Friday, January 23, 2015

You want to do what?!?! The importance of informed consent in treatment

By Gail  A. Edelsohn, MD, MSPH

We come across ads in print, on television and on the Internet for medications and therapies that promise to make your child do his homework without a screaming match, behave better and generally restore harmony to home life. Not so easy, taking a medication raises a host of questions:  How long does the therapy take? Should I as the parent sign off on this? What about the possible serious side effects, such as significant weight gain, thoughts about suicide, risk of diabetes or a life-threatening condition?

Parents and legal guardians make decisions about psychosocial therapy and medication treatment for children and adolescents every day. But who should give permission and sign informed consent?  What should parents, advocates, guardians be looking for or consider before signing informed consent? Is signing a form enough?  What about the child or teen - do they have a voice regarding their own treatment?
What is Informed Consent?
Psychiatric informed consent involves a parent or legal guardian giving permission for his/her child to undergo evaluation and treatment.  It is a process which partly involves receiving sufficient relevant information about the condition, prognosis, risks and benefits of treatment to be given and other types of treatment available. Informed consent is NOT simply a signed and dated form. Parents and guardian should expect informed consent to include:

  The purpose of the treatment
  • To address a specific condition or diagnosis?
  • To lessen symptoms?
  •  To change behaviors?
  The effects of treatment
  • How will you know if it is working?
  •  How long till you see an effect?
  Risks of treatment
  • Side effects of medications
  • Consequences of psychosocial treatment (e.g., therapy can be emotionally difficult)
  Risks of NO treatment
  • Will symptoms improve over time without treatment?
  • Will things get worse or lead to other consequences? (e.g., Untreated individuals are more likely to use substances, get into legal trouble)
  What alternative treatments are available?

For medication
  • Is it FDA approved for this age and condition? (i.e., prescribed FDA on label)
  • If it is prescribed off-label, why?
  • Are there any FDA warnings about the medication and what do they mean?
  • What is the plan for stopping or phasing out the medication?
     Parents and legal guardians are asked to give legal permission or informed consent for treatment.  If a child is in foster care, it may be the parent or it may be child welfare service or court that can give consent.   Where a child is living (home, out of home placement) does not tell you who the legal guardian is.  In some states an adolescent may give informed consent for psychiatric treatment depending on the state’s legislation about mental health procedures. Ideally the parents/guardians and the child should be involved in treatment decision making.

Children also have a voice in this process.  Children and youth should be involved in giving assent.  Assent involves providing the child or teen with information about the therapy or medication in terms appropriate to their age and stage of development. The assent process should include opportunities for the child/adolescent to ask questions and have their concerns addressed.

Gail A. Edelsohn, MD, MSPH, is senior medical officer with Community Care Behavioral Health, clinical professor of psychiatry and human behavior,  Jefferson Medical College, and clinical professor of psychiatry and behavioral science, Temple University School of Medicine.

Friday, January 2, 2015

The Power of Words: Addressing the Stigma of Mental Illness

Jenna Bowen, medical student, University of Wisconsin
Reviewed by Claudia Reardon, MD

Crazy.  Insane.  Deranged. Mad.  Lunatic. —Misused as nouns, adjectives and lay-diagnoses, their use perpetuates stereotypes of the wide variety of people who experience mental illness.
Maybe you know someone or, more likely, a number of people who experience depression, anxiety, bipolar disorder or other brain disorders.  According to the National Institute of Mental Health, 1 in 4 American adults and 1 in 5 American youth experience a form of mental illness every year. People with mental illness are teachers, accountants, neighbors, sisters, fathers and friends. Anyone you know could be experiencing mental illness, but afraid to come forward and be treated. Maybe that person is you.
People living with mental illness continue to have an identity that is beyond a diagnosis, similar to other medical conditions. While managing mental illness may be challenging at times—similar to challenges faced by people with diabetes, high blood pressure, or other medical illness— there is greater difficulty in getting the treatment needed because of feelings of shame and stigma surrounding mental illness. However, treatment for mental illness works. Research shows the majority (65 percent to 80 percent) of individuals with mental disorders will improve with appropriate treatment and ongoing monitoring. People with mental illness need to know that they will continue to be seen as people – your brother, best friend, daughter —and not “crazed” or “insane” if they appropriately seek help for a treatable medical condition that they happen to be experiencing.
Bring Change 2 Mind, an organization aimed to end stigma and discrimination surrounding mental illness, offers recommendations to reduce your impact on the stigma surrounding those with mental illness.
  • Use "person first" vocabulary. When we say a person is schizophrenic, we make their mental illness fully define their identity. Instead, be clear that this is a disease that individuals manage and live with— "He is living with schizophrenia."
  • Avoid the verb "suffers" when discussing mental illness. Instead, choose, "lives with mental illness" or "is affected by mental illness."
  • There are many phrases and terms; "crazy," "nuts", "psycho", "schizo", "retard" and "lunatic" that may seem insignificant, but really aren't.

