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Mental Health: The Economic Case for Investment

By Ashley L. Peterson / 2022-01-31
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The economic case for mental health investment: a failure to invest can produce significant economic costs

Investing in mental health care and workplace mental health programs takes money, and in the short term, that can be an obvious deterrent. However, it can really pay off in the longer term. A number of organizations have each put together solid economic cases for investment in mental health, and this post will take a look at some of them.

For those of us dealing with mental illness, it’s about so much more than dollars and cents. Still, governments care about $$$, and the money argument is on our side.

World Health Organization

In a 2013 report, the World Health Organization (WHO) pointed out that mental illness is associated with significant social costs. Mental disorders contribute to premature mortality due to suicide and an increased risk for developing and prematurely dying from other health conditions. The costs associated with accessing care can be high, and this can have a devastating impact on families.

International figures have shown that people with mental illness are over-represented among those living in poverty. There are high rates of unemployment and underemployment among people with mental illness. This limited labour participation and output has a negative impact on gross domestic output (GDP). Improved mental health outcomes can mean more people getting back to work and decreased welfare payments.

The report concludes with this cautionary statement: “For each year of inaction and
underinvestment, the health, social and economic burden will continue to rise. Doing nothing is therefore not a viable option.”

Canada

The Mental Health Commission of Canada (MHCC) has identified mental health promotion and early intervention in childhood and adolescent is an important way to offset both lasting negative impacts on quality of life and economic losses associated with illness.

A 2017 MHCC report stated that it’s important to focus on mental health promotion and early intervention. It also indicated that improvements at the primary level should be able to serve the needs of many people with mild to moderate illnesses, who make up the majority of people who are affected by mental illness, while about 1.5% of the population would need specialized or intensive services.

In 2015, mental health spending accounted for about 7.2% of overall health spending in Canada. This is which lower than many other Western countries; in the UK’s National Health Service, for example, it’s around 13%.

The MHCC identified a number of areas where mental illness can have indirect economic costs:

  • employer costs related to absenteeism, presenteeism, and turnover
  • public and private disability costs
  • costs of government income assistance and social supports for people who are unable to work
  • lost tax revenue from unemployment and underemployment

Practices that reduce overall costs

These are some of the practices that the MHCC found were associated with overall cost savings:

  • community-based rapid response teams for youth experiencing suicidal thoughts
  • early psychosis intervention programs are associated with reduced health care costs and increase the likelihood of clients having paid employment
  • improving access to psychotherapy can save $2 for every $1 spent
  • offering timely collaborative care to people off work on short-term disability can result in fewer days spent on disability per person and fewer people transitioning to long-term disability
  • for high-end service users, an investment of $22K per person for a housing first approach with assertive community treatment can save $42K in costs that would have otherwise been incurred (based on data from the MHCC’s large At Home/Chez Soi study)
  • incorporating peer support into discharge planning related to long-term hospital stays can facilitate earlier discharges
  • community crisis resolution teams can be a cost-effective alternative to hospital admission
  • crisis houses have a lower daily cost than hospital admission and are associated with greater client satisfaction

The UK

A 2011 report from the Centre for Mental Health in the UK pointed out that most mental health spending is on dealing with illnesses that have already reached the crisis stage and necessitating long-term support, yet 50% of mental health conditions are already present by age 14. Focusing investment on mental health promotion, prevention, and early intervention is often lower cost than intervening at a later stage, and it is likely to have a wide range of payoffs for the public sector and society more broadly.

The report added that some payoffs are spread out over a long time frame, but the costs of intervening can be recouped in a relatively short time frame. For some interventions, cost recovery occurred within 1 year, while many others paid off within 2-5 years).

Australia

Modelling by Australia’s National Mental Health Commission identified a number of mental health prevention and early intervention strategies that would improve national productivity and lead to savings for the health care system. One such intervention was broader implementation of the online MoodGYM program to prevent anxiety disorders in young people.

Workplace mental health

The American Psychiatric Association Foundation’s Center for Workplace Mental Health reports that 80% of employees who are treated for mental illness report higher levels of work efficacy and satisfaction, and treatment can lead to lower overall medical costs, increased productivity, less absenteeism, and decreased disability-related costs. The site has cost calculators for employers to get estimates of how much depression, alcohol, and substance misuse could be costing them.

