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Correlates of Treatment Outcome for Patients With Mood Disorders

In my last blog post, I described end-of treatment outcomes for patients with mood disorders. Here, I will elaborate on factors that were correlated with treatment outcome for these patients. Please be advised that these results are specific to my practice and my patients, and should not necessarily be generalized to other clinicians or populations.

Diagnosis
Type of mood disorder diagnosis was strongly correlated with treatment outcome. Patients with Depressive Disorder NOS (DDNOS; n = 3) fared best. Two-thirds of these patients (n = 2) completed treatment and achieved full remission. The remaining one-third (n = 1) attended treatment for two months and made significant progress before quitting prematurely.

Patients with Mood Disorder NOS (MDNOS; n = 4) had varying outcomes. Half of them (n = 2) completed treatment; of these, one achieved full remission and the other made significant progress. Of the remaining MDNOS patients, one quit prematurely after making some progress and the other regressed and was referred to a higher level of care.

Both of the patients in this sample with Dysthymic Disorder also had a diagnosis of Major Depressive Disorder (MDD). For statistical purposes, I am subsuming these individuals under the category of MDD, as that is the more severe of the two diagnoses. Patients with Major Depressive Disorder (MDD; n = 11) had varying outcomes. Eighteen percent (n = 2) completed treatment and achieved full remission; 9% (n = 1) quit treatment after making significant progress; 45% (n = 5) either quit treatment or moved away after making some progress; and 27% (n = 3) were referred to other providers.

The presence of both dysthymic disorder and MDD (n = 2) did not have a consistent impact on treatment outcome – one of these individuals completed treatment and achieved full remission, while the other regressed and was referred to a higher level of care.

None of the patients with bipolar disorder (n = 3) completed treatment or achieved full remission. However, one of the patients with bipolar disorder remained in treatment for over a year and made significant progress, but was eventually referred to another treatment provider to address other treatment needs.

Comorbidity
Presence of a co-morbid diagnosis was a negative prognostic factor. Only 18% (n = 2) of the patients with comorbid disorders completed treatment, and only 9% (n = 1) achieved full remission, while the remaining 9% (n = 1) made significant progress. In contrast, 40% (n = 4) of patients without a comorbid diagnosis completed treatment, and all of these patients achieved full remission.

Medication
Patients who did not take psychiatric medication during treatment with me were more likely to make progress in treatment and more likely to achieve remission than those who took psychiatric medication. All of the patients who did not take medication (n = 8) made at least some progress in treatment. In contrast, 30% of those who took medication either made no progress (n = 2) or regressed (n = 2) during treatment. Half of the patients who did not take medication (n = 4) achieved remission by the end of treatment, compared to 8% (n = 1) of those who took medication.

My hypothesis is that patients who took medication had poorer outcomes not because their medication didn’t work or made them worse, but rather because taking medication is confounded with severity of mood disorder and with comorbidity. In other words, those with more severe mood disorders and/or comorbid conditions were more likely to require medication in order to function, whereas those with mild to moderate mood disorders were less likely to need medication.

Age and Family Involvement
Younger age was a significant predictor of treatment completion. Patients who completed treatment ranged in age from 16 – 29, with an average age of 19.7. Those who did not complete treatment ranged in age from 12 – 59, with an average age of 28.6.

Being under 18 years old was a protective factor. None of the adolescents under 18 quit treatment prematurely. Of the 6 adolescents in this sample, 50% (n = 3) completed treatment and attained full remission, 33% (n = 2) were referred to other treatment settings after a year or more of treatment with me due to other needs, and the remaining 16% (n = 1) engaged in treatment as a 17-year-old and made some progress, but quit shortly after his 18th birthday. I suspect that the high level of parental involvement that I require for adolescent patients is the primary reason why they are likely to remain in treatment and have positive outcomes. In addition, younger patients tend to have shorter duration of illness compared to adult patients, and early intervention is also predictive of positive outcome.

For patients over 18, family involvement often included spouses and significant others instead of parents, based on the patient’s living situation and relationship status. Sixty percent (n = 9) of the patients over 18 in this sample had no family involvement whatsoever, 27% (n = 4) had a low level of family involvement, and 13% (n = 2) had a moderate level of family involvement. None of the patients over 18 had a high level of family involvement.

Importantly, amongst the adults in this sample, family involvement was not necessary in order to make progress in treatment or attain remission. None of the adults who attained full remission (n = 2) had family members involved in their treatment. Likewise, 67% (n = 2) of the adults who made significant progress in treatment had a low level of family involvement and 33% (n = 1) had no family involvement at all.

None of the patients over age 30 (n = 5) completed treatment. I hypothesize that there are several reasons for this: 1.) Older patients had a longer duration of illness, which means that their illness was more entrenched and more difficult to treat; 2.) The majority of these patients (80%; n = 4) had no family support at all; 3.) All of these older patients paid reduced rates for my services, which indicates that they were of lower socio-economic status, and which may suggest that they value my services less than those who pay full price; 4.) I saw all of these patients during my post-doctoral year, when I was less experienced and not yet fully licensed. Therefore, it is reasonable to assume that the quality of my services was somewhat lower back then than it is now that I am fully licensed and more experienced; and 5.) I prefer working with child and adolescent patients and find that I tend to be more effective with them. For these reasons, particularly #5, I no longer treat adult patients beyond their mid-twenties.

Gender
Average duration of treatment was comparable for males and females (6.8 months vs 7.4 months, respectively). Rates of remission were similar between males and females. Twenty percent (n = 1) of males completed treatment and achieved remission, compared with 25% (n = 4) of females. However, amongst those who did not achieve remission, females were more likely to make significant progress than males. Twenty-five percent (n = 4) of females made significant progress, compared with none of the males.

Hospitalization
Hospitalization during treatment with me predicted regression in treatment. Of the patients who were hospitalized during treatment with me, 67% (n = 2) had regressed by the end of their treatment with me. In contrast, none of the patients who were not hospitalized during treatment had regressed as of their final session with me.

I hypothesize that patients who remained out of the hospital during treatment with me were responding well to treatment, which would explain why they were more likely to achieve remission or at least make significant progress. In contrast, being hospitalized during treatment may have been an indication that the patient was not responding well to treatment, which explains why they were likely regressed as of their last session with me.

Surprisingly, history of hospitalization before entering treatment with me was not related to outcome. Of the 8 patients who had been hospitalized previously, 25% (n = 2) achieved remission, 25% (n = 2) made significant progress, 38% (n = 3) made some progress, and only 12% (n = 1) regressed in treatment with me. These percentages are comparable to those of the 13 patients who had not been hospitalized before beginning treatment with me: 23% (n = 3) achieved remission, 15% (n = 2) made significant progress, 38% (n = 5) made some progress, 15% made no progress, and 8% (n = 1) regressed.