Be an advocate for those that you know, and the many that you don’t know, who are living with some form of mental illness by breaking down stigma, and being conscious of language surrounding brain disordersTo learn more check out:
·         Bring Change 2 Mind
·         NAMI – Stigma Busters

Friday, December 5, 2014

Study highlights lack of access to mental health care

By Arshya Vahabzadeh,MD 

A new study from the CDC’s National Center for Health Statistics once again highlights that too many people living with mental health conditions are not getting needed care.

Study authors Laura A. Pratt, PhD, and Debra J. Brody, MPH, found that nearly 8% of Americans aged 12 and up had depression (moderate or severe depressive symptoms in the past 2 weeks). The rate of depression was twice as high among people living below the poverty level, 15%.

 Far more alarming, the study showed yet again that people with depression are going untreated. While nearly 90% of people with severe depressive symptoms reported difficulty with work, home, or social activities related to their symptoms, only about one-third (35.3%) had seen a mental health professional in the past year, according to the study. Among those with moderate depressive symptoms, only 1 in 5 had seen a mental health professional.

While there are many reasons people don’t get needed mental health care, including mental health stigma and lack of access, discrimination in mental health coverage by insurance companies shouldn’t be among the reasons. Federal law now requires that insurers cover mental health illnesses the same as physical ailments, such as heart disease, diabetes and cancer.

However, many people don’t know their rights when it comes to getting mental health treatment. To address this glaring problem, the American Psychiatric Association has released a new poster --
available to mental health professionals -- that explains in simple terms your rights under the law and what to do if you think your rights are being denied. Download a copy at

Tuesday, December 2, 2014

World AIDS Day

By Annelle Primm, MD, MPH

World AIDS Day
December 1, 2014
Focus, Partner, Achieve:  An AIDS-Free Generation

World AIDS Day is a key opportunity to raise awareness and to commemorate those who lost their lives to this often deadly disease. But, today, we can also be hopeful about achieving an AIDS-free generation.  Increased access to treatment, new and better prevention services and care, and advances in treatment are all reasons for hopefulness.  And that amounts to greater peace of mind.
An estimated 35 million people worldwide have HIV and more than 39 million people have died from the virus since the first cases in 1981. In the U.S., more than 1.2 million people live with HIV, but nearly 1 in 7 of those don’t know they have the virus.
An estimated 50,000 people in the U.S. are newly infected each year.  It’s why I continue to tell people the importance of getting tested.  There’s no shame, just a need for information.

What is the Connection Between HIV and Mental Health?
Mental and neurological disorders have an intertwined and often complex relationship with HIV and AIDS. Yet mental health issues are often overlooked in HIV interventions and treatment.

  • About 60% of people with HIV also have depression.  Sometimes one may be tempted to “blame” depression on their HIV status, but the reality is that depression can happen to anyone and treatment works
  • Pre-existing mental disorders (including substance use) can complicate HIV-related illness.  It’s important for physicians to know all they need to know about your health, and for you to be comfortable sharing  
  • Nearly 50% of people with HIV experience impaired motor skills, trouble with memory and poor concentration.  If you experience such changes, those are important to inform your doctor about
  • Mental illness can make it more difficult for people to adhere to HIV-medication regimens
  • New antiretroviral treatments and combination therapies can affect the central nervous system and/or have psychiatric side effects
  • Mental illnesses can be especially challenging to recognize and diagnose in people with HIV/AIDS.  That’s why the APA works to educate and provide tools and training to physicians.

