress management techniques.You can learn more about studies that are recruiting by visiting http://www.nimh.nih.gov/joinastudy or http://www.clinicaltrials.gov (keyword: stress).

5 If you’re overwhelmed by stress, ask for help from a health professional. You should seek help right away if you have suicidal thoughts, are overwhelmed, feel you cannot cope, or are using drugs or alcohol to cope.Your doctor may be able to provide a recommendation.You can find resources to help you find a mental health provider by visiting http://www.nimh.nih.gov/findhelp. Call the National Suicide Prevention Lifeline Anyone experiencing severe or long-term, unrelenting stress can become overwhelmed. If you or a loved one is having thoughts of suicide, call the toll-free National Suicide Prevention Lifeline (http:// suicidepreventionlifeline.org/) at 1-800-273-TALK (8255), available 24 hours a day, 7 days a week. The service is available to anyone.All calls are confidential. For More Information For more information on conditions that affect mental health, resources, and research, visit http://www.mentalhealth.gov, or the NIMH website at http://www.nimh.nih.gov. In addition, the National Library of Medicine’s MedlinePlus service has information on a wide variety of health topics, including conditions that affect mental health.