Fighting Stigma

Fighting mental illness stigma through education

[saynotostigma]

Side note: Sorry this is a secondary blog

So many of you post awesome things and I would love to like and follow them with this blog, but I can't since it's my secondary blog.  

Just know, I'd love to show support and solidarity via this blog/identity.

[saynotostigma]

Schizophrenia - The diagnosis

So, schizophrenia is not an easy diagnosis to make and not that many people have it (I'll do another post about prevalence, genetics, causes, etc. later). 

What I'm about to give you is what's called a differential diagnosis....

Basically, there are 14 or so different diagnoses within the Psychotic Disorder group.  To make a diagnosis, one has to combine evidence, critical thinking, and clinical judgment.  In short - do a differential diagnosis - by, not only ruling out diagnoses, but also ruling in a diagnosis.

BTW, there is no ONE way to do a differential diagnosis.  They key is to be thorough.  

That said, what I'm about to give is not thorough.  In real life, it takes several sessions with a client, focused clinical interviews, a detailed personal history, and reading over any information released by other agencies, doctors, or therapists.

Take a deep breath

1. Is there evidence of at least one psychotic episode?

Hallucinations, delusions, disorganization, or negative symptoms? If yes, move on.

If no, then there is no diagnosis of Psychotic Disorder.

2.  Were there substances involved when the psychotic symptoms happened?

If it looks like substances (medicine or illicit) were the cause then it's a diagnosis of Substance/Medicine Induced Psychotic Disorder

If substances were involved, but it's not clear they're the cause, stop.  To determine if substances were the cause you have to see if there are psychotic symptoms when the client is not under the influence or in withdrawal.  This takes time, the client should be clean and sober for a while before ruling out substance-induced psychosis.

If there is no connection with substances or medicine, move on.

3.  Does the person have a medical condition which could explain these symptoms?

You're not a medical Dr., so always have someone with suspected psychotic symptoms go see a medical doctor. 

If Dr. says "Yep, it's medical condition X.",  there's a diagnosis of Psychotic Disorder Due to Another Medical Condition

If Dr. says no medical problem, move on.

4.  After ruling out substances and medical conditions, rule out other mental disorders.  There are Mood Disorders and at least one Personality Disorder (if not two) that may have psychotic features. So, rule out other mental disorders, Psychotic Disorders are among the last disorders to be ruled-in.

5.  Now that you've ruled other things out, look at the client again.  Sometimes people only experience one of the psychotic symptoms (sometimes more) for a significant portion of time.  If there is at least one symptom present, how long does the episode last?

Between 1 day and 1 month? This yields a diagnosis of Brief Psychotic Disorder

Shorter? Look closely and start back at #1.

Longer?  Move on

6.  Sometimes these episodes last longer than one month.  So, does the person have at least two of the psychotic symptoms (and at least one of them is delusion, hallucinations, or disorganization) most of the time, from 1 to 6 months?

If yes to 2+ symptoms for 1-6 months, This would be a diagnosis of Schizophreniform Disorder

If mostly catatonia and no hallucinations or delusions, move on to 7.

If mostly delusions, but not really anything else (except maybe related hallucinations), skip to 8.

If all criteria are met for longer than 6 months, skip to 9.

If the criteria isn't met here, then look again at Mood Disorders with Psychotic Features and double-check the diagnoses you ruled out.

7. So, there's catatonia but no hallucinations or delusions?

If there is catatonia, you have to figure out if it is related to another mental disorder, a medical condition, or is "unspecified" (which just means it doesn't fit neatly anywhere else).  

If one of those things is the cause, then specify that type of Catatonia

If all those things are ruled out then there is a diagnosis of Catatonia.

8.  So, there's delusions and maybe some related hallucinations, but none of the disorganized or negative symptoms?  

The diagnosis would likely be for Delusional Disorder

9.  Does the person have at least two of the psychotic symptoms (and at least one of them is a delusion, hallucination, or disorganization) most of the time for over 6 months?

If yes, then there may be a diagnosis of Schizophrenia

But...are there any mood/affective elements?  If so, keep going...

10. Do the psychotic symptoms co-occur with symptoms similar to depression or mania?  Remember back to ruling out Mood Disorders...

If so, maybe no schizophrenia.  Maybe there should be a diagnosis of Schizoaffective Disorder

If not, go back to Schizophrenia

Now, there are a few wrenches to throw in here.  First, there's a Personality Disorder called Schizotypal which displays some bizarre thinking and behavior as well as interpersonal difficulties.  It can be mistaken for Schizophrenia. 

