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Saturday, May 10, 2014

DBSA Jackson -- Bill Proposals in Washington that will impact you the consumer

Hello everyone,

Larry Drain, DBSA Tennessee Legislative Liaison, returned from Washington this week. He sends the following information to educate us. He does not intend for it to replace our personal education on these matters.


             Comparison of Murphy and Barber Mental Health Proposals

New York Association of Psychiatric Rehabilitation Services   May 8, 2014


House and Senate Mental Health Bills

Helping Families in Mental Health Crisis Act of 2013 H.R.3717 (Murphy)

Strengthening Mental Health in Our Communities Act of 2014 (Barber)

Stated Purpose

To make available needed psychiatric, psychological, and supportive services for individuals diagnosed with mental illness and families in mental health crisis, and for other purposes.

To improve the responsiveness, coordination, accountability, accessibility, and integration of person-centered behavioral health services to provide  timely and appropriate help to individuals, families, and communities;

to reduce mental health crises, homelessness, and incarceration by strengthening community based services, including early intervention, outreach, engagement, prevention, crisis support, rehabilitation and peer-run services

to ensure access to evidence-based and emerging best practices based on the values and principles of trauma-informed care and mental health recovery, delivered in a culturally and linguistically competent manner;

to advance the principles of the ADA that support people to fully participate in the most integrated settings within their chosen communities;

to develop an integrated behavioral health workforce through improved training and education, recruitment, and retention;

to increase mental health awareness and reduce stigma and discrimination through mental health training, education, and literacy; and

to ensure the full implementation and enforcement of mental health parity for all Americans.

Creates Higher Level Federal Mental Health Administrator

Assistant Secretary for Mental Health and Substance Use Disorders within the federal Department of Health and Human Services (HHS) whose duties would include the establishment of a National Mental Health Policy Laboratory to identify and implement policy changes and to disseminate information about evidence-based practices  and an Interagency Serious Mental Illness Coordinating Committee, which would include representatives from various federal agencies

Creates White House Office of Mental Health Policy which will

monitor and recommend changes to federal mental health policy;

develop and annually update and submit to Congress a National Strategy for Mental Health to make recommendations around

·       performance-based program and budget priorities, improved coordination among Federal, state, local and tribal governments and others including adults and children with serious mental illnesses

·       strategic research, innovation, and demonstration agenda;

·       strategies' to promote community integration consistent with the ADA and Olmstead requirements; to enhance prevention and early intervention services for children  and adolescents with mental illness;

·       ways to promote the expansion of Medicaid -financed intensive community-based services such as supported housing, assertive community treatment (ACT), mobile crisis, supported employment, and peer-support services and Medicare-financed psychiatric rehabilitation, assertive community treatment (ACT), and intensive case management.

make recommendations regarding Federal mental health services funding;

coordinate the mental health services provided by Federal departments and agencies and coordinate Federal interagency mental health services;

develop and annually update a summary of research findings about advances related to causes, prevention, treatment, early screening, diagnosis or rule out, intervention, and access to services and supports for individuals with serious mental illness and children and adolescents



Removes or restricts numerous SAMHSA functions: Moves numerous duties to the Assistant Secretary, including oversight over the Center for Mental Health Services, over the administration of $400+ million community mental health block grant program, which would only be given to states that advance court ordered treatment, notably outpatient commitment (AOT).  

Cuts SAMHSA Projects of Regional and National Significance (a category that includes consumer and family support technical assistance centers and statewide networks) in half and requires them to be submitted to Congressional committees.

Prohibits SAMHSA from hosting or sponsoring any conference without giving at least 90 days' notice to congressional committees.

Terminates SAMHSA funding for any program not authorized or required by statute.

Reauthorizes major SAMHSA programs and services through FY 2019 for community-based mental health services, while putting in place new oversight and reporting requirements to ensure programs deliver measurable outcomes for the individuals and families. 


Does not include any conditional connection between state block grant approvals and the presence or strengthening of court ordered treatment including outpatient commitment (AOT) while requiring annual reports on how block grant funded programs met their proposed goals and objectives



Sharing Patient Information

Requires that caregivers are treated as the individual's personal representative who can give and get protected health information, even without the individual's consent, when the individual's service provider believes it is necessary "in order to protect the individual's health, safety, or welfare or the safety of one or more other individuals."

Allows an educational agency or institution to disclose individual's educational records to caregivers.

No mention.

