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How Effective Is Mental Health First Aid?

By Ashley L. Peterson / 2022-10-03
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How effective is mental health first aid? - image of a brain and a first aid kit

I was recently browsing the blog of Pete Earley, the author of the book Crazy: A Father’s Search Through America’s Mental Health Madness, and I came across a post on a recent Manhattan Institute report criticizing Mental Health First Aid (MHFA). The Manhattan Institute is a conservative think tank, and I’ve previously taken issue with In Defense of Stigma, an article by MI fellow Stephen Eide. I was expecting to be entirely unimpressed by the report on MHFA, and while it certainly had some flawed assumptions, it also made some interesting points that I wanted to discuss.

The report, written by Caroline D. Gorman and published in June 2022, is titled Mental Health First Aid: Assessing the Evidence for a Public Health Approach to Mental Illness. Before we talk about what the report has to say, let’s take a quick look at what MHFA is.

Background on Mental Health First Aid

MHFA was originally developed in Australia in the year 2000. According to MHFA International, MHFA aims to “empower and equip individuals with the knowledge, skills and confidence needed to support a friend, family member or co-worker experiencing a mental health problem or experiencing a crisis such as being suicidal.”

In terms of the spectrum of intervention (prevention, early intervention for people who are getting sick, and treatment for people who have an illness), MHFA is primarily aimed at early intervention, although the skills that are taught can be useful at any point along the spectrum. MHFA International cites research that says, “People are more likely to seek help if someone close to them suggests it.”

MHFA objectives (Canada)

The Mental Health Commission of Canada identifies the following objectives for a mental health first aid course:

“Course participants will learn how to recognize signs that a person may be experiencing a decline in their mental well-being or a mental health crisis and encourage that person to:

  • Talk about declines in their mental well-being
  • Discuss professional and other supports that could help with recovery to improved mental well-being
  • Reach out to these supports
  • Assist in a mental health or substance use crisis
  • Use MHFA actions to maintain one’s own mental well-being”

MHFA action plan (US)

The Mental Health First Aid site in the US identifies a 5-step mental health first aid action plan:

  1. Assess for risk of suicide or harm
  2. Listen nonjudgmentally
  3. Give reassurance and information
  4. Encourage appropriate professional help
  5. Encourage self-support and other support strategies

The Manhattan Institute report

What didn’t surprise me about the report was that it framed untreated mentally ill people as dangerous. It linked untreated mental illness with the New York City subway attacks in 2021 and 2022 and the school shootings in Newtown, Connecticut, and Parkland, Florida. I think that link is far more tenuous than the report’s author makes it out to be, but I’ll just let it be and move on to the issue of mental health first aid.

The report characterizes MHFA this way:

“In essence, it works similarly to that of a public screening program, meant to capture instances of disorder that otherwise may have gone unnoticed. The overarching goal of the program is to connect mentally ill individuals—the intended beneficiaries—with an appropriate level of treatment before a crisis leads to tragedy.”

But is it really? I’m not sure that it is.

Where is the money going?

The report notes that mental health first aid training for teachers was part of President Barack Obama’s response to the Sandy Hook Elementary School shooting in 2012. In 2015, Congress allocated $20 million to MHFA training for the general public. Since then, at least 20 states have provided funding for MHA. The federal budget for MHFA-like programs was $24 million for 2022 and $64 million for 2023. That’s not a huge amount in the bigger picture, but it’s not negligible, either.

Criticism of the evidence base

The main criticism with respect to research findings on MHFA is that there’s a lack of evidence to show that it improves outcomes for mentally ill people or helps them to receive appropriate treatment. Much of the research focuses on how training helps trainees rather than how it helps the “intended beneficiaries”, i.e. people with mental illness. There are few randomized controlled trials and limited independent research; much of the evaluation that’s occurred has been done by the developers of MHFA.

As one example of the lack of effectiveness, the report cited a study published in the Journal of Adolescent Health that found that training campus residence hall residence advisors in MHFA was not associated with any increase in utilization of mental health services by students living in those halls compared to students in residence halls where the advisors hadn’t received MHFA training.

Trainees’ mental health

One of the concerns raised that I thought was rather weak was that MHFA might make trainees more likely to seek mental health help themselves, which could lead to over-diagnosis. In the study that involved training residence advisors, the RAs who received training were more likely to seek professional help themselves. The report made that out to be a bad thing, but if the author is criticizing MHFA for not getting more people to seek help, isn’t that a good thing?

Along the same lines, the report’s author expressed concern about findings from a different study that people who did not report having mental health problems themselves prior to training went on to report that they did have mental health issues after the training. The author rather conveniently left out this crucial bit in the paper that was published in BMC Psychiatry:

“In the present study there was a significant increase in the percentage who perceived themselves as having a mental health problem and a non-significant trend for an increased perception of family members as having mental health problems. However, in absolute terms the changes were not so great as to be a concern and may, in fact, reflect accurate re-labelling.”

Essentially, it was probably the same deal as with the RAs—getting training made people realize huh, I have a problem that I should seek help for. The “intended beneficiaries” end up being the trainees themselves.