And, sometimes a Psychotic Disorder doesn't quite fit any of these categories neatly.  We used to then call it Psychotic Disorder Not Otherwise Specified, but now it's divided into Unspecified Schizophrenia Spectrum and Other Psychotic Disorder and Other Specified Schizophrenia Spectrum and Other Psychotic Disorder.

Lastly, I hope it goes without saying that any diagnosis requires that the individual have impairment and/or distress due to these symptoms.  And these psychotic symptoms have to be occurring most of the time over the course of a month or so (except in the case of Brief Psychotic Disorder).

[saynotostigma]

Psychotic Disorders - A Primer

Recent events - involving a man with a history of a diagnosis of schizophrenia and the Texas court system - have led me to move this blog forward faster than I intended.

Despite the fact that I want to jump into the deep end, there are some things that have to be cleared up first – namely our language.

What do schizophrenia, psychotic, psychosis, and psycho all mean? 

Are they the same?

The short answer: No.

The long answer: After the break….   But I will tell you what you psychotic disorder doesn't entail...

Violence and criminality.  Antisocial personality disorder and psychopathy include things like lack of empathy, criminality, disregard for others, etc.  That is separate from a Psychotic Disorder. Schizophrenia and psychopathy are not in the same diagnostic category - they're not the same.

I am going to start this off with a broad presentation of Psychotic Disorders. Why? Schizophrenia is one of many psychotic disorders.  To understand schizophrenia, you have to understand what a psychotic disorder is.

I promise I will go into detail later.  This is just to get us all on the same page.

Psychotic Disorder is an overarching label for a group of diagnoses. These disorders are typified by the presence of some of the following features: positive symptoms, disorganization, and negative symptoms. Which diagnosis a person has is largely dependent upon which set/subset of symptoms that person presents.  I'll get to that later, I promise.

POSITIVE SYMPTOMS- A positive symptom is a symptom someone has or shows (as opposed to something they lack – see negative symptoms).  Positive symptoms manifest as delusions or hallucinations.

Delusion – a firm belief that the person refuses to change even when strong counter-evidence is presented.

Delusions have a theme.  That theme may be persecutory (fearful that someone will be harmed), referential (based on a belief that gestures, comments, cues, etc. are about the individual), grandiose (feeling that oneself is exceptional or has great wealth or fame), nihilistic (convinced that a catastrophe is immanent), or somatic (having an unusual belief about one's body or bodily function).

Sometimes delusions are bizarre.  That is, regardless of what the belief is about (theme), the content is clearly implausible given the person's culture or ordinary experience.  Bizarre delusions include believing that one's thoughts have been removed or that thoughts have been implanted into one's mind.  Sometimes, individuals believe that an outside force controls their body or actions.

However, some people have non-bizarre delusions.  Again, the theme doesn't matter.  A non-bizarre delusion is plausible given the individual's culture or experience.  For example, it is non-bizarre to believe that one's employer is reading one's work email.

Hallucination – perceptions (or things like perceptions) that are not generated by an outside stimulus (so, no one else perceives these things, because there’s nothing THERE to be perceived).

Hallucinations can involve any of the five senses, but auditory hallucinations are the most common.  It is important to realize that an auditory hallucination occurs when someone hears a voice that no one else hears.  This voice is not a voice in the person's head; it is heard just like every other voice - as if with the ear.

Not every hallucination is a symptom.  Hallucinations that occur upon waking or going to sleep are not indicative of a psychotic disorder.  And, hallucinations that are a normal part of a religious or cultural experience are not evidence of a pathology and should not be seen as a symptom of a disorder. Substance-induced hallucinations also do not count

DISORGANIZATION - Disorganization is something like being jumbled.  We have the idea that communication and action have a purpose.  Individuals who show disorganization in their thoughts (via speech) or in their behavior, seem to show that there is something amiss about their ability to keep themselves together in a culturally appropriate way.

So, disorganized thought comes out in speech (because we can't get at people's thoughts otherwise).  Sometimes individuals with disorganized thoughts change topics quite suddenly and often. The conversation bounces around.  In another person, disorganized thought may look more like "close answers."  The person doesn't change topics, but what the person talks about is only minimally related to the topic at hand or the question asked.

For example: "Q: Do you have children? A:  Children, ah, they're a blessing from God right?  How many children did God have?  Are we all God's children? Does that make us brother and sister?  Does that make Jesus my older brother?  I didn't get along with my oldest brother."  

And lastly, sometimes people speak and it seems like a completely unrelated string of words. For example: "The pickles like blue; have six the nice grape-ly apple."

Sometimes disorganization comes out in behavior.  We expect people to behave in a predictable way.  When someone is constantly and inappropriately silly or unpredictably agitated, then there may be disorganization.  Catatonia can happen, too.