A 2020 report by Deloitte UK identified screening and early, targeted intervention yielded the greatest return on investment. Proactively addressing workplace culture and improving awareness of workplace mental health tended to yield a greater ROI than trying to be reactive in supporting employees once their mental health had worsened.

Deloitte also identified stigma as an ongoing issue that’s important to address. Their report mentioned a finding in a Business In The Community survey that 9% of employees who disclosed mental health problems being either fired, demoted, or disciplined.

Short-sightedness costs $$$

Given that many politicians’ main priority seems to be getting re-elected, it’s not surprising that long-term thinking isn’t much of a priority. However, short-term thinking is shitty for those of us dealing with mental illness, plus it’s expensive for society.

While it would be nice to see change because it’s the right thing to do, dollars and cents speak pretty loudly, so the economic case for investment is a pretty important one to be able to make.

What do you think would have to change to get the powers that be to pay more attention to mental health?

References

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.

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Quotes on Mental Illness Stigma

By Ashley L. Peterson / 2022-01-24
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Matthew Quick quote about mental illness stigma

Stigma is a big deal for those of us dealing with mental health issues. I’ve written about it in my latest book, A Brief History of Stigma, but there are a lot of other people talking about it too. Here are some great quotes on mental illness stigma that I’ve come across.

The problem with the stigma around mental health is really about the stories that we tell ourselves as a society.

Matthew Quick, author of The Silver Linings Playbook


The mentally ill frighten and embarrass us. And so we marginalize the people who most need our acceptance. What mental health needs is more sunlight, more candor, and more unashamed conversation.

Glenn Close


Mental pain is less dramatic than physical pain, but it is more common and also more hard to bear. The frequent attempt to conceal mental pain increase the burden: It is easier to say ‘My tooth is aching’ than to say ‘My heart is broken’.

C.S. Lewis


It’s so common, it could be anyone. The trouble is, nobody wants to talk about it. And that makes everything worse.

Ruby Wax


This disease comes with a package: shame. When any other part of your body gets sick, you get sympathy.

Ruby Wax

Ruby Wax has also done a TED Talk about stigma.


Stigma against mental illness is a scourge with many faces, and the medical community wears a number of those faces.

Elyn R. Saks


No one would ever say that someone with a broken arm or a broken leg is less than a whole person, but people say that or imply that all the time about people with mental illness.

Elyn R. Saks

For more from Elyn Saks, check out her TED Talk.


Mental illness is nothing to be ashamed of, but stigma and bias shame us all.

Bill Clinton

"Stigma and bias shame us all" – Bill Clinton
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.

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What Is… a Paraphilic Disorder

By Ashley L. Peterson / 2022-01-20
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Characteristics and examples of paraphilic disorders

In this series, I dig a little deeper into the meaning of psychology-related terms. This week, we’ll look at paraphilic disorders.

Paraphilias involve atypical patterns of sexual arousal. Paraphilic disorders are a more extreme version of paraphilias, involving arousal patterns that are a) intense and persistent and b) cause significant distress or functional impairment or cause harm to nonconsenting others.

Types of paraphilic disorders

There are a variety of paraphilias, but the DSM-5 identifies these specific paraphilic disorders:

  • pedophilic disorder (I’ve opted not to include this particular disorder in the scope of this post)
  • voyeuristic disorder
  • transvestic disorder
  • exhibitionist disorder
  • sexual masochism disorder
  • sexual sadism disorder
  • fetishistic disorder
  • frotteuristic disorder

Individuals may have a combination of multiple paraphilic disorders.

In the DSM-5, the naming of these disorders was revised from the previous names in the DSM-IV to more clearly separate the paraphilias from the associated disorders. The American Psychiatric Association has explicitly stated that people who engage in consenting atypical sexual behaviour should not be inappropriately diagnosed with a disorder.

Voyeuristic disorder

Most people who have voyeuristic interests don’t have voyeuristic disorder. It rises to the level of disorder when it involves repeated and intense arousal by secretly observing unsuspecting individuals (watching porn wouldn’t count towards this) as well as either acting out of urges with nonconsenting individuals or experiencing functional impairment. As an example of functional impairment, people may spend so much time searching for viewing opportunities that it interferes with work or other areas of functioning.

