Resilient Health May 2018 by Resilient Health

A NATIONAL BEHAVIORAL HEALTHCARE SYSTEM PATIENTS TREATED:

TREATMENT SERVICES FOR:

• Adolescents (12-17 years) • Adults

• Primary Mental Health • Substance Use • Dual Diagnosis • Pain • Cognitive Deficits • Trauma and Emotional Dysregulation • Adolescent and Adult Eating Disorders (Females Only) • Adolescent Transgender and Gender Identity

LEVELS OF CARE: • Detox • Residential Treatment • Partial Hospitalization Program • Intensive Outpatient Program • Outpatient Program • Continuing Care

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Issue

In this

May 2018

RESILIENT Health

MESSAGE FROM THE EDITOR Welcome to the May Issue...................................................... 4

FEATURE ARTICLES Brain Wellness Part I: Neuroanatomy and Neurophysiology Essentials................................................. 6

RESILIENT HEALTH is published monthly and copyrighted by Sovereign Health, Inc., all rights reserved. Permission must be granted by the publisher for any use or reproduction of the magazine or any part thereof. Opinions expressed are those of the authors alone and do not necessarily represent the opinions, policies or positions of RESILIENT HEALTH or Sovereign Health, Inc. Â©2018, Sovereign Health, Inc. Printed in the U.S.A.

Is Addiction a Mental Illness?................................................10

Editor-in-Chief TONMOY SHARMA, MBBS, MSc

QUIZ CORNER: Anxiety Test ............................................... 20

Communications Manager LISE MILLAY STEVENS, M.A. Managing Editor EDWARD ZINTEL e.zintel@sovhealth.com Senior Staff Writer DANA CONNOLLY, Ph.D. Graphic Designer VINOD SHARMA Content Specialist AMIT MALAVIYA

FREE SUBSCRIPTION! Sign up for your free subscription to RESILIENT HEALTH at www.reshealth.net today!

Land of the Free and Depressed: The cost of depression in America ................................13 Stigma-Free Living: A Tale of Life with Bipolar Disorder...........................................................16

Notes from ATA18: Is Telehealth the Antidote to the U.S. Opioid Epidemic?............................................21 At A Glance: Behavioral Health In The News.........................26 FAST FACTS: Eight Habits of Above Average Therapists.....................28

RESILIENT HEALTH A Behavioral Health Resource from Sovereign Health Publications, Inc. 1211 Puerta Del Sol, Suite 200 San Clemente, CA 92673 Editorial Tel: (949) 276-5553, ext. 391 Email: editor@reshealth.net Website: www.reshealth.net

MESSAGE from the Editor W

elcome to the May issue of RESILIENT HEALTH! May is Mental Health Month. The 2018 focus is on “what we as individuals can do to be fit for our own futures–no matter where we happen to be on our own personal journeys to health and wellness” (https://bit.ly/1gmuHEo). After all, we can’t talk about human health without including mental well-being. Access the toolkits and help to spread the word about mental health and raise awareness in communities across the United States.

Tonmoy Sharma, MBBS, M.Sc.

We’re launching a new series, Brain Wellness, to highlight the importance of this organ in mental health and addiction. Our first installment provides a detailed overview of the inner workings of the brain and the processes that derail healthy behaviors and drive unhealthy ones in addiction and mental illnesses. Also this month, we look at the emerging field of telehealth. Our reporter is providing up-to-date coverage in this and upcoming issues to keep us abreast of the latest in this cutting-edge, high-tech treatment option (See the breaking news from the American Telemedicine Association’s annual conference in Chicago on page 21). Telehealth is invaluable in its ability to keep patients connected during recovery and its long reach in providing treatment options in under-served and rural communities. The feature on depression in America enumerates the billions of dollars annually lost to this devastating condition; the societal costs (suicide, despair) are both staggering and tragic. Our provocative piece “Is Addiction a Mental Illness?” compares the causes and symptoms of these brain disorders and weighs the value of treating addiction as one would a mental condition. Read our interview with Andrea Paquette, executive director and founder of the Stigma-Free Society, for a fascinating first-person take on stigma, addiction, mental illness and recovery. Her intimate account about living with co-occurring bipolar and substance use disorders is a study in resilience and determination, qualities that helped her grow and be successful despite her mental illnesses. Our Fast Facts section offers a quick test for patients to determine if they’re suffering from anxiety, a disorder often seen with other mental conditions, especially eating disorders. Undiagnosed anxiety can create barriers to treatment and if untreated, can have long-term effects on clients’ ability to recover and move forward with their lives. This useful tool will help you catch this pervasive but often subtle disorder and take the appropriate steps to alleviate its symptoms. Thank you for reading our May issue! May you prosper in all you do in our field.