Catatonia isn't just sitting still for a long time (although that can happen). Catatonia is really about behavior that doesn't seem to be goal directed or purposeful.  So sitting still for a long time seems to have to have no purpose. On the other hand, moving constantly with no purpose is also a type of catatonia. 

NEGATIVE SYMPTOMS - if positive symptoms are behaviors or manifestations a person does, then negative symptoms are things a person DOESN'T do.

Sometimes a person with negative symptoms lacks, or doesn't show, expected non-verbal communication. For example, there may be little to no facial expression, eye contact, voice intonation, or gestures.   Basically, the non-verbal things we do that add to our speech (especially the emotional character) are missing.

It is not uncommon for someone with a psychotic disorder to show a decrease in motivation; this is called avolition.  The person may sit in the same place for long periods or show little interest in work or social activities.  Many people mistake this symptom for defiance or non-compliance with a treatment program.  It may, in fact, be an untreated negative symptom of a disorder.

Sometimes speech difficulties show up as something other than evidence of disorganized thought.  Sometimes it seems that the individual is really struggling to talk at all.  Often this manifests with an individual answering complex, open questions with simple yes/no answers.  Complex speech does not occur, but the individual is not mute.  This is a form of alogia.

In some ways like an aspect of depression, individuals with anhedonia, are unable to experience pleasure despite experiencing positive stimuli, the individual does not experience pleasure; this person may also be unable to remember previously felt pleasures.

Here's a look at someone with a diagnosis of schizophrenia (a type of psychotic disorder): https://www.youtube.com/watch?v=gGnl8dqEoPQ

Reference: DSM-5

[saynotostigma]

To Clarify: The is and isn'ts of depression and some social justice

This post has undergone a few revisions after thoughtful comments from friends.

What lies beyond the break?

Validation of multiple possible expressions of depression

Validation of multiple possible causes of depression

Direct critique of stigma and the role it plays in causing and perpetuating mental health problems

Opening the door for recognition that mental health is a social justice issue.

And, yes, one day I will talk about Texas.

Depression is not clearly one thing.  It is different for everyone.

Just because someone's depression doesn't seem bad enough to you or isn't like your depression, that doesn't mean the depression isn't real and doesn't hurt.  

Depression comes in many shapes and sizes and there is evidence that it presents differently between men and women.  In fact, it does differ from person to person.

People cope with depression differently.  Some people may grind themselves into the ground and not seek help.  Others may reach out to friends or professionals.  Both of these are coping skills that have been learned and reinforced over time.  They are not necessarily evidence that a depression is or is not severe.

There are different causes of depression.  None are more or less legitimate than any other.

There is likely no single thing that causes anyone's depression, but if there is - that's ok.

Depression caused by biology or genetics is not any more or less real than depression caused by life, environmental, social, interpersonal, or economic stressors.  Some people confuse the latter with a weakness of will or character.  It is no such thing.  

For example, experiencing childhood neglect or abuse not only affects relationships with parents, but with others.  Consider what relationships look like through the lens of someone who has been abused by a family member?  Where does one find safety and support?  Where does one develop a sense of worth and hope and possibility, if the ones charged with caring for you don't treat you as valuable?  There are many possible outcomes for this person, and one of them is depression.  

By calling this person's response to childhood abuse and neglect a weakness of will, one is shifting the blame from the perpetrator to the victim.  This victim-blaming implies that, had the victim been stronger, the damage would not have been done.  No, indeed, the character flaw is within the perpetrator and the strength lies in the individual who continues to take one more breath despite the invalidation that has happened.

But isn't it dangerous to talk about non-biological causes? No, it is dangerous to AVOID talking about non-biological causes.

There are people who latch on to psycho-social causes/contributors to depression as evidence of a character flaw in the depressed individual.  

Doing so AVOIDS addressing real social, economic, political, and interpersonal problems that do, in fact, have a significant impact on the well-being of a person.  Oppression, abuse, neglect, trauma, poverty, etc. are all real and depression related to these stressors is also real -and should not be stigmatized.

The person who experiences depression due to any of the above experiences is not the one to blame; the blame lies with those who oppress, abuse, neglect, traumatize and economically injure others.

Fighting stigma is a social justice issue for many reasons.

Without social justice, people will continue to experience an environment which negatively impacts their mental health.  As a social justice advocate, I work to create a culture and community that is safe for all people.  My hope is that minimizing the instances of abuse, neglect, trauma, hate, etc., in turn improves mental health - I would love to advocate myself out of a career!

And without social justice, those who inflict this harm will perpetuate the harm and shame by blaming the victims for their pain.   Part of my role as advocate is to also call out stigma and shaming when I see it and to fight with those suffering from mental health issues so that they can avoid internalizing or believing the stigma.  

