End of Treatment Outcomes for Patients with Mood Disorders (2009 – 2017)

Description of the Sample

This analysis includes all patients with a primary diagnosis of a mood disorder who participated in an evaluation followed by a minimum of one therapy session with me between the start of my practice in 2009 and spring 2017.  Given that this is an analysis of end of treatment outcomes, patients who are currently in treatment with me were not included in this sample.

The sample includes 34 individuals (29 females and 5 males) who ranged in age from 12 – 59 years old, with a median age of 20.  The majority of patients in this sample (65%) had a primary diagnosis of Major Depressive Disorder.   Other primary diagnoses included Unspecified Depressive Disorder, Bipolar Disorder, Mood Disorder Not Otherwise Specified, and Persistent Depressive Disorder (formerly known as Dysthymia).

More than half of these patients (56%) had a secondary diagnosis.  The most common secondary diagnoses were anxiety disorders. Other secondary diagnoses in this sample included ADHD, eating disorders, and PTSD.

Approximately 30% of the sample had a history of psychiatric hospitalization, most commonly for suicide attempts or suicidal ideation, prior to staring treatment with me.

Description of Treatment Received

The length of treatment varied dramatically, from one week to 3.7 years.  Number of sessions attended also varied dramatically, from 1 session to 135 sessions.  The broad range of treatment duration and sessions attended reflects the reality that some individuals decided not to proceed with treatment after one or two sessions, whereas other individuals attended sessions off and on, as needed, for the duration of their high school or college years.  The average duration of treatment was 11.9 months and the average number of sessions attended was 28.  So, a typical patient with a mood disorder attended approximately 28 sessions over the course of one year.

The type of treatment received was tailored to the individual patient, based on his or her presenting symptoms, circumstances, age, and preferences.  Forty-one percent of patients received Cognitive-Behavioral Therapy (CBT), 18% received a Dialectical Behavior Therapy (DBT) skills-based approach (NOT a comprehensive DBT program), 30% received integration of CBT and supportive counseling, and 11% interpersonal psychotherapy or supportive counseling.

Level of family involvement varied depending on the patient’s age, presenting symptoms, preferences, and living circumstances.  For the purposes of this assessment, high level of family involvement means that at least one family member attended all or most sessions with the patient.  Moderate level of family involvement means that family members attended some sessions and maintained ongoing communication with me throughout treatment.   Low level of family involvement means that at a family member was involved in the evaluation and/or at least one session, but most sessions were individual.  Among all patients in this sample, 18% had a high level of family involvement, 21% had a moderate level of family involvement, 18% had a low level of family involvement, and 44% had no family involvement.  Degree of family involvement was higher, in general, for adolescent patients than for adult patients, with all patients under age 18 having at least some family involvement in their treatment.  Fifty percent of adolescent patients (under age 18) had a high level of family involvement, while 42% had a moderate level of family involvement and the remaining 8% had a low level of family involvement.

Nearly ¾ of patients saw a psychiatrist and took psychotropic medications during treatment.  Nearly ¼ of patients were hospitalized during treatment, most commonly for suicidal ideation or suicidal gestures.

Treatment Completion and Recovery Rates

Of all patients who began treatment with me for a mood disorder, 15% achieved complete recovery, 24% made significant progress, 41% made some progress, 15% made no progress, and 6% regressed.  For a detailed description of what terms such as “complete recovery” and “significant progress” mean, please see this blog post from 2013.

Eighteen percent of patients completed a full course of treatment with me.  Completing a “full course of treatment” was defined as a mutual ending in which the patient, his/her family (in cases where family was involved) and I mutually agree that treatment goals have been met and treatment is no longer needed.  Of these “treatment completers,” 83% achieved full recovery and the remaining 17% made significant progress towards treatment goals.

The length of time required to complete a full course of treatment varied dramatically from person to person, depending on symptom severity and progress in treatment.  Time required to complete treatment ranged from 1 month to 3 years, with a mean of 16.6 months.  Likewise, number of sessions required to complete treatment varied dramatically between individuals.  Number of sessions attended for treatment completers ranged from 4 – 96 sessions, with an average of 23 sessions.  So, on average, individuals who were most successful in treatment (e.g., those who completed treatment and achieved full remission from their mood disorders) attended an average of 23 sessions over the course of 16 months.