Barriers to treatment

As the MHFA approach identifies stigma as a major barrier to seeking treatment, changes in trainees’ attitudes toward mental illness are often included as an evaluation metric. However, stigma reduction doesn’t necessarily translate into improved access to or quality of mental healthcare.

According to the report, “The underlying premise of MHFA is that a lack of knowledge about mental health leads mental illness to go unrecognized, which means people are not connected to treatment and fewer crisis situations are averted.” Yet when trainees’ knowledge was assessed prior to training, they were already pretty good at recognizing mental illness, so it’s questionable how much mental illness is actually getting recognized more often as a result of MHFA.

Can mental illness be prevented?

Another criticism in the Manhattan Institute report was that focusing on mental illness prevention doesn’t make sense when we don’t know what actually causes it, and therefore don’t know how to prevent it. I don’t entirely agree with that, as factors like adverse childhood experiences are known to increase risk, but I do think it’s a valid point that we’re not going to be able to just magically prevent mental illness from happening.

This bit struck me as rather odd: “Certain social circumstances may increase the risk of developing some mental illnesses. PTSD, for example, can occur from exposure to death, sexual violence, or the threat of either.” Given that it’s not possible to have PTSD without trauma, I’m not sure where the author was going with that.

Another odd bit: “Perhaps unsurprisingly, MHFA ignores primary barriers to managing mental illness-related crises: treatment access for the mentally ill most at risk of crisis and a scarcity of specialty health-care providers and services.” I’m not sure how that has anything to do with MHFA.

Odd statements aside, I think there is a valid point that taking a public health approach that emphasizes education and prevention (with MHFA being a representative example of such an approach) when there are serious issues with treatment availability doesn’t necessarily do that much to help people dealing with serious mental illness.

Should treatment be the priority?

The report points out systemic issues like a lack of psychiatrists in many parts of the US (especially rural areas), more than 60% of psychiatrists not accepting Medicaid, a lack of psychiatric inpatient beds, people getting discharged prematurely, and people not getting admitted to hospital because of insurance issues. In a given year, fewer than half of people with a diagnosable mental illness actually get treatment.

The report’s author calls for government support for treating serious mental illness, “in part because there are market failures in the provision of health care and services for this population.” That’s certainly something we can agree on. Among the recommendations she made were increasing funding to assertive community treatment and assisted outpatient treatment teams, supportive housing with case management, and mental health courts, and increasing psychiatric inpatient capacity.

My take

It seems to me like this Manhattan Institute report is criticizing MHFA for not getting more scary crazy mentally ill people into treatment. I don’t actually think it’s realistic to expect that MHFA would do that. There are multiple, complex reasons why people with serious mental illnesses don’t engage in treatment, and MHFA is unlikely to address the majority of those reasons.

If MHFA can help to decrease stigma, I think that is a good thing for people with mental illnesses, even if it doesn’t get more people into treatment. One thing I would like to see is MHFA being delivered by people who have lived experience of mental illness. Contact is more effective for stigma reduction than education, so why not combine the two rather than just doing the educational component?

In terms of whether MHFA is the best place to be allocating limited public financial resources, I honestly don’t think it is. I think governments should be prioritizing treatment when they’re doling out public money; in particular, I think there needs to be a shift in emphasis from acute care after things have gotten really bad to community-based care that can help keep people out of hospitals. If private citizens, community groups, or employers want to pursue MHFA training, that’s great, but I’d like to see governments funding professional services. For example, I would much rather see students have access to counselling services in school than have all the teachers trained in mental health first aid.

What are your thoughts on the usefulness of mental health first aid?

Book cover: A Brief History of Stigma by Ashley L. Peterson

My latest book, A Brief History of Stigma, looks at the nature of stigma, the contexts in which it occurs, and how to challenge it most effectively.

You can find it on Amazon and Google Play.

There’s more on stigma on Mental Health @ Home’s Stop the Stigma page.

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Book Review: You Are Not Alone

By Ashley L. Peterson / 2022-09-28
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Book cover: You Are Not Alone by Ken Duckworth

You Are Not Alone: The NAMI Guide to Navigating Mental Health by Ken Duckworth, NAMI’s medical director, is the first book released by the National Alliance on Mental Illness. The book includes excerpts from interviews with 130 people who either self-identify as having a mental illness or have a loved one who does, and the author writes, “Mental illness and recovery are human experiences, so I consider experience-based evidence an authoritative source for this book.”

The book opens with the author talking about his history with NAMI and his family’s experience with his father’s bipolar illness. Throughout the book, he comes across as talking with readers on the same level rather than being an expert talking at readers.

The book is divided into four parts. The first part looks at mental health conditions and mental health care, the second part focuses on people’s experiences with their recovery journeys, the third part focuses on family members, and the final part is devoted to traditional experts answering commonly asked questions.

The author acknowledges the flaws with the DSM diagnostic system, and he’s also realistic about the problems with the mental health care system, or lack thereof: “The mental health ‘system’ throughout the United States is chaotic and full of gaps. It has long been broken and fragmented, and if you try to wait for the system to be less confusing and frustrating, you will be waiting a very long time.” The book talks about medical model and recovery model strategies (focusing on symptoms and living a good life, respectively), and the author encourages a both/and rather than an either/or approach.