I would have suspected that history of hospitalization would be confounded with illness severity, and therefore would predict poor treatment outcome. However, it is possible that the individuals who had been hospitalized before entering treatment with me had not been given appropriate outpatient treatment, hence the escalation of illness need for hospitalization. Perhaps these patients were able to benefit from their treatment with me, and it is possible that, in some cases, hospitalization could have been avoided if they had received effective outpatient treatment sooner.

Attendance at Therapy Sessions
Attendance at therapy sessions was correlated with treatment retention as well as treatment outcome. Sixty-seven percent (n = 4) of those who completed treatment attended all of their appointments, while the remaining 33% (n = 2) had only one missed appointment. Eighty percent of patients who attained full remission (n = 4) had perfect attendance in therapy; the remaining 20% (n = 1) missed only one appointment. None of the patients who missed more than one appointment completed treatment or achieved full remission.

I suspect this relates to the old adage: “You get out of it what you put into it.” A patient who frequently misses appointments probably places little value on their mental health, which may explain why they tended to drop out of treatment prematurely. Those who were diligent about their treatment prioritized their mental health and worked hard in therapy. Those who were conscientious and responsible about attendance were, most likely, conscientious and responsible about completing therapy homework, taking their medication consistently, and making positive life choices in general. Thus, it is natural that these individuals had better treatment outcomes.

Fee for Services
Payment of full fee for services was a predictor of treatment completion and achieving full remission. Sixty-seven percent of patients (n = 2) who paid my full rate completed treatment, compared with only 22% of patients (n = 4) who paid a reduced rate. Given that so few patients in this sample paid my full rate (n = 3), it is difficult to draw any conclusions about how these individuals differ from those who pay a lower rate.

However, in my practice, the correlation between payment of full services and better treatment outcome has been consistent across diagnoses, regardless of the number of clients in the sample. As I have noted in recent posts, individuals who pay lower fees are, by definition, of lower socio-economic status (SES). These individuals may have more financial stressors than those of higher SES, and may have other life obstacles in general (limited access to healthcare, transportation difficulties, unemployment, single parent families) which interfered with their ability to progress in treatment.

In addition, those who pay reduced rates were much more likely than those who pay full rate to no-show for sessions or to cancel at the last minute. This finding suggests to me that, on average, individuals who paid reduced fees placed less personal value on their sessions, had less respect for my time, did not prioritize their recovery, and/or were generally irresponsible, compared with individuals who paid full rate.

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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.

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Show Me The Science

The debate over evidence-based practice (also known as empirically-supported treatment) in psychology is contentious and polarizing. Evidence-based practice, as defined by the APA, is “the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences.” The debate over evidence-based practice can be summarized as follows:

Proponents of evidence-based treatment argue that clinical psychologists are scientists, that psychotherapy is (or should be) based upon scientific theory, and therefore therapists must use the best available scientific evidence in their practice of psychotherapy. They argue that the public must be protected from therapies which are not evidence-based, as such therapies may be ineffective or harmful.

Opponents of the evidence-based practice movement argue that psychotherapy is an art rather than a science, and that the essence of what they do – the “human element” – cannot possibly be manualized or subjected to clinical trials. Opponents are typically therapists who practice relationship- or insight-oriented approaches. They see their work as diametrically opposed to the principals of evidence-based practice.

I understand and appreciate the arguments of the opponents, and I do believe they have some valid points. However, I have established my professional identity as a strong proponent of evidence-based treatment.

When you visit a physician for an illness and she prescribes a medication, you can safely assume that the medication has been FDA-approved for your particular illness, that it is likely to be effective, and that it is unlikely to seriously harm you.

Imagine the following scenario: Drug A was used to treat Illness X twenty years ago. Then, ten years ago, clinical studies showed that Drug B is significantly more effective than Drug A in treating illness X. A physician, Dr. Dolittle, continues to prescribe Drug A for Illness X because he really believes it works, and because he was taught that Drug A works well when he was a medical student 20 years ago. Dr. Dolittle does not inform his patients that Drug B exists, because he doesn’t believe it will work for them and he has no experience with it.

The scenario described above would not happen in medicine, would it? And if it did happen, Dr. Dolittle would be reprimanded by the medical board and may have his license revoked.

Believe it or not, this scenario happens in psychology all the time. Most people outside the field would be shocked to learn that the majority of psychological treatment out there is NOT evidence-based.

I have seen patients who underwent years of psychodynamic therapy for severe depression, without getting any better, without being told about cognitive-behavioral therapy (CBT) and without being referred to a psychiatrist for a medication evaluation. I have seen patients with anxiety disorders whose psychiatrists have prescribed multiple medications for them, never once referring them for psychological treatment, without ever mentioning that CBT at least as effective, if not more so, than medication for most anxiety disorders. I have seen patients who suffered from eating disorders for many years, who have seen many therapists, who have had multiple stints in residential treatment and have taken numerous medications, but were never restored to their ideal body weight and never provided with the support they needed to eat properly. And finally, a substantial portion of my case load is comprised of teenagers with eating disorders who have experienced months or years of ineffective, non-evidence-based treatment. The families of these teenagers were never informed about Family-Based Treatment (FBT), which is the only empirically-supported treatment for adolescents with eating disorders. Their parents discovered FBT on their own through desperate late-night internet searches.

These patients are pleasantly surprised to see how quickly and dramatically they improve with evidence-based treatment. They are also angry that they were not provided with, or at least informed about, effective treatment from the start. I believe that all patients and their families deserve to be fully informed about the range of different treatment options available to them, including evidence-based treatment. I do believe that there is a place for non-evidence based treatment, but patients and families should know from the outset what they are getting.

Evidence-based practice is not about using treatment manuals verbatim, or only relying upon randomized clinical trials. Treatment manuals are necessary for research and dissemination, but they are not intended to be followed verbatim with every patient in the real world. Manuals don’t treat patients – they merely provide a guide and a plan of action which may be revised and altered as needed for each unique patient. The basic principles and techniques of the treatment are the brick and mortar; the details of each room can and should be tailored to the individual.

Clinical psychology is a science, but it is not as precise as the so-called “hard sciences” like physics or mathematics. The brain is too intricate; human behavior too complex to be boiled down to immutable formulas. There is, and always will be, room for intuition, creativity, spontaneity, and that intangible “human element” that cannot be manualized or subjected to laboratory research. But the evidence base is there, so we owe it to our patients and to our profession to use it. Otherwise, we are no better than Dr. Dolittle.

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How to Help Your Depressed Teenager: Tips for Parents

If your child is depressed, it is important to act now. Untreated depression causes tremendous suffering and can lead to serious medical and emotional problems, including suicide. Adolescents with untreated depression have difficulty learning and making and keeping friends. They are also more likely to abuse drugs and engage in self-injury. You must intervene now in order to help your teenager blossom into the wonderful person she was meant to be.

1. Educate yourself on depression in adolescents.

Learn the signs and symptoms of depression and know how to differentiate between normal sadness or “teen angst” and clinical depression. All teenagers are moody and irritable at times, and sadness is a natural and healthy response to a loss or disappointment. Depression is a serious but treatable mental illness which affects between 2-5% of adolescents at any point in time.