[saynotostigma]

Depression: Where does it come from? Part Two: Social and situational factors

Preface:  

In the last post I made a point of talking in terms of sex and not gender, since I was discussing biology.  But now that I'm moving to social, cultural, and situational issues, I am switching to gender.  I am going to try hard to avoid binary gender distinctions, except to provide examples; however, it is important to note that where someone falls on the gender identity spectrum does impact personal identity, the way the dominant culture sees that person, the way that person was raised and the lessons learned along the way, and even the specific experiences that person has.  So, outside of a few gender specific examples, I am going to stay as gender-generic as possible.

So, my last post was on the biological factors that may impact the development or progression of depression.  But there are likely other things that impact depression.  These factors include cultural messages, socialization, and life stressors.

What does that mean?  The short version: the culture you are in or grew up and the lessons you learned growing up can negatively impact your mental health.  Moreover, the situation(s) that you currently find yourself in can also have an impact.

THE LONG STORY

Social/Cultural Factors

If you live in a society in which who you are or how you identify as a person is regarded poorly or you are oppressed, then you have an increased chance of experiencing depression.  Women, for instance, who have experienced oppression in terms of sexual harassment and sexual violence are more likely to experience depression.  Women of color have even higher levels of depression due to the compounding of racial and sexist oppression.

Individuals with disabilities, the elderly, members of the LGBTQIA community, individuals living in poverty, and anyone else who finds themselves in a subordinate status runs the increased risk of developing depression. 

Why?  It’s possible that the day-in-day-out experience of invalidation or subordination takes its emotional toll – how long can anyone be expected to fight injustice without injury?  It’s also possible that people start internalizing, or believing, the negative stereotypes of the dominant culture.  So, not only are these people getting beaten up emotionally (and maybe physically) by others, but they may also be unintentionally doing it to themselves.  But, in the end, it’s not clear how oppression links to depression, but statistically experiencing oppression increases the risk of experiencing depression.

Socialization Factors

Even the way that one is raised can affect the risk of developing depression.  Why is that?  Well, if one grows up with certain attitudes about life or about how to deal with difficulties, that’s generally what one will attempt later when obstacles do arise.  However, if what you learned is not currently helpful, then it may do more harm than good. 

For example, some people were taught to believe in meritocracy.  In a meritocracy, people get what they deserve.  Economically speaking, good, hard workers get good, stable jobs that pay well.  If you don’t have a good, stable job that’s a reflection on you as a person, because bad people also get what they deserve.  Unfortunately, this belief isn't accurate.  There are plenty of good, hardworking people who are unemployed.  But if those people grew up believing in a meritocracy, what might they be believing about themselves now?

But the belief in a meritocracy extends beyond economics.  For example, individuals who experience violence may believe that they deserved it, because “only bad things happen to bad people.”   

These beliefs that one is brought up believing can work for the individual (as motivators), but they can work against the person.  It’s important to look closely at these beliefs to see if they’re really accurate.  Unfortunately, sometimes they’re so deeply rooted, it’s hard to challenge them on one’s own. 

Cognitive-Behavioral Therapy is one of the best known treatments for these negative, or non-helpful thoughts.  The cornerstone of CBT is that there is an inherent connection between someone's thoughts, feelings, and behaviors.  According to CBT, negative, or non-helpful thoughts perpetuate, if not cause, depression.

Other possible socialization factors: learned helplessness, enforced modesty, body image expectations.

Life Stressors

While no one can say what does and does not count as a stressor, what I am about to give is a brief list of possible stressors.  Some people have not found these things stressful; some people have.  Others would like to add to this list.  What is important to note is that if someone says something is a stressor – it is.  Only the individual having the experience can determine whether or not it is stressful (or traumatic).   The following are details of just two possible life stressors.  And by no means are these the only ways to understand or experience these events.

Puberty:  Ugh, it’s bad enough that the body is haywire.  Developmentally, this is an important phase of life.   Adolescents are trying to strike a balance between being accepted by peers and asserting themselves as individuals.  During this process they are receiving feedback not only from peers and family but also from popular culture.  It’s really the beginning phase of self-identity (which doesn't end until mid 20s BTW), and being validated or invalidated during this time hurts. 

I’m not going to get into the many different identities that could be forming during this stage, but at the very least adolescents are receiving messages about how to be.  Many of these messages make demands beyond an adolescent’s capabilities.  And sometimes an adolescent’s desire or identity doesn't match the “typical” or “usual” one.   The invalidation of one’s identity can lead individuals to question their worth or choices and can manifest as depression.

