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Archive for the ‘Mental Illness’ Category

The Baker Act and Mental Health Court in Sarasota

Sunday, August 4th, 2013

130804 mental health court

Prior to 1971, the laws in Florida regarding due process and civil rights of persons in mental health facilities – which dated back to 1874 – were in a sorry state of affairs.  With signed affidavits by three laymen and the approval of a county judge, you could be committed to a mental health hospital.  There was no specific period of commitment before a person’s confinement would be reconsidered by a judge. The standards were so lax that, reportedly, the crony of a local judge would periodically have his wife committed so he could carry on a dalliance with another woman. 

All this ended in 1971 due to the work of Florida state representative Maxine Baker, who spearheaded the passage of the Florida Mental Health Act. Referring to the treatment of persons with mental illness before the passage of her bill, Representative Baker stated, “In the name of mental health, we deprive them of their most precious possession – liberty.”   The Baker Act, as it would come to be known, prohibited the indiscriminate admission of persons to state institutions or the retention of persons without just cause.  The law also prohibited the placement of persons with mental illnesses in jails, unless they had committed criminal acts. (more…)


Advances in Treatment of Depression

Friday, July 19th, 2013

130718 depression txI was born in 1955, as the Dark Ages of mental health treatment in the 20th Century was coming to an end.  There were 600,000 mentally ill people – 356 per 100,000 – more or less permanently hospitalized in public or private asylums.  Those ravaged by severe and persistent mental illness couldn’t walk the streets without being victimized, being arrested for crimes big and small, or worse.   With our limited understanding of mental illness – even though the standard of care varied widely -hospitalization was actually the most humane form of treatment available.

Over the next few years, medications that would manage depression and psychosis came into popular use, and these folks were  deinstitutionalized, and treated in community mental health centers.  (President Kennedy, who had a sister with mental illness, enacted the nationwide system.)  Not much progress was made in the next two decades with regard to medication.  The side effects of antidepressants were often worse than the cure, so many continued to suffer, or self-medicated with alcohol and other drugs.

As Viet Nam ended, a whole new population of hurting souls were searching for solace.  Depression, Posttraumatic Stress Disorder and addictive illness plagued these walking wounded, and the existing system and treatments provided, in most cases, cold comfort.

Psychotherapy was making advances, though, and cognitive behavioral therapy now offered relief to many whom depressive thoughts and beliefs had incapacitated.  Albert Ellis’s Rational Emotive Behavioral Therapy (REBT) also changed lives.

What makes mental illness – and treatment of depression in particular – so challenging is the wide disparity in presentation. There is a high degree of variation in symptoms, course of illness, and response to treatment, indicating that depression may have a number of complex and interacting causes. This intricate constellation posed a major challenge to researchers attempting to understand and treat the disorder. But in the 80’s, scientists began to better understand the role of the brain in mental illness.    This, with the advent of Selective Serotonin Reuptake Inhibitors (SSRIs) like Prozac presaged the second wave of treatment advances.   Relief for mild to moderate depression as now available to millions.

Recent advances in research technology are now bringing scientists at the National Institutes of Mental Health closer than ever before to characterizing the biology and physiology of depression in its different forms, and to the possibility of identifying effective treatments.

 One of the most challenging problems in depression research and clinical practice is refractory (hard to treat) depression. While approximately 80 percent of people with depression respond very positively to treatment, a significant number of individuals remain “treatment refractory.” Even among treatment responders, many do not have complete or lasting improvement, and adverse side effects are common. Thus, an important goal of NIMH research is to advance the development of more effective treatments for depression — especially treatment-refractory depression — that also have fewer side effects than currently available treatments.

130718 Depression BrainNIMH is far from the only place advances are being made.  Evidence from neuroscience, genetics, and clinical investigation now demonstrate conclusively that depression is a disorder of the brain. There are new conceptualizations of the pathogenesis and pathophysiology of major depression.  With this, new medications are being developed.  The neuropharmacology of affective disorders is a rapidly advancing field of scientific interest.

Genetics research indicates that vulnerability to depression results from the influence of multiple genes acting together with environmental factors. Studies of brain chemistry and of mechanisms of action of antidepressant medications continue to inform the development of new and better medical and psychotherapy treatments.

Modern brain imaging technologies are revealing that in depression, neural circuits responsible for the regulation of moods, thinking, sleep, appetite, and behavior fail to function properly, and that critical neurotransmitters — chemicals used by nerve cells to communicate — are out of balance. Soon, and certainly during my lifetime, a clinical psychotherapist will not begin a course of treatment without first looking at the patient’s brain scans.  More people will find relief, and more lives will be saved.  I look forward to that day.


What is Depression?

Tuesday, July 16th, 2013

130715 DepressionEverybody gets the blues.  When the dog dies, you lose a job or a boyfriend, a check bounces, the roof leaks, you get sick, your team loses – you feel down, sad and empty.   In a relatively short time though, you bounce back.  You get better because the circumstance changes, you take some action or your feelings just go away.

For some of us, though, things don’t get better.  Our mood is persistently sad.  We lose interest or pleasure in activities that we once enjoyed. We experience a significant change in appetite or body weight.  We can’t sleep or sleep too much.  We don’t have any energy.  Feelings of worthlessness or inappropriate guilt are complicated by difficulty thinking or concentrating.  We have recurrent thoughts of death or suicide.

If you have five or more of these symptoms during the same two-week period, you meet the diagnostic criteria for Major Depression.  How bad do the symptoms have to be?  Most of us tend to minimize how bad we are feeling, but the defining question is do the symptoms interfere with your ability to function: to get things done around the house, to go to work, to interact with those you love.

130715 depression1The problem is more pervasive and serious than we think.  6.7% of us will contract Major Depression during the next year, and there’s a one in five chance that sometime during your life you’ll suffer from this condition.  A recent study sponsored by the World Health Organization and the World Bank found Major Depression to be the leading cause of disability in the United States and worldwide.

And Major Depression can kill you.  Over 80% of people who die by suicide have Major Depression.   We tend to think that this extreme outcome is pretty rare, but suicide is the tenth leading cause of death in the U.S.  In 2009, it accounted for 34,598 deaths.  Suicide is a major, preventable public health problem.

How do we prevent suicide? By treating the underlying depression.   Women tend to suffer from depression more than men, and this has biological and cultural sequelae.  The primary reason may be that while men tend to “act out” – fighting, drinking or other acts of aggression, women who are depressed tend to turn inward, feeding that sense of hopelessness associated with depression.

130715 Depression2Depression can appear two other diagnoses.  First, depression is associated with Bipolar Disorder, which was previously known as Manic-Depression.  Persons with Bipolar Disorder swing between the “poles” of major depression and mania, which is abnormally and persistently elevated mood, accompanied by grandiosity, decreased need for sleep, racing thoughts and impulsive behaviors.

A less severe form of depression that lasts at least two years is known as Dysthymic Disorder, or dysthymia.  Many people with dysthymic disorder also experience major depressive episodes.

To see the criteria doctors and therapists use to diagnose depression, click here.

Next time, I’ll talk about how treatment of depression has changed over the last few decades.