Depression involves a pervasively sad or irritable mood that lasts at least two weeks, but usually several months or more, and causes a noticeable change in functioning. Depressed adolescents also experience physiological symptoms such as changes in appetite and weight, lack of energy, insomnia or hypersomnia, and physical aches or pains. They tend to have poor self-esteem and irrationally negative thoughts, lose interest in activities and friends, isolate themselves, and feel guilty or worthless for no good reason. Many depressed teens feel hopeless and have recurrent thoughts of death or suicide.

2. Take your child to the pediatrician for a complete physical exam to rule out organic causes of depression.

In some cases, depression is the result of a general medical condition such as hypothyroidism or mononucleosis. Depression can also be a side effect of certain medications. Some teens may exhibit depression as a result of abusing alcohol, drugs, or prescription or over-the-counter medications. Finally, simple things like sleep deprivation, too much stress, and nutritional deficiencies can manifest as depression. It is important that your child receives a complete physical exam in order to rule out any of these potential causes.

3. Let go of guilt and blame.

Depression is no one’s fault. Your child did not choose it and you did not cause it. We know that depression is a heritable brain disorder which is often (though not always) triggered by stressful life events and brain changes during puberty. It is unhelpful, even counterproductive, to blame yourself or your child for her depression. While your child is depressed, her moods and behaviors are to some degree out of her control. She cannot “choose to be happy” or “snap out of it.”

4. Don’t be too quick to medicate.

Psychotropic medication has its place, and under certain circumstances, it may be a very helpful adjunct to psychological treatment for depression. Far too often, however, psychiatrists and other physicians use medication as the first line of defense against depression. This is especially dangerous for children and adolescents, whose brains are still developing and who are more likely to suffer from serious side effects.

In addition to the risk of side effects and the lack of evidence about the long-term effects of antidepressants on a developing brain, there are other dangers to using medicating as the first, or only, line of treatment.

First, there has been very little research on the effects of antidepressants in youth. Second, there is only one antidepressant medication (Prozac) which has been FDA-approved to treat depression in adolescents, but doctors regularly use other medications “off-label” to treat them. Third, psychotherapy is more effective than medication for most adolescents with mild-to-moderate depression. Fourth, a child who receives medication without psychotherapy will not learn the necessary skills or make the necessary life changes needed to sustain lasting improvement and prevent relapse. The effects of medication expire when the medication is stopped, whereas the effects of good psychotherapy are longer-lasting.

In order to protect your child from being prescribed unnecessary or harmful medication, I recommend first taking your child to a psychologist (Ph.D. or Psy.D.) rather than a psychiatrist (M.D.). Psychologists perform psychological assessments and conduct psychotherapy but do not prescribe medication. Most psychiatrists, on the other hand, prescribe medication to the vast majority of patients they see, while conducting little (if any) psychotherapy.

If it becomes evident later on that your child could benefit from medication as an adjunct to psychotherapy, you can always ask your child’s psychologist or pediatrician to refer you to a child psychiatrist with whom he/she has a working relationship.

5. Seek evidence-based psychological treatment.

All therapy is not created equal. Some psychological treatments have been shown to work, while others have not. Research supports the effectiveness of three different types of psychotherapy for depressed adolescents: individual cognitive-behavioral therapy (CBT), group CBT, and interpersonal psychotherapy for adolescents (IPT-A). All three of these treatments are relatively short-term, usually consisting of 12-16 weekly sessions over the course of 3-4 months.

CBT focuses on the relationships among thoughts, feelings, and behaviors. CBT directly targets the adolescent’s present symptoms, without much emphasis on the past. The CBT therapist helps the adolescent identify patterns of thinking and acting which are contributing to her depression and teaches her new ways of thinking and behaving that facilitate positive feelings. CBT be delivered individually, with your child meeting 1-on-1 with a therapist, or in a group consisting of one or two therapists and 6-12 other adolescents who are experiencing depression.

IPT-A focuses on the adolescent’s social functioning and her current relationships with important people in her life. Through IPT-A, the adolescent develops her social skills, learns more effective ways of communicating, identifies connections between certain relationship patterns and her depressive symptoms, and learns to cope effectively with life transitions.

Be conscientious and selective in your search for an appropriate therapist for your child. Try to find a psychologist who has experience in treating adolescent depression. Speak with the psychologist briefly over the phone before making an appointment. Ask her about her philosophy of treatment, and make sure she practices evidence-based treatment.

6. Insist upon being fully informed and actively involved in your child’s treatment.

There is quite a bit you can do to help your child recover from depression, so don’t let any professional tell you otherwise. Treatment works best when you are fully informed and actively involved. Your child will probably be meeting with the therapist individually during most sessions. However, you should be involved in the initial evaluation and treatment planning. You should expect the therapist to check in with you on a regular basis to provide updates on your child’s progress. The therapist should always return your calls in a timely fashion and should definitely tell you if your child is engaging in dangerous behavior.

At the start of treatment, have a frank conversation with the therapist about confidentiality and boundaries. You, the therapist, and your child should come to a clear agreement about what types of information will and will not be disclosed to you as the parent. It is important that your child forms a comfortable, trusting relationship with her therapist. It is even more important, however, that you are made aware of any harmful behaviors (e.g., drug or alcohol use, unprotected sex, eating disorders, cutting) and involved in the process of helping your child overcome these issues.

7. Be willing to consider antidepressant medication under certain circumstances.

Antidepressants are vastly over-prescribed. They should not typically be used as a first-line treatment and should not be prescribed unless the patient is also in psychotherapy. However, there are certain circumstances under which medication may be beneficial and even life-saving:
• If your child has been in evidence-based psychotherapy for two or three months but has not shown any improvement, consider adding an antidepressant to your child’s treatment plan as an adjunct to psychotherapy.
• Depression has a strong genetic component. If your child has a first-degree relative (mother, father, or sibling) who suffers from a mood disorder, this suggests that your child’s depression is likely to be genetic and biologically-based. In this situation, it is more likely that your child will benefit from antidepressants.
• Research has shown that severe depression responds best to a combination of psychotherapy and antidepressant medication. In contrast, mild- to moderate depression can typically be successfully treated with psychotherapy alone. Most cases of depression are mild or moderate, so check with your child’s psychologist to determine the severity of her illness. Adolescents with severe depression are often too ill to engage in psychotherapy without the added benefit of medication to normalize their brain chemistry.
• Your child’s medication should be prescribed and monitored by a board-certified child and adolescent psychiatrist, not by her pediatrician. While pediatricians are able to prescribe antidepressants, they do not have the expertise necessary to monitor your child’s progress and ensure that she is on the correct dose of the right medication.
• You and your child should meet with the psychiatrist for a thorough evaluation before any medication is prescribed. Be sure to ask the psychiatrist about any potential side effects or drug interactions of which you should be aware.
• Your child should be closely monitored by her psychiatrist while she is on the medication, especially during the first month and after a change in dosage. After that, the psychiatrist should follow up with your child at least monthly to monitor her progress and change her dosage if necessary.