4 RESILIENT HEALTH | May 2018

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Letter to the

E D I TO R

Dear Editor, Your publication sounds very interesting. If it is in your wheelhouse, I think it would be helpful to be clear that your publication serves mental health conditions, period. I say this because while my son had a drug problem, once that was treated (and I realize that can be a lifelong struggle), he now has a mental health problem. As we know, there is often a chickenand-egg issue in dealing with dual diagnoses. I often think about how my mother had to deal with a sister in her 40s who died of breast cancer (in the 1960s) and then a son of AIDS (in the 1980s). These were taboo and not talked about by design (stigma, shame, lack of support, etc.). This world is changing for mental health partially shaped by other forces such as sexual harassment, racial discrimination and so forth. The timing of your publication couldn’t be more prescient. Good luck, Georgia Case

Reply from the

E D I TO R

Thank you for your feedback and letting us know that RESILIENT HEALTH is indeed a relevant resource in these unfortunate times. Your son has made a tremendous step in beating his drug problem; it’s unfortunate that his mental health issue was not identified earlier. As you so wisely observe, mental disorders and substance use feed into each other. We sincerely hope he finds the help he needs so he can lead the healthy life he deserves. It’s such a tragedy that your mother was negatively affected by the all-too-common stigma associated with diseases such as HIV and cancer. We have come a long way in bringing illnesses out into the open, but there is still a need to demystify and destigmatize behavioral health issues; this was one of the main impetuses behind our launching RESILIENT HEALTH. Please help us to educate others by sharing our website (www.reshealth.net) so others may learn that addiction and mental disorders are diseases like any other, worthy of understanding, compassion and treatment. We also appreciate your comment regarding who we serve; just wanted to clarify that RESILIENT HEALTH is for a variety of audiences—anyone with both a mental health and a substance use issue, their loved ones and anyone else who wants to learn more about behavioral health. Best of luck to you, your son and anyone else you hold close to your heart.

www.reshealth.net

RESILIENT HEALTH | May 2018 5

Brain Wellness Part I:

NEUROANATOMY AND NEUROPHYSIOLOGY ESSENTIALS By Dana Connolly, Ph.D.

he human brain is a remarkable organ with capacities that are still not fully understood. Only over the past few decades has it become clear that brain cells can and do regenerate and form new connections throughout a person’s lifetime. This capacity allows the brain to recover in whole or in part after injury from stroke, trauma, addiction and other insults. Working with patients who are experiencing mental illness or addiction requires an in-depth understanding of all aspects of human nature, particularly the mind. Conventional psychiatry and 6 RESILIENT HEALTH | May 2018

behavioral health science approach treatment from a neurological standpoint and target interventions based on neuroendocrine (neural and endocrine in structure or function) and cognitive science. Therefore, the purpose of this series is to review the fundamental principles of brain health, including recent developments and clinical applications for mental health care professionals.

In the Beginning Brain development begins between the third gestational week, when embryonic stem cells begin to differentiate into neural progenitor

cells – ones that differentiate into different types of brain cells before most women even realize they are pregnant. These cells follow an elaborate pattern of layering, migration, further differentiation, proliferation and regression as the brain, spinal cord and nervous system form in utero. The brain continues to grow rapidly after birth and continues to “hard wire” itself until around age 25 and even beyond. This amazing process results in a fully formed brain and nervous system. The diagram on page 7 illustrates the major brain structures and functions. www.reshealth.net

circuits form is miraculous and only recently well-defined.

The information processing cells that comprise the nervous system are called neurons. Neurons consist of the cell body (control center) and the processes (structures that extend from the cell body), such as dendrites (signal receivers) and axons (signal transmitters). The axon terminals are structures at the end of the axon that contain chemicals called neurotransmitters, which pass information on from neuron to neuron through chemical and electrical synapses. The following diagram details the neuron, including the organelles of the neuron body and the synapse:

Critical Connections Connections between neurons form pathways, which result in patterns of thought and behavior over time. The pathways that neural signals follow are like hiking trails. New trails are created the first time someone hikes in a new area, which can be difficult to forge. The more the trail is used, the easier it gets to traverse. Learning and habit formation occurs in a similar fashion through the process of neural plasticity. Neural plasticity is the capacity of nervous tissue to modify itself structurally and functionally as needed, including cell growth, cell repair, apoptosis (cell death) and the development of new circuits, which formulate new ways of thinking or behaving. The process by which these www.reshealth.net

Ann Graybiel of the Massachusetts Institute of Technology and her colleagues have shown that a region deep inside the brain called the striatum is key to habit formation. First, a person thinks about doing something using the prefrontal cortex, which sends electrochemical signals to the striatum, which sends the necessary signals through the basal ganglia, resulting in action. If the action is repeated, neuropathways form that loop the striatum to the sensorimotor cortex and the prefrontal cortex is bypassed. The loops, together with the memory circuits, result in automatic behavior requiring little or no thinking. The process of habit formation is useful as it allows people to multitask, but it can make it difficult to break bad habits. One reason lifestyle changes are difficult is because it takes time to create new neuropathways, loops between the striatum and sensorimotor cortex, and requires the consistent concentration of the prefrontal cortex. But that’s not the only reason lifestyle changes are difficult. Neurotransmitters also play a powerful role in habit formation.

Brain Chemicals The striatum is also at the core of the brain’s reward center and where neurotransmitters normally converge. The activation of neurotransmitters profoundly affects emotions, thoughts and behavior. The chart on page 8 reviews the trigger and function of neurotransmitters. Activities that result in positive feelings tend to be repeated; these RESILIENT HEALTH | May 2018 7

repeated behaviors formulate the striatal circuits. Healthy lifestyle habits therefore will create healthy striatal circuits. Unhealthy lifestyle habits create unhealthy striatal circuits. This basic diagram of the reward center of the brain illustrates the striatum in relationship to other structures and neurotransmitter pathways:

Neurotransmitter

Source

Function

Adrenaline

Stress

Fight or flight response

Noradrenaline

Severe stress

Fight or flight response

Dopamine

Pleasure

Motivation

Serotonin

Exercise, sunlight

Sleep, digestion, happiness

GABA

CNS stimulation

Regulates CNS, motor control, vision

Acetylcholine

Muscle action, awakening

Thought, learning, memory

Glutamate

Neurogenesis

Learning, memory

Endorphins

Exercise, love, sex

Euphoria, pain reduction

little dopamine and lots of new dopaminedependent nerve cells screaming for more drug (and they don’t take “no” for an answer). This process results in chemical dependency, in which a person’s prefrontal cortex is hijacked by the perceived physical need for more of the intoxicating substance.