Extends or preserves  Medicaid and Medicare reimbursement for various programs and same day services or medications


Allows states the option to use Medicaid to fund inpatient psychiatric hospital services and psychiatric residential treatment facility services for individuals between the ages of 21-65 if such facilities demonstrate an average stay of less than 30 days.

Allows for same day behavioral health and primary care services

Maintains in law that Medicare Part D will cover anti-psychotic and anti-depressant  medications


Does not expand Medicaid reimbursement for inpatient psychiatric care to individuals between the ages of 21-65;

HHS will grant funding to state mental health agencies to develop and administer a web-based acute psychiatric bed registry

Extends Medicaid Home and Community-based Services to include youth in need of services provided in psychiatric residential treatment facilities

Provides for Medicare reimbursement for marriage and family therapist services

Maintains in law that Medicare Part D will cover anti-psychotic and anti-depressant  medications

Provides grants to state mental health agencies to develop and administer a web-based acute psychiatric bed registry

Allows for same day behavioral health and primary care services

Requires HHS to issue a final rule on Medicaid and Children's Health Insurance Program (CHIP) plans by January 1, 2015.

Extends coverage for psychiatric services


Eliminates 190-day lifetime limit on inpatient psychiatric care services

Requires a federal study to detail enforcements in implementing the federal mental health parity act and to describe federal and state government efforts to ensure compliance with the parity act.

Protection and Advocacy Programs for Individuals with Mental Illness


Cuts funding from $35 million to $5 million (85% reduction).

Prohibits lobbying or retaining a lobbyist to influence

Prohibits "systemic" lawsuits, including class actions, limiting them to bringing individual cases involving abuse or neglect.

P&As would also be prohibited from "counseling an individual with a serious mental illness who lacks insight into their condition on refusing medical treatment or acting against the wishes of such individual's caregiver."

Reauthorizes and maintains current program

Programs to aid  students with behavioral health conditions, their families, their schools and communities


Reauthorizes and revises a grant program to enhance services for students with mental health or substance use disorders at institutions of higher education. Requires the Secretary

Calls for a national awareness campaign to reduce stigma among college students, to provide information on how to assist students demonstrating signs of a serious mental illness and on the importance of seeking mental health treatment. 


Calls for a national media campaign to reduce the stigma associated with mental illnesses that focused especially on individuals between the ages of 16-24.

Increases funding for the Safe Schools-Healthy Students program, for increased access to school employment mental health professionals, for comprehensive staff development for school and community service personnel working in the schools and for mental health training for children, parents and family members

Funds grants to assist local communities and schools in applying a public health approach to mental health services both in schools and in the community that provide comprehensive,

age-appropriate services and supports, be linguistically and culturally appropriate, be trauma-informed, and incorporate age appropriate strategies of positive behavioral interventions and supports.

Requires an independent evaluation concerning the use of mental health services for children, including the use of psychotropic medications

Criminal Justice programs

Reauthorizes Mentally Ill Offender Treatment and Crime Reduction Act funding law enforcement training, jail diversion, correctional mental health and substance use treatment, discharge planning, and community reentry programs; expands supports for veteran's treatment courts and veteran's outreach programs.

Requires the collection and sharing of data about homicides, law enforcement officers or individuals killed by law enforcement involving people with mental illnesses

Gathers data around the cost of federal, state or local imprisonment for persons with serious mental illnesses

Continues funding for Correctional Facility Grants enhance correctional facilities capacities to identify and treat  mental health and substance abuse related conditions, to implement, and enhance appropriate post-release transition plans, that encourages alternatives to solitary confinement and segregated housing

housing; and provides mental health training to COs.

Includes same provisions and add grants to improve responses to 'high utilizers' of emergency, housing, judicial, corrections, and law enforcement services by funding up to 6 demonstrations that will:  

involve multidisciplinary teams that implement and coordinate community based crisis responses and long term plans;

promote training of criminal justice, mental health, substance abuse, emergency room, healthcare, law enforcement, corrections, and housing personnel;   support alternatives to hospital and jail admissions; and

develop protocols and systems among law enforcement, mental health, substance abuse, housing, corrections, and emergency medical service operations.

Suicide Prevention

Reauthorizes and revises the Suicide Prevention Technical Assistance Center).

Reauthorizes a program of grants for the development of state or tribal youth suicide early intervention and prevention strategies.

Seems essentially the same

Children's Programs

Reauthorizes grants for community mental health services to children and restricts such funding to those that use evidence-based practices.