Fifteen percent of patients moved to another geographic location during their treatment (either to attend college or to live elsewhere permanently), prior to completing a full course of treatment with me.  As of their last session with me, 60% of these “movers” had made significant progress in their treatment and the remaining 40% had made some progress.  These individuals were referred to other treatment providers in near their universities or new homes for continued treatment.

The dropout rate for patients with mood disorders was fairly high: 50% of patients discontinued treatment with me prematurely.  As of their last session with me, 18% of these “discontinuers” had made significant progress towards treatment goals, 59% had made some progress, and 24% had made no progress.   On average, individuals who discontinued treatment sooner made less progress, while those who remained in treatment longer made more progress towards their treatment goals.   Three quarters of the individuals who made no progress dropped out of treatment after just one or two sessions, and the remaining one quarter dropped out after 5 sessions.  In contrast, those who made significant progress prior to dropping out of treatment attended an average of 20 sessions.

I do not have data on what happens to patients after they discontinue treatment, so this is purely speculation, but I believe several factors contribute to the high dropout rate among patients with mood disorders.  First, depression frequently interferes with a person’s motivation and ability to carry out tasks, and tends to make people hopeless and pessimistic.  Individuals with these symptoms may have a more difficult time persisting towards a goal, such as scheduling appointments and continuing with treatment over a number of months, and they may feel less hopeful about having a positive outcome in treatment.  Second, some patients and families may be satisfied with “good enough,” and may drop out of treatment after making good progress but before achieving all treatment goals.  In contrast, I have high standards for my patients: I believe that full recovery is possible for most people, and when full recovery does not seem achievable, then a full and meaningful life with well-managed symptoms is an alternative good outcome.  I work diligently with patients and their families in pursuit of these goals.

Eighteen percent of patients with mood disorders were referred to other clinicians who could better meet their needs.  I made these referrals when a patient was not progressing in treatment, and when it did not appear likely that they would make progress in the near future.  As of their last session with me, 17% of referred patients had made significant progress, 33% had made some progress, 17% had made no progress, and 33% had regressed.

Predictors of Treatment Outcome

Not surprisingly, completion of a full course of treatment emerged as a strong predictor of positive treatment outcome.  83% of individuals who completed treatment achieved full recovery, while the remaining 17% made significant progress towards treatment goals.  None of the individuals who discontinued treatment prematurely achieved full recovery.

Another strong predictor of positive treatment outcome in this sample was referral source.  Eighty percent of individuals who achieved full recovery were self-referred (e.g., they found my practice through an online search), while the remaining 20% were referred by word of mouth (e.g., by a friend).    In contrast, none of the individuals who were referred to my practice by their psychiatrist, pediatrician, or another therapist completed a full course of treatment or achieved full recovery, although a number of them made significant progress.  My interpretation of this finding is that individuals who proactively sought my services of their own volition may be especially dedicated to improving their mental health, more invested in their treatment, and thus more likely to persevere through a full course of treatment and achieve recovery.   In the case of self-referred adolescents, their parents were the ones who actually brought their children to treatment.  These parents, on the whole, were particularly attuned to their child’s needs and struggles, researched their child’s symptoms and the variety of treatment approaches available, sought my services proactively, and were especially motivated to help their child recover.  Perhaps this parental conscientiousness, attunement, and empowerment helped facilitate recovery for their children.

Level of family involvement in treatment predicted treatment completion and full recovery for adolescent patients but not for adult patients.  All of the adolescents who completed treatment and recovered had moderate or high levels of family involvement.  In contrast, 75% of the adults who completed treatment and achieved full recovery had no family involvement in their treatment, while the remaining 25% had a low level of family involvement.

Individuals who took psychotropic medication were somewhat less likely to recover than those who did not: 40% of individuals who achieved full recovery were taking medication during treatment, whereas 76% of individuals who did not achieve full recovery were taking medication during treatment.  It is unlikely that taking psychotropic medication caused patients to have a worse outcome.  I believe the most likely explanation for this finding is that taking psychotropic medication is a marker of severity: individuals with more severe forms of mood disorders (e.g., Bipolar Disorder, Severe Recurrent Major Depressive Disorder) are more likely to need medication and are perhaps less likely to achieve complete remission of symptoms.

Hospitalization during treatment emerged as a predictor of less favorable outcome.  None of the individuals who were hospitalized during their treatment with me completed a full course of treatment or achieved full recovery.  It is unlikely that being hospitalized actually caused patients to quit treatment or caused them to make less progress in their treatment.  It is more likely that hospitalization, like taking psychotropic medication, is a marker of severity, and those individuals with more severe illnesses are less likely to experience complete remission of symptoms.