The Brain Deranged Unhealthy lifestyle habits can cause derangements in neurotransmitters and abnormal neural pathway formation. For example, psychostimulants like cocaine or methamphetamine increase dopamine concentrations in the reward center by blocking reuptake of dopamine at the axon terminal. Accumulations of dopamine induce abnormal dopamine-dependent pathways that may persist for months even after a single exposure to a drug. To make matters worse, the mechanism that normally releases dopamine is shut off because there is so much extracellular dopamine. When the drug is metabolized, and the dopamine rush dissipates, there is 8 RESILIENT HEALTH | May 2018

As a result, healthy lifestyle habits should be encouraged at birth and be consistent. Like programming a computer, “hard wiring” the brain with healthy neuropathways results in the brain “defaulting” toward healthy behaviors later in life. But because of neural plasticity, positive change is always possible. Even people with chemical dependency can re-create healthy striatal circuits, but the need for the development of healthy lifestyle habits cannot be underemphasized in such cases.

Proper Care and Feeding of a Brain As remarkable and resilient as the brain is, it still needs certain basic conditions to function properly. Having a brain is a lot like having

a pet ‒ they are both incredible assets capable of taking their owners on amazing journeys. But like a pet, caring for a brain requires the owner to take time every day to keep it healthy. The brain needs the same things a pet does, such as oxygen, water, food, exercise, rest, stimulation and love. But if brain owners neglected their pets the same way they do their brains, the ASPCA would be knocking at their doors. Fortunately for the brains of neglectful owners, existing brain cells can repair themselves and new neurons and synapses do develop. But the quality of daily lifestyle habits determines the quality of cell repair. From neural connections to interpersonal connections, the way we live affects our brains from the molecular level to the spiritual level. The next installment of this series will summarize how daily lifestyle habits promote or prevent brain wellness. Dana Connolly, Ph.D., is a senior staff writer for Sovereign Health. She earned her Ph.D. in research and theory development from New York University and has decades of experience in clinical care, medical research and health education. For more information and other inquiries about this article, contact the author at news@sovhealth. com, visit us at SovHealth.com, Facebook and LinkedIn, or follow us on Twitter.

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SPECIAL SECTION

Treating Substance Use Disorders:

A Resolution to Embrace Measurement-Based Care Why Measuring Treatment Outcomes is a 21st Century Mandate for Treating Addiction

e are well into the second decade of the 21st century. On almost a weekly basis, new discoveries gleaned from advanced neuroimaging techniques, rigorous clinical trial outcomes data, and the development of novel neuropsychiatric medications are opening new pathways in addiction treatment. Individuals with substance use, and those with the comorbidities of addiction and an underlying psychiatric condition, should be reaping the beneﬁts of evidence-based addiction treatment. But sadly, data show that health care professionals are not implementing evidence-based science (Scott & Lewis, 2015) in treating the 21.5 million Americans who have a substance use disorder (SAMSHA, 2016).

Dr. Tonmoy Sharma, MBBS, MSc CEO, Sovereign Health

of symptoms, and empowers patients to participate in their own care while improving their outcomes (Lambert et al.; 2005).

n 2015, the Kennedy Forum released an Issue Brief titled “Fixing Mental Health Care in America: A National Call for Measurement-Based Care in the Delivery of Behavioral Health Services,” which illustrated the domino eﬀect caused by a

espite the deleterious effects of not implementing an MBC model, clinicians have been slow to change. It is worth noting that, in general, it takes 17 years for 14 percent of research to reach consumers (Balas & Boren; 2000). In addition, clinicians have negative perceptions about MBC, including that the burden of training themselves and their staffs is too onerous, negative feelings about prescribed manuals and protocols, and a belief that specific evidence-based practices may not be appropriate for their clients and their practice settings (Scott & Lewis, 2015).

e know that quality health care, including substance use and addiction care, should be ﬁrmly rooted in established biomedical research. Measurement-based care (MBC) — the practice of basing clinical care on client data collected throughout treatment (Scott & Lewis, 2015) — is a core component of evidence-based practices (Klerman, Weissman, Rounsaville & Chevron, 1984; Beck & Beck, 2011). Over the past decade, MBC has emerged as an incontrovertible, evidence-based method that can be used for virtually any health issue (Lambert et al., 2003; Trivedi et al., 2007), and research has shown that applying MBC (such as monitoring symptom change using idiographic assessments) is beneﬁcial for improving client outcomes (Weisz et al., 2011). Overall, MBC elucidates treatment progress, allows for adjusting treatment plans as necessary, reduces exacerbation

services. Providers and, indeed, entire health care systems miss opportunities for ongoing improvement. A lack of symptom rating scales precludes individual practices and health care networks from proving the eﬃcacy of their treatment protocols to third-party payers. This lack of empirical data on treatment success leads to chronic federal and state underfunding of behavioral health treatment, and decisions about reimbursement for services rendered are not aligned with treatments that are proven to be the most beneﬁcial (Kennedy Forum, 2015).

non-MBC approach in behavioral treatment. The conclusions are mind-boggling; per the Brief, a mere 18 percent of psychiatrists and 11 percent of psychologists monitor the eﬃcacy of speciﬁc treatment approaches by routinely administering symptom rating scales and therapist assessments to their patients. This lack of assessment cements clinical inertia, and creates barriers to improving clinical

iven the stakes, we cannot accept that these perceived barriers to MBC are insurmountable, unresolvable or even valid. A lack of evidence-based treatment spells failure for clinicians, institutions, health care networks and, most importantly, our patients. Let us resolve to embrace our brave new world of clinical innovations and scientific advances that enable us to provide the best measurement-based care for substance use and addiction treatment.