Topics covered in the book included peer support, cultural issues, becoming an advocate, and legal issues around things like involuntary treatment, privacy, and police and criminal justice system involvement. The final section included an FAQ chapter with various experts answering questions, as well as a chapter with clinicians and researchers addressing questions about care for depression, OCD, borderline personality disorder, trauma, co-occurring disorders, bipolar disorder, and psychosis. It felt like a lot of disparate things to cram into two chapters.

There was a chapter on making meaning of suicide loss, and there were a couple of comments I found quite interesting. An interviewee who had lost a brother to suicide said “The last engagement he had was with another person who was talking to a classmate about how to divide homework problems, and I found him twenty minutes later. If you’re struggling with suicidal ideation, you’re not talking about homework problems.” The author, whose brother died by suicide, wrote “My brother ordered a computer monitor the day he died, and it arrived the day of his funeral. People who are contemplating suicide don’t do that.” Except they do; if the action hasn’t happened yet, there is some degree of ambivalence, and tasks of living continue in that space of ambivalence.

While the goal was to be comprehensive, I found the book kind of unfocused, and I felt like that detracted from the overall usefulness. I’m all for sharing people’s stories, but the way excerpts from the interviews were pulled together (often a paragraph or two at a time) created a bit of a hodgepodge that made it hard to feel connected to the individuals. While I can see the potential value of interviewing 130 people and interspersing bits of their comments throughout the book, I think it does make it harder for readers to feel like they’re really getting a sense of who these people are.

As you might expect from a NAMI book, there is a NAMI promotional element. Although it wasn’t unexpected, I did think it was a little overdone. Another element that wasn’t unexpected was optimism about recovery and stories of people doing really well. There was plenty of acknowledgement that things have been hard in the past tense, but there wasn’t a lot of present tense struggling conveyed. As a present-tense-struggler myself, I found it a bit unbalanced, but I think probably a lot of the people who end up reading this book will like the recovery emphasis.

At over 400 pages, this book is a serious commitment. The length and the lack of focus and structure don’t make a great combination; it tends to promote skimming, which takes away from the power of some of the interviewees’ contributions.

I can see this book being useful for family members who are looking to learn as much as they can about what this whole mental illness thing is about, and that’s probably the main target audience that NAMI is aiming for. It’s probably going to be less useful for people who’ve been around the block a few times dealing with their own illness.

You Are Not Alone is available on Amazon (affiliate link).

I received a reviewer copy from the publisher through Netgalley.

You can find my other reviews on the MH@H book review index or on Goodreads.

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Review: Living with Chronic Mental Illness Podcast

By Ashley L. Peterson / 2022-09-23
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microphone and headphones
Image by Tumisu from Pixabay

I wanted to share with you a new podcast created by my friend Mike Edward called Living with Chronic Mental Illness. It’s about his own journey with chronic schizoaffective disorder. As the host says, “It’s the story of challenging moments, of failures, of successes, of love, of loss, and of hope. This is the story of how ignorance lost its bliss.”

It seems like sometimes people try to portray a sanitized picture of mental illness in an attempt to make it more socially acceptable.The downside of this is that there are a lot of us who don’t have a neat and tidy experience of mental illness, and I like that this podcast captures the reality that life with a chronic mental illness is hard. The host is honest and open about the challenges he’s faced and the fact that he continues to face challenges on an ongoing basis due to his illness.

I tend to have a hard time concentrating on auditory information, so I liked that the episodes are on the shorter side, each lasting about 5-10 minutes.

The podcast is embedded below, and you can get to it via Linktree. New episodes are posted weekly on Mondays at 12am. I encourage you to check it out!

Podcasting has certainly been growing in popularity. An article on Buzzsprout from earlier this month offers the following statistics pulled from various sources:

  • In 2022, 62% of Americans age 12+ have listened to a podcast
  • 38% of Americans age 12+ listen to podcasts at least monthly, and 26% listen weekly
  • The number of podcast listeners in the US has grown from 46.1 million in 2017 to 82.7 million in 2021

Here are some Buzzsprout platform stats from August 2022:

  • 118.8 million downloads
  • 170.5K new episodes
  • 114.3K active podcasts

Personally, I’ve never thought about doing a podcast or being a guest on one; I’m a writer, not a talker. Aside from podcasts created by friends, I’m not a podcast listener, either; the written word is a better medium for me than the spoken word. However, there are probably a lot of people for whom the written word is not an ideal medium, and venturing out into things like podcasting is a way to reach different audiences. And when it comes to getting the word out about the reality of mental illness, the more different audiences that can be reached the better.

Besides Living with Chronic Mental Illness, another podcast I would recommend is Perfectly Imperfect by my friend Johnzelle Anderson. It focuses on Black mental health and social justice issue. If there are any mental health-related podcasts you’d like to recommend, feel free to drop the links in the comments below.

Are you a regular podcast listener? Do you have any thoughts on whether the rise in popularity of podcasting will impact the popularity of blogging?