Reauthorizes the National Child Traumatic Stress Network

Seems essentially the same

Veterans Programs

Awards funding for veteran peer to peer programs

Devotes a separate section that requires mental health assessments before enlistments or commissions to officer status, unlimited eligibility for mental healthcare for combat veterans, timelines to create integrated healthcare records for veterans and a pilot educational loan repayment program for VA psychiatrists;

Improves collaboration between the VA and DOD; and increases the number of mental health professionals in the VA.



Provides for training on youth suicide early intervention and prevention strategies and for a primary care physician training grant program.

Provides funding for scholarships and loan repayment funding to further develop the behavioral health workforce

Provides funding to develop and share education and training to healthcare professionals on identifying, referring and treating individuals with serious mental illnesses

Provides funding to enhance psychiatrist services in Indian health programs

Adds occupational therapists to the list of "behavioral and mental health professionals" under the National Health Service Corps

Other Notable Provisions

Increases funding for the brain initiative at the National Institute of Mental Health.

Advances grants to expand tele-psychiatry and primary care

Evaluates the combined paperwork burden of certain community mental health centers as well as of certified federally qualified community mental health clinics.

Creates incentives for meaningful use of certified electronic health records (EHR) technology

Expand research on models like the Recovery After an Initial Schizophrenia Episode research project of the National Institute of Mental Health and the North American Prodrome Longitudinal Study, as well as on the determinants of self and other directed violence and brain related research.

Extends funding eligibility for Medicare and Medicaid Health Information technology to behavioral health providers

Emphasizes that research should further the prevention, early detection and treatment of serious mental illnesses


Encourages and provides new funding for collaborative and integrated behavioral and medical health services and for efforts to assess barriers to behavioral health integration

Recommends that  technical assistance be provided to expand use of evidence based practices for the prevention and treatment of geriatric mental health disorders

HHS can require hospitals that on multiple occasions do not demonstrate effective discharge planning processes to enter into a system improvement agreement

Extends funding eligibility for Medicare and Medicaid Health Information technology to behavioral health providers


Friday, May 9, 2014

Borderline Personality Disorder relations to Bipolar Disorder and Depression

NIMH information on treatment, etc.

What is borderline personality disorder?

Borderline personality disorder is a serious mental illness marked by unstable moods, behavior, and relationships. In 1980, the Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III) listed borderline personality disorder as a diagnosable illness for the first time. Most psychiatrists and other mental health professionals use the DSM to diagnose mental illnesses.
Because some people with severe borderline personality disorder have brief psychotic episodes, experts originally thought of this illness as atypical, or borderline, versions of other mental disorders.1 While mental health experts now generally agree that the name "borderline personality disorder" is misleading, a more accurate term does not exist yet.
Most people who have borderline personality disorder suffer from:
  • Problems with regulating emotions and thoughts
  • Impulsive and reckless behavior
  • Unstable relationships with other people.
People with this disorder also have high rates of co-occurring disorders, such as depression, anxiety disorders, substance abuse, and eating disorders, along with self-harm, suicidal behaviors, and completed suicides.
According to data from a subsample of participants in a national survey on mental disorders, about 1.6 percent of adults in the United States have borderline personality disorder in a given year.2
Borderline personality disorder is often viewed as difficult to treat. However, recent research shows that borderline personality disorder can be treated effectively, and that many people with this illness improve over time.1,3,4

What are the symptoms of borderline personality disorder?

According to the DSM, Fourth Edition, Text Revision (DSM-IV-TR), to be diagnosed with borderline personality disorder, a person must show an enduring pattern of behavior that includes at least five of the following symptoms:
  • Extreme reactions—including panic, depression, rage, or frantic actions—to abandonment, whether real or perceived
  • A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)
  • Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future (such as school or career choices)
  • Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating
  • Recurring suicidal behaviors or threats or self-harming behavior, such as cutting
  • Intense and highly changeable moods, with each episode lasting from a few hours to a few days
  • Chronic feelings of emptiness and/or boredom
  • Inappropriate, intense anger or problems controlling anger
  • Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.
Seemingly mundane events may trigger symptoms. For example, people with borderline personality disorder may feel angry and distressed over minor separations—such as vacations, business trips, or sudden changes of plans—from people to whom they feel close. Studies show that people with this disorder may see anger in an emotionally neutral face5 and have a stronger reaction to words with negative meanings than people who do not have the disorder.6