References

Balas, E. A., & Boren, S. A. (2000). Managing clinical knowledge for health care improvement. Yearbook of Medical Informatics, 65–70; Beck J.S., Beck A.T. (2011). Cognitive behavior therapy: Basics and beyond. New York: Guilford Press; Kennedy Forum (2015). Fixing Behavioral Health Care in America: A National Call for Measurement-Based Care in the Delivery of Behavioral Health Services; http:// thekennedyforum-dot-org.s3.amazonaws.com/documents/KennedyForum-MeasurementBasedCare_2.pdf; Klerman G.L., Weissman M.M., Rounsaville B.J., Chevron E.S. (1984). Interpersonal psychotherapy of depression. New York: Basic Books; Lambert, M. J., Whipple, J. L., Hawkins, E. J., Vermeersch, D. A., Nielsen, S. L., & Smart, D. W. (2003). Is It time for clinicians to routinely track patient outcome? A meta-analysis. Clinical Psychology: Science and Practice, 10, 288–301; Lambert, M. J., Harmon, C., Slade, K., Whipple, J. L., & Hawkins, E. J. (2005). Providing feedback to psychotherapists on their patients’ progress: Clinical results and practice suggestions. Journal of Clinical Psychology, 61, 165–174; Scott K., Lewis C.C. (2015). Using Measurement-Based Care to Enhance Any Treatment. Cognitive and Behavioral Practice, 22:49-59; Simons, A. D., Rozek, D. C., & Serrano, J. L. (2013). Wanted: Reliable and valid measures for the science of cognitive behavioral therapy dissemination and implementation. Clinical Psychology: Science and Practice, 20, 181–194; Substance Use and Mental Health Services Administration (2016). Mental and Substance Use Disorders. SAMSHA; Rockville, MD. https://www.samhsa. gov/disorders; Trivedi, M. H., Rush, A. J., Gaynes, B. N., Stewart, J. W., Wisniewski, S. R., Warden, D., … Howland, R. (2007). Maximizing the adequacy of medication treatment in controlled trials and clinical practice: STAR*D measurement-based care. Neuropsychopharmacology, 32, 2479–2489; Weisz, J. R., Chorpita, B. F., Frye, A., Ng, M. Y., Lau, N., Bearman, S. K., … Hoagwood, K. E. (2011). Youth Top | www.reshealth.net RESILIENT HEALTH May 2018 9 of Consulting and Clinical Psychology, 79, 369. Problems: Using idiographic, consumer-guided assessment to identify treatment needs and to track change during psychotherapy. Journal

IS ADDICTION A MENTAL ILLNESS? By Resilient Health Staff

ddiction is a brain disease, but it’s not typically treated as one. Why? What makes addiction different from a mental illness? Is addiction different from a mental illness in the first place? To address this question, it may help to review some of the similarities and differences between addiction and mental illnesses.

Similarities Between Mental Illness and Addiction Substance use and mental

disorders share many traits. Examples include the following: 1. Both addiction and mental illness have genetic links. 2. People with mental illness are more likely to have family members with mental illness, and people with substance addiction are more likely to have family members with substance use issues. Researchers suspect that people with drug addiction have genetic variants that impede dopamine receptors from functioning correctly (https://bit.ly/2FdJ1Tm).

10 RESILIENT HEALTH | May 2018

3. Both addiction and mental illness are biological. 4. Addiction, like mental illness, is a disease and not a moral failing. People who are coping with addiction have brain structures that look and behave differently than people without addiction (https://bit.ly/2vJ8B39). The same is true of people with mental illness (https://bit.ly/2ANfD4x). 5. Both addiction and mental illness can have environmental triggers. Not everyone who is genetically predisposed to mental illness www.reshealth.net

will develop a mental disorder, just like not everyone who is genetically predisposed to addiction will develop a substance use disorder. This is because both mental illness and addiction can have environmental triggers. For instance, people who are predisposed to addiction may not develop one until they receive prescription opioids, just as people who are predisposed to PTSD may never develop symptoms if they don’t experience a traumatic event.

Preventative Care Can Make a Difference Although mental illness and addiction are both diseases, they can be prevented (or their onset can be delayed) by maintaining good health habits. People who are at risk for mental illness can practice good sleep habits, avoid stress, exercise regularly and eat healthfully, all of which have been found to positively influence mental health. People who are predisposed to addiction can maintain similar habits and/or abstain from drugs and alcohol to reduce the likelihood of developing a disorder. Mental illness and addiction often require lifelong treatment. People with schizophrenia may need to take medication and attend therapy for the rest of their lives, whereas those afflicted with alcoholism may need to consistently attend peer support group meetingss. It’s possible to relapse with mental illness just as it’s possible to relapse with substance addiction. For instance, people with for treated bipolar disorder may find their symptoms grow worse during a stressful period. They may require new medication or even hospitalization. The symptoms associated with www.reshealth.net

addiction can also wax or wane depending on life circumstances. In addition to these similarities, most doctors believe that addiction is a mental illness. Substance use disorder (https://bit.ly/2hJ3GU6) are included in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), which contains extensive information on every mental disorder.