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Suicidality and Other People’s Perspective

By Ashley L. Peterson / 2022-09-19
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Book Review: Strangers to Ourselves

By Ashley L. Peterson / 2022-09-14
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Strangers to Ourselves: Unsettled Minds and the Stories That Make Us by Rachel Aviv explores the different ways in which people try to make sense of mental illness, both on an individual and societal level. The book tells the story of six different people who experienced mental illness, including the sociocultural factors that shaped those experiences. One of these stories is of the author’s own experience of being hospitalized at age six for anorexia nervosa.

The author is a writer for The New Yorker, and her journalistic background is very apparent in the stories she tells. Of the other five individuals whose stories were told in the book, two of them were still alive and directly interviewed by the author. One of these five was someone who had been a co-patient of the author’s during her childhood hospitalization.

The book opens with the author’s own story, then moves on to Ray Osheroff, who was a notable figure in the conflict between a psychoanalytical approach to psychiatry and an evidence-based approach. He had a lengthy stay for severe depression at an institution called Chestnut Lodge, where the treatment team insisted that psychoanalytic therapy was the only way he could get better. Although he was only getting worse, they refused to put him on medication. He later sued Chestnut Lodge for malpractice for not using evidence-based treatment, and the book explores the debate that this lawsuit sparked within the field of psychiatry.

Next up is Bapu, a deeply spiritual Indian woman who was diagnosed with schizophrenia. In telling her story, the author explores issues around spirituality and psychosis, culture, and the ways families respond to mental illness.

The story of Naomi Gaines, a Black woman who killed one of her children while psychotic, addresses how racism impacts how mental illness is framed and treated and how it impacts access to care. It also looks at the effects of deinstitutionalization, the large numbers of mentally ill people who end up in the criminal justice system, and the limitations of the M’Naghten Rule, which is the legal test that’s commonly used in the US to establish an insanity defense. In Naomi’s case, doctors didn’t feel that she met the M’Naghten standard, and her public defender didn’t think a jury would accept an insanity defense. The book also looks at the poor care that people with mental illness receive in prison. In Naomi’s case, while in prison for second-degree murder, her antipsychotic was stopped due to cost. Unsurprisingly, her mental health deteriorated, and she was put in segregation for two months.

Next was the story of Laura Delano, a woman who’d been diagnosed with bipolar disorder and later borderline personality disorder. She took 19 different medications over the course of 14 years. The author observes, “While Black women tend to be undermedicated for depression, white women, especially ambitious ones, are often overmedicated, in order to ‘have it all’: a family and a thriving career.”

Laura ended up going off of medication because of emotional and sexual numbness, and she had significant difficulties with withdrawal, which led to her getting involved in online communities of others who’d also struggled with psychiatric medication withdrawal. The book explores the ways that people relate to the medications they are taking or have stopped taking and how this can shape identity and the stories people construct about their illnesses. The author also contrasts her own experience with Laura’s—while Laura’s doctors had pushed meds, the author had been taught to see her illness as “a kind of stress reaction… In a sense, Laura and I were mirrors on which different faces of psychiatry had been reflected.”

The author also shares her own experiences taking the antidepressant Lexapro as an adult. It sounds like it was prescribed not because of a psychiatric diagnosis, but rather to help with psychological rigidity around feelings of inadequacy. It was initially intended to be for short-term use, but she felt better on it and worse when she tried to come off of it. On a low dose, the author writes, “I was not depressed, but I was less social, flexible, and spontaneous. It seemed I had reached my baseline personality.” She ended up deciding to go back up to the full dose, and she’s remained on the Lexapro for over a decade. She adds, “I also realize that I’ve endowed my pill of choice with mystical capacities—it contains the things I’m not but wish I was—and merely the idea of swallowing such a thing has healing power.”

It was interesting to examine my own reactions to this. I’m very pro-medication as an option for treating mental illness, but I must admit, I judged the psychiatrist who started her on the Lexapro. Why? In part, it’s because I’m into evidence-based medicine, and prescribing medication for something it’s not indicated for seems like poor practice, but there’s also a more personal element to the reaction. I think that’s at least partly because I take meds to try to get back some of the self that my illness obscures, and taking meds to be a different person from the self feels… backward, maybe? Or maybe I’m just envious of the idea of taking meds as a self-enhancer rather than in an attempt to stay alive and maintain some degree of functioning.

The book has a lot of detail, drawing on interviews with many people associated with each story. It’s impressive in terms of journalistic quality, although my personal preference would have been to leave out some of the details that seemed less relevant. Then again, that’s at least partly because I wasn’t feeling well when I read it. I liked the author’s approach of looking at the bigger-picture factors that came into play in each individual’s story and how this shaped the way these individuals and those around them understood the illness. Both the depth of investigation and the big-picture view make this a unique and fascinating book.

Strangers to Ourselves is available on Amazon (affiliate link).

I received a reviewer copy from the publisher through Netgalley.

You can find my other reviews on the MH@H book review index or on Goodreads.

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Book Review: Everything You Need to Know About OCD

By Ashley L. Peterson / 2022-09-07
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book cover: Everything You Need to Know About OCD by D

Everything You Need to Know About OCD by Dr. Lynne M. Drummond with Laura J. Edwards is, as the title suggests, a comprehensive book covering OCD and its treatment. The lead author clearly has considerable clinical expertise working with clients with hard-to-treat OCD.