The following variables did NOT predict treatment outcome: age, gender, ethnicity, duration of illness, diagnosis, presence of co-morbid diagnoses, rate paid for services, type of treatment received, or history of hospitalization prior to starting treatment.

End of Treatment Outcomes for Patients with Mood Disorders

Since opening my practice in 2009, I have evaluated 30 patients with mood disorders. Former patients who attended at least one treatment session with me following their evaluation were included in this sample. Patients who are currently in treatment with me were not included in this sample. As you read, please bear in mind that these data are specific to my practice and my patients, and should not be generalized to other therapists or other patient populations.

The 21 patients in this sample had a range of different mood disorder diagnoses. The most common diagnosis was Major Depressive Disorder (43%; n = 9). Other mood disorder diagnoses included Mood Disorder Not Otherwise Specified (19%; n = 4), Depressive Disorder Not Otherwise Specified (14%; n = 3), Bipolar Disorder (14%; n = 3), and Dysthymia (10%; n = 2). Approximately one quarter of the sample (24%) was male.

Patients ranged in age from 12 to 59, with a median age of 21. Most of these patients had been suffering from their mood disorder for years before beginning treatment with me, and most had received some sort of psychological or psychiatric treatment in the past. Duration of illness prior to intake ranged from 1 month to 35 years, with an average duration of 8.4 years. These figures reflect the length of time since symptoms began, which is usually substantially earlier than diagnosis.

Many mood disorders, such as Major Depressive Disorder and Bipolar Disorder, tend to be episodic, characterized by periods of remission and periods of relapse. Thus, the “duration of illness prior to treatment” figures reflect the total length of time from the onset of first symptoms to the initial session with me. Many patients had periods of mild or absent symptoms and good functioning in between mood disorder episodes.

Most of the patients in this sample had relatively severe forms of mood disorders. Thirty-eight percent of them (n = 8) had been hospitalized for a suicide attempt, suicidal gesture, or related psychiatric issue prior to beginning treatment with me, and many of these individuals had been hospitalized multiple times. Fourteen percent of patients (n = 3) had to be hospitalized during the course of their treatment with me.

This sample was ethnically diverse, comprised of 43% White Hispanic, 43% White Non-Hispanic, 10% multi-racial, and 4% Black Hispanic. The majority of patients in this sample (86%; n = 18) paid a reduced fee for my services; only 14% (n = 3) paid my full rate. Thus, most of these patients were of lower socio-economic status and/or were college students responsible for supporting themselves.

Approximately half of the sample (52%; n = 11) had a comorbid psychiatric disorder. The most common comorbid diagnoses were Anxiety Disorder Not Otherwise Specified (14%; n = 3) and Eating Disorder Not Otherwise Specified (14%; n = 3).

The patients in this sample received various types of treatment, depending on their age and symptoms. Nearly half of the patients in this sample (48%; n = 10) received Cognitive-Behavioral Therapy (CBT). Patients whose illnesses were characterized by impulsivity and self-harm received a Dialectical Behavior Therapy (DBT) skills-based approach (38%; n = 8). Patients with milder symptoms and social difficulties received supportive counseling focused on self-care and interpersonal relationships (14%; n = 3). Sixty-two percent of patients (n = 13) were also seeing a psychiatrist and taking psychotropic medication during their treatment with me.

The level of family involvement in a patient’s treatment varied based upon his or her age, symptoms, and preferences as well as logistics. In this sample, 43% (n = 9) of patients had no family involvement, 19% (n = 4) had a low level of family involvement, 19% (n = 4) had a moderate level of family involvement, and 19% (n = 4) had a high level of family involvement.

I require the parents of all patients under 18 to be fully informed and actively involved in their child’s treatment. Therefore, all patients under 18 in this sample had moderate to high degrees of family involvement in treatment. This means that the patient’s parents participated fully in the evaluation and treatment planning, and participated in a portion of most therapy sessions (e.g., the last 10 minutes of each session) for the purposes of providing feedback, setting goals, and evaluating progress. These parents also had regular access to me via phone and email for the purpose of sharing information about their child and asking questions. For patients over age 18, family members were involved as appropriate, as needed, and as requested by the patient. For example, many college-aged patients had parents involved in their treatment, particularly when it came to issues of psychiatric consultation and hospitalization.