To be diagnosed, the condition must be present for at least 6 months, and the individual must be at least 18 years old. It’s estimated that as many as 12% of males and 4% of females have this condition, but most don’t seek out evaluation or treatment. The disorder tends to be chronic.

Transvestic disorder

Most people who cross-dress don’t have transvestic disorder. This is a disorder of sexual arousal, not a question of what clothes people choose to wear. Arousal by items of clothing themselves is considered to be a form of fetishism, while transvestic disorder is arousal from wearing the clothing or fantasizing about doing so.

The disorder involves repeated and intense sexual arousal produced by cross-dressing, as well as clinically significant distress or impairment in functioning. The condition must be present for at least 6 months for a diagnosis.

Transvestic disorder occurs almost entirely in males. In the DSM-IV, the diagnosis was limited to heterosexual males, but this restriction was removed in the DSM-5. There may be a pattern of accumulating items that one feels aroused in, experiencing guilt and shame, and then purging these items.

Exhibitionist disorder

Again, most people who are into exhibitionism don’t have an exhibitionist disorder. To be diagnosed with the disorder, there must be clinically significant distress or functional impairment, or else people have acted out their urges with a nonconsenting person. This may involve public masturbation.

This disorder is estimated to occur in about 2-4% of males, and it’s less common in females. There may be co-occurring antisocial personality disorder or conduct disorder.

Most people with the disorder don’t engage in physically aggressive sexual behaviours. Among those who offend criminally, recidivism rates are higher than other sex offenders, at 20-50%.

Sexual masochism disorders

Sexual masochism (being aroused by being humiliated or abused) is not a disorder; however, it can rise to the level of disorder when it causes clinically significant distress or impairment in functioning.

Sexual sadism disorder

Sexual sadism involves experiencing arousal from inflicting suffering on others. To be considered a disorder, it must involve either acting out urges on a nonconsenting person or clinically significant distress or impairment in functioning. The condition must be present for at least 6 months. It’s particularly problematic if it co-occurs with antisocial personality disorder.

The onset of sadistic activities tends to occur by early adulthood, and they often increase in severity over time.

Less than 10% of rapists are diagnosed with this disorder, but it’s much more common among people who have committed sexually-motivated homicides (37-75%).

Fetishistic disorder

Fetishes involve intense arousal by nonliving objects or specific nongenital body parts. The disorder involves clinically significant distress or impairment in functioning, and the fetishes don’t involve genital vibrators or clothing used in cross-dressing.

Frotteuristic disorder

Frotteuristic disorder involves at least six months of recurrent and intense arousal involving touching or rubbing against a nonconsenting person, with either acting out on those urges or clinically significant distress or functional impairment. The acts typically take place in crowded environments, and they’re most commonly performed by those between the ages of 15 and 25.

According to Medscape, as many as 30% of men may experience frotteuristic disorder. That initially struck me as very high, but given how many allegations keep coming up of sexual misconduct, maybe that is accurate.

How/why they occur

These patterns are typically established by the time an individual reaches puberty (although in exhibitionist disorder, the onset is usually during adolescence). In general, paraphilias are more common in men, although it’s not clear why this is.

Their development may be influenced by trauma that impacts normal development or exposure to highly charged sexual experiences. Childhood sexual abuse is thought to be a key contributor.

Symbolism and accidental conditioning may also play a role. Abnormalities in brain functioning may be involved in the development of these disorders, but that remains unclear.

Sexologist Kurt Freund suggested that paraphilic disorders could arise from distortion of the courtship phases of search, pretactile interaction, tactile interaction, and genital union (i.e. sex).

Unsurprisingly, there are plenty of ideas on paraphilias from the field of psychoanalysis. For example, exhibitionists are thought to view their mothers as rejecting them based on their different genitalia. For an adult man, displaying his penis would be a way to prove his manhood to adult women and force them to accept him. In the case of fetishistic disorders, the fetish is seen as serving a defensive function as an adjunct to a penis whose potency is otherwise uncertain.

Paraphilic disorders are commonly comorbid with other conditions, including personality disorders, substance use disorders, anxiety disorders, or mood disorders. People with personality disorders involving low self-esteem or problems with anger management or delayed gratification are particularly vulnerable.