The book looks at the processes involved in OCD, including distressing thoughts increasing when one tries to suppress them, and thought-action fusion (the belief that having a thought is the moral equivalent to performing the act that the thought relates to—I’ve got a blog post coming up on that). It covers different types of OCD as well as common co-occurring conditions. Autism spectrum disorder is one of the co-occurring conditions mentioned, and the author explains how to differentiate between autistic rituals and OCD rituals.

There’s a chapter devoted to medication treatments, side effects, and commonly asked questions about med use. I found it interesting that the author chose to use the term “dopamine blockers” rather than “antipsychotics.” Dopamine blocker is actually a more accurate term than antipsychotic, but the choice definitely seemed like an acknowledgement of the associated stigma. Three’s also a chapter on emerging research that looks at the role of treatments like neurosurgery (a far cry from the icepick lobotomies performed back in the day) and deep brain stimulation (which is also used for depression)

The book gives a lot of attention to exposure and response prevention (ERP). The author recommends constructing a hierarchy for exposures, but not for compulsions. She writes, “It can often be tempting to gradually reduce compulsions or even place these on a hierarchy. In reality, this rarely works because it is extremely difficult to cut down on such behaviours. It is much better and easier in the long term to stop the compulsive behaviours entirely.” For exposures to be most effective, the author recommends doing them three times a day and for long enough each time for the anxiety level to drop by half, which she says initially might take a couple of hours. There’s definitely no promising an easy fix here.

A lot of the example exposures the book offered are things that are more extreme than what a “normal” person would typically do. The author explained this in terms of a treatment pendulum. If OCD is at one end and extreme risk-taking is at the other, exposures should swing past normal into risk-taking territory to make people less likely to return to the slippery slope back to OCD.

In the chapter for family and caregivers, the book emphasizes the importance of not going along with OCD compulsions and reassurance-seeking. The author recommends calling the police if not going along with the OCD results in threats or violence. The fact that this was mentioned a few times hints at how profoundly unwell her patients are.

There are lots of case examples throughout the book, and many of these involve patients who were extremely debilitated by their illness. Many of these examples include ERP programs, and there are a number of these for each different OCD theme (e.g. contamination, symmetry, taboos like pedophilia, and fear of harm to self/others through either thoughts/actions or failure to act).

The author explains that the term pure-O OCD that’s sometimes used is actually inaccurate, as obsessive rumination has two parts: the distressing thoughts (obsessions) and mental compulsions to ward off harm from distressing thoughts, reduce distress, or put things right. She writes about how to differentiate these two parts and offers strategies to overcome the fact that mental compulsions can occur involuntarily even if one tries not to do them.

The author is based in the UK, so some of the discussion about treatment availability won’t be relevant to readers outside of the UK, but I don’t think that detracts from its suitability for an international reader base.

This book isn’t a light read. The language used isn’t difficult, it’s laid out well, and there are concise point-form summaries at the end of each chapter, but it’s packed with facts. There are lots of details, but they’re relevant rather than extraneous. The book would be a great choice if you’re wanting to learn a lot about OCD or if you’re looking for information related to difficult-to-treat OCD. For people whose OCD is on the milder side and isn’t causing a massive disruption in their lives, some of the other books on OCD that I’ve reviewed would probably make a better starting point, but if you’re looking for a really comprehensive resource, this is it.

Everything You Need to Know About OCD is available on Amazon (affiliate link).

I received a reviewer copy from the publisher through Netgalley.

You can find my other reviews on the MH@H book review index or on Goodreads.

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Book Review: The Panic Attack Relief Workbook

By Ashley L. Peterson / 2022-08-24
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Book cover: The Panic Attack Relief Workbook by Mayra Diaz

The Panic Attack Relief Workbook by Mayra Diaz lays out a seven-week plan for people to be able to better manage panic. It incorporates cognitive behavioural therapy (CBT), acceptance and commitment therapy (ACT), and exposure therapy. As the title indicates, it’s a workbook with exercises to fill out.

The book begins with background information about how panic affects the brain and body, as well as different disorders that can involve panic. It also provides background information about different CBT and ACT strategies. The rest of the book is laid out as seven chapters to cover week by week, with a different focus area for each week’s exercises.

The first week focuses on understanding how panic impacts your well-being. It included keeping a panic attack log to connect situations, emotions, and sensations, along with exercises to examine and identify panic’s impact on your life, the fears that your mind is treating as threats, and triggers. There are also exercises involving deep breathing, grounding, and progressive muscle relaxation.

Other weekly focus areas include breaking the cycle of negative thoughts, facing your fears, and mindfulness acceptance. There’s a mix of education, self-monitoring, self-reflection, coping tools, exposures (including exposures to feared bodily sensations) and other strategies to address thoughts, feelings, and behaviours. There are also coping statements scattered throughout the book.

One line I quite liked was “You can’t control your emotions, but you can feel capable of managing them.”

A wording choice that struck me as a bit odd was when the author encouraged readers to teach others about what they’ve learned, while at the same time being careful to avoid playing armchair therapist. She wrote, “You have learned a lot about panic, but you are not a mental health expert.” It’s a very minor thing and I know what she was going for was “you are not a mental health professional”, but I’m kind of feisty, and telling people living with mental illnesses that they’re not experts in their conditions sparks a bit of that feistiness.