Patients in this sample attended between 1 and 96 sessions, with a mean of 19 sessions. Duration of treatment ranged from 1 month and 39 months, with a mean duration of 7 months. In other words, the typical mood disorder patient attended 19 sessions over the course of 7 months.

Twenty-nine percent of patients (n = 6) completed treatment and 38% (n = 8) quit treatment prematurely. I referred twenty-four percent of patients (n = 5) to other treatment providers who could better meet their needs, and 9% of patients (n = 2) moved to other geographic locations during their treatment and were referred to other providers near their new homes.

Patients who completed treatment attended between 1 and 96 sessions, with an average of 23 sessions. Duration of treatment for those who completed treatment ranged from 1 to 39 months, with an average duration of 11 months. Thus, it typically took approximately 23 sessions over the course of 11 months to complete treatment.

Each patient was given an end-of-treatment rating which describes their state as of their final session with me, regardless of the reason why treatment ended.

• Patients were classified as being in “full remission” if they had not experienced any symptoms of their mood disorder within the past two weeks, and their social / occupational / academic functioning were good.

• Patients were classified as having made “significant progress” if their mood disorder symptoms over the past two weeks were substantially less severe, less frequent, and less intense than at intake, but were still occurring, and their social / occupational / academic functioning were relatively good.

• Patients were classified as having made “some progress” if their symptoms over the past two weeks were somewhat less severe and less frequent than at intake, and if their social / occupational / academic functioning were fair.

• Patients were classified as having made “no progress” if the frequency, intensity, and duration of symptoms had not improved since intake, and social / occupational / academic functioning had not improved since intake.

• Patients were classified as “regressed” if their symptoms over the past two weeks were more severe or more frequent than at intake and their social / occupational / academic functioning had declined since intake.

Of the patients who completed treatment, 83% (n = 5) achieved full remission from their mood disorder and 17% (n = 1) made significant progress. Of the patients who quit treatment prematurely, 25% (n = 2) had made significant progress by their last session with me, 63% (n = 5) had made some progress, and 12% (n = 1) had made no progress. Among the patients whom I referred to other providers, 40% (n = 2) regressed during their treatment with me, 20% (n = 1) made no progress (n = 1), 20% (n = 1) made some progress, and 20% (n = 1) made significant progress.

In my next post, I will discuss factors that are correlated with treatment completion and good outcome in these mood disorder patients.

Leaving the Nest: 10 Tips for Parents

It’s back to school time! A new crop of 18-year-olds are leaving home to begin pseudo-independent lives in college. This is the time of year when my inbox is flooded with emails from other clinicians who are using professional list-serves to assemble treatment teams for their patients who are going off to universities in other cities or states.

“Looking for psychologist and psychiatrist in Atlanta for student entering freshman year at Emory. Bipolar disorder diagnosed in February 2011; has been stable on new meds since suicide attempt in June. Patient is very insightful but needs close monitoring.”

“Need treatment team in Boston for incoming freshman at Boston University with 4 year history of bulimia and major depression. Weight is normal but patient engages in binge/purge symptoms 3-4 times per week. Patient has delightful personality but is very entrenched in ED symptoms.”

“20-year-old patient with anorexia nervosa, social anxiety, and OCD just released from our day treatment program needs multidisciplinary treatment team in Chicago as she returns for her junior year at Northwestern University. Patient was discharged at 90% of ideal body weight and is compliant with meal plan. Needs nutritionist, psychologist, psychiatrist, and internist familiar with EDs.”

“23-year-old patient with major depression and alcoholism is entering graduate school at UMass Amherst and needs treatment team. Has 2 months sobriety.”

As I read vignettes such as these, I can’t help but wonder whether it is in the best interest of these vulnerable young people to be away at college. Adjectives like “compliant” and “insightful” and “delightful” seem to be inserted to justify the decision to send the patient away to school and/or to entice clinicians to take on these challenging cases. Qualifiers like “2 months sober” and “90% of ideal body weight” do nothing to quell my apprehension. Frankly, they frighten me more.

Let me be frank: a psychiatric diagnosis is a game changer. Any artificial deadlines, such as an 18th birthday or the start of the school year, are irrelevant. Psychiatric disorders are serious, potentially disabling (think major depression, which is a leading cause of lost productivity in the workplace), even deadly (think anorexia nervosa, which carries a 20% mortality rate). Individuals with psychiatric diagnoses can and do recover and go on to lead productive, fulfilling lives, but this requires prompt, effective treatment and a supportive, low-stress environment for a sustained period of time.