Unfortunately, both HIV and mental illness still carry a significant burden of stigma and discrimination.

As HIV/AIDS increasingly becomes a chronic disorder with the improvement of treatments, the need for mental health care and services is rising.  World AIDS Day is also a day to recognize the many psychiatrists and other mental health clinicians working with HIV patients who also have complicated psychiatric or substance use comorbidities.

Looking for ways to take action?
  Here are a few simple, powerful, and engaging ways you can take action:

Annelle Primm, MD, MPH is the Deputy Medical Director of the American Psychiatric Association

Monday, November 10, 2014

Native Americans and Suicide

By Arshya Vahabzadeh, MD & Brad Zehring, DO

Mental illness does not discriminate - it affects every age, sex, religion, and ethnic group.

The Indian Health Service conducted a study in 2008 that noted that the rate of suicide for American Indians and Alaska Natives is higher than any ethnic group within the United States. The study reported that suicide in these populations is up to 70% higher, especially in ages 10 to 24. Sadly, this statistic is not decreasing. Mental health professionals and society need to recognize the etiology of the despair that leads to suicide so that treatment and appropriate allocation of resources can be made.

The statistics are alarming, but possibly more alarming is the silence around this tragedy. Since suicide is taboo on most reservations - there are reports that a death by suicide often is not reported or legal authorities classify it as an accident. Due to the silence and misrepresentation, the numbers could be even greater.

It is important to break the silence on the troubling trends within Native American reservations. Native Americans must be willing to discuss their stressors and be open to getting education necessary to cope, deal, and treat their stressors. Mental Health professionals must be willing to understand their culture and adapt. Alex Crosby, MD, MPH, medical epidemiologist of the CDC has been recorded as saying that Native American suicide is so prevalent that it has become acceptable practice when tensions build up. Suicide should never be an acceptable option.

Reasons for troubling trends among Native Americans
There are a lot of thoughts on why mental illness and suicide have increased in the Native American population. There has been a lot of discussion of generational trauma due to the disempowerment and oppression of Native Americans and Alaska Natives. It has been discussed that this has caused adverse childhood experiences that lead to high rates of depression and other mental illness that are precursors to suicide.

While disempowerment and oppression could very well be contributing factors - poverty seems to be a growing problem on reservations. Poverty tends to put stress on educational standards decreasing the educational opportunities for those on the reservation – leading to a viscous cycle. There are few jobs on the reservation causing adolescents and young adults to leave their families and move to where there are jobs. However, parents age and get ill causing tension between the traditional Native American family structures where youth takes care of the elderly and providing for the immediate family.

In addition to poverty, substance abuse is a big problem on the reservation. Substance abuse can affect mood, often negatively, which increases the tension and is a risk factor for suicide. Domestic violence and sexual assault are also known problems on the reservation. These stressors have led to unstable environments for children growing up. Add untreated mental illness to the mix and it is easy to see how hopelessness and despair thrive often leading to the belief that suicide is the only way out.

The Way Forward
Recently, the American Foundation for Suicide Prevention joined a Native American Mental Health panel sponsored by Congressional Native American Caucus and Center for Native American Youth. The panel focused on ways of improving mental health resources and suicide prevention. The IHS and the Substance Abuse and Mental Health Services Administration (SAMHSA) collaborated on targeted suicide prevention programs. The IHS established the Suicide Prevention Initiative and SAMHSA provided funding to the IHS to address youth suicide and provide suicide prevention for high-risk populations.

As we move forward as Mental Health professionals, it will be important to continue to collaborate with the Native American population, especially with Mental Health professionals with experience with the population and their culture. Understanding their culture and etiology of stressors will go a long way in providing the appropriate resources and treatment.
Resources for Help
In the US:
·         Suicide help
·         1-800-273-TALK

Outside the US:
·         International Association of Suicide Prevention (IASP)