Differences Between Mental Illness and Addiction There are very few differences between mental illness and addiction. The main difference is that addiction involves mindaltering substances, many of which are illegal or morally frowned upon. For this reason, people with substance use disorders experience a distinct stigma and are often treated as though they are corrupt or fundamentally bad. (Mental illness, it should be noted, has its own serious stigma.) The stigma associated with drug addiction is often reflected in the vocabulary used to describe it. For instance, people who are addicted

to drugs are said to “abuse” them, implying that they are actively harming another entity when they are only harming themselves. (Clinicians prefer the term drug “misuse”). People who are addicted to substances are thought to have to “hit rock bottom” before being motivated to seek treatment, whereas people with mental illness are urged to seek treatment as soon as possible, an ultimately healthier course of action. The sooner a person with drug misuse seeks treatment, the more successful the outcome can be.

Why Treat Addiction Like a Mental Illness? As mentioned, addiction is included in the DSM-5, the official guidebook on mental health. Clinicians and patients can both benefit from interventions that are typically reserved for mental health disorders, such as therapy and brain wellness practices. Addiction is a brain illness. It’s vital that health care specialists treat it as such.

RESILIENT HEALTH | May 2018 11

S E RV I C E S O F S OV E R E I G N HEA LTH

Addiction / Dual Diagnosis Sovereign Health is a leader in the treatment of addiction, mental health disorders and dual diagnosis. Dual diagnosis refers to a mental health condition and substance abuse occurring simultaneously. Sovereign believes that addiction is a chronic brain disease that may include periods of relapse. It is important to note that repeated relapses after periods of sobriety may indicate the presence of an underlying disorder requiring professional treatment.

Treatment Programs Offered:

At Sovereign Health, we specialize in the complex assessment and multidisciplinary care required to successfully treat patients who are struggling with dual diagnosis. Our behavioral health team of masterand doctoral-level therapists are uniquely qualified to treat the mental health conditions that often accompany substance abuse.

• Detoxification

We attribute much of our success to the holistic approach we employ with each individual patient. Multidisciplinary aspects of care are all interrelated and each person has different needs. From arrival to discharge, our treatment team includes each dual diagnosis patient in all decision-making related to his or her own plan of care.

• Telehealth

Patients Served • Adolescents • Adults • Males, Females and Transgender

Levels of Care • Detoxification • Residential Treatment • Partial Hospitalization • Intensive Outpatient • Outpatient • Recovery Management

For more information, please visit

www.sovhealth.com

12 RESILIENT HEALTH | May 2018

• Primary Mental Health • Substance Use • Dual Diagnosis • Eating Disorders • Pain Recovery • CROSS: Christian Recovery Offering Significant Success • POWER: Primary Opportunities for Women Experiencing Recovery • PRIME: Personal Recovery Integrating Men’s Experiences

24/7 ADMISSIONS HELPLINE

www.reshealth.net 888.701.7488

Land of the Free and Depressed

The cost of depression in America By Ralph Ryback, M.D.

merica, the land with the freedom to pursue happiness, isn’t exactly happy. Americans are stressed, burned out and depressed. We spend more time at work and less time on vacation than people in other Western countries, which may contribute to the tremendous depression statistics. It’s no surprise that depression affects approximately 15 million American adults, or about 6.7 percent of the U.S. population 18 years of age and older on a yearly basis (https://bit.ly/2hJrUTz). In a www.reshealth.net

country where we measure our success by our possessions opposed to our relationships with people who matter, happiness studies have proven that Americans are more dissatisfied with their lives than many other societies around the world.

a financial standpoint is now a major burden on the United States The cost of depression is not only measured from a monetary standpoint but can be measured by social and emotional hardships as well.

The World Happiness Report (https://bit.ly/2HrubL8), reveals that the United States, one of the wealthiest countries in the world, is No. 15 on the Ranking of Happiness. It’s no surprise, then, that the cost of depression from

The Diagnosis The famous mnemonic SIGECAPS is what is taught in college to easily remember all the diagnostic signs and symptoms for depression. Five out of eight of these symptoms must be present for at least RESILIENT HEALTH | May 2018 13

two weeks for a diagnosis of depression: • Problems with Sleep • Loss of Interest • Feelings of Guilt • Lack of Energy • Loss of Concentration • Change in Appetite • Psychomotor agitation • Suicidal ideation People might argue that with a minimum two-week duration, depression is often situational and can present in patients because of a breakup, financial hardship, a physical illness or the loss of a loved one. Regardless of whether depression is situational or a major disorder, it costs the United States $210 billion annually (https://bit.ly/2puZDkG).

The Numbers According to an article in the Journal of Clinical Psychiatry (https://bit.ly/1UA457u), depression in this country is “a leading cause of disability for ages 15 to 44, resulting in almost 400 million disability days per year, substantially more than for most other physical and mental conditions. The economic burden of depression, including major depressive disorder (MDD), bipolar disorder and dysthymia, is spurred by millions spent on direct medical costs, suicide-related mortality, lost productivity at the workplace and the less unquantifiable human and social cost. This economic burden is continuing to rise. According to a study published by the Journal of Clinical Psychiatry (https:// bit.ly/1UA47u) annual costs related to major depressive

disorder rose to $210.5 billion in 2010. This dramatic increase shows that we’re failing at treating this disease. From missed days of work leading to loss of productivity (https:// bit.ly/2qXWzxs), to the earnings made by the pharmaceutical and insurance companies, mental illness is now a costly business. This is not surprising as Americans are hooked on pharmaceutical drugs (https://bit.ly/2qZc2xf). Patients walk into their doctor’s office with a virus yet demand antibiotics, and we as physicians are so overly concerned with our patient satisfaction ratings that we hand out these prescriptions. We are guilty of overprescribing for everything: chronic pain, anxiety, viral sinusitis and the list goes on. Antidepressants are extremely profitable for the pharmaceutical companies, yet incredibly harmful to the U.S. economy. Yes, studies have proven that antidepressants as well as psychotherapy are extremely efficacious in treating depression, but this doesn’t change the fact that these medications are burning holes in our wallets.