The transition to college presents numerous challenges to even the healthiest and most well-adjusted young people: leaving their hometown, family, and friends; living independently in a different city or state; adjusting to dorm life; navigating new peer relationships and social pressures; managing one’s time and money; choosing a career path and taking academically rigorous courses; assuming full responsibility for nutritional intake, sleep schedule, physical activity, and medical care.

Let’s face it: the typical college lifestyle does not promote physical or mental health. Late nights spent studying or partying, daytime napping, chronic sleep deprivation, erratic eating habits consisting mostly of processed snacks and caffeinated beverages in lieu of balanced meals. Most college students drink alcohol socially, and many drink to excess multiple times a week. Widespread use of illicit drugs as well as rampant abuse of black market prescription drugs as study aids (e.g. Adderall) or sleep aids (e.g., Xanax) is a mainstay of university life. Casual sex with multiple partners, often unprotected and usually under the influence of alcohol, is the norm on most campuses.

Navigating these challenges successfully requires a certain level of mental and emotional stability. Maintaining good self-care in an environment where virtually everyone else practices unhealthy habits requires a maturity and strength of character that is beyond the reach of most 18, 19, and 20 year olds.

I have treated patients before, during, and after college, and have counseled their parents throughout this process. I worked at three different university counseling centers during my doctoral training. During that time I worked with dozens of students struggling with psychiatric illnesses and gained an intimate understanding of what universities do, and don’t do, to support students with mental health problems.

Now, as a psychologist in private practice near two large universities, I treat a number of college students as well as high-school students who hope to go away to college in the near future. I also have a few patients who had attempted to go away to college in the past, but experienced a worsening of symptoms, a full-blown relapse, or in some cases life-threatening complications which rendered them unable to live independently. These are young people who have returned home to the safety of their families and are now going through treatment to repair the damage with hopes of living independently in the future.

I have developed the following professional recommendations for parents of young people with psychiatric illnesses based on these clinical experiences as well as the latest scientific research:

1.) If your child is a junior or senior in high school and hopes to go away to college in the future, begin working with her and her treatment team now to establish criteria to assess her readiness for going away to college. I recommend collaboratively establishing a written plan which includes specific, measurable criteria which the child must meet before she is permitted to leave home.

2.) If your child has had life-threatening symptoms (suicide attempt, drug/alcohol abuse, eating disorder), ensure that her condition is in full remission for at least 6 months prior to letting her go away to college. For example:
– A child with bipolar disorder should have at least 6 months of mood stability without any manic or major depressive episodes.
– A child who has attempted suicide should have a minimum of 6 months without any suicidal behaviors, gestures, or urges.
– A child with a substance abuse problem should have at least 6 months of complete sobriety.
– A child with anorexia nervosa should have at least 6 months of eating independently without restriction while maintaining 100% full weight-restoration with regular menstrual periods.
– A child with bulimia nervosa should have at least 6 months of normalized eating with complete abstinence from all binge/purge behaviors.

3.) A young person going off to college should have, at most, minimal or mild mental/emotional symptoms. For example, a child with an anxiety disorder who has occasional panic attacks, or who feels somewhat anxious at parties around new people, may be able to function well at college, but a child who has panic attacks multiple times a week or who avoids most social situations is not yet ready to go away.

4.) Ensure that your child has effective tools to manage any symptoms that may arise. This may include CBT or DBT skills to manage feelings of depression or anxiety.

5.) Work with your child and her treatment team to develop a self-care plan that includes plenty of sleep, physical activity, time management, and balanced meals and snacks at regular intervals.

6.) Do not rely upon university services (student health center or student counseling center) to provide therapy, psychiatric, or medical services for your child. University counseling centers are not equipped to manage the needs of students with major mental health issues. Most student counseling centers are over-worked, under-staffed, and underfunded. By necessity, most have limits on the number of sessions each student can attend, and most will not support parental involvement in treatment decisions or even communicate with parents at all.