Suicide and Self-harm

Self-injurious behavior includes suicide and suicide attempts, as well as self-harming behaviors, described below. As many as 80 percent of people with borderline personality disorder have suicidal behaviors,7 and about 4 to 9 percent commit suicide.4,7
Suicide is one of the most tragic outcomes of any mental illness. Some treatments can help reduce suicidal behaviors in people with borderline personality disorder. For example, one study showed that dialectical behavior therapy (DBT) reduced suicide attempts in women by half compared with other types of psychotherapy, or talk therapy. DBT also reduced use of emergency room and inpatient services and retained more participants in therapy, compared to other approaches to treatment.7 For more information about DBT, see the section, "How is borderline personality disorder treated?"
Unlike suicide attempts, self-harming behaviors do not stem from a desire to die. However, some self-harming behaviors may be life threatening. Self-harming behaviors linked with borderline personality disorder include cutting, burning, hitting, head banging, hair pulling, and other harmful acts. People with borderline personality disorder may self-harm to help regulate their emotions, to punish themselves, or to express their pain.8 They do not always see these behaviors as harmful.

When does borderline personality disorder start?

Borderline personality disorder usually begins during adolescence or early adulthood.1,9 Some studies suggest that early symptoms of the illness may occur during childhood.10,11
Some people with borderline personality disorder experience severe symptoms and require intensive, often inpatient, care. Others may use some outpatient treatments but never need hospitalization or emergency care. Some people who develop this disorder may improve without any treatment.12
Studies suggest early symptoms may occur in childhood

What illnesses often co-exist with borderline personality disorder?

Borderline personality disorder often occurs with other illnesses. These co-occurring disorders can make it harder to diagnose and treat borderline personality disorder, especially if symptoms of other illnesses overlap with the symptoms of borderline personality disorder.
Women with borderline personality disorder are more likely to have co-occurring disorders such as major depression, anxiety disorders, or eating disorders. In men, borderline personality disorder is more likely to co-occur with disorders such as substance abuse or antisocial personality disorder.13
According to the NIMH-funded National Comorbidity Survey Replication—the largest national study to date of mental disorders in U.S. adults—about 85 percent of people with borderline personality disorder also meet the diagnostic criteria for another mental illness.2
Other illnesses that often occur with BPD include diabetes, high blood pressure, chronic back pain, arthritis, and fibromyalgia.14,15 These conditions are associated with obesity, which is a common side effect of the medications prescribed to treat borderline personality disorder and other mental disorders. For more information, see the section, "How is borderline personality disorder treated?"

What are the risk factors for borderline personality disorder?

Research on the possible causes and risk factors for borderline personality disorder is still at a very early stage. However, scientists generally agree that genetic and environmental factors are likely to be involved.
Studies on twins with borderline personality disorder suggest that the illness is strongly inherited.16,17 Another study shows that a person can inherit his or her temperament and specific personality traits, particularly impulsiveness and aggression.18 Scientists are studying genes that help regulate emotions and impulse control for possible links to the disorder.19
Social or cultural factors may increase the risk for borderline personality disorder. For example, being part of a community or culture in which unstable family relationships are common may increase a person's risk for the disorder.1 Impulsiveness, poor judgment in lifestyle choices, and other consequences of BPD may lead individuals to risky situations. Adults with borderline personality disorder are considerably more likely to be the victim of violence, including rape and other crimes.

How is borderline personality disorder diagnosed?

Unfortunately, borderline personality disorder is often underdiagnosed or misdiagnosed.20,21
A mental health professional experienced in diagnosing and treating mental disorders—such as a psychiatrist, psychologist, clinical social worker, or psychiatric nurse—can detect borderline personality disorder based on a thorough interview and a discussion about symptoms. A careful and thorough medical exam can help rule out other possible causes of symptoms.
The mental health professional may ask about symptoms and personal and family medical histories, including any history of mental illnesses. This information can help the mental health professional decide on the best treatment. In some cases, co-occurring mental illnesses may have symptoms that overlap with borderline personality disorder, making it difficult to distinguish borderline personality disorder from other mental illnesses. For example, a person may describe feelings of depression but may not bring other symptoms to the mental health professional's attention.
No single test can diagnose borderline personality disorder. Scientists funded by NIMH are looking for ways to improve diagnosis of this disorder. One study found that adults with borderline personality disorder showed excessive emotional reactions when looking at words with unpleasant meanings, compared with healthy people. People with more severe borderline personality disorder showed a more intense emotional response than people who had less severe borderline personality disorder.6

What studies are being done to improve the diagnosis of borderline personality disorder?

