Wednesday, July 16, 2014

Diversity Mental Health Month: Why It is Needed and How It Came to Be

By Steve Koh, MD, MPH, MBA

July of 2014 is the very first APA Diversity Mental Health Month. This emphasis on mental health needs of diverse populations is much needed. While we have diversity oriented month observances for specific population groups like the Black History Month (February), National Women’s History Month (March), Asian Pacific American Heritage Month (May), Gay and Lesbian Pride Month (June), American Indian Heritage Month (August), and Hispanic Heritage Month (September), we have not had a dedicated month more broadly addressing diverse populations and mental health issues.

I cannot overemphasize the importance of this month. For the first time, together, we will bring attention to the unique and challenging needs of the diverse populations with mental illness and substance use disorders, work to decrease mental health disparities, and engage with diverse populations to help promote and grow future mental health champions in the communities.

The concept for Diversity Mental Health Month came from a group of participants in APA’s Minority Fellowship program.  The program’s goal is to eliminate racial and ethnic disparities in mental health and substance abuse care by providing specialized training and mentorship. The fellowship fosters those with diverse backgrounds who have chosen to become physicians specializing in mental health and to do this work with the diverse populations.  

But what happens when we go home? What then? We felt that it was easy to get lost when we left our APA meetings in Washington DC. How do we galvanize our colleagues at home to look at the importance of minority mental health issues? To recognize the stigma of being an ethnic and cultural minority and also suffering mental illness? To understand that many minority students do not consider going into field of medicine let alone mental health profession? To appreciate the importance of cultural competency and humility in working with diverse patient population?

Without involvement a coordinated effort by the APA, it was our belief that while we personally benefited from the fellowship experience, our impact would be limited. There needed to be a designated time for all of APA to bring attention to this important patient population.  So the idea was born to create a Diversity Mental Health Month. The APA Assembly asked APA staff to help create a month designated to minority mental health issues and for the APA to actively promote the month.

I hope that others are excited about this new endeavor of the APA as I am. The challenges are great but together we can bring the needed attention to this area of our profession.

Many resources, including an infographic with basic data on mental health disparities, and brochures and fact sheets on specific populations, suggested activities, video messages, and more, are available at




Wednesday, July 2, 2014

Depression & Cancer

By Brad Zehring, DO @DrZehringDO

“Cancer can take away all of my physical abilities. It cannot touch my mind, it cannot touch my heart, and it cannot touch my soul”  - Jim Valvano

But, what happens when it does?

Depression is a multifactorial disorder that requires acknowledgement of the biological, psychological, and social aspects of a person’s life. Professionals in the mental health community describe this as the biopsychosocial model. It provides an understanding of the factors influencing a person’s mental and physical state of being.

When mental health professionals talk about depression they often do so in regards to Major Depressive Disorder (MDD). According to DSM 5 (Diagnostic and Statistical Manual of Mental Disorders), 5 out of 9 criteria are needed to diagnose MDD. It requires a depressed mood or anhedonia (lack of enjoying what was previously enjoyed) for greater than 2 weeks including: disturbances in sleep, guilty/hopeless/worthless feelings, poor concentration, low energy, changes in appetite (weight loss or weight gain), psychomotor agitation or retardation, and suicidal ideation.
Depression affects your entire body. But, the physical aspects of depression are often overlooked. It is common for people with depression to experience weight changes, digestive problems, headaches, back pain, muscle and joint pain, and disruptions in sleep cycle. Many symptoms that are present in cancer.

Depression has been linked with many health problems, including cancer. Cancer is a heavy word. The enormity of the word brings many images to the forefront of our imagination: radiation, chemotherapy, losing hair, sickness, weakness, and death - among others. There is so much symptom overlap between cancer and depression it can be hard to recognize the etiology of the symptoms.

It is important that health care professionals, family members, and other caretakers are vigilant with a person’s mental well being after they are diagnosed with cancer. Even if a person has never experienced depression previously, their risk of depression is increased when they find out they have cancer. Research shows that the incidence of depression increases proportionately with the cancer’s progression. It is believed those with depression have increased likelihood of depression because of increased immune response (cytokines) within the body.

It is important not to assume that someone with cancer has an appropriate depressed mood due to his or her circumstances.  This is why it is important to screen for depression in those diagnosed with cancer. Screening for depression can help “tease out” symptoms related to depression and symptoms related to the cancer. Treating depression in patients with cancer can help them focus on their treatment and have the motivation to do everything needed to possibly achieve remission. Proper treatment gives them the ability to focus on their future. Cancer alone is enough, but when combined with untreated depression the results can be deadly.

After recognizing depression in someone with cancer, there are ways to treat depression in parallel with cancer treatment. There are two forms of treatment. One involves medication and the other involves psychotherapy, or talk therapy. The typical medications for depression are antidepressants like Selective Serotonin Reuptake Inhibitors (SSRI) and Serotonin and Norepinephrine Reuptake Inhibitors (SNRI). These medications have been around for a long time and are generally well tolerated. They take anywhere from 2-6 weeks for clinical efficacy. These medications should be monitored with cancer treatment, as there can be drug interactions and side effects that may not be present in someone taking these medications without cancer. In addition to medications, psychotherapy can be effective. More specifically, Cognitive Behavioral Therapy (CBT) can help people change their negative thoughts about cancer and their future. For the most efficacious treatment a combination of both should be implemented.

