UNDERSTANDING THE REAL COSTS OF DELAYING MENTAL HEALTH TREATMENT

One of the many reasons I love my work is that I have the honor and pleasure of seeing most of my clients get better. Do I have special skills that other mental health clinicians do not? No, my work simply mirrors the statistics on the efficacy of mental health treatment. Research shows that therapy is effective at least 80 percent of the time.

Since therapy usually helps, and no one wants to suffer, why are we our own worst enemies when it comes to getting help? Our tough inner critic tells us "you should be able to snap yourself out of this", or "you don't have it so bad, think about what Mary next door has been through", or "you need to help the kids, you're not as important." My wish for folks suffering from mental health challenges or family struggles is that they view mental health treatment as a tool that can help them move towards their future, not as a failure and a last resort.

Recently I have noticed an increase in the length of time clients are waiting to get themselves or their kids to treatment. My colleagues have shared the same observation with me. There are good reasons: financial challenges, increasingly spartan or absent insurance coverage, busy family schedules, and the still present stigma in our culture towards mental health treatment. The problem with delayed treatment is that it increases the likelihood of the development of a second mental health challenge, a substance abuse problem, and physical illness.

Not only does the client get worse if not getting help, but family members and co-workers are also sorely tested by caring for or working with a depressed, highly anxious, bi-polar or substance-involved individual. Many times the people that end up in my office have anxiety or depression that has been triggered by living or working with someone who has not sought help for their own challenges. Delays in getting help often leads to multiple family members in crisis. Jobs are lost, marriages fail, and academic careers stall.

The decision to see a therapist does not bind you to a never-ending series of weekly appointments. One of the important roles a trained therapist plays for you or your child is "assessment".  We evaluate a client's functioning in their environment: home, school, work, relationships, and community. We work with clients to collect data by interview, observation, surveys and test (psychologists) instruments. Thanks to the assessment process, clients can decide whether to enter the "therapy or treatment" phase of mental health treatment after gaining an understanding of their diagnosis and treatment options. After the assessment, I may recommend that a client meet with a psychiatrist, nutritionist, career counselor or life coach. Sometimes I work with parents to help them sort through parenting challenges without ever seeing the child.

The bottom line is that there may be much to gain by investing in a few visits. Unfortunately, waiting until you or your child are too sad to get out of bed in the morning, or your daily glass of wine has turned into a daily bottle, will likely cost more time and more money, and more importantly, needless suffering.

Let the Sunshine In

As a clinical social worker, I have observed firsthand the effects that vitamin D levels can have on mood.  The shorter days of Winter are tough on many people. Vitamin D- which our bodies make when exposed to the sun, is crucial for making hundreds of enzymes and protein and interacting with more than 2,000 genes vital for health and fighting disease- is in limited supply.  Vitamin D deficiency has been linked to chronic modern diseases such as heart disease, diabetes, cancer, osteoporosis, and depression. 

Several studies suggests that Vitamin D deficiency and depression are linked, and that increasing Vitamin D levels can help. We do not know whether low levels of vitamin D cause depression, worsen it, or are a symptom of the underlying depression. One study included  adult women with depression, all of whom were taking antidepressants. The women were also being treated for Type 2 Diabetes or an underactive thyroid gland. All were deficient in vitamin D, with levels under 21 ng/mL. Levels below 21 ng/mL are considered vitamin D deficient.  The women received vitamin D therapy for eight to 12 weeks. After treatment, their levels increased to 32 to 38 ng/mL. The women also reported improvements in symptoms of depression following vitamin D therapy. One woman's depression score changed from indicating a major depression to mild depression.  

I believe that many doctors and mental health professionals have had similar experiences with patients. I have had three clients who presented with major depression, tested below 10ng/ml in vitamin D, and after 10 weeks of receiving vitamin D supplements and weekly therapy, experienced a remission in their depression. Of course we can't measure how much improvement was caused by the increase in Vitamin D, and how much was caused by therapy.  My stance regarding treatment is to  use every helpful, healthy tool available to combat depression.

In addition to the clients who have suffered from major depression and had their Vitamin D levels tested, I have had many clients who have described and exhibited increased symptoms of depression in the late Fall and Winter. Seasonal Affective Disorder (SAD) is real, can be debilitating, and is prevalent when vitamin D stores are low.  In one study, eight subjects with SAD received 100,000 I.U. of vitamin D daily and all experienced a significant lessening of their depression as measured by the Hamilton Depression Inventory. Vitamin D blood levels improved by 74% in all eight subjects.  Vitamin D may be an important treatment for SAD. More, larger studies will be necessary to confirm these findings.