Drug Prices More than 30 million Americans are currently on antidepressants. The U.S. accounts for approximately 5 percent of the global population, but buys more than 50 percent of the pharmaceutical drugs worldwide (https://bit.ly/2HZXrJM). Antidepressants such as serotonin reuptake inhibitors and serotonin and norepinephrine uptake inhibitors cost an average out-ofpocket expense of $15 (https:// bit.ly/2HoJeJr) in 2010 for

14 RESILIENT HEALTH | May 2018

Americans who were covered by insurance. Of course, with inflation, this price has since risen. Retail prices (the cost without insurance coverage) for commonly prescribed antidepressants range from approximately $20 a month to more than $1,000 a month depending on the specific antidepressant, dosage, pill form (tablet or capsule) and whether it’s available in generic or brand name. For example, a 10-milligram capsule of fluoxetine (generic Prozac) costs $28 a month, whereas a 10-milligram tablet of escitalopram (generic Lexapro) retails for $87 a month.

Social Factors We know that economic hardship is associated with having depression, but financial disasters are not the only loss. Depression results in emotional and social burdens as well. Depression can result in relationship problems and divorce, drug and alcohol addiction, selfharm and suicide, eating disorders and even physical abuse. These horrible effects have a financial cost to the greater community. Drug and alcohol treatment, for example, can cost thousands of dollars out of pocket each month; divorce proceedings and lawyers are pricey; funeral costs expensive, not mention the emotional harms of broken families and the loss of a loved one. Self-medicating to relieve depression by using a line of cocaine, a couple shots of whiskey or a few painkillers may initially quiet emotional pain, but once a substance leaves the system, the www.reshealth.net

depressive feelings come back and often hit harder than ever, even spiraling into an addiction. According to studies (https:// bit.ly/2vG9Ekp), the divorce rate is as much as nine times higher in couples with a partner who struggles with untreated depression. Mental health professionals know that people living with a clinically depressed individual are at higher risk of becoming depressed themselves; depression impacts everyone close to the depressed person.

The Solution? There is no single antidote to depression, but there are “recipes” for happiness that can help people shake their depressive symptoms and lighten the mood of those around them. Surprisingly, there is a science of happiness (https:// bit.ly/2HPI3Ct), which has great potential in individuals who are

miserable and on the border of depression. Non-pharmacological therapies have proven to be efficacious in treating depression. Light therapy, acupuncture, yoga, meditation and exercise can help cultivate happiness, but these therapies also cost money. The reasons for being depressed are pertinent to the costs of depression and our general, declining health. Perhaps the problem is how Americans live that results in such high rates of depression. Culturally, Americans are set up to become depressed because of unrealistic expectations (https://theatln.tc/2pfAd8j). If we lived more like the Scandinavian societies, depression rates would likely plummet and, as a result, the cost of depression would be drastically lower (these nations are considered to be ranked

among the highest on the Happiness Index (https:// bit.ly/2xmXB8u). What if, like those societies, we worked and lived in an environment where we were allowed more vacation, more time off to spend with our families, instead of immersing ourselves in materialism and acquiring goods? What if there was no need to take out a loan for higher education or to pay off our medical bills? What if? I bet we’d take a bite out of depression in America. Maybe we’d even swallow it whole. Ralph Ryback, M.D., has taught at many institutions including Harvard Medical School. This article first appeared at psychologytoday.com on March 21, 2016. Kristen Fuller, M.D., contributed to this article.

MENTAL HEALTH MONTH

ealing with a mental health concern can be a lot to handle. It’s important to remember that mental health is essential to everyone’s overall health and well-being, and mental illnesses are common and treatable.

problems. It can also help people recover from these conditions. Eating healthy foods, managing stress, exercising and getting enough sleep can go a long way in making your patients both physically and mentally healthy.

So much of what we do physically impacts us mentally. That’s why this year’s theme for May is Mental Health Month–“Fitness #4Mind4Body”–is a call to pay attention to both physical health and mental health, which can help achieve overall wellness and set your patients on a path to recovery.

MHA has developed a series of fact sheets (available at www. mentalhealthamerica.net/may) on the importance of exercise, diet and nutrition, gut health, sleep and stress management. Also new this year is the #4Mind4Body Challenge, where everyone is invited to complete a small task each day during the month of May–and write about it on social media using #4Mind4Body. Learn more at www. mentalhealthamerica.net/challenge.