7.) Prior to your child’s departure for college, establish a treatment team off-campus.
– Interview the clinicians over the phone and schedule a family meeting in person with the clinician before the school year starts, during the time you are helping your child move into the dorms. If the clinician is reluctant to talk with you over the phone or refuses to meet with you in person, this is a red flag.
– I recommend selecting a clinician who welcomes individualized, appropriate parental involvement in college students’ mental healthcare. This means working collaboratively with parents based upon the individual patient’s needs in light of her diagnosis, history, and developmental stage, irrespective of her chronological age.
– Ensure that your child signs releases of information allowing you to communicate with the clinician regarding your child’s care (law requires that persons over 18 must provide written permission for a mental health professional to release information to anyone, including parents).
– Use the initial family meeting to provide the clinician with any relevant history about your child’s condition. Written psychological evaluations or discharge summaries from previous treatment providers are very helpful in this regard.
– Work collaboratively with the new clinician and your child to establish frequency of contact, and nature of communication, between you and the new clinician. For instance, I often work out a plan wherein I call parents every two weeks, or once a month, with a general progress report on the patient, without revealing the specific content of sessions (e.g., “Mary is adjusting well to dorm life. She’s had some mild anxiety but she seems to be managing it well.” Or “Annie has been struggling with an increase in depressive symptoms over the past week. I will keep you posted and notify you right away if there is any indication of suicidality or deterioration in functioning.”) Be very clear about the type of information that will be shared between clinician and parents. It is important for the patient to establish a trusting relationship with the clinician and to feel secure that, in general, “what happens in therapy stays in therapy.” It is equally important for the parents to be reassured that they will be notified promptly if the child’s condition deteriorates.

8.) Have a safety net in place. Decide exactly what extra supports will be provided, and under what circumstances, if the child should experience an increase in symptoms while away at college. For example: an increase in symptoms lasting longer than one week may result in the child coming home for the next weekend, or perhaps a parent would travel to stay with the child in a hotel for a week or two.

9.) Have a plan B.
– Work collaboratively with your child and her new treatment team to establish what conditions would warrant a more serious intervention.
– Some situations, in my opinion, warrant a medical leave and an immediate return to the safety of home. For example, a suicide attempt or gesture, an episode of alcohol poisoning, a weight loss of more than 5 pounds (in the case of anorexia nervosa) or a recurrence of binge/purge symptoms lasting longer than a couple of weeks (in the case of bulimia).

10.) Always remember, and reiterate to your child: whatever happens is feedback, not failure.
– A medical leave of absence is not the end of the world. Nor is it permanent. It is simply an indication that your child temporarily needs more support than can be provided in the college setting. It is no different from a young person taking a leave of absence for major surgery or cancer treatment (try getting that done in the student health center!).
– Many young adults recover more swiftly from a relapse compared to the first time they were ill – the benefit of maturity and the motivation of wanting to return to college and independent living can be very helpful in this regard. If your child does well at home and recovers from the relapse, she may be able to return to school away from home the following semester or the following year.
– Depending on the circumstances and the course of your child’s illness, it is possible that the best scenario for her would be to live at home and attend college locally, or transfer to a school in-state and come home each weekend. Again, this is not the end of the world. If her recovery is robust after college, she will still have the opportunity to go away to graduate school or start the career of her dreams somewhere else.

Attending college is a privilege and a gift, not an inalienable right. It is not something that one must automatically do right after graduating from college. Living away from home, apart from one’s primary support system, to attend a faraway school is a privilege unique to American culture, and is not a prerequisite for success in any way. In most other countries, young people who do attend college (and not everyone does) do so locally while living at home until they are married.

Take your child’s psychiatric diagnosis very seriously, and do the right thing for her health. As her parent, it is not only your right but your duty to make these decisions, and you should be supported by a treatment team that empowers you to do so.

Palliative Care for Anorexia Nervosa?

I recently read an article in the International Journal of Eating Disorders entitled Managing the Chronic, Treatment-Resistant Patient with Anorexia Nervosa (Strober, 2004). Though eloquently written and artfully persuasive, this was probably the most depressing journal article I have ever read. The author, Michael Strober, seeks to help readers “resolve the paradox of caring for patients who seem so decidedly opposed to change.” Essentially, Strober advises psychologists to avoid pushing, or even encouraging, full nutrition and weight restoration in chronically ill patients with AN because these attempts will backfire by upsetting the patient emotionally and thus leading to premature termination of therapy. Instead, he argues, therapists “can expect little, should seek nothing, and must largely defer to the patient in regards to the objective of the time shared together.”