I thought the author did a really good job of providing clear, concise explanations, which allowed a lot of useful stuff to be packed into a book that’s relatively short and very easy to read. It’s also very aesthetically appealing. I liked the short sections and point-form key takeaways at the end of each chapter. The tone was supportive and encouraging but not preachy, which I also liked. Overall, I thought it was very well done.

The Panic Attack Relief Workbook is available on Amazon (affiliate link).

I received a reviewer copy from the publisher through Netgalley.

You can find my other reviews on the MH@H book review index or on Goodreads.

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A Display of Public Ignorance About Depression

By Ashley L. Peterson / 2022-08-16
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Image by Andrew Martin from Pixabay

People are dumb; there’s nothing new about that. Public ignorance about depression in particular was on display recently in a news article I came across, and it annoyed me, so I thought I’d write about it.

First, let’s start with some background. The news related to the findings of an article published last month in the journal Molecular Psychiatry titled The Serotonin Theory of Depression: A Systematic Umbrella Review of the Evidence. The authors concluded that there wasn’t evidence to the serotonin hypothesis, which was put forward back in the 1960s as a potential explanation for why antidepressants that affect serotonin are helpful for people with depression. The review looked specifically at the serotonin hypothesis; it didn’t evaluate whether or how well antidepressants work.

I’ve written before about the serotonin hypothesis, the idea of a chemical imbalance, the efficacy of antidepressants, and what we know about how antidepressants work, so I won’t reiterate all of that here; there are links to those posts at the bottom of the page. Basically, though, it’s been recognized for years that depression is not a matter of a lack of serotonin, but antidepressants, including those that affect serotonergic neurotransmission, do work better than placebo.

A misleading headline

One of the news outlets that reported these research findings was CBC News, in an article from August 13, 2022, titled Have We Been Treating Depression the Wrong Way for Decades? The article included a couple of subheadings (“Are antidepressants effective against depression?” and “Research calls antidepressants into question”) that were also misleading, suggesting that the paper was about antidepressant effectiveness despite the fact that it was not. The article itself wasn’t misleading, but it seems like it probably fell victim to an editor who prioritized clickbait value over accuracy.

What really stood out for me, though, was the level of ignorance in the comments that were left on the article. As much as we might like to hope that there’s been progress in how well people understand mental illness, there’s clearly a very long way to go.

What people thought causes depression

Quite a few comments blamed depression on modern society, including unattainable standards, politics, entitlement, financial issues, neoliberal capitalism, the news, and social media.

Here are a couple of examples (all quoted text includes original spelling/grammar):

“Funny how people growing up in the first half of the 20th century, with 2 worls wars, the depression, dirty 30s, working 80 hours a week on the farm or 60 hours a week in factories werent so much into ‘navel gazing’ about ‘depression’, and the like.”

“Every one is depressed now, studies show the saturation of news reporting in people’s daily lives couple with television entertainment is overwhelmingly negative and produces the expected depressive condition. Unplugging is the best solution.”

More comments on depression

In response to a comment about it being hard for people who haven’t been depressed to understand it, one person wrote: “I have been through it..after you reach a certain age you realize it is just a crutch…if you are in good health , and dont have a real mental condition like Scitzophrenia, and can be productive, whether physically, intelectually or artistically, there is no reason to be depressed.” I just don’t even know where to start with that.

Someone else wrote, “Everyone gets depressed at some point. Reflection of those times make the happy times that much more enjoyable.” Everyone gets sad at some point, but no, everyone does not get mentally ill at some point, and no, depression is not some gift to make you appreciate life more.

How people thought depression should be treated

People had assorted suggestions for things that they thought would be most effective for depression. The most commonly mentioned were exercise, a healthy diet, getting outside, and sunshine. One person got very specific about the supposed effectiveness of exercising, saying that it “would solve 90 percent of all cases.”

Some people thought the answer to depression was keeping busy, while others thought it was being less busy.

One person wrote, “I have always meds are not a solution to depression. People are depressed because of problems. So, the only way to cure them of depression is for them to solve the problems. How would meds help them?” Someone else pointed out that even rich people with apparently great lives can get depressed, to which the original commenter responded that those people don’t have enough problems. I guess it’s sort of like the whole keep-busy-but-not-too-busy thing.

Some people thought finding a friend was the answer:

“What lonely people who are depressed need is people, not entirely drugs. When we companion those afflicted with others perhaps via media means, to others who are similarly affected, we are at step one. Love of one another.”

“It’s likely that many people suffering depression just need a friend, a true friend.”

Then there was someone with a suck it up, buttercup attitude: “Just a general observation but if the placebo affect works for some people as stated in this article, so to would the attitude of just buck up and keep on, keepin on.”

The idea that meds mask symptoms

Aside from all the ranting about Big Pharma, the most common concern people expressed about antidepressants was that they mask symptoms rather than correct the underlying problem. Okey dokey, but given that the underlying problem is probably pretty complex and no one actually knows what it is, treating symptoms is what we’re left with.