8. Create a home environment conducive to overall physical health and mental wellbeing.

Basic self-care habits such as sleep, nutrition, exercise, and stress release are extremely important for someone suffering from depression. Teenagers are notorious for staying up late, eating lots of junk food, and guzzling soda at all hours of the day. While most teens can “get away with” these habits for a few years, teens recovering from depression cannot afford to take shortcuts with their health. Depressive symptoms can be caused or exacerbated by sleep deprivation, poor nutrition, inactivity, and chronic stress.

Prioritize health and well-being above all else. Establish regular bedtimes to ensure that your child gets a minimum of 8 hours of sleep every night. Many adolescents need 9-10 hours of sleep or even more in order to function optimally. Require your child to eat nutritious, balanced meals with the entire family. Supplement her diet with multivitamins and Omega-3 essential fatty acids, which have been shown to improve mood, memory, and general mental functioning. Encourage her to enjoy some physical activity every day. Minimize the stress and tension in your household. Help your child create a balance of study time, personal time, friend time, and family time.

9. Encourage healthy social relationships and fun activities.

Depression causes adolescents to withdraw from their friends and family and lose interest in activities they once enjoyed. Unfortunately, social isolation and inactivity only exacerbate depressive symptoms. Ensure that your child stays connected to the family by sharing meals with the family every day and involving her in a weekly family outing or game night. Encourage her to go out with her friends or invite them over to the house.

See to it that your child is involved in activities that create a sense of purpose, nurture her talents and burgeoning self-concept, and help her connect with other like-minded kids and adults. If your child is artistic, sign her up for art lessons or encourage her to audition for a play. If she is musical, encourage her to join the marching band or take dance classes. If she is athletic, encourage participation on a sports team. Many adolescents find a sense of meaning in volunteer work or involvement in religious activities.

Depressed adolescents often lose motivation and lack the interest and energy to initiate activities on their own. However, once they become involved and engaged in activities, they usually begin to feel a little bit better. Remind your child of this when she expressed reluctance to do something fun or social.

10. Provide your child with plenty of nurturing, comfort, and physical contact.

No parent wants their child to suffer. It will be very difficult to and heart-wrenching to watch your child struggle with depression. However, it is important that you remain calm, steady, compassionate, and optimistic.

Depressed adolescents often feel worthless and guilty for worrying their parents. Tell your child that you love her infinitely and unconditionally, regardless of whether she is happy or depressed. Ensure your child that she is not to blame for being depressed and that she has done nothing wrong. Let her know that you are concerned about her depression, that you are here to support her, and that you will take all the necessary steps to get her good treatment and help her recover.

Physical contact through affection, hugging, kissing can be very comforting to a distraught adolescent. If your child resists being touched, use a soothing voice and reassuring words to comfort her and let her know that you are always available for a hug whenever she needs one. Express empathy towards your child and be willing to listen to her thoughts and feelings. However, you must keep in mind that depressed adolescents may have many irrational thoughts and negative perceptions about themselves and others. For example, your child may be extremely self-critical, believe that no one likes her, tell you her life is a living hell, or fear that you are angry with her. You can gently explain to your child her depression is causing her to see things through a “negative filter” such that many of her perceptions are colored by the depression and are not necessarily accurate.

11. Be patient and realistic.

Recovery from depression takes time. Your child will not feel better right away, nor should you expect her to. It takes weeks for the effects of psychotherapy and medication to become evident. Your child may begin to feel hopeless and worry that she will be depressed forever. This hopelessness is a symptom of depression, rather than an accurate assessment of her situation. You must remain hopeful and optimistic regardless of your child’s attitude. Reassure your child that recovery takes time; that she will begin to feel better soon; that she must stick with treatment.

It is often helpful to lower your standards while your child is depressed. This is difficult for many parents to accept. However, it is important to recognize that depression is a very real and very disabling condition that will have a major impact on your child’s functioning, personality, and behavior. Depression in teens can manifest in a variety of ways. Some teens may suffer a decline in academic performance due to inability to concentrate. Many depressed teens will become quiet and withdrawn; others will become angry and volatile. Some depressed adolescents will act out, abuse drugs, cut themselves, or get into trouble at school. However your child’s depression manifests, be aware of one thing: your child will NOT seem like herself while she is depressed. Just be aware of this fact and accept it. This is not to say that you must tolerate blatant disrespect, delinquency, or dangerous behavior. Continue to maintain appropriate boundaries and limits to keep everyone safe. However, recognize that your child is suffering from a serious mental illness that impairs her ability to function. If her grades slip, or she doesn’t do her chores, or she mouths off to you more than usual, show compassion and empathy, and try to maintain perspective.

Some adolescents experience one episode of depression and that’s it. However, more than half of adolescents who experience major depression will go on to have more episodes in the future. This does not mean that treatment didn’t work, or that your child failed, or that you failed your child. This is simply the nature of major depressive disorder. The good news is that if your child has been successfully treated the first time, you know exactly what to do if she begins to develop symptoms again. With the knowledge, insight, skills, and professional contacts gained the first time around, relapse should be briefer and easier to manage.

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Fighting the Wrong Battles

I’ve become increasingly annoyed at the conflation of “body dissatisfaction” with “eating disorder.” The former is a culturally-driven socio-political phenomenon, whereas the latter is a severe, biologically-based mental illness. The former afflicts over 85% of American females, whereas the latter strikes only a small fraction of us (less than 1% for anorexia nervosa and 2-3% for bulimia nervosa).

There has been a great deal of controversy surrounding supermodel Kate Moss’s comment that “Nothing tastes as good as being thin feels,” and around Ralph Lauren’s ridiculously photo-shopped ads. Eating disorder clinicians and activists have been quite vocal about their opposition to these media bytes, arguing that they encourage eating disorders. I know that these professionals and activists have noble intentions, but I believe they are fighting the wrong battles.

I object to underweight models not because I believe they cause eating disorders, but because being underweight is harmful to the models’ physical and mental health, and viewing these images on a regular basis contributes to body dissatisfaction in most people. I refuse to have magazines in my office waiting room not because I believe they cause eating disorders, but because I am opposed to the blatant objectification of women. Besides, I think that fashion magazines are sexist, superficial, and boring.

Hanging in my office is a certificate of membership from NEDA (National Eating Disorders Association) which thanks me for my “support in the effort to eliminate eating disorders and body dissatisfaction.” I really wish they had eliminated those last three words.