Strober states that the therapist’s attempts to encourage re-feeding “will feel like an assault” to the patient and are “certain to induce peril.” He warns therapists that their efforts to coerce patients into hospitalization or other much-needed medical care will result in “a potentially dangerous exacerbation of symptoms.” The article presents two tragic case studies of women in their late 20’s who have been chronically ill with AN since early adolescence. Each story is presented as a cautionary tale describing the deleterious effects of requiring full nutrition and weight restoration in these types of patients. Finally, Strober admonishes therapists to be aware of their counter-transference with such patients and advises them to “concede the reality that there may be little to do to drastically alter the course of a patient’s illness,” and notes that “this is neither failure nor inferiority.”

I view this entire philosophy as a manifestation of both failure and inferiority. Failure on the part of professionals who fear an emaciated patient’s wrath more than they fear her death. Failure on the part of a profession which espouses the dogma that avoiding premature termination of treatment is more important than avoiding premature termination of the patient’s life. Failure on the part of a philosophy that values nurturing the therapeutic relationship more than it values giving a patient a fighting chance at life, health, and happiness. These patients have not failed treatment. Treatment has failed them.

Strober argues that there is a place in our field for palliative care for treatment-resistant anorexics. I disagree. Anorexia nervosa is, by definition, resistant to treatment. The “peril” that ensues during re-feeding is real and universal. Re-feeding is agonizing for the patient herself, her friends and family, and her treatment team. Anyone who has ever made the heroic journey from AN to recovery will tell you that. I have never met an anorexic who gladly relinquished rigid control over her diet, voluntarily prepared and consumed high-calorie meals, and excitedly welcomed weight restoration without struggle. A person such as this would not have been diagnosed with AN in the first place. Chronically ill patients with AN are not resistant to treatment. Treatment is resistant to them.

Towards the end of the article, Strober warns therapists to keep their counter-transference in check by not pushing patients too hard, not expecting recovery, and resigning themselves to the reality that these patients are destined for a lifetime of illness and misery followed by a premature death. He notes that many therapists are not well-suited for providing palliative care to treatment-resistant anorexics. I, for one, am certainly not cut out for that type of work. I am not able to sit impassively with a patient who has been ill for fifteen years without taking draconian measures to propel her towards health. I recognize that responsibility for her recovery, at least initially, lies with me and with her family. I would not expect a patient with that level of illness to embrace recovery. That’s my job, not hers.

Individuals with AN are almost universally brilliant, talented, sensitive, and intense. They have so much potential, so many gifts to offer the world. They are physicians and nurses and lawyers, scientists and professors and teachers. They are outstanding athletes, writers, singers, dancers, actresses, and artists. Consider three-time Grammy-winning singer Karen Carpenter who died of AN at age 33 and world-class gymnast Christy Henrich, who died of AN at age 22. These women were beloved daughters, loyal sisters, caring friends.

It baffles me that, in a society which purports to value human life, we allow these precious lives slip away. The Bush administration placed restrictions on stem-cell research, supposedly out of concern for the sanctity of life. Nearly half of Americans are opposed to abortion. Our society believes that elderly, terminally ill patients in excruciating pain must not be allowed to die, as evidenced by the fact that doctor-assisted suicide is illegal in every state except Oregon. States have laws which allow for the involuntary hospitalization of imminently suicidal and floridly psychotic patients, recognizing that these individuals are not well enough to care for themselves. Psychiatric hospitals use 4-point restraints, sedatives, and padded rooms to prevent patients from injuring themselves. Prisoners are forbidden from having sharp objects and belts in order to protect them from taking their own lives. Death row inmates who attempt suicide are resuscitated. Don’t we owe the same to innocent people who are suffering from a horrible eating disorder?

Military Suicides

When American men and women make the courageous choice to join the armed forces, they realize that they may sacrifice their lives for their country. What they may not realize is that they are now more likely to commit suicide than they are to die in military combat.

The incidence of suicide in the military has increased steadily since the Iraq war began in 2003. There were 67 suicides in 2004, followed by 85 in 2005, 102 in 2006, and 115 in 2007. The 2008 statistic – 128 suicides – is the highest we’ve seen since record keeping began in 1980. Shockingly, military suicides outnumbered combat fatalities during the month of January 2009.

A recent APA Online article entitled Uncertainty about Military Suicides Frustrates Services describes the military’s attempt to understand this devastating suicide epidemic and how they plan to address it.

I am frustrated and saddened, though not surprised, to learn about the alarmingly high rate of military suicides. A combination of circumstances has created the perfect storm for suicides in the military. Consider the following:

• Service members are usually between the ages of 18-24. Neurological changes, developmental issues, and psychosocial stressors make individuals in this age group particularly vulnerable to mental illness.