Treatment

The majority of people with paraphilic disorders don’t seek out treatment voluntarily. No treatments for the actual paraphilias themselves have been identified, and interventions are aimed at managing behaviours.

Psychotherapy (particularly cognitive behaviour therapy) and support groups may be helpful. In the case of fetishistic disorder, treatment tends to be more effective when the focus is on underlying dynamics rather than the fetish itself.

Orgasmic reconditioning is a behavioural approach that involves masturbation beginning with the individual’s usual fantasies, and then switching to a more acceptable fantasy just before orgasm. This is repeated with the aim to substitute fantasies progressively earlier before orgasm.

SSRI antidepressants may have some benefit in some cases of voyeuristic disorder and exhibitionist disorder. Transvestic disorder doesn’t tend to respond to medications, but SSRIs may be helpful if there’s an OCD element present. Mood stabilizers may have some benefit in terms of impulse control in paraphilic disorders.

Antiandrogen drugs, like gonadotropin-releasing hormone analogues or medroxyprogesterone acetate, may be used to reduce testosterone levels. These drugs may be able to reduce behaviours that are likely to lead to arrest.

Sexual sadism disorder is generally not responsive to treatment.

Thoughts

I like that the DSM-5 makes a distinction between paraphilias and paraphilic disorders. Even if they do exist on a continuum, it makes sense to me to at least try to avoid unnecessarily pathologizing people and factor in actions directed at nonconsenting individuals. Then again, perhaps using behaviour that would be considered criminal as a deciding factor diagnostically is a bit weird.

What are your thoughts on this group of disorders?

Sources

The Psychology Corner: Insights into psychology and psychological tests

The Psychology Corner has an overview of terms covered in the What Is… series, along with a collection of scientifically validated psychological tests.

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Book Review: Losing Our Minds

By Ashley L. Peterson / 2022-01-19
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Losing Our Minds: The Challenge of Defining Mental Illness by psychologist Lucy Foulkes explains why it’s so hard to define what mental illness is and how it happens. The author herself has experienced mental illness, and while this is not a major focus in the book, I thought it was great that she did bring that perspective into it.

The author explains that it’s important to understand not only what mental illness is, but also what it isn’t. Regarding the medicalization of mental illness, she advocates for making a distinction between normal, unavoidable human distress and the more severe manifestations that constitute illness. The book takes a very middle ground kind of approach, acknowledging that psychological pain exists, causes distress, and is valid, but recognizing that not all suffering constitutes a disorder.

The first chapter looks at reported rates of mental illness in the population, breaking down what those numbers mean and questioning whether or not more people are experiencing mental illness now compared to in the past. I thought the author did a good job of taking readers through her process of evaluating different statistics and making it clear that numbers can’t simply be taken at face value.

The book then looks at the normal/disorder continuum and how that fits with categorical diagnostic systems like the DSM. Attention is given to various factors that can influence the development of mental illness in the areas of biology, environment, and the various processes going on during adolescence. The author takes the approach that mental illness is complex, and it can’t be reduced down to either all one thing, whether that’s biology or environment.

There’s an interesting chapter devoted to social media, and again, the author’s approach was very balanced. She addressed both positives and negatives associated with social media use, cautioning against oversimplification, especially when there isn’t a lot of data to go on. She suggested that social media may be more likely to reflect and amplify what’s already going on for individuals rather than create brand new issues. For example, cyberbullying is a problem, but most people who are being cyberbullied are also being bullied in their in-person world.

After looking at these different factors that can influence the development of mental disorders, the book returns to the question of whether mental illness is becoming more prevalent, as seems to be a common perception. The author points out how difficult this is to determine. For example, if suicide rates are going up, how much is that influenced by changes in reporting of suicides (in 2018, the standard for reporting suicides in England and Wales shifted from beyond a reasonable doubt to a balance of probabilities) or under-treatment of depression in children and adolescents due to the FDA black box warning on antidepressant use in this population group?

In the chapter devoted to language, the author advocates for reserving some language for serious illness rather than using the language of disorder to refer to all experiences of distress. She adds that linguistic inflation can contribute to people getting the wrong advice for what they’re actually experiencing.