I think the conflation of sadness with depression is analogous. The former, in its extreme and persistent form, is one symptom of the latter. The former is a natural, healthy emotional state that every human being experiences from time to time, while the latter is a serious mental illness caused by a combination of neurobiological, psychological, and environmental factors. I remember an incident that illustrates this principle beautifully. I was conducting an initial evaluation with an adolescent girl and her parents. When I asked the father whether he thought his daughter was depressed, he replied: “I don’t believe in depression.” Interesting response, I thought. As if depression were something like God or heaven or Santa Clause, something to be believed in or not. I asked the father to elaborate on his beliefs. He replied: “I think we all get sad sometimes, and that’s OK.” I smiled and gently responded that I agree with him – yes, all of us do get sad sometimes, and yes, that’s OK. However, some people experience prolonged, intense feelings of sadness accompanied by sleep and appetite disturbances, fatigue, thoughts of suicide, loss of interest, and difficulty concentrating. These people are experiencing major depression.”

Imagine if, in exchange for my membership in the National Depression Association, I received a certificate thanking me for my support in the effort to eliminate Major Depressive Disorder and sadness.” Laughable, isn’t it? Well, so is the ED/Body Dissatisfaction comparison. It trivializes the anguish that eating disordered people experience, and it falsely encourages those whose lives have not been touched by eating disorders to think that they “know how it feels.” Well, guess what. They don’t.

Eliminating all sadness in the world would probably not affect the prevalence of Major Depressive Disorder because sadness is but one symptom of depression, whereas depression is not a result of sadness. Likewise, eliminating body dissatisfaction would be fantastic for everyone, but it would not result in the elimination of eating disorders.

Contrary to popular belief (and, sadly enough, the belief of many eating disorders professionals), the media’s glorification of thinness is not responsible for the so-called “epidemic” of anorexia nervosa. Also contrary to popular belief, the incidence of anorexia nervosa has not increased dramatically in recent decades. Cases of what would now be diagnosed as anorexia nervosa have been documented as early as the medieval times, long before thinness was considered fashionable. These fasting saints shunned all sustenance to the point of emaciation not because they wanted to be skinny, but because they believed it brought them closer to God.

Unbeknownst to many, anorexia nervosa occurs in many non-western cultures. For example, recent studies have shown that the prevalence of anorexia nervosa in China and Ghana is equal to its prevalence in the US. The major difference is that patients in non-western cultures relate their starvation to profound self-control, moral superiority, and spiritual wholeness rather than to a desire to be thinner. Today’s American anorexics, like their medieval predecessors and non-western counterparts, all experience prolonged inability to nourish themselves, dramatic weight loss to the point of emaciation, amenorrhea, and denial of the seriousness of their condition. The self-reported reasons for starvation, it seems, are the only things that change across time and culture. I believe that an anorexic’s so-called reasons for starvation are simply her attempts to derive meaning from her symptoms, which are always filtered through a cultural lens. An anorexic does not starve herself because she wants to be thin, or because she wants to be holy, or because she wants to show supreme self-control. She starves herself because she suffers from a brain disease, of which self-starvation is a symptom.

Recent research suggests that anorexia nervosa is not a culture-bound syndrome, but bulimia nervosa is. Anorexia nervosa seems to be a distinct genotype that has been around for centuries and that manifests itself in various cultures and eras. Bulimia nervosa, on the other hand, appears to occur in individuals with a certain genetic / neurobiological predisposition who are exposed to a culture which combines massive amounts of readily available, highly palatable foods with a cultural mandate for thinness. This research implies that reducing or eliminating the cultural glorification of thinness may indeed reduce the prevalence of bulimia nervosa, but will have no effect on the prevalence of anorexia nervosa. I suppose that, once this awful waif model craze blows over, anorexics will simply find another “reason” to starve.

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The Power of Expectations

A recent study found that parents’ stereotypes about teen rebelliousness fuel’s teens’ misbehavior. In this longitudinal study, researchers interviewed a large sample of 6th and 7th graders and their parents regarding expectations for the child’s behavior as he or she enters adolescence. At the one-year follow-up, teens whose parents had negative expectations about their child falling into stereotypical teenage behavior (e.g., drugs, premature sexual activity, rule-breaking) were more likely to have engaged in these behaviors. This was true even after controlling for many other predictors of such behaviors.

My guess is that several factors may be at play here:

1.) Parents whose sons and daughters had behavior problems during childhood may be more likely to have negative expectations as their child enters adolescence. Indeed, having a history of childhood conduct problems does increase the likelihood of engaging in substance use, premature sex, and rule-breaking behavior in adolescence.

2.) Parents with a personal history of adolescent misbehavior and parents with older adolescents who misbehave may presume that their child will follow a similar path. Children whose parents and older siblings engage in drug or alcohol use, delinquency, or early sexual activity are, in fact, more likely to engage in these behaviors themselves. Genetics play a powerful role in addictions, risk-taking, and impulsive behaviors. In addition, children whose family members engage in substance use have easier access to drugs and alcohol themselves. Finally, parents and older siblings are powerful role models who teach their children, through example, what is and is not acceptable behavior.

3.) Parents’ negative expectations become self-fulfilling prophecies. Some parents convey, whether subtly or overtly, that drug use, drinking, and sex are as much an inevitable part of adolescence as menarche and chest hair. These parents may be less likely to set firm limits with their children and may not impose consistent consequences for engaging in misbehavior. Perhaps the children of these parents are more likely to internalize their parents’ negative expectations and engage in misbehavior.

So, in addition to genetics and social learning, stereotypes and negative expectations play a powerful role in shaping children’s behavior. The same phenomenon, I’m afraid, is present between therapist and patient (minus the genetics, of course). Stereotypes and negative expectations play a powerful role in bad psychotherapy. There are many unsubstantiated theories of psychopathology that, when espoused by therapists and used in “treatment,” can easily become self-fulfilling prophecies. Here are a few examples:

1.) A therapist presumes that a teenager’s depression is the result of family dysfunction. In order to give the patient a sense of autonomy and protect his confidentiality, the therapist does not involve the family and instead focuses exclusively on the patient. Sessions are spent discussing the problems in the patient’s relationship with his parents. Meanwhile, the parents are growing increasingly worried about their son’s frequent crying, social withdrawal, angry outbursts, and declining school performance. The patient tells his parents that his depression is their fault. Mother blames father for working too much and not spending enough time with the patient. Father blames mother for coddling the patient. The parents’ marriage becomes strained, and the younger brother begins to act out as well.

2.) A therapist asserts that a patient suffering from anorexia nervosa or substance abuse will recover “when she wants to” or “when she’s ready.” The therapist then waits to see signs of “readiness” before pursuing aggressive intervention. Meanwhile, the patient is in the grips of a powerfully self-rewarding, self-perpetuating cycle of starvation or substance abuse and is thus rendered, by virtue of the illness, unable to “choose” recovery. The patient’s symptoms do not abate. Thus, the therapist continues to espouse the belief that the patient is not ready to choose recovery. The patient does not improve, and she concludes that she was not ready for treatment. Now, in addition to her life-threatening and agonizing symptoms, she is carrying around a massive load of guilt, self-blame, and probably blame from her loved ones as well, who don’t understand why she won’t choose recovery. Her symptoms worsen.