People may assume that therapy is what can actually correct the underlying problem, but that’s not necessarily true. It seems like people hear that the serotonin hypothesis was wrong and jump to the conclusion that biology isn’t involved at all, which is not actually a logical conclusion to arrive at. If nothing else, there is a heritable element to many mental illnesses, including depression, which means there is some degree of biological element. Medications that exert a biological effect have a therapeutic effect, and that would not happen if there wasn’t a biological component to the illness. The fact that the brain is really complex and science hasn’t pinned it down yet doesn’t mean that biology can’t be involved and depression is purely psychological.

There are plenty of medical conditions that are treated symptomatically rather than by resolving the underlying pathophysiology. Chronic illnesses are chronic because the underlying problem sticks around. We don’t tell most people with chronic illnesses to just suck it up rather than treating the symptoms, although unfortunately, people with fibromyalgia and ME/CFS (chronic fatigue syndrome) get told that far too often.

Use what works

Meds don’t work for everybody, and they’re not tolerable for everybody, but when they do work, they can be game-changing. Just because science hasn’t figured out why they work isn’t a reason to stop using them when they are effective.

As for people’s ignorance about depression, I think there will always be people who will happily choose ignorance if they haven’t been directly affected by a health condition. And if anyone tells me that I just need to exercise more and get more sunshine and do some gardening, I will quite happily tell them where they can shove it.

book cover: Managing the Depression Puzzle, 2nd Edition, by Ashley L. Peterson

Managing the Depression Puzzle takes a holistic look at the different potential pieces that might fit into your unique depression puzzle.

It’s available on Amazon and Google Play.

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Low-Barrier Housing and NIMBYism in Action

By Ashley L. Peterson / 2022-08-02
Posted in
bedding where homeless people sleep on the ground underneath a bridge

NIMBYism, the idea that certain development projects are okay, but Not In My BackYard, is discrimination with a prettier hat on. NIMBYs don’t come right out and say the actual reasons for their opposition; instead, they offer other reasons, perhaps to reduce their own cognitive dissonance because they don’t want to think of themselves as having stigmatized attitudes. This post was prompted by a recent story on CBC News story about Vancouver city council approving a low-barrier housing development despite some loud public opposition.

A low-barrier supported housing development

The proposed development in question is for a 13-story building with 129 units of low-barrier supportive housing adjacent to a new SkyTrain (our version of a subway) station that’s being built. Low-barrier housing targets adults who are homeless or at risk of homelessness, low-income, and in need of support in order to maintain a successful tenancy (source: BC Housing). People accessing this kind of housing often (but not necessarily) are dealing with mental illness or addictions.

The Kitsilano Coalition, a group of community members opposed to the development, argues that supportive housing units should be spread out across the city rather than being concentrated in one building. The CBC article quotes a member of the coalition as saying “We asked for a model that is what’s proven by the science, which is to disperse individuals across the city in smaller numbers amongst people that are living in regular condo buildings and rental buildings so that people don’t feel stigmatized.”

She also stated, “We don’t understand why we, the community members, ended up being the people advocating for the best solution for the vulnerable members in our society.”

Straight from the NIMBY horse’s mouth

The Kitsilano Coalition has created a website that articulates their arguments. It states that “the supportive housing model is a failure.” Here are some excerpts:

  • The proposed housing model is “unsafe for both the residents and the surrounding community and does not come close to adequately responding to the residents’ addictions and mental health issues. Placing housing like this in a neighbourhood without having an adequate plan for supports in place perpetuates the willful neglect of the public and people this is intended to help.”
  • “Statistics show that supportive housing rules leave people isolated and put them at higher risk of harmful outcomes as a result of the restrictive environment.” (No actual statistics are offered to support this claim.)
  • ‘We believe a better alternative is scattered-site housing with supports rather than an unnecessary level of institutionalization imposed on people living in our neighbourhood.”
  • “The ‘Low Barrier’ terminology means that there are no requirements for tenants to be screened for mental health or substance abuse issues. Whilst it is feasible some tenants may enter this housing from Correctional Institutions, there are no criminal records screenings, as a prerequisite for tenancy.”
  • “There are no requirements for any tenants to seek out mental health or substance abuse support.” (their emphasis, not mine)
  • They note that their concerns have been met by the city with “accusations of NIMBY-ism and stigmatization.”

Everyone deserves a roof over their head

Low-barrier housing exists because everyone deserves to have a roof over the head. Just because someone has an untreated mental illness, an active addiction, or a criminal record does not mean that they should just be homeless and that’s the end of that. Engaging in treatment for any sort of health condition should not be a requirement to have a place to sleep indoors. The target population is people that the rental housing market either cannot or does not accommodate, so social housing is needed that doesn’t have the same barriers to getting housed as the rental market.

What’s not being said

If people are concerned about potential consequences related to drug use, they should just come out and say it so the issue can actually be addressed directly. What really makes this a NIMBY situation is that the coalition is claiming that they’re looking out for the best interests of vulnerable people. I would be incredibly surprised if any members of the coalition from the wealthy Kitsilano neighbourhood had spoken to a single homeless or at-risk-of-being-homeless individual who belonged to the vulnerable population they claim to speak for.

While I think the issue of the potential impact of active drug use on the neighbourhood is certainly worth having open discussions about, the idea that people should be screened for mental health issues and be required to seek out mental health support is a more blatant example of stigma.