The book ends with two chapters focused on getting help. The first is about professional help, the different forms that may take, and the reality of how difficult it can be to actually access. The final chapter looks at ways we can help ourselves and other people in our lives. The author reiterates that experiencing distress is hard, but it’s a fundamental part of being human, and not everything is immediately fixable.

I really liked this book. There’s so much talk of black and white in popular conversations about mental health and illness, and this book fully embraces the grey areas. The author skillfully validates both illness and non-illness experiences of suffering, while at the same time establishing that treating all experiences of suffering as though they’re the same or as though they’re all disordered doesn’t serve anybody.

The book brings together a lot of different ideas about mental illness in a very balanced way, making it clear that not every idea is going to match up with every individual’s experience. The author draws on a lot of research findings, but these are presented in an accessible way, with appropriate context to help readers understand what those pieces of information actually mean.

I was impressed by the way that the author presented the complexity of mental illness in a simplified way without sacrificing that inherent complexity or getting into reductionism. Overall, I thought that the book was extremely well done, and it will make an interesting read both for people who have personal experience with mental illness and those who do not.

Losing our Minds 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.

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.

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What is… Melancholic Depression

By Ashley L. Peterson / 2022-01-13
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Depression with melancholic features: a cluster of depressive symptoms including anhedonia and psychomotor retardation

In this series, I dig a little deeper into the meaning of psychological terms. This week’s term is melancholic depression, also known as depression with melancholic features.

The word melancholia comes from the Greek for black bile, part of the ancient four humours medical belief system. In the 5th century BCE, Hippocrates first identified melancholia as a disease with various mental and physical symptoms. In the 16th and 17th centuries, the idea of a melancholic temperament became fashionable in English art and literature.

What is now called depression with melancholic features has been referred to in the past as endogenous (as opposed to reactive) depression, and before that, melancholia.

Diagnosis

In the DSM-5, the melancholic features specifier can be used to describe a major depressive episode (in major depressive disorder or bipolar disorder) with a certain cluster of symptoms. That symptom cluster includes:

  1. anhedonia (near-total inability to feel pleasure)
  2. lack of positive reaction to normally pleasurable things
  3. a quality of mood that’s distinct from grief/loss, i.e. it subjectively feels different
  4. early morning awakening
  5. psychomotor retardation (slowed movement and thinking) or agitation
  6. significant loss of appetite
  7. symptoms that are worse in the morning
  8. excessive/inappropriate guilt

Either symptom #1 or 2 must be present, in addition to at least 3 symptoms from #3-8. Symptom #5 (psychomotor changes) is nearly always present. The full criteria for a major depressive episode must be met, including the presence of symptoms almost all day, almost every day, for at least 2 weeks, with clinically significant distress or impairment in social and occupational functioning.

While many people experiencing a major depressive episode experience some of these symptoms, it’s this particular symptom cluster occurring together that gets labelled as melancholic features. There are many different potential combinations of symptoms in a major depressive episode, and not everyone who’s having a major depressive episode has a features specifier of any kind.

There’s some question as to whether melancholic depression represents a distinct illness from depression with atypical features, which involves a cluster of symptoms like increased sleep and appetite, mood reactivity to pleasurable stimuli, and leaden paralysis. At this point, though, the DSM’s categorical system treats them as different features of the same illness.

The biology of melancholia

There do appear to be differences in how melancholic depression affects the brain, including changes that can be seen on electroencephalogram (EEG) and MRI across groups of patients with melancholic vs. non-melancholic depression.

Melancholic depression appears to have a strong biological component, including a genetic element. There appear to be disruptions in the hypothalamic-pituitary-adrenal (HPA) axis that connects the brain and the adrenal glands, as well as elevated inflammation.

Despite these elements that have been observed across groups of patients, no biological feature has been identified, at least at this point, that’s a definite diagnostic marker.

Characteristics of melancholic depression

People with melancholic features tend to have relatively normal childhoods, and when well, they tend not to have significant problems with relationships and work functioning. The depression is more likely to be identified as an imposed illness rather than a logical reaction to life stressors.

Episodes can occur with no apparent situational triggers, and they tend to be more severe than one might expect given the situational circumstances. Melancholic episodes can also occur in response to minor, non-severe stressors, and researchers from Queen’s University have suggested that melancholic depression may be especially sensitive to stress. This would fit with the idea of inflammation playing some role in this particular form of depression.