3.) A therapist presumes that a patient’s symptoms are the result of a grave trauma, although the patient does not report a history of trauma and there is no other evidence to suggest trauma. Therapy focuses on uncovering this trauma in order to resolve the patient’s symptoms. The therapist asks leading questions in order to confirm her hypothesis that the patient has been abused. The patient, who trusts the therapist and believes in her methods, develops a false memory of abuse. The patient continues to struggle with her symptoms. The therapist tells the patient that she must unravel the roots of her problems, and that it will take many years for her to recover. It does.

4.) A therapist presumes that a patient’s eating disorder is the result of over-controlling parents or relentless boundary violations. The patient is told that, in order to recover, she must break free from her parents’ tyranny and set boundaries for herself. The patient wants desperately to recover but struggles with restrictive eating and drastic weight loss. The therapist helps the patient explore various events of her childhood which supposedly demonstrate parental over-control (“My dad wouldn’t let me wear short skirts to school!”) or boundary violations (“My mom read my diary when I was 13!”). The patient recalls more and more of these types of incidents and discusses them in therapy while she continues to starve and lose weight. Meanwhile, her parents are doing everything in their power to ensure that she eats more: they force her to attend family meals, they pack her lunch for her, they cook for her. These “controlling” behaviors provide more grist for the therapy mill. Eventually, at the therapist’s encouragement, the patient moves out of her parents’ house, gets her own apartment, and stops coming to therapy. The therapist assumes that, released from her overbearing parents, the patient has addressed the root of her illness and has recovered. She has not.

These theories perpetuate themselves, and some practitioners cling to them like religious dogma. Like religious zealots, they latch onto evidence that confirms their belief, and they disregard any evidence to the contrary. They view every patient through the lens of their theory and structure their treatment accordingly. When your only tool is a hammer, everything looks like a nail.

Unless you have suffered from a mental illness, it is difficult to imagine how much it crushes your spirit, distorts your thoughts, warps your perception of reality, and alters your behavior. Unless you have sought therapy yourself, you may not realize just how vulnerable you are, especially as an adolescent or young adult, when you are sitting on the therapist’s couch with all of those distorted thoughts and feelings and perceptions. You are absolutely miserable, and you can’t stand feeling this way any more. The therapist is the expert, the savior, the one who will rescue you from your despair. She comes to know you better than anyone else in your life, and you are certain that she has your best interest in mind. You tell her your deepest secrets, you listen, you trust her, and you do whatever she says you need to do.

My point here is not to overly-dramatize the therapeutic relationship, because I think my description is actually quite realistic. My point is to convey just how harmful stereotypes, negative expectations, and unsubstantiated theories of mental illness can be. Bad therapy is not just ineffective – it has the potential to be every bit as harmful as a surgical error.

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Lifestyles of the Depressed and Anxious

Despite miraculous advances in science, medicine, and technology, the rates of mental illness in the western world are higher than ever before. For instance, the rate of depression in the United States is ten times higher today than it was just two generations ago. Most mental illnesses are biologically-based and genetically-transmitted, but genes don’t change that fast, and we are biologically quite similar to our ancestors. Prior to the 20th century, human beings faced more risk and hardship on a regular basis than most of us will ever know, all without the advantage of modern science and medicine. But somehow, they were more resilient. How can this be?

Research suggests that many features of the modern lifestyle are toxic to our mental health. Most Americans have at least one, if not many, of the following issues:

• Too little sleep (less than 8 hours per night)
• Not enough exercise
• Insufficient exposure to sunlight
• Insufficient time outdoors
• Hectic, overscheduled lifestyles
• Too little “down time” to relax and unwind
• Poor eating habits (dieting, skipping breakfast, overeating, having too few fruits and vegetables, skimping on protein and dairy and carbohydrates and fats, eating too many processed foods, insufficient intake to meet one’s energy demands)
• High levels of stress
• High levels of caffeine consumption (more than 2 caffeinated beverages per day)
• Excess alcohol consumption
• Use of illegal drugs
• Over-reliance on prescription and over-the-counter medications
• Social isolation
• Underutilization of family and community supports
• Intense pressure (self-imposed and socially prescribed) to achieve and perform

Sound familiar?

Any one of these issues has the potential to trigger a mental illness in someone who is biologically vulnerable. The unfortunate reality, however, is that most Americans are dealing with several of these concerns simultaneously. No wonder we are so depressed and anxious!

Hundreds of years ago, our lifestyles were much simpler and much healthier. Our better habits were reflected in our mental health. Consider the Amish, who pride themselves on resisting societal change and maintaining their 18th century lifestyle. The Amish have very low rates of mental illness. I believe this is largely attributable to their lifestyles: they are physically active every day, they get plenty of sleep, they simplify their lives, they have low levels of stress, they eat naturally and nutritiously without dieting, they are deeply spiritual, they have a strong sense of community, and they rely upon their families, neighbors, and churches for social support.

Consider the Kaluli, an aboriginal hunter-gatherer tribe native to the highlands of New Guinea. Relatively untouched by modern society, their lifestyles closely resemble those of our ancestors. They live and work outdoors, they are physically active for most of the day, they eat naturally and bountifully from the land, they get plenty of sleep, and they rely heavily on their families and communities for support. A western anthropologist who studied the Kaluli people for nearly a decade found that clinical depression was virtually nonexistent in their tribe.

I would bet that many Amish and Kaluli people have biological predispositions for mental illnesses, but these genes are less likely to be expressed in an environment that protects and nurtures the body, mind, and spirit. We are less likely to develop body image problems if we grow up in a society without dieting and without a narrowly-defined, media-promoted, unhealthy standard of beauty. We are less likely to develop eating disorders if we live in a society in which everyone eats, effortlessly and without guilt, the types and quantities of foods that their bodies need. We are less likely to suffer from anxiety or depression if we are well-rested, well-nourished, and well-supported by our families and communities. Our children are less likely to show signs of inattention and hyperactivity if they get plenty of fresh air and outdoor exercise and have minimal exposure to television, computers, video games, and cell phones. We may discover that, if we are truly caring for ourselves, we don’t need a cup of coffee to wake up in the morning, we don’t want to go out drinking on the weekends, and most of our aches and pains will diminish without the use of Advil. We may find that we actually enjoy going to bed at 9:00 and rising with the sun, spending more time outdoors, being more physically active, and letting go of excess stress that weighs us down.

Perhaps our minds are not suited for the modern world. The evolution of our brains has not kept up with advances in science, technology, and other aspects of modern life. I am not suggesting that, in a Survivor-like twist of events, we turn back time and return to our ancestral hunter-gatherer environment. Science and technology and modern society are remarkable in many ways, and I feel fortunate to live in the twenty-first century. I am suggesting, however, that we take a critical look at the way we live our lives and examine the effects that our behaviors and lifestyles have on our mental health. We can learn a few lessons from the Kaluli and the Amish. We can place more emphasis on our own self-care and encourage our friends and family to do the same.