The talk about statistics and “proven by the science” bugs me because it’s obviously bullshit, as they’re not offering any sort of evidence to support those claims. They talk about a “restrictive environment” and “institutionalization” as though providing housing to homeless people is just far too confining for them. On the other hand, they claim that housing people in this way perpetuates “willful neglect.” Hmm…

Denying it doesn’t make it less NIMBYish

When the coalition says they’re being falsely accused of NIMBYism, I suspect that they do actually lack the self-awareness to recognize this in their stance. From their position of wealth and social privilege, these are people who likely want to see themselves as supporting marginalized people rather than further marginalizing them. Instead of acknowledging concerns that might make them look a little bit prejudiced, they seem to prefer to claim the role of advocate and saviour.

However, if it looks like a duck, walks like a duck, and quacks like a duck, chances are pretty good that it’s a duck, despite the NIMBY veneer of civility.

Social justice and equality - graphic of Earth surrounded by diverse children

The Social Justice & Equality page has info and resources on a wide variety of social issues.

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Irritability in Depression: When Mean Bitch Comes Out to Play

By Ashley L. Peterson / 2022-07-19
Posted in
illustration of an irritated woman
Image by prettysleepy1 from Pixabay

Depression can affect mood in a number of ways, including causing irritability. This is sometimes a feature of my own depression, and it can get pretty ugly.

In the DSM-5, adults must have at least one of depressed mood or anhedonia to receive a major depressive disorder or bipolar depression diagnosis, but in children, irritable mood on its own can fulfill the depressed mood criterion. Some researchers have argued irritability should be a core symptom for adults as well as children. It seems that the main argument against this is that irritability is too nonspecific, and including it would risk over-diagnosing people who aren’t actually depressed.

What the research says about irritability

About half of people with major depressive disorder experience irritability as part of their illness. Irritability is associated with more severe depressive episodes and comorbid anxiety disorders. In a study by Fava and colleagues, people who experienced irritability were more likely than those without irritable depression to have experienced a depressive episode that lasted 12 months or more.

While some research has suggested that irritability tends to be an indicator of bipolar rather than unipolar depression, this finding hasn’t been consistent across studies. Irritability may also be part of a depressive episode with mixed features (also known as a mixed episode).

Antidepressant treatment can help with depression-related irritability, and this effect can start showing up only a week after initiating antidepressant treatment.

My own experience

I can get really irritable sometimes during depressive episodes. It’s not something that I experience most of the time when I’m depressed, but when it does show up, it’s vicious. I swear at people, I put them down, and I’m a pretty nasty piece of work. Yet that’s not who I am as a person; it’s a very clear departure from my normal self. It doesn’t help that my more adaptive coping mechanisms tend to go offline the sicker that I get, and my inner 4-year-old starts revelling in her hissy fits. It’s hard to say how much of my depressive irritability is being bothered by things that wouldn’t normally affect me vs. disinhibition leading me to run with irritation that I would normally shrug off; it’s probably some of both.

One of my former psychiatrists told me that I could be “a real bitch” sometimes when I’m sick. He wasn’t trying to criticize; he was just telling it to me straight, and I agreed with him.

I remember one occasion when I was at a restaurant where a friend was performing at an open mic night. One of her other friends, who I only vaguely knew, said something inconsequential that bugged me, and I totally went off on her. It was ugly, and my friend was clearly embarrassed by me, which pissed me off even further.

In the context of hospital

The irritability is particularly likely to come out to play when I’m hospitalized involuntarily and my autonomy is limited. That’s definitely one of the reasons why my hospitalizations have been quite difficult. I think there was only one out of my five hospitalization when I didn’t swear and more generally flip out at the doctors or nurses, and that was the only one in which I was voluntary for the entire stay. Some of the irritability from my most recent hospitalization was on display in the post A Dickless Prick: A Letter to My Psychiatrist.

I do recognize when I’m irritable and I’m aware that it’s because of the illness, but that doesn’t help me to control it. Mostly, I just try to avoid people when I’m feeling that way, but in hospital, that’s just not an option. On top of that, I’ve generally not been very impressed with how staff have treated me while in hospital, so I’m pretty low on fucks to give about how I treat them.

Recognizing irritability as part of depression

For me, irritability isn’t an early warning sign of the beginnings of a depressive episode; it usually only bubbles up when things are already pretty dire. However, I think it’s useful to recognize that depression can show up as irritation, as it can be a clue that some sort of additional intervention is needed. Because it’s so nonspecific, it can be easy to brush off as being due to circumstances or being a bit sleep-deprived, but for people who already know they have a mood disorder, it’s worth paying attention to.

Do you ever experience irritability as part of your own illness? Are you able to mostly keep a lid on it, or does it sometimes explode outward in other people’s direction?

References

book cover: Managing the Depression Puzzle, 2nd Edition, by Ashley L. Peterson

Managing the Depression Puzzle takes a holistic look at the different potential pieces that might fit into your unique depression puzzle.

It’s available on Amazon and Google Play.

The post Irritability in Depression: When Mean Bitch Comes Out to Play appeared first on Mental Health @ Home.

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