The Lundby Study, a longitudinal community-based study in Sweden, showed that people whose first depressive episode had melancholic features were at a greater risk for recurrence of their depression compared to people with a non-melancholic first depressive episode.

Melancholic features have been associated with greater cognitive dysfunction than non-melancholic depression, including poorer processing speed, problem-solving, and visual memory. Psychotic features are also more common in this form of depression.

Researchers have observed deficits in reward-based learning tasks, meaning people are less likely to develop behaviours geared towards maximizing rewards. This may be related to dysfunction in dopamine signalling in the brain’s reward areas.

Response to treatment

Melancholic depression tends to respond better to biological treatments like antidepressants and electroconvulsive therapy (ECT) than it does to psychotherapy, and it’s less responsive to placebo than other forms of depression.

Some research has shown an improved response to antidepressants that target multiple neurotransmitter systems rather than just serotonin, although there have been contradictory findings. In keeping with this, some studies have suggested that tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) may be the most effective. It can sometimes be helpful to add other medications to augment antidepressants, including atypical antipsychotics or psychostimulants (e.g. Ritalin, Dexedrine).


My own symptom pattern tends toward melancholic features, although not always. The anhedonia and psychomotor retardation are pretty prominent. I get the early morning awakening, decreased appetite, and guilt, but they’re usually kept under control when I’m well-medicated. I’ve never had atypical features to my depression, and when my sleep and appetite are affected, they’re always decreased, not increased.

If you have a depressive illness, what is your pattern of symptoms like?

You can find the rest of the what is… series in the Psychology Corner.

References

  • Bruun, C. F., Arnbjerg, C. J., & Kessing, L. V. (2021). Electroencephalographic Parameters Differentiating Melancholic Depression, Non-melancholic Depression, and Healthy Controls. A Systematic Review. Frontiers in Psychiatry, 1439.
  • Fletcher, K., Parker, G., Paterson, A., Fava, M., Iosifescu, D., & Pizzagalli, D. A. (2015). Anhedonia in melancholic and non-melancholic depressive disorders. Journal of Affective Disorders184, 81-88.
  • Harkness, K. L., & Monroe, S. M. (2006). Severe melancholic depression is more vulnerable than non-melancholic depression to minor precipitating life events. Journal of Affective Disorders91(2-3), 257-263.
  • Nöbbelin, L., Bogren, M., Mattisson, C., & Brådvik, L. (2018). Risk factors for recurrence in depression in the Lundby population, 1947–1997. Journal of Affective Disorders228, 125-131.
  • Parker, G. (2017). An update on melancholia. Psychiatric Times, 34(1).
  • Wikipedia: Melancholia and Melancholic depression
  • Zaninotto, L., Solmi, M., Veronese, N., Guglielmo, R., Ioime, L., Camardese, G., & Serretti, A. (2016). A meta-analysis of cognitive performance in melancholic versus non-melancholic unipolar depression. Journal of Affective Disorders201, 15-24.
Book cover: Managing the Depression Puzzle by Ashley L. Peterson, showing head made of puzzle pieces

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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Book Review: Relationship OCD

By Ashley L. Peterson / 2022-01-12
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book cover: Relationship OCD by Sheva Rajaee

Relationship OCD by Sheva Rajaee is written from the perspective of a therapist who herself has dealt with relationship OCD (ROCD). What a perfect combination! I love that more and more mental health professionals are willing to talk about their own mental health challenges.

Throughout the book, the author emphasizes the importance of learning to tolerate uncertainty. She writes that addressing ROCD isn’t just about managing anxiety, but also about changing expectations about what love and partnership should involve. She describes the myth of the one (MOTO) that we’ve been exposed to pretty much forever, and how unlike real relationships that myth is.

If you feel concerned that you don’t feel the “butterflies” that you think that you’re supposed to feel, the author points out that the feeling of butterflies is actually an anxiety response driven by the amygdala, and the steadiness of a non-anxiety-provoking person could actually be a good thing.

The book describes two different areas of focus for anxiety in ROCD. One is partner-focused, which involves a preoccupation with the partner’s perceived flaws. The other is relationship-focused, which is a preoccupation with the quality of the relationship. The author explains that for most people, ROCD comes from some combination of nature and nurture, and she ties this in with attachment styles.