Cancer is a serious illness and a well-developed multi-disciplinary approach is necessary to best treat the patient. Cancer can cause a lot of different disturbances in physical and mental health. It is important to have health professionals, like psychiatrists and psychologists, part of the treatment team to ensure proper treatment of the whole patient.

Wednesday, May 28, 2014

Telemedicine, Here I Come!

By Hind Benjelloun, MD @hbenjelloun 

My decision to pursue a career in telemedicine was a long process. I had a comfortable, stable clinical position at a highly regarded academic center in a lively city. But I kept wondering if my career needed a boost. I found myself thinking, career development takes risk. Medicine is an ever-changing and growing field. I felt that I had to embrace some changes myself if I wanted to keep up.

Telemedicine is a relatively new discipline. The idea of incorporating health care with technology, specifically the web, may have some rolling their eyes or shaking their heads. But, simply put, it is the future of healthcare; and it is certainly getting the buzz these days.

The American Telemedicine Association is rapidly growing and developing its services and its role in healthcare. Many medical and scientific organizations are recognizing the importance of the discipline as well. You can see it reflected in the number of publications, conference seminars, and available CME. Tech gurus are predicting that the recent acquisition of Oculus by Facebook will be a game changer in the tech industry and will further grow telemedicine’s influence.

So I took the plunge into a field in its infancy. I went for it.  Telepsychiatry! After almost ten years at Georgetown University Medical Center, I drastically shifted gears to pursue a full time career in crisis telepsychiatry.

In this career change, I have been labeled a pioneer among colleagues and friends. It feels wonderful to immerse myself in such an innovative healthcare movement. My healthy narcissism embraces it and it strengthens my confidence in what some may call a risky career decision. Today, telepsychiatry is revolutionary in the way it enhances access to care. And although right now telepsychiatry is primarily seen as a means of engaging the rural patient population, it will progress in the medical community as a future medical norm. The evidence is growing and continues to demonstrate the boom of telemedicine and its success.
Still, taking the leap into telepsychiatry had its downsides.

Because of its youth, telemedicine lacks a number of accessible mentors who can guide the process. There are few clinicians who have an “institutional” knowledge of telemedicine to share. This means that other than the anecdotal accounts that you may read in a journal or blog post about what it’s like to venture into the world of telemedicine as a provider, there aren’t many reputable sources to turn to.  I had trouble knowing what to expect.

I started working with InSight, a national telepsychiatry provider company earlier this year. As a crisis telepsychiatrist with InSight, I have the ability to seamlessly transition between seeing patients at multiple hospitals in multiple states back to back. Today, I love my job. But the legislative hurdles I had to jump through to get going were a major headache.

I was completely committed to offering services right away when I made the decision to start practicing telepsychiatry. I was ready to go. But I had no idea what kind of challenges I would encounter as I attempted to receive licensing from medical boards that all work independently of each other.

After the first hurdle of becoming licensed, I thought I had passed the finish line. But to my surprise, I was back to waiting on privileges from hospitals that were scrutinizing my immunization records and testing my knowledge of their fire code. This all seems so frivolous and a waste of time, effort and money. Didn’t they understand that I would be seeing patients remotely?

When I finally began working with a regular schedule, I found myself asking, why did it take so long for me to be able to actually see patients and provide care?

The answer lies in legislation. The laws and regulations in place for telemedicine are significantly outdated. Why is my medical license in one state insufficient in another? Big changes are needed to reflect the advent of technology’s integration into medicine. And when it comes down to it, it’s the patients who suffer from these outdated practices the most.

The shortage of psychiatric prescribers, as well as other types of providers in the United States is a growing problem. Telemedicine is an important way of addressing that shortage with the providers we already have.

Thankfully, there is yet hope. The Federation of State Medical Boards (FSMB) has recognized this unnecessary obstacle to patient care and the strain inflicted on telemedicine as an industry.  At its annual meeting at the end of April, the FSBM will vote on adopting the federation’s Interstate Medical Licensure Compact, a licensing option that would allow qualified physicians to expedite licensure in all states who participate in the Compact. Telemedicine as a field of practice would be transformed dramatically with the adoption of the Compact. Fingers crossed.

I am enthusiastic about potential for growth of telepsychiatry and telemedicine. But I believe providers must take an active role in pioneering this new form of care, and pushing for its successful implementation for the people who need it—our patients.

Bottom line—we are in this for our patients, and it is our patients who will benefit the most from telemedicine and a successful reevaluation of the legislation that regulates it.

Wednesday, March 12, 2014

How Psychotherapy Changes the Brain

By Serina Deen, MDMPH

When I first see patients for evaluation, they often tell me that they’ve debated starting a “biological” treatment such as medication, versus a “psychological” treatment such as psychotherapy. I’m happy to report that as brain imaging technology advances, we’re finding that this distinction may be obsolete. 