Recent neuroimaging studies show differences in brain structure and function between people with borderline personality disorder and people who do not have this illness.22,23 Some research suggests that brain areas involved in emotional responses become overactive in people with borderline personality disorder when they perform tasks that they perceive as negative.24 People with the disorder also show less activity in areas of the brain that help control emotions and aggressive impulses and allow people to understand the context of a situation. These findings may help explain the unstable and sometimes explosive moods characteristic of borderline personality disorder.19,25
Another study showed that, when looking at emotionally negative pictures, people with borderline personality disorder used different areas of the brain than people without the disorder. Those with the illness tended to use brain areas related to reflexive actions and alertness, which may explain the tendency to act impulsively on emotional cues.26
These findings could inform efforts to develop more specific tests to diagnose borderline personality disorder.6

How is borderline personality disorder treated?

Borderline personality disorder can be treated with psychotherapy, or "talk" therapy. In some cases, a mental health professional may also recommend medications to treat specific symptoms. When a person is under more than one professional's care, it is essential for the professionals to coordinate with one another on the treatment plan.
The treatments described below are just some of the options that may be available to a person with borderline personality disorder. However, the research on treatments is still in very early stages. More studies are needed to determine the effectiveness of these treatments, who may benefit the most, and how best to deliver treatments.


Psychotherapy is usually the first treatment for people with borderline personality disorder. Current research suggests psychotherapy can relieve some symptoms, but further studies are needed to better understand how well psychotherapy works.27
It is important that people in therapy get along with and trust their therapist. The very nature of borderline personality disorder can make it difficult for people with this disorder to maintain this type of bond with their therapist.
Types of psychotherapy used to treat borderline personality disorder include the following:28
  1. Cognitive behavioral therapy (CBT). CBT can help people with borderline personality disorder identify and change core beliefs and/or behaviors that underlie inaccurate perceptions of themselves and others and problems interacting with others. CBT may help reduce a range of mood and anxiety symptoms and reduce the number of suicidal or self-harming behaviors.29
  2. Dialectical behavior therapy (DBT). This type of therapy focuses on the concept of mindfulness, or being aware of and attentive to the current situation.1 DBT teaches skills to control intense emotions, reduces self-destructive behaviors, and improves relationships. This therapy differs from CBT in that it seeks a balance between changing and accepting beliefs and behaviors.30
  3. Schema-focused therapy. This type of therapy combines elements of CBT with other forms of psychotherapy that focus on reframing schemas, or the ways people view themselves. This approach is based on the idea that borderline personality disorder stems from a dysfunctional self-image—possibly brought on by negative childhood experiences—that affects how people react to their environment, interact with others, and cope with problems or stress.31
Therapy can be provided one-on-one between the therapist and the patient or in a group setting. Therapist-led group sessions may help teach people with borderline personality disorder how to interact with others and how to express themselves effectively.
One type of group therapy, Systems Training for Emotional Predictability and Problem Solving (STEPPS), is designed as a relatively brief treatment consisting of 20 two-hour sessions led by an experienced social worker. Scientists funded by NIMH reported that STEPPS, when used with other types of treatment (medications or individual psychotherapy), can help reduce symptoms and problem behaviors of borderline personality disorder, relieve symptoms of depression, and improve quality of life.32 The effectiveness of this type of therapy has not been extensively studied.
Families of people with borderline personality disorder may also benefit from therapy. The challenges of dealing with an ill relative on a daily basis can be very stressful, and family members may unknowingly act in ways that worsen their relative's symptoms.
Some therapies, such as DBT-family skills training (DBT-FST), include family members in treatment sessions. These types of programs help families develop skills to better understand and support a relative with borderline personality disorder. Other therapies, such as Family Connections, focus on the needs of family members. More research is needed to determine the effectiveness of family therapy in borderline personality disorder. Studies with other mental disorders suggest that including family members can help in a person's treatment.33
Other types of therapy not listed in this booklet may be helpful for some people with borderline personality disorder. Therapists often adapt psychotherapy to better meet a person's needs. Therapists may switch from one type of therapy to another, mix techniques from different therapies, or use a combination therapy. For more information see the NIMH website section on psychotherapy.
Some symptoms of borderline personality disorder may come and go, but the core symptoms of highly changeable moods, intense anger, and impulsiveness tend to be more persistent.34 People whose symptoms improve may continue to face issues related to co-occurring disorders, such as depression or post-traumatic stress disorder.4 However, encouraging research suggests that relapse, or the recurrence of full-blown symptoms after remission, is rare. In one study, 6 percent of people with borderline personality disorder had a relapse after remission.4


No medications have been approved by the U.S. Food and Drug Administration to treat borderline personality disorder. Only a few studies show that medications are necessary or effective for people with this illness.35 However, many people with borderline personality disorder are treated with medications in addition to psychotherapy. While medications do not cure BPD, some medications may be helpful in managing specific symptoms. For some people, medications can help reduce symptoms such as anxiety, depression, or aggression. Often, people are treated with several medications at the same time,12 but there is little evidence that this practice is necessary or effective.
Medications can cause different side effects in different people. People who have borderline personality disorder should talk with their prescribing doctor about what to expect from a particular medication.