May is Mental Health Month was started 69 years ago by the national organization, Mental Health America, to raise awareness about mental health conditions and the importance of good mental health for everyone. Last year, Mental Health Month materials were seen and used by more than 230 million people, with more than 10,000 entities downloading MHA’s tool kit. May is Mental Health Month is focused on how a healthy lifestyle can help prevent the onset or worsening of mental health conditions, as well as heart disease, diabetes, obesity and other chronic health www.reshealth.net

Living a healthy lifestyle is not always easy, but it can be achieved by gradually making small changes and building on those successes. By looking at overall health every day–both physically and mentally– everyone can go a long way in ensuring that they focus on the fitness of mind and body. For more information on May is Mental Health Month, visit Mental Health America’s website at www.mentalhealthamerica.net/may. RESILIENT HEALTH | May 2018 15

ANDREA PAQUETTE

Stigma-Free Living:

A TALE OF LIFE WITH BIPOLAR DISORDER

ipolar disorder is a serious brain illness characterized by unusual and dramatic changes in mood, thoughts and behavior. Living with bipolar disorder can be challenging, frightening and even dangerous as it can gravely affect a person’s ability to function normally in his or her life. Despite the ups and downs of bipolar disorder, it’s a treatable condition and seeking treatment can help to make life more manageable. Andrea Paquette, executive director and founder of the StigmaFree Society spoke in a recent question and answer session about her personal experience of living with a co-occurring bipolar and substance use disorder. She shared

her personal story of resilience and determination that helped her grow and be successful despite her mental illness. Paquette is now making a difference in the lives of other people affected by mental health conditions.

Question: What is your personal experience with mental illness? Paquette: My first, and only, major breakdown occurred after I drove across Canada from British Columbia to Ottawa to pursue my dream political career. For several months, I was toppled by a deep mania and a crippling psychosis. I started to act out of character and would do things like give away my diamond ring to a man

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in a wheelchair or spend hours writing strategies to fulfill my grandiose ideas about winning the federal election to become Prime Minister. In December 2004, I was hospitalized for the first time. I was given medications for psychosis and diagnosed with bipolar disorder—I was 25 years old. Three weeks after my hospitalization, I was without money, a job or a place to live, as I had been kicked out by my former roommates. At this point in my life, I had also been abandoned by all my friends and had no family members living nearby. I barely had my sanity. Feeling defeated, I returned to British Columbia in hopes of a better life. After making the decision www.reshealth.net

to stop taking the medications due to their unmanageable sideeffects, I suffered at the hands of a depression that gripped me so badly that I could not take a shower nor cook myself something to eat. I attempted to take my own life by swallowing a very large amount of pills; I awoke in the intensive care unit after three days, distressed that I had lived to see another day. Months after being released from the hospital, I journeyed to South Korea to teach English to children. Eventually, I became a university professor and returned to Canada after living two years overseas. I had an extensive history of selfmedication with drugs and alcohol, so I decided to stop all substance use and sought meaningful work in the provincial government as

Andrea Paquette speaks at Stigma Stomp Day in 2013.

a policy analyst for the Ministry of Social Development. In 2009, I started “Bipolar Babe: Stomping Out www.reshealth.net

Stigma,” a project that aimed to get people to talk about mental health. I began to speak at engagements in the local community, sharing my personal story of living with a mental health condition with youth in schools. One of my friends and I created www.bipolarbabe. com. I formed a non-profit society called the Bipolar Disorder Society of British Columbia, which is now Stigma Free Society; it offers five programs in Victoria and the Lower Mainland. I have shared my story with audiences large and small, reaching more than 12,000 people. Although I still have my challenges, I embrace the belief that no matter what our challenges are, we can all live extraordinary lives.

Q: How did you overcome the difficulties you were facing? Paquette: The first step was admitting that if I continued to go on the way I had been, then I would surely die. I decided to go to a Narcotics Anonymous meeting with an old friend. It was then that I realized for the first time that I was not the only one facing severe problems. Although I did not agree with the Alcoholics Anonymous philosophy that I was “powerless” over my addiction, I did believe that I had the power to stop drinking and using drugs. I decided to change my life with my power of choice and a dedicated relationship with God. I also prayed a lot and wrote my worries and fears to my higher power in a journal. I decided to get rid of any “friends” that would be detrimental to my recovery process and focused on keeping busy. I also told my employer about my mental health issues, which created more

understanding of my scheduling requests and helped to foster a routine in my life. I surrounded myself with positive people. I went back to university for my Masters and eventually did the Landmark Forum. The Landmark Forum helped me realize that even though I had an illness, I was not defined by it.

Q: How long have you been in recovery? Paquette: I’ve been in recovery from drugs for eight years. About five years ago, I had one slip up with alcohol for a four-month period. At that time, I believed that I would be fine to drink if I could go three years without any alcohol. I had a new boyfriend at the time and wanted to enjoy a few glasses of wine with him; he told me to stop drinking or he would leave me. Those words encouraged me to stop drinking and it has been five years since I have had a drop of alcohol. Even though that boyfriend is no longer in my life, I maintain my sobriety to this day for my own well-being and don’t rely on others to keep me sober. I realize that I have a special relationship with myself and that the most important person that I owe my sobriety to is myself and God.

Q: What are some of your strengths, and how did these strengths help you through the treatment process? Paquette: I was kicked out of my house at age 17 due to my mother’s issues with bipolar disorder. Although this was a traumatic event, I was forced to manage life on my own with some help from my boyfriend’s mother, which taught me how to live wholly independently at RESILIENT HEALTH | May 2018 17

a young age. My resiliency was, and remains, my biggest strength. I drew a lot of strength from God in the way that I understood him at the time, and knew that in my heart, even in the dire moments, that I was not alone. I didn’t rely solely on my own strengths to get me through the process of my journey of recovery, but the right people, circumstances and opportunities appeared during my crisis. Still, it was up to me to decide what to do in each situation. I did learn to accept help and embrace support when it was necessary, which is something that I wasn’t used to doing, and it took strength to see beyond my own capabilities and realize that I couldn’t do everything on my own. Support came to me whether it was from the government, strangers, friends or family.