There’s an interesting chapter devoted to sex anxiety. It incorporates cultural myths and moralization about how sex should be, ideas about what kind of fantasizing is okay, and the effects of anxiety on desire and arousal. Real-life sex just isn’t the way it is in movies, it’s not always mind-blowing, and you don’t have to be gettin’ it on multiple times a week for your sex life to be considered acceptable.

The middle section of the book covers strategies that can help with managing ROCD, including addressing cognitive distortions, using acceptance and commitment therapy tools, and doing exposure and response prevention. The author explains that these tools won’t get rid of your anxiety, and that’s not the goal, anyway; rather, they’ll help you to tolerate it more effectively.

The chapter on healing shame talks about how we become indoctrinated into “the cult of what’s normal.” We soak up all kinds of messages about how we should look, feel, behave, and live our lives, and this knowledge is stored implicitly, outside of our conscious awareness. The author explains the benefit of self-compassion to address shame around not living up to these expectations about what’s normal.

There’s also a chapter on what healthy relationships look like, and the author cautions that you shouldn’t trust your gut, as emotions on their own will never be able to confirm for you that you’ve met the right person or that you’ll live happily ever after. I liked that she was very realistic about how there’s no way to predict the future of a relationship, and sometimes divorce ends up being the right thing.

The author was also very realistic about ROCD recovery, writing that intrusive thoughts and uncertainty aren’t going to just disappear. She acknowledges that ongoing maintenance work will probably be needed.

I thought this book did a really good job of popping the bubble of the assorted problematic messaging we’re exposed to regarding relationships. The author balances warmth and kindness with telling readers that being uncomfortable and being uncertain is a necessary part of the process. She’s down-to-earth, and I thought she had a very healthy, realistic outlook on relationships. This book was really well done, and I think it will be very helpful to people dealing with relationship anxiety, whether it’s full-fledged OCD or not.


Now, some more general thoughts about expectations about relationship perfection. We’re exposed to all this myth of the one messaging that has very little to do with reality. I wonder if the issue is less that we’re being presented with it and more that it often gets presented as if it’s truth rather than reality.

While there are certainly relationships that involve really deep connections. The whole soulmate nonsense strikes me as total garbage. Yet if you Google “soulmate,” there are all these articles telling you how to tell if you found yours. One of the related searches Google suggests is “signs your soulmate is thinking of you.” Oh just fuck all the way off. The top search result I see is an article on Marriage.com saying that you thinking of them all the time is a sign that they’re thinking about you. Um, no, it doesn’t work that way.

Personally, I see books, tv, and movies that are obviously not real as less problematic than all these sources trying to make it out to be reality. Fantasy is fun to indulge in, especially if you can recognize that there’s a line between it and reality. Pretending that line doesn’t exist is a whole other can of tuna.

Do you have any thoughts on the myth of the one and all that goes along with it?

Relationship 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: Safe, Wanted, and Loved

By Ashley L. Peterson / 2022-01-10
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Book cover: Safe, Wanted, and Loved by Patrick Dylan

Safe, Wanted, and Loved by Patrick Dylan is a memoir about the author’s wife’s experiences of mental illness, how that affected the family, and the difficult journey in the direction of recovery.

The book’s powerful opening line is the author’s wife, Mia, saying “Pat, I am going to prison.” At that point, she was first demonstrating indications of psychosis. The book then moved forward in time, with sections at the beginning of each chapter moving back in time to earlier points in their relationship. I thought the pacing of this was quite well done, hooking the reader’s attention at the beginning and then gradually filling in more bits of backstory to give a view of Pat and Mia’s lives beyond just the way they were affected by mental illness.

The family then faced the issue of how to get proper care for Mia as the psychosis worsened. For people who haven’t dealt with this kind of thing before, this will likely be eye-opening, and for those of us who’ve been on the patient side of things, it’s interesting to see the family member perspective.