Other Treatments

Omega-3 fatty acids. One study done on 30 women with borderline personality disorder showed that omega-3 fatty acids may help reduce symptoms of aggression and depression.36 The treatment seemed to be as well tolerated as commonly prescribed mood stabilizers and had few side effects. Fewer women who took omega-3 fatty acids dropped out of the study, compared to women who took a placebo (sugar pill).
With proper treatment, many people experience fewer or less severe symptoms. However, many factors affect the amount of time it takes for symptoms to improve, so it is important for people with borderline personality disorder to be patient and to receive appropriate support during treatment.

How can I help a friend or relative who has borderline personality disorder?

If you know someone who has borderline personality disorder, it affects you too. The first and most important thing you can do is help your friend or relative get the right diagnosis and treatment. You may need to make an appointment and go with your friend or relative to see the doctor. Encourage him or her to stay in treatment or to seek different treatment if symptoms do not appear to improve with the current treatment.
To help a friend or relative you can:
  • Offer emotional support, understanding, patience, and encouragement—change can be difficult and frightening to people with borderline personality disorder, but it is possible for them to get better over time
  • Learn about mental disorders, including borderline personality disorder, so you can understand what your friend or relative is experiencing
  • With permission from your friend or relative, talk with his or her therapist to learn about therapies that may involve family members, such as DBT-FST.
Never ignore comments about someone's intent or plan to harm himself or herself or someone else. Report such comments to the person's therapist or doctor. In urgent or potentially life-threatening situations, you may need to call the police.

How can I help myself if I have borderline personality disorder?

Taking that first step to help yourself may be hard. It is important to realize that, although it may take some time, you can get better with treatment.
To help yourself:
  • Talk to your doctor about treatment options and stick with treatment
  • Try to maintain a stable schedule of meals and sleep times
  • Engage in mild activity or exercise to help reduce stress
  • Set realistic goals for yourself
  • Break up large tasks into small ones, set some priorities, and do what you can, as you can
  • Try to spend time with other people and confide in a trusted friend or family member
  • Tell others about events or situations that may trigger symptoms
  • Expect your symptoms to improve gradually, not immediately
  • Identify and seek out comforting situations, places, and people
  • Continue to educate yourself about this disorder.

Where can I go for help?

If you are unsure where to go for help, ask your family doctor. Other people who can help are:
  • Mental health professionals, such as psychiatrists, psychologists, social workers, or mental health counselors
  • Health maintenance organizations
  • Community mental health centers
  • Hospital psychiatry departments and outpatient clinics
  • Mental health programs at universities or medical schools
  • State hospital outpatient clinics
  • Family services, social agencies, or clergy
  • Peer support groups
  • Private clinics and facilities
  • Employee assistance programs
  • Local medical and psychiatric societies.
You can also check the phone book under "mental health," "health," "social services," "hotlines," or "physicians" for phone numbers and addresses. An emergency room doctor can provide temporary help and can tell you where and how to get further help.

What if I or someone I know is in crisis?

If you are thinking about harming yourself, or know someone who is:
  • Call your doctor.
  • Call 911 or go to a hospital emergency room to get immediate help or ask a friend or family member to help you do these things.
  • Call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255) or TTY: 1-800-799-4TTY (4889) to talk to a trained counselor.
  • If you are in a crisis, make sure you are not left alone.
  • If someone else is in a crisis, make sure he or she is not left alone.

Thursday, May 8, 2014

Are there alternatives to medicine for depression? How about Skype?

Eldercare Experts Find Skype Can Beat Depression Better Than Meds

Eldercare Experts Find Skype Can Beat Depression Better Than Meds

Story tools

Photo: Joe Bachicha, 80, overcomes depression with long walks and reaching out to his three daughters. Other seniors find comfort via Skype. (Veronica Zaragovia, KUT)

AUSTIN, Texas--Almost 3 million people in Texas are between the ages of 65 and 85, according to the office of the state demographer. That number is expected to more than double by the year 2040.
Texas – like the rest of the country – lacks enough geriatric mental health professionals to match the population. So experts are looking at alternatives to help seniors overcome depression -- that includes one approach using technology.