Pregnancy:   Spousal support and equality in the marriage are good protective factors against depression.  On the flip side, if the work of parenting or household responsibilities are not equally distributed then stress increases.  With this increased stress comes a higher risk of depression.  Women are at higher risk of depression after pregnancy and this may be due to two things: 1) broadly speaking, women are more likely to be given a greater share of household and parental responsibilities, and 2) after childbirth women undergo a drastic hormonal and physical change. 

Other life stressors:  dating, marital/relational conflict, discrimination, harassment, divorce/recently single, isolation, role change (recently unemployed, care-giving for loved one, no longer primary source of income for family, etc.)

So, what does this mean?

Well, there are some things that happen in life that are more stressful than others.  One’s ability to successfully cope with those stressors depends on a lot of factors.  The interaction the culture you live in (Is life already hard?), the way you were raised (Were you taught helpful coping skills?), and life events (PLUS a possible biological vulnerability) can manifest as depression.

Now, from a diagnostic standpoint, there is a difference between Adjustment Disorder with Depressive Features and Major Depression.  I would likely be encouraged to give a diagnosis of Adjustment Disorder if there was a recent event that seemed to lead to the current depressed episode.  But, that doesn't mean that the depression isn't real.  It just means that the therapist thinks that if the event can be dealt with, the depression will pass. And, therapists can always change diagnoses. 

References:

Koss, Heise, Russo (1994) The global health burden of rape. Psychology of Women Quarterly, 18, 509-537.

Mazure (1998) Life stress and risk factors for depression. Clinical Psychology: Research and Practice, 5, 291-313.

Whiffen (2001) Depression in J. Worrell (Ed.) Encyclopedia of women and gender: Sex similarities and differences and the impact of society on gender (Vol 1, pp. 303-315). San Diego, CA: Academic Press

Worrell and Remer (2003) Feminist perspectives in therapy: Empowering diverse women 2nd ed. Hoboken, NJ: Wiley.

Wyche (2001) Sociocultural issues in counseling women of color. in R.K. Unger (Ed.) Handbook of the psychology of women and gender (pp. 330-340). New York: Wiley.

[saynotostigma]

Depression: Where does it come from? Part One: Biology

But really, the short answer is, "No one knows."

The long answer:  it is probably the result of a complex relationship between a genetic or biological factors plus environmental, social, and psychological stressors.

So, this post will focus on the biological components.  I’ll look at the social, environmental, and life stressors in the next post.  Remember, there probably isn’t ONE cause for any one person’s depression and it may be the case that different depressions have different causes.

Chemical imbalance:  One of the prevailing theories is that depression is due to a chemical imbalance in the brain.  Generally, scientists theorize that insufficient serotonin and/or norepinephrine are the culprits.   This theory sites the effectiveness of antidepressants like Prozac and Zoloft as evidence for the chemical imbalance theory.  However, given that some studies have found that talk therapy can be at least as effective as medication for Mild to Moderate Major Depression, one has to wonder how often brain chemistry is the (only) culprit.  Here's an interesting article about cognitive therapy vs. medication in treating depression http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2748674/

Genetics:  It is not uncommon for mental illness to run in families.  There is evidence to support the claim that Major Depression is heritable.  That is: when we look at children of parents with Major Depression, those children have an increased chance of developing the disorder even when they are adopted out of the home (So these children didn't learn to be depressed from their depressed parents, they inherited it.).  For more information on the genetic component http://www.ncbi.nlm.nih.gov/pubmed/11007705

Chronic pain or illness:  Chronic pain/illness and Major Depression often go hand-in-hand.  It is difficult to pull them apart to see if one causes the other of it a third thing predisposes people to chronic pain AND depression.  Whatever the case, chronic pain and depression increase an individual’s risk for attempting suicide.   For more information about chronic pain and depression: http://www.nimh.nih.gov/health/publications/depression-and-chronic-pain/index.shtml

Hormones:  This is more commonly a problem for women, since the hormones involved are believed to be estrogen and progesterone.  Studies have found that some of women’s depressive episodes often coincide with pre-menstruation, pre- and post-partum periods as well as menopause.  This suggests that the hormone changes that occur during these periods contribute to the development of Major Depression. Now, it should be noted that these hormonal periods also co-occur with pain (premenstrual cramping, bloating, and fatigue), role changes (stresses and new responsibilities that come with motherhood, for example), and life changes (menopause may also occur around the time that children leave the home and family/friends die).  So, it is difficult to pull apart hormonal influences and life/role changes.  Here's a little from the Mayo Clinic about women and depression http://www.mayoclinic.org/diseases-conditions/depression/in-depth/depression/art-20047725

Remember, environmental, social, and psychological elements can impact the development and severity of depression as well.  And, it is not clear when biological elements do and do not contribute to Major Depression.