When I was working at a university counseling center, a colleague of mine had a client – a college freshman – who met full criteria for major depression and an anxiety disorder. This young man’s case was puzzling initially because his symptoms appeared rather suddenly after starting college and he had no family history of depression or anxiety. After a thorough evaluation, my colleague recommended a few simple behavioral changes such as improving his sleep hygiene, increasing the number of hours he slept each night, decreasing his consumption of alcohol and caffeine, and increasing his physical activity. Within two weeks of changing his habits, his symptoms had disappeared entirely and he was back to his full-functioning, high-energy self.

The moral of this story is that poor self-care not only triggers or exacerbates mental illness in those who are biologically vulnerable, but it can actually create a syndrome that appears identical to a mental illness in those without a predisposition.

Very few people fully appreciate the value of self-care. Children are taught to excel in school and sports and music and arts and various other extracurricular activities. They are taught to follow the Ten Commandments and keep their rooms clean and mind their manners and look pretty. As they grow older, they are taught to stay away from drugs and have safe sex and watch their waistlines. But who will teach them good mental hygiene? Self-care is either glossed over or ignored completely in school. Many well-intentioned parents don’t model good self-care – they are overworked, overscheduled, overtired, overmedicated, over-caffeinated, and undernourished. These parents may encourage good grades and good behavior, but they are unlikely to instill good self-care habits in their children. Most physicians overlook the role of lifestyle factors in triggering or exacerbating mental illnesses, and they use medication as the first line of treatment, even if the patient’s problem could be addressed more effectively with behavioral interventions. Many therapists do not teach their clients the importance of self-care in preventing and reducing the impact of mental illness, instead choosing to target cognitive distortions or family relations or interpersonal skills. Don’t get me wrong – these issues are important as well – but without the baseline of good nutrition, plenty of sleep and exercise, stress management, and other healthy habits, the client is likely to continue to struggle with some level of depression or anxiety.

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Jagged Little Pills

More Americans than ever before are taking psychotropic medication. The number of people on antidepressants doubled between 1996 – 2006, yet the number of people seeing mental health professionals declined during that time period. Over 80% of prescriptions for psychotropic drugs are written by primary care physicians. I find these trends a little hard to swallow.

The overuse of psychotropic medication and the corresponding underutilization of behavioral and psychosocial treatments are disturbing on several levels. First, these trends are clearly driven by greed and profit. It serves the financial interests of the pharmaceutical industry and the insurance companies to minimize patient contact with healthcare professionals, even at the expense of quality of care. Pharmaceutical companies, with their numerous advertisements on television, on the internet, and in magazines, have the potential to reach a very large number of consumers.

Second, clients are not fully informed about all of their treatment options. More information is usually better than less information. The problem, however, is that most Americans don’t have the education and training to understand this information, nor should they. It is up to the professionals to use their knowledge and expertise, as well as their clinical judgment, to decide whether, when, and what medication to prescribe for a particular patient. That’s the way it should be. Remember the good old days when your doctor told YOU which medications you should take? Now, the commercials use cartoon neurotransmitters and wind-up dolls and present overly-simplified portraits of recovery from depression, while urging you to “Ask your doctor” how the drug du jour can help you. Another ad reads: “Taking an antidepressant? Still having symptoms of depression? Adding Abilify to your antidepressant may help.” The benefits are exaggerated and the serious side effects are downplayed. The ad does not tell you that psychotherapy, lifestyle changes, increased social support, improved nutrition, regular exercise, and adequate sleep are also likely to help. But hey, who has time for all of that? And when is the last time you saw a TV commercial touting the benefits of Dialectical Behavior Therapy? The result of this advertising is that patients go to a psychiatrist who quickly prescribes a medication after a brief evaluation and, in most cases, does no psychotherapy whatsoever. Even worse, the majority of patients will go to their primary care physician who, after a five or ten minute conversation, prescribes the psychotropic medication that the uninformed client saw on TV last night or the one of which she has samples left over from yesterday’s drug representative’s visit. There is usually minimal, if any, follow-up care, and many of these patients are maintained on a dosage of medication that is so low that it results in no therapeutic benefit whatsoever. Except maybe a placebo effect.

Third – and this point is closely related to my first and second points – clients are not getting adequate, quality mental health care. For many mental illnesses, such as panic disorder, bulimia nervosa, mild depression, generalized anxiety disorder, and PTSD, certain forms of psychotherapy are more effective than medication. For other mental illnesses, such as recurrent major depression, the combination of psychotherapy and medication generally produces the best outcome. In many cases, adding psychotherapy to medication treatment allows clients to take fewer medications and lower doses of medication. Clients who receive a combination of psychotherapy and medication are less likely to relapse when the medication is discontinued, compared to clients who are treated with medication alone. The benefits of good psychotherapy are long-lasting and, in some cases, curative. In contrast, medication is merely palliative, and its benefits usually fade once it is discontinued. For certain conditions, such as bipolar disorder, schizophrenia, and recurrent major depression, medication is clearly indicated as a necessary component of treatment and should be started immediately after diagnosis. Even in these cases, medication alone is often insufficient. Clients’ symptoms can be reduced even further, and their quality of life improved even more, when psychotherapy is combined with medication.

Finally, the fact that psychotropic medication is grossly over-prescribed and over-marketed seems to trivialize the experience of people who genuinely need psychiatric medication. Many times, I have raised the issue of psychiatric medication with clients whom I think can benefit from it. Many times, they have responded: “Oh, no. I don’t want to take a happy pill.” Or “No, I don’t want to use medication as a crutch.” Or “I don’t want to become dependent on something.” Or “That’s the easy way out.” I believe that our society’s nonchalance regarding psychotropic medication is directly responsible for some clients’ aversion to it. However, the fact that psychotropic medication is prescribed at the drop of a hat does not negate the reality that some people genuinely need it and some people truly benefit from it.

My own experience as a therapist has reinforced what I have learned by studying the research. My views on psychotropic medication can be summarized as follows: medication can be a very helpful adjunct to psychotherapy for clients who clearly need it. In other words, while I am by no means anti-medication, I am somewhat conservative in my approach to it. Case in point: although virtually all of my clients have a diagnosed mental illness, only half of them are taking psychotropic medication. For most clients, the first form of treatment should be psychotherapy focused on improving self-care, making lifestyle changes, acquiring coping skills, improving symptoms, and dealing with interpersonal issues. Medication may be introduced as an adjunct to therapy if the client does not make substantial improvement with therapy alone. I have seen many clients make marked improvements or recover completely without ever taking psychotropic medication. With clients for whom medication is clearly indicated (e.g., those with bipolar disorder), I will refer them to a psychiatrist immediately while also emphasizing that therapy, behavioral interventions, and self-care are important aspects of treatment as well. I don’t like my clients to take psychotropic medication prescribed by their family doctor for all of the reasons mentioned above. If a client comes to me on a psychotropic medication prescribed by their family doctor, I explain the importance of seeing a psychiatrist (e.g., they have specialized training in psychiatric illnesses and are more knowledgeable about psychotropic medication, they provide more thorough evaluations and better follow-up care than general practitioners) and I provide them with psychiatric referrals.