Psychotherapy is also “biological” in that it can lead to real functional and structural changes in the brain.   In fact, sometimes psychotherapy and medication produce surprisingly similar changes in the brain.  We still have a lot to learn about the topic, but below are some examples of what researchers have been finding so far.
Functional Changes in the Brain:
In one study, researchers at UCLA found that people who suffered from depression had abnormally high activity in an area of the brain called the prefrontal cortex.  Those who got better after they were treated with a type of therapy called interpersonal therapy (IPT) showed a decrease in activity in the prefrontal cortex after treatment.  In other words, IPT seemed to “normalize” brain activity in this hyperactive region.

Another study looked at people who have obsessive compulsive disorder (OCD), who tend to have an overactive area of the brain called the caudate nucleus.  Treatment with a type of therapy called cognitive behavior therapy (CBT) was associated with a decrease in the hyperactivity of the caudate nucleus, and the effect was most evident in people who had a good response to CBT.  In other words, the better the therapy seemed to work, the more the brain activity changed.
Changes in Brain Volume:
People with chronic fatigue syndrome (CFS) suffer from debilitating fatigue.  People with CFS tend to have a decrease in a type of brain tissue called grey matter in the prefrontal cortex of the brain.  Researchers in the Netherlands gave people with CFS 16 sessions of CBT, and found significant increases in gray matter volume in the prefrontal cortex.  This seems to suggest that the CFS patients were able to “recover” some gray matter volume after CBT.
Similarities and Differences to Medications
Psychotherapy sometimes seems to work in similar ways as medications, and other times appears to have different mechanisms of action.
In the study mentioned previously about people with depression, both IPT and the antidepressant paroxetine (Paxil) showed a decrease in prefrontal cortex activity.  And with OCD patients, both CBT and the antidepressant fluoxetine (Prozac) produced similar decreases in activity in the caudate nucleus. 
However in a different study, the antidepressant Venlafaxine (Effexor) produced changes in different parts of the brain than IPT in depressed patients.  This shows that there is variability in how different treatments work in the brain.
How Psychotherapy Produces Brain Change
We now know that the brain keeps changing, even after we become adults.  Learning leads to the production of new proteins, which in turn can change connectivity in our brains in a process called neuroplasticity.   Indeed, researchers in Germany showed that certain neurochemicals involved in neuroplasticity increased in depressed patients who got better after a course of interpersonal therapy. 

Picking a Treatment that Works Best for You
Even though we know that both medication and psychotherapy can change our brain, we still have a long way to go in learning exactly how that happens and when to use what treatment. Given a specific mental illness, sometimes medications work best, sometimes psychotherapies are the best option, and sometimes it’s a combination of the two.  In addition, there are different types of psychotherapies that work for different illnesses, just as there are many different types of medications.  If you’re considering seeking help for mental illness, it would be helpful to talk with a trained professional about what would work best for you. 

Read tips on what to expect during your first visit with a psychiatrist  
"Let's Talk Facts" brochure on Psychotherapy
Brain Awareness blog post from NIMH Director Tom Insel, MD

Six tips for talking to your doctor about medication

For more information about psychotherapy

Wednesday, February 5, 2014

Effective Addiction Treatments are Available

By John Renner, MD and Frances Levin, MD

We are all saddened by the death of Philip Seymour Hoffman and the many other individuals who have died because of overdoses of heroin or pain medications.  For all of those individuals who struggle with opioid use problems, it is important to realize that help is available and that effective treatment can restore them to productive lives.  Some 4.7 million people in the U.S. have used heroin at least once in their lives.  It is estimated that nearly a quarter of people that use heroin become dependent on it.

Whether it be through mutual support programs such as NA, long-term residential treatment, or addiction pharmacotherapy with buprenorphine, methadone or ER naltrexone, no individual need fear that their condition cannot be treated.  Friends and family members also need to be educated in the use of intra-nasal naloxone for the reversal of opioid overdoses.  

APA has long fostered the development of addiction focused training
programs for psychiatrists.  Many psychiatrists have been specifically trained to provide office-based addiction pharmacotherapy and to manage the co-occurring psychiatric disorders that often complicate recovery from substance use disorders.  

More information:
·         Information on addiction
·         Opioid Overdose Prevention Toolkit (SAMHSA)
·         Substance use treatment locator (SAMHSA)
·         Buprenorphine Physician and Treatment locator (SAMHSA)
·         For psychiatrists:  Providers Clinical Support System for Medication Assisted Treatment

Blog contributors:

John Renner, MD
Member, APA Council on Addicition Psychiatry (Past Chair)
Director of Addiction Fellowship Program,

Professor of Psychiatry,  Boston University School of Medicine
Associate Chief of Psychiatry, VA Boston Healthcare System

Frances Levin, MD
Chair, APA Council on Addiction Psychiatry
Kennedy-Leavy Professor of Psychiatry, Columbia University Medical Center
Director, Addiction Psychiatry Fellowship,
New York Presbyterian Hospital
New York State Psychiatric Institute