[saynotostigma]

Stigma and Depression Myths

I started thinking that I didn't really connect diagnosis with stigma, so why do a post on diagnosis?  Well, I think the more people know about a disorder they less mysterious it is, and the more likely they are to take it seriously. 

But also, I wanted to dispel some myths.  And I want to make that clearer now:

1.  Having depression is not the same as feeling sad.  Feeling sad is normal and healthy.  Having depression, if there's sadness present, is sadness plus a physical impact.  Notice that most of the criteria involve physiological changes. 

2.  Having depression does not require that someone feels sad.  Remember criteria 2?  Loss of interest in pleasurable activities?  Some people's depression manifests as a lack of feeling or an emptiness - as an inability to feel.  Sometimes people say it's like being an "emotional zombie."  They're not sad or happy or anything. 

3.  Depression weighs heavily on people.  Not only do people with depression lack the mental desire to get up and move, but their bodies don't want to do it either.  Some people describe depression as a heavy, wet, wool blanket that they have to tote around.  Everything is a chore and uncomfortable, and not because they're being difficult or surly.  The disorder makes things difficult.

[saynotostigma]

Major Depressive Disorder - Diagnosis

Now, I’m going to present you with the basic diagnosis of Major Depression AKA Major Depressive Disorder .  In no way is this a substitute for seeing a therapist or medical doctor.  Like I said before, diagnosing is complex and social psychologists have warned us that we have a tendency to notice only what fits our current beliefs.  A second opinion on important matters is vital.  If you're worried, talk to someone you trust.

So, what follows is a basic outline of a Major Depressive Episode and how that fits into a diagnosis of Major Depression.  The following is consistent with the DSM-IV-TR and DSM-V. 

Major Depressive Episode

There are 9 possible criteria.  A person must meet at least 5 of them INCLUDING meeting criteria 1 or 2.  Criteria 1 or 2 is a MUST.  When looking at these criteria, they have to describe recent changes – these are unusual (for the person) and not intentional.  Now, if the person usually is sad/depressed and you can’t imagine a time when he or she hasn’t been – that is still problematic and worth looking into.  Remember most of the time ≠ all of the time.  Some people with depression can sometimes feel pleasure/happiness.  That does not invalidate their depression.

Depressed mood most of the day, nearly every day

Noticeable loss of interest or pleasure in most everything, almost all the time

Significant change in weight (when change is unintended) or significant change in appetite

Sleeps too much or not enough (yes, sometimes depressed people have difficulty sleeping)

Change in the amount that the person moves (person may become restless or, on the other end, may slow down)

Fatigue/loss of energy most days

Feelings of worthlessness or excessive or inappropriate guilt most of the time, most days (but, feeling bad about being sick does not count)

Difficulty thinking, concentrating or making decisions most of the time, most days.

Recurrent thoughts of death, recurrent thoughts of suicide (even without a plan), having a suicide plan, or making a suicide attempt

So, let’s say that 5/9 criteria have been met.  Now, do these symptoms cause impairment and distress?  It’s not a disorder if it’s not negatively impacting the person.

If there is impairment/distress, then the clinician will have to rule out all of the other things that look like Major Depression: substance use, a medical condition, bereavement or other stressors (maybe), and any other psychological disorders.  Not everything that looks like Major Depression responds to the same treatments as Major Depression; so, it is important to get the diagnosis right. 

The Many Faces of Major Depression

Severity:  Can range from mild to severe and even severe with psychotic features (for example, having hallucinations).  Sometimes severe Major Depression can look like schizophrenia - that's why clinical training is important.

Duration:  Major Depression (by definition) must last at least 2 weeks.  But it can last over 2 years.

Frequency:  Some people only experience one Major Depressive Episode, others experience multiple episodes. 

Subtypes:  Somewhere between 4-9 subtypes (depending on the diagnostic manual used)

The Whole Story

Now, looking back at those criteria, I want you to realize that these are only the diagnostic criteria.  It does not capture the myriad of ways depression rears its head. 

Some people lose interest in sex or experience sexual dysfunction.  Some people experience memory loss.  Some people have very negative thoughts.  Some people’s depression worsens their self-esteem.  Some people get angry or are irritable.  The point is, Major Depression looks different for each person.  What I’ve given you here is only the diagnostic criteria.  It is the barest representation of Major Depression.

For a broader look at Major Depression and other related disorders check out http://www.youtube.com/watch?v=XiCrniLQGYc and its website http://www.blackdoginstitute.org.au/index.cfm

Lastly, depression is a real thing.  Please be kind and supportive of those who may be experiencing Major Depression (even if that person is you).