In order to rectify this situation, I believe that the following things must happen:

1.) Primary care physicians should not prescribe psychotropic medications. Instead, they should identify those patients who may have a mental illness and refer them to a psychologist or a psychiatrist for treatment.
2.) Psychiatrists should fully inform patients about the risks and benefits of taking medication, the risks and benefits of not taking medication, and scientifically-sound information on the effectiveness of medication. In addition, psychiatrists should inform patients about the effectiveness of various forms of psychotherapy, either in lieu of medication or in addition to medication. Psychiatrists should only prescribe medication to patients who are also in therapy.
3.) Psychologists and other therapists should be conservative in referring patients for psychiatric treatment and in recommending psychiatric medication.
4.) The pharmaceutical companies should stop advertising to consumers. They can still market themselves to physicians and mental health practitioners, since these professionals have the training and knowledge to use this information appropriately.
5.) Insurance companies should provide coverage for psychotherapy that is equal to the coverage they provide for psychotropic medication. Likewise, insurance companies should reimburse psychologists and other therapists at the same rate as psychiatrists.
6.) Every American should have access to local, affordable, quality, evidence-based psychotherapy.

Optimistic? Yes. Idealistic? Yes. Impossible? Absolutely not. It may not happen anytime soon, but for now, I can practice what I preach and apply my philosophy to my own clinical work.

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Informed Consent

The American Psychological Association’s ethical guidelines require that psychologists obtain informed consent for treatment from all patients and parents of minor patients. But what does it mean for consent to be truly informed?

In standard practice, informed consent generally amounts to a frazzled patient or harried parent signing a consent form after a perfunctory glance. Patients and parents are often in crisis when they first present for treatment, and signing the form is just one more hoop to jump through before getting into therapy. Most therapists’ consent forms cover business procedures and confidentiality issues. This is important information, but does it amount to truly informed consent?

I don’t think so.

I believe that the APA’s ethical guidelines should be revised to require full disclosure in informed consent for psychological treatment. Specifically, therapists should be required to disclose 1.) The patient’s diagnoses and explanations of these diagnoses, 2.) What factors caused or contributed to the patient’s illness, as evidenced by the most recent empirical research and the clinician’s informed judgment, 3.) What treatment methods are available for treating the patient’s condition, 4.) Which of these methods are evidence-based, 5.) Which method(s) the therapist will use, 6.) Why the therapist has selected these methods, 7.) The anticipated course of treatment and prognosis, based upon recent empirical research, and 8.) Scientifically informed, practical resources (e.g., books, articles, websites) on the patient’s condition and the type of therapy that will be used. For patients under 18, all of the above should be explained to the parents and to the child, using language appropriate to the child’s age and developmental level. Finally, parents should be provided with guidance as to how they can help their child recover. I’m talking about specific recommendations, not just blanket statements like “be supportive.”

In my consent for therapy forms, which patients (and parents of minor patients) read and sign before meeting with me, I specify the types of treatment I use, all of which are evidence-based. After the evaluation, I provide patients(and parents of adolescent patients) with empirical research on their particular disorder, as well as information on the efficacy of various types of treatment and who recommends these treatments (e.g., APA, Society for Adolescent Medicine, etc.). I explain the type of treatment I recommend for them, why I have selected this type of treatment, how it works, and what to expect on the road to recovery. If there is a type of treatment that is likely to be effective for the patient but that I do not offer (e.g., psychiatric medication, residential treatment), I provide them with referrals to these types of treatments and explain why I think they would be beneficial. At this point, the patient has all of the information she needs to make an informed choice about treatment.

Most patients seeking therapy, and most parents seeking therapy for their children, are not aware that there are different types of psychological treatments with varying degrees of efficacy. I think most people outside of the field assume that therapy is therapy and that therapists are pretty much interchangeable, like dentists or surgeons. Many people assume that as long as you like your therapist and feel comfortable with her, that’s all that matters. While the therapeutic relationship is undoubtedly a critical aspect of treatment, there are other factors to consider in selecting a therapist. Often times, people want to see a psychologist with decades of experience. This is an understandable, albeit unreliable, method of seeking good treatment. The older, more experienced therapists were trained decades ago in theories that have since been discarded, in therapeutic methods with no scientific backing. Sometimes they become set in their ways of practicing, clinging to old theories like religious dogma in spite of evidence to the contrary. Granted, many experienced therapists have kept up with recent developments in the field and have educated themselves. Sadly, many have not.

Informed consent in therapy is complicated by the fact that different professionals have vastly different, and often contradictory, views on the causes of various mental disorders and how best to treat them. To make matters worse, the public has access to a tremendous amount of information on mental health issues through the internet, much of which is either unsubstantiated or patently false. Consequently, many patients arrive in our offices with deeply entrenched false beliefs about their illnesses. As professionals, it is our job to set the record straight.

I have had a number of patients come to me seeking therapy for the first time after being unsuccessfully treated for anxiety or depression by their primary care physician. I use the term “treated” very loosely here – their doctor spoke with them for a few minutes and wrote them a prescription for a low dose of antidepressants or sleeping pills, only to follow up with them a year later. They were not informed about evidence-based psychological treatments. They were not informed about behavioral methods of treating insomnia. And of course, they were not informed that their dose of Prozac is far too low to have any therapeutic benefit. Similarly, I have had patients come to me after years of therapy for depression or self-injury who have done endless amounts of exploration into the supposed causes of their supposed issues, without ever learning the skills they need to recover.

Parents of eating disordered children have come to me for Maudsley family-based therapy after months or years of unsuccessful therapy, after multiple hospitalizations and stints in residential treatment. These families were never informed about the Maudsley Method by any of their child’s previous treatment providers. These parents, desperate to help their children, did their own research on the internet late at night, sifting through the mounds of information to try to find the one thing that would save their child’s bright future. I’ve seen patients, who have been through years of eating disorder treatment with other professionals, who have never once been told that they have a biologically-based, genetically-transmitted mental illness which is neither their fault nor their choice.

Parents of eating disordered children have a right to be informed about the Maudsley Method at the time of diagnosis. The research is clear that Maudsley is the most effective treatment for adolescents with a short duration of illness who are still living at home with their families. For various reasons, Maudsley is not the best choice for every patient or family. Nonetheless, families have the right to know it exists and to decide for themselves whether they wish to pursue it. Patients with depression, anxiety disorders, and personality disorders have the right to be informed about evidence-based treatments such as CBT, DBT, and ACT. Many lives, many years of chronic illness, and many dollars spent on ineffective treatments could be saved if patients and parents were fully informed about evidence-based treatment options from the outset. If a patient has cancer, it is her physician’s duty to inform her of the various life-saving treatment options, some of which may be available in that physician’s office or the local hospital, and some of which are only available in the nearest major city. Why should psychology be any different?