Joe Bachicha, 80, gets food delivered to his home in Austin five days a week by a Meals on Wheels volunteer. Bachicha has three daughters, and he sees them often. But on weekdays, he’s usually on his own at home.

"I just don’t feel like going out. There’s no place to go, really. I don’t do very much except housework and yard work, and that’s about it," he says.

Good Days and Rough Days

Bachich's wife, Margaret, died about eight months ago.

"Luckily we were able to keep her at home, so she died right here in the house," Bachicha says. "My two daughters were with me when she passed away, which was a big, big help."

Since then, he says he has good days. But there are as many rough days.

"When I’m feeling down usually what I do is take the dog for a long walk and that helps me. Helps me get out of my depression," Bachicha says.

Bachicha, unlike most men his age, did see a psychiatrist.

"When I went to see my primary care doctor, when it was time to see him, it was recently that I’d lost my wife. So I was feeling pretty bad. And I broke down there with my primary doctor and that’s when he referred me to the psychiatrist," he says.

The psychiatrist offered medication, but Bachicha refused it. And he hasn’t seen a psychiatrist since.
"I always confer with my daughters about it. I always let them know and they’re very understanding," he says. "I feel more comfortable with my daughters than I do with a doctor."

Experts hope more seniors like Bachicha will find alternatives to medicine.

Professor Namkee Choi teaches at the University of Texas School of Social Work. She’s working on a project about problem-solving therapy for low-income older adults with depression.

"The anti-depressant medications are not that effective with low-income homebound older adults because medications don’t treat psychosocial stressors," Choi says.

Psychosocial stressors include lack of transportation, financial concerns, dealing with many caregivers and also grappling with bereavement. 

Non-Medication Approaches

"Since depression is so disabling as a condition, we have to think about having people do what we have them do with every other chronic condition," says Professor Nancy Wilson, who teaches at Baylor College of Medicine in Houston. "It's no different than diabetes or heart disease. There needs to be a therapeutic approach to their care."

Wilson is Choi's research partner.

"Older adults prefer non-medication approaches when they’re available, and it’s particularly sad when low-income older adults for whom medication isn’t effective are given that as the treatment and not given the option to do something that would be their preference," Wilson says.

The seniors in their study got psychotherapy through a computer screen at home, using video conferencing technology like Skype.

In the beginning, some doubted the success of this method. 

"They said older adults don’t use technology and it’s not gonna work," Choi recalls. "And when we were talking to our participants, most said I hope I’ll get in-person sessions rather than tele-sessions."
At the end of the six-week study, some still disliked it. But 94 percent of the participants praised the experience.

"This was the best experience. And some people actually cried when they were talking about this actually changed my life and they were so proud," Choi says. 

Choi and Wilson say they’re focused on improving access to psychotherapy because it’s hard for homebound seniors to get to a clinic.

"And also because of the shortage of geriatric mental health providers," Choi says. "There are not enough clinicians who can go around and do in-home, in-person sessions. So if we use tele-health delivery methods, we can serve more older adults with fewer clinicians. And it’s cheaper."

Public health experts are paying attention to this as the Texas population continues to grow and age. 

An Aging State
"If we think about aging in the state, and kind of look at the population, it’s a phenomena that’s largely being driven by the non-Hispanic white population in the state," State Demographer Lloyd Potter says. 

"When I say aging, it’s really talking about the age structure of the population becoming older. So there are relatively fewer younger people," Potter notes.

Joe Bachicha says he tried to learn how to use a computer with little success. But he says his walks with his dog do a lot for him. Choi and Wilson hope more seniors will follow in his footsteps – being more active and talking about their depression.

Veronica Zaragovia wrote and broadcast this story through the MetLife Foundation’s Journalists in Aging Fellows program, organized by The Gerontological Society of America and New America Media. Go to the KUT website to hear her public radio version. 