And just in case:

http://www.suicidepreventionlifeline.org/

http://www.suicide.org/international-suicide-hotlines.html

[saynotostigma]

Depression: The numbers

The next few blog posts will be about Major Depression.

One way to fight stigma is to realize that it is quite prevalent.  Depression is one of the most common mental illnesses in the US; to drive this point home I'm going to start with depression statistics.  I know....STATS ARE BORING!  That's why I've tried to put these numbers in perspective for you.  But I do think it is important to realize how pervasive this disorder is an how early it can hit.

The Substance Abuse and Mental Health Services Administration and the Centers for Disease Control and Prevention (in the US) published the following data.  You can find this data and others at

www.samhsa.gov/data/Short_Reports.aspx and www.cdc.gov/workplacehealthpromotion/implementation/topics/depression.html

Lifetime prevalence:

50% of all people will experience at least one Major Depressive Episode in their lifetime

Adolescent prevalence:

Data from 2004 to 2006 indicates that approximately 8.5% of adolescents (2.1 million kids) aged 12-17 had experienced at least one Major Depressive Episode in the past year.  To put it in perspective, that's about the same amount as number of farms in the US (2.2 million according to the EPA)

Adolescent females were twice as likely as adolescent males to experience a Major Depressive Episode (12.7% vs. 4.6%).  How many is 12%?  According to the American Academy of Ophthalmology, that's how many green/light brown eyed people there are in the US.

Young adult prevalence (18-22 years old):

Data from 2008 to 2010 indicates that a little over 8% of young adults had experienced at least one Major Depressive Episode.  Again, females had a higher prevalence than males (~12% vs. ~5%).   8% puts us close to 2 million people.  That's somewhere in between the number of employees that Walmart (2.1 million) and McDonalds (1.9 million) have worldwide.

Racially the highest prevalence was among young adults who were both non-Hispanic and multi-racial (~17.7%).   Do you know what else occurs at a rate of 17%?  Males make up 17% of school teachers. 

Adult prevalence (people over 18 years of age):

The CDC reports that 18.8 million American adults (9.5% of the adult population) will suffer from a depressive illness over the span of one year.  That's more people than follow Jimmy Fallon on Twitter (13.1 million)!

Again females were more likely to have experienced a Major Depressive Episode than males (9.5% to 5.3%). 

Suicide: Risk factors for suicide are complex, but being depressed increases the risk of attempting suicide.

In a meta-analysis (a study of other studies) Hawton, Casañas I Comabella, Haw, and Saunders (2013), found that 9 out of 10 people who die by suicide have a psychiatric disorder at the time of death.  Half to 2/3 of those with a psychiatric disorder had major depression.

That means that 45-60% of people who die by suicide have major depression at the time of death.

Studies vary, but up to 15% of people who have been diagnosed with major depression die by suicide.

So, lots of people have it.  But what is it?  That's next.

[saynotostigma]

Stigma: Enabled by a label. How do dignoses happen?

So, before I begin writing about mental illness, I thought you should get a little context.

When I write about mental illness, I will be writing based on illnesses typically diagnosed by mental health professionals (although PCPs do it, too).  So, you should probably know a little bit about diagnosis. 

How does anyone know they or someone else has a mental illness?  Setting aside the obvious epistemic problems, mental illnesses are diagnosed by trained professionals.  While some people “diagnose” themselves or others after a Google search or a trip through Web MD, diagnosing actually takes training.

Mental illnesses can be diagnosed by a broad range of people with different types of training.  The mental health professional you see may call themselves a counselor, therapist, counseling psychologist, clinical psychologist, licensed clinical social worker, psychiatric nurse practitioner, or psychiatrist (MD).   Training in diagnosing and treating mental illness varies, but what we all typically use in the United States when diagnosing is the Diagnostic and Statistical Manual of Mental Disorders (DSM)

I was trained under the DSM-IV-TR but the DSM-5 will be completely rolled-out and in use by Fall 2014.  Essentially this giant (900+ page) book details out the criteria for each mental illness (along with other helpful information).  I won’t go into the process of creating the DSM-5, but you should know that it is the product of the American Psychiatric Association and heaps of "expert committees" which include both psychologists and psychiatrists.  That said, it tends to follow a medical model for understanding mental illness.  Because we use a manual people tend to believe that diagnoses are objective - basically clinicians check boxes on a list and if the client has enough checks he or she gets a diagnosis.  Unfortunately, it's not so simple or objective.