Vitamin D is called the sunshine vitamin because our bodies produce it when exposed to sunlight. Sunlight is an excellent source of vitamin D.  A person sitting outside in a bathing suit in New York City gets more vitamin D in 20 minutes than from drinking 200 glasses of milk.  Many experts suggest getting 10 to 15 minutes of sunshine sans sunscreen three times weekly.  Talk to your doctor about the pros and cons of sun exposure for you. 

Vitamin D is also added to milk and other foods, and is available in small amounts in fatty fish like tuna, salmon, and mackerel; beef liver, cheese, and egg yolks. It can be hard to get as much as we need from our diets, which is why supplements are often needed. Many, but not all, doctors include Vitamin D levels in their standard battery of blood tests when patients come in for a physical. Make sure you check with your doc if you are depressed, and request a blood test for Vitamin D levels. Your health depends on it.

Teens, Therapy and Privacy

Nervous about coming to therapy? 


Of course you are! That is a healthy and very common reaction. Why? You feel alone and vulnerable, and to top it off you are going to talk to a complete stranger about your personal life! You are entrusting the therapist with information that you may not have shared with your closest family members or friends.

Never fear;  therapists have a code of ethics which states that we must keep your private information to ourselves. There are only a few situations in which a therapist is obligated, by law, to break confidentiality:

1. You present a danger to self or others. If the therapist thinks you might hurt yourself or someone else, they need to tell your parent(s) and possibly others.

2. You are the victim of emotional, sexual or physical abuse or neglect.
In this case, the therapist may need to report the information you share to people who work to protect children. However, most therapists will tell you that they feel they need to do this to keep you safe before they make a call or file a report. In Connecticut, I  need to file a report with a state agency called the Department of Children and Families, and a social worker would then look into the situation, gather information, and make every effort to make sure you are protected from future abuse.

In the vast majority of experiences with clients, there is no need to break confidentiality. However, if it is essential to break confidentiality, I discuss my reasoning and next steps with clients before I do so.

Most of the time teens are understandably worried about less serious issues getting back to their parents- like relationship or school problems-  that they are not comfortable sharing with them.  Here's the good news: in many cases therapists do a great job of working with teens to help them decide if, when, and how to share sensitive information with parents. Two aspects of my work I find very rewarding are helping teens learn more helpful ways of thinking about problems, and teaching new approaches to talking to parents.

If you are working with a therapist or school counselor, you should and can check with them about confidentiality. Let them know what information you are not comfortable sharing with teachers, parents, or others.

If you have any questions or concerns about therapy and confidentiality, please ask, and I will be happy to answer them for you.

Be well,
Laura

Medicine, Therapy, or Both?

Twice yesterday clients asked good questions about medication, therapy, and how they relate to each other.

A new client, "Mr. X"*,  was prescribed an anti-depressant by his doctor for ongoing depression due to his wife's death several years ago.  He asked my opinion about anti-depressants. He was reluctant to take an anti-depressant, feeling that he should be able to "get over it" on his own.  Like many wise individuals, my client is concerned about his health, and does not want to ingest anything that could harm him. Although like all medications, anti-depressants can cause side-effects, for most people the benefits far outweigh the side effects. Furthermore, we live in an era when there are a number of effective medications for depression, and if the first medication you try leaves you with undesirable side effects, there is a good chance that the next one your doctor prescribes will not.

What I have observed is that for some clients, anti-depressants are a temporary bridge between depression and a return to being "yourself".  Many people who are depressed are bothered by cloudy thinking and/or circular, repetitive thoughts. In such a state, clients are not always able to use therapy to it's full potential. However, anti-depressants help many people return to their normal, logical thought process. When clients can think clearly, they are able to use techniques that they learn in therapy and apply them to their outside life. Once a client feels that they are functioning and feeling better, it is often possible to gradually discontinue anti-depressants. Contrary to what some believe, anti-depressants are not addictive, but discontinuation absolutely needs to be monitored by a qualified physician.

"Bridge the Gap" between medicine and therapy

At this point you may be wondering if I am in the back pocket of a pharmaceutical firm. Absolutely not. I cannot prescribe medication. In fact, I always work with a client on natural stress reducing and mood boosting techniques before making a referral for a medication evaluation.  However, in some situations, the ongoing stress of a death, job loss, or family problems can wear people down to the point where their brain chemistry needs stronger support- ie-medication.

Many well-done independent studies have been done to research what the best treatment is for depression. The results are consistent: many people get better from therapy, many people get better from anti-depressants, but the most effective, quickest way to feel better is through a COMBINATION of medication and therapy. 

Regardless of what "Mr. X" decides regarding medication, I look forward to working with him to help him find his unique path to healing.

Be well,

Laura

 *Details changed to protect client's anonymity.