Borderline Personality Disorder relations with BP

Differentiating Borderline Personality Disorder from Bipolar DisorderBorderline personality disorder (BPD) and bipolar disorder frequently co-occur (numbers range from 8% to 18%), although they are distinct clinical entities (Paris J et al, Compr Psychiatry2007;48(2):145–154). A proper diagnosis guides the most effective treatment, but you’ve probably faced the difficult challenge of diagnosing these conditions, which share several clinical features.
BPD can be described by four types of psychopathology: affective disturbance, impulsivity, cognitive problems, and intense, unstable relationships. What’s most important—in addition to seeing that your patient meets DSM-IV criteria for BPD—is to establish that patterns of affective instability, impulsivity, and unstable relationships have been consistent over time. Thus, obtaining a detailed history is crucial. Also, the key features we see in BPD, such as dissociation, paranoia, and cognitive problems, are often affected by the patient’s environment and, particularly, his or her relationships. A patient might have a history of rapid and sudden deterioration when relationships change—such as threatening suicide after a breakup or severe mood swings when separated from her family. Generally, the more intense or significant the relationship is, the greater the risk of chronic stress and mood dysregulation.
Many of the same features are seen in patients with bipolar disorder, such as dysphoria, hyperactivity, impulsivity, suicidality, and psychotic symptoms. As a result, borderline patients with this cluster of symptoms are often misdiagnosed with bipolar disorder, possibly because of the effectiveness of psychopharmacological treatments for such symptoms. In fact, a more thorough assessment might show that these patients actually suffer from a personality disorder. In one study, more than one third of those misdiagnosed with bipolar disorder met DSM-IV criteria for BPD (Zimmerman M et al, Compr Psychiatry2010;51(2):99–105).
In BPD, mood changes are generally short-lived, lasting only for a few hours at a time. In contrast, mood changes in bipolar disorder tend to last for days or even weeks or months. Mood shifts in BPD are usually in reaction to an environmental stressor (such as an argument with a loved one or a frustration in the waiting room), whereas mood shifts in bipolar disorder may occur out of the blue. Some clinicians consider BPD an “ultrarapid-cycling” form of bipolar disorder, but there’s little evidence to support this link (Gunderson JG et al, Am J Psychiatry 2006;163(7):1173–1178). Patients with BPD might rapidly cycle through depression, anxiety, and anger, but these mood shifts rarely involve elation; more often, the mood shifts are from feeling upset to feeling just “OK.” Likewise, the anxiety or irritability of BPD should not be mistaken for the mania or hypomania of bipolar disorder, which usually involve expansive or elevated mood.
At a more existential level, patients with BPD—particularly younger patients— often struggle with feelings of emptiness and worthlessness, difficulties with self-image, and fears of abandonment. These are less common in bipolar disorder, where grandiosity and inflated self-esteem are common, especially during mood episodes. And while both conditions may include a history of chaotic relationships, a patient with BPD may describe relationship difficulties as the primary—or sole—source of her/his suffering, while the bipolar patient may see them as an unfortunate consequence of his behavior.
A pattern of self-harm and suicidality often serves as a cue for diagnosing BPD (but are not necessarily required). But both can be seen in bipolar disorder, too. In BPD, suicide threats and attempts may occur along with anger at perceived abandonment and disappointment. Patients often explain these impulses as a way to be relieved of pain, or to “stop their thinking,” more so than to end their lives, per se. Patients with BPD may experience “micropsychotic” phenomena of short duration (lasting hours or at most a few days), including auditory hallucinations, paranoia, and episodes of depersonalization. However, patients generally retain insight, and can acknowledge that “something strange is happening” without strong delusional thought. When psychotic symptoms occur in bipolar disorder, they happen in the context of a mood episode, they tend to last longer, and patients may be unable to reflect on their behavior.

This article originally appeared in The Carlat Psychiatry Report -- an unbiased monthly covering all things psychiatry.
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Accurate diagnosis of BPD and bipolar disorder can be difficult, but it’s essential for proper treatment and optimal outcome. Remission rates in BPD can be as high as 85% in 10 years (Gunderson et al, Arch Gen Psychiatry 2011;68(8):827–837), particularly with effective psychotherapeutic treatments (Zanarini MC, Acta Psychiatr Scand 2009;120(5):373– 377). Unfortunately, such treatment is not always available. Some medications can be used in BPD, such as an SSRI for impulsivity, severe and persistent depression and/or suicidality, or an atypical antipsychotic for recurrent dissociative symptoms or disinhibition. However the only consensus seems to be that medications should be used as adjuncts to psychotherapy (Silk KR, J Psychiatric Practice 2011;17(5):311–319). The long-term use of a mood stabilizer or atypical should be reserved for known cases of bipolar disorder.
TCPR’s VERDICT: Clinicians sometimes think of a BPD diagnosis as pejorative (chronic and untreatable) and may be reluctant to disclose it, but patients and their families often find it helpful to be informed of the diagnosis. Similarly with bipolar disorder, accurate diagnosis often determines prognosis and effective treatment. For the clinician, however, it’s imperative that you make the proper diagnosis in these two often overlapping, but fundamentally quite distinct, conditions in order to optimize your patients’ outcomes.