• Service members are separated from their family, friends, and natural support systems for many months at a time. These extended absences contribute to homesickness, loneliness, depression, financial strain, marital problems, and infidelity.

• Service members are exposed to horrific violence on a daily basis. Their lives are constantly in jeopardy, and many are wounded in the line of duty. They witness their friends being shot, maimed, and killed.

• Service members are fighting a protracted, poorly managed, generally unpopular war with no clear end in sight.

• Military leaders and medical personnel are insufficiently trained in identification of psychological problems.

• There is a huge stigma associated with seeking mental health treatment amongst service members. The stigma often prevents service members from seeking the care they need.

• Service members are worried, often justifiably, that seeking mental health services may have a detrimental impact on their military career.

• Service members do not have sufficient access to adequate psychological services.

• Excessive drinking is deeply engrained in military culture.

• Service members have easy access to deadly weapons.

Given these conditions, it is not at all surprising that suicide is a problem in the military.

Lieutenant Justin D’Arienzo, Psy.D., a naval psychologist, described these systemic problems in a recent issue of the APA’s Monitor on Psychology. When D’Arienzo was serving on an aircraft carrier, he was solely responsible for the mental health of 8,000 people. He quickly discovered that he did not have time to see everyone who needed his services. In comparison, the ship carried 5 physicians, 4 dentists, and 40 medical assistants. To make matters worse, military psychologists are poorly compensated in comparison to other healthcare professionals in the service. The salary for a navy psychologist is about half that of a navy physician. This scenario sends the following not-so-subtle messages: psychologists are less valuable than physicians and dentists, psychologists are not needed as much as physicians and dentists, and service members’ physical health and dental health are more important than their psychological wellbeing. None of these messages are true.

The recent increase in military suicides is just one of many factors that points to the glaring need for improved mental health care for our service members. I have a few ideas as to how to improve this situation. Let me preface this by noting that, as an optimist and an idealist, I often have ideas that are less than practical. Nonetheless, here are my thoughts:

• The military hires more psychologists so that the number of military psychologists is commensurate to the number of military physicians. This will ensure that there are enough psychologists to meet the mental health needs of all service members.

• Military psychologists are paid the same salary as military physicians. Let’s face it: money talks. Higher salaries will increase the competition for these jobs and attract the best and brightest psychologists in the field. It also sends a clear message that soldiers’ mental health is valued as much as their physical health and dental hygiene.

• Every service member is required to attend weekly therapy sessions before, during, and after deployment. If all service members are required to attend therapy as a matter of course, this will eliminate the inner conflict troubled soldiers experience when considering whether to seek help, and it will remove the stigma of seeking mental health services. Further, mandatory weekly therapy is a preventative measure – soldiers can process their emotions and learn healthy coping skills before they reach the point of major depression or full-blown PTSD. Soldiers go through mandatory physical training to ensure that they are in top shape for combat. Mandatory therapy will help the troops stay psychologically fit for duty.

• More frequent therapy (e.g., 2-3 times per week) is available for those who are having great difficulty coping or who are beginning to show signs of mental illness.

• Confidentiality is maintained in the same manner as it is for civilian therapy clients.

• The length of deployment is shortened for all service members.

• Troops who develop major depression, PTSD, or other psychiatric problems are sent home to their families for more intense treatment with no adverse effect on their military career.

• Military leaders and military medical personnel are provided with more training on how to spot mental health issues in troops.

Regardless of my political beliefs and personal views on this war, I have tremendous respect for the brave men and women of our armed forces. The troops deserve high-quality, accessible mental health care. They have risked their lives serving and protecting our country. Isn’t it about time we serve and protect them?

1. Military Suicide Rate. Chicago Tribune, May 29, 2008.
2. Army says suicides among soldiers at highest level in decades. Paula Jelinek, Boston Globe, January 30, 2009.
3. Army Official: Suicides in January ‘Terrifying.” Barbara Starr & Mike Mount, CNN.com, February 5, 2009.
4. Uncertainty about military suicides frustrates services. APA Online. July 31, 2009.
5. Pentagon: Military’s Mental Health Care Needs Help. CNN.com. June 15, 2007.
6. The Military’s War on Stigma. Sadie F. Dingfelder. APA Monitor on Psychology. June 2009.
7. Stahre et al. (2009). Binge Drinking Among US Active-Duty Military Personnel. American Journal of Preventative Medicine, Volume 36, Issue 3.