Q: How has your life changed for the better now that you’re in recovery? Paquette: I still face challenges every day, but drugs and alcohol are not an option for me anymore. I know that it would destroy everything that I have built in my life. It wasn’t until I ceased all substances that my life began to improve. In time, I created and founded a charity based on my personal experiences of mental health recovery and I’ve become a mentor and inspiration for many people. It wouldn’t only be tragic for myself to falter in my recovery, but to all the people who love and support me. I still have my challenges with my mental illness as bipolar disorder is a lifelong mental health

condition, but I’ve luckily found stability in my current lifestyle, and medications that have kept me healthy for nearly a decade. Yes, I still experience depression from time to time, but we all have our life challenges, even if I feel things a lot more intensely than the average person. The fact that I can actually feel now is a blessing and I’m able to deal with life’s challenges in a positive and constructive way. I’ve come to the full acceptance that I’ve made some poor decisions, but I’ve also made some very positive choices that have led me into a place of confidence that I’ll maintain this amazing and blessed life that I have now.

Q: Have you faced any stigma regarding your mental illness? Paquette: I have faced a lot of stigma, and it cropped up after I had my first major breakdown. After I was diagnosed with a mental illness, my roommates wouldn’t even allow me to return to my apartment. I was affected by stigma at several past places of employment and had been fired from a serving job because they told me there was “something wrong with me” and that I always looked depressed. They were right–I attempted suicide a mere week later, but during those times, nobody asked me if I needed help. Another time, a past boss teamed up with the human resources department and conducted an attendance review on my working hours, but the attendance structure didn’t take into consideration episodic illnesses. I had to go to work even if I was sick, so I didn’t lose my job and the fact that I had a mental illness was not even a consideration in their evaluation.

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I never told anyone that I was also dealing with drug and alcohol recovery as I feared I would have experienced even more stigma. I feel that the stigma around drug and alcohol recovery is even worse than that of mental illness because people assume that drug and alcohol use is a choice, while having a mental illness is not. People often fail to recognize that alcohol and drug dependency is the same as a disease that grips your being so tightly that you feel powerless to stop. Leaving drugs and alcohol behind was one of the biggest challenges that I’ve ever had to tackle in my life, which is why I constantly remind myself about the reasons for leaving that albatross behind. To take it back in any form whatsoever would only spell my doom and destruction and my valuable life is not something I will ever part with again.

Q: Why do you think it’s important to help people who have mental illnesses? Paquette: Mental illness and substance use can make you feel powerless to change your circumstances. There were moments when I felt hopeless and that my only option was to wait out my impending doom until I was tossed to the streets. If it weren’t for the kindness and support of others, then I wouldn’t be where I am today. It’s in the kindness of others that I was able to eventually find some peace and stability and it was in those moments that I knew that I wasn’t alone. Sometimes, a simple smile or hello meant the world to me when I felt alone. Helping someone with a mental illness or substance use issue could often mean the difference of someone www.reshealth.net

even wanting to continue to live on any given day. It’s in our kind gestures and demonstrations of kindness that remind people that life is truly worth living.

Q: What advice do you have for someone who is currently struggling with the problems you faced but is afraid or unwilling to seek treatment? Paquette: The reason why I share my personal story, especially about the part of attempting suicide, is because I want people to know that life doesn’t ever have to get this bad. I tell my story because I want people to know that there’s always help and there’s always hope. Sometimes, when we’re in a situation that seems unmanageable, it’s impossible to see that there’ll be an end to the pain; however, it’s in these moments that we’re given two choices: give up or take this crisis as an opportunity to grow.

www.reshealth.net

Don’t ever give up. I could exist here in the world and simply let life fade away with no meaning at all or I could have a significant impact in the lives of others. After I realized that life was not all about me, I was able to embrace and see the value in life; I knew I could find meaning by bringing light and hope to the world. It’s through our struggles that we gain the gift of empathy for other people, so I feel it’s our responsibility to help others as we once needed support, too–whether it’s being a friend, sponsor or volunteer, or even just being a listening ear, we all deserve support and understanding.

About Andrea Paquette Andrea Paquette is the executive director and founder of the Stigma-Free Society, an organization formerly known as the Bipolar Disorder Society of British Columbia. She’s an award-winning mental health activist, educator, facilitator, speaker and published author.

Over the years, Paquette has presented her story to more than 12,000 people at more than 200 schools, workplaces, community organizations and events. Paquette received the Coast Mental Health’s 2015 Courage to Come Back Award, the Victoria, B.C., 2013 Mel Cooper Citizen of the Year, and the National Council for Behavioral Health’s 2013 Award for Mentorship in Washington, D.C. She’s also recognized for receiving Vancouver Island’s Business and Community 2015 Top 20 under 40 Award. She was named as an official spokesperson for the 2016 Faces of Mental Illness Campaign for the Canadian Alliance on Mental Illness and Mental Health. A Bell Let’s Talk Public Service Announcement that aired nationally and multiple media outlets have also showcased her personal story.

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ANXIETY TEST Could your patient be suffering from an anxiety disorder? Below is a list of questions that relate to life experiences common among people who have been diagnosed with a social anxiety disorder (social phobia). Have your patient read each question carefully and indicate how often he or she has experienced the same or similar challenges in the past few months. Do you experience intense anxiety or worry and find it difficult to control?