Diagnoses are typically based off of information gathered from the client, but sometimes we use information from family, friends, teachers and other clinicians (if the client says it's okay to talk to those people).   If you see a mental health professional for the first time, you will likely experience a session called an intake.  It is a very nosy time in which the clinician asks you a series of personal questions.  Intakes help the clinician better understand you as a person, but they can also be used to help the clinician learn about your symptoms.  This evidence helps the clinician critically think and it guides further questioning; this is all in the hopes of determining what diagnosis you may have. Sometimes all these questions aren't enough and the clinician may decide that assessments (psychological tests) would be helpful in making things clearer. 

Diagnosing is both a science and an art.  There are studies to support the use of these DSM criteria to make a diagnosis, but it takes skill to weed through discussions to find which criteria fit and which don't.  For example, clinical judgment is used to determine if hearing voices is evidence of an auditory hallucination or if it is a culturally accepted phenomenon which should not be pathologized.  Because an accurate diagnosis requires an understanding of the person and their context, many clinicians do not make a formal diagnosis until after several sessions with the client.  In the end, diagnoses change.  Some get added; some are removed; some are clarified. Most people don't fit the criteria for a diagnosis forever.

But note that if a diagnosis enters official documentation, that diagnoses can be seen by anyone with access to that document (insurance companies for example), and unless all copies of that document are destroyed – that diagnosis (even if later is deemed inaccurate) can be seen by others.  This fact alone makes some clinicians wary of making some diagnoses - these things stick with people and the stigma sticks with them, too.

There are other worries about diagnosing people.  Some counseling theories, for example, argue that diagnosing people pathologizes what they’re experiencing.  When you say someone has a mental illness, it’s not uncommon to think that there is something “wrong” with that person.  But that may not be the right way to look at it.  Some theorize that “mental illness” is the manifestation of problematic/dysfunctional thoughts/feelings/behaviors that are the result of dealing with oppression, stress, or trauma (to name a few serious life obstacles).  "Symptoms" are survival skills people have learned which have now become unhelpful or distressing.  The problem is not with the person dealing with oppression, stress, or trauma; but, instead, the problem lies with oppression, stressors, and traumatizers.  If we only focus on the person’s “pathology” we fail to see that he or she doesn’t need to be fixed – the environment needs to be fixed.

Even if you disagree that the environment is the primary cause of at least some mental illness, it is hard to ignore the fact that diagnoses are labels, and labels enable stigma.  This stigma can be both internal and external to the individual. Often when people think about stigma, they imagine non-mentally ill people forming problematic and prejudiced believes against the mentally ill.  However, stigma can be internalized; individuals with mental illness can believe all the awful things others are saying about them.  Individuals who internalize stigma have much poorer outcomes than those who don't, but even experiencing external stigma has a negative impact on outcomes.

So, clinicians need to tread carefully when using diagnoses and check-in with clients and their families to see how they feel about that diagnosis and how they are coping.  Some people actually feel better knowing that they’re not alone or that what they’re experiencing is real.  Others feel damaged and ruined.

If diagnosing is so problematic, then why do it? The cynical answer: because we want to get paid.  If a clinician wants reimbursement from a third-party payer, then that payer wants to know that this treatment is for a legitimate illness.  Referring to the DSM diagnosis gives your treatment legitimacy and (if lucky) the client’s treatments are covered.  Hopefully at least one problem with this seems obvious: surely not every legitimate illness has been investigated and is included in the book.

However, some people see diagnosing as a very important part of the treatment process.  How do we know how to proceed without knowing what we’re dealing with?  How can I decide between two similar problems my client has without doing a differential diagnosis based on evidenced-based criteria?  How am I to communicate with other clinicians if I don't use the shared diagnostic language?

The long and the short of it is that diagnosing is serious business.  It has serious implications for the client.  False positives and misses negatively impact treatment, and even an accurate diagnosis can be difficult for the client to deal with. While I'm not sure stigma hinges on a diagnosis, I do think that greater awareness about how diagnosing works can begin the demystification process.  And at the very least, diagnosis provides a very clear label that makes stigmatizing much easier.

[saynotostigma]

And so it begins....

Because I've seen how stigma has negatively impacted my clients, I've decided to use social media as a platform for fighting stimga. Each week, I'm going to try to focus on one "diagnosis", mental health issue, etc. and provide education about it: diagnostic criteria, prevalence, outcomes, and social impact of the "diagnosis", for example. I see lots of people wanting to be advocates, but not really having enough understanding to be most effective.

Moreover, stigma often occurs because people don't know the facts or misunderstand them. My ultimate goal is that learning about mental illness makes people more likely to engage with those they suspect have an illness. Studies have shown that positive contact between people promotes compassion and corresponding behaviors. In fact, positive contact helps both stimatizer and stigmatizee. If there are mental health issues you'd like me to address, just ask. My aim is to write for a general, lay person audience. If you'd like more technical information, just ask.