Once Mia did end up getting treatment, there was confusion about her diagnosis, which continued for much of the book. The reader is taken through the trial and error process of finding medication that would be helpful for her. Her treatment team’s approach with meds struck me as strange, in a separate post, I’ll address the issue of doctors sometimes relying heavily on benzodiazepines to manage problems that those drugs don’t actually treat. It wasn’t until finally getting diagnostic clarification, which required going not just out of town but out of state, that she was able to find the right medication to keep her illness under control. Mia’s journey is a good example of the challenges so many people with mental illness face trying to get the right diagnosis and the right meds for them.

The issue of medication side effects came up at different points in the book, including people asking Mia if she was pregnant due to medication-induced weight gain (yup, been there, done that). There were also some more severe effects that necessitated stopping the medication. I thought there was a good balance of presenting the pros and cons of medications and weighing particular side effects against the benefits of the associated medication. The book also got into the family’s hesitancy around medication, even while they recognized the necessity for it.

I thought the book was really effective at capturing how frightening psychosis can be for loved ones who don’t understand what’s happening, especially if the unwell individual becomes paranoid about family members. Difficult issues like involuntary treatment and police involvement also came up. The reader learns about psychosis and psychiatric treatment as the author shares his own journey of suddenly being faced with having to learn about these things.

Mia’s illness had a significant impact on the family, and the book explored all of the challenges that the author, his and Mia’s children, and other family members faced in trying to cope. I thought the author’s openness around this was a real strength of the book. I also appreciated that the author was very clear about differentiating the illness from Mia herself, and recognizing that it was the illness causing challenges for the family, and Mia was not to blame for that.

While stigma comes up at different points throughout the book, it’s addressed more explicitly in the epilogue. The author explained that protecting his wife from stigma was very front of mind in deciding how to handle things when she first got sick. However, when they did disclose, suddenly other people were disclosing their own experiences, which is very consistent with my own experiences of disclosure. One of the book’s key take-home messages is that we need to talk more about mental illness and break the taboos that stigma has imposed.

Overall, I thought this was an excellent book. It was well written and demonstrated strength through vulnerability. This would be a particularly valuable read for family members of people dealing with mental illness, but I think it could also be really helpful for people who have a mental illness to see the family member perspective. And more generally, I think the more books out there talking about the reality of mental illness, the better, because people need to hear real human stories to counteract the stereotypes.

This video is an interview the author did with Patrick J. Kennedy.

Safe, Wanted, and Loved is available on Amazon (affiliate link).

You can find Patrick Dylan on his website Safe, Wanted, and Loved.

I received a free copy in exchange for an honest review.

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

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.

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Book Review: Complex Borderline Personality Disorder

By Ashley L. Peterson / 2022-01-05
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Book cover: Complex Borderline Personality Disorder by Daniel J. Fox

Complex Borderline Personality Disorder by Daniel J. Fox is aimed at people who have borderline personality disorder along with a co-occurring mental disorder. It describes how these combinations can present and how to manage them.

The co-occurring conditions that it addresses are bipolar disorder, depression, psychosis, ADHD, and PTSD/complex PTSD. The author refers to BPD in combination with any of these other disorders as complex BPD, or CBPD. For each combination, there’s a chapter that focuses on symptoms followed by a chapter that focuses on management of the conditions. There’s an emphasis on gaining awareness of and insight into your symptoms, and the book guides readers through teasing apart what symptoms related to what. There are exercises throughout the book, and the author encourages readers to start a journal to make notes and do the exercises in.

The author describes personality disorders this way: “Personality disorders are best defined as the inability to adjust your thoughts and behaviors based upon the environment you’re in.” He explains that CBPD is very common among people with BPD, but without a systematic approach to assessment, the chances of missing a co-occurring disorder are over 50%.

The book differentiates between surface structure content and core content. Core content “makes up the internal part of yourself that represents how you think and feel about yourself, others, and your world,” while “Surface structure content are the behaviors or symptoms that rise to the surface as a result of the core content.” The author explains that medications can help to manage surface content but not core content.

The author used wording I hadn’t heard before when describing diagnostic criteria, “socioeconomic dysfunction,” to refer to the criteria in the DSM-5 related to impairments in social and occupational functioning. Maybe it’s just that I haven’t come across that usage, but in my head, socioeconomic means something different.

The section on depression talked about differentiating major depressive episodes from what the author referred to as BPD depressive episodes, which are short and intense, with an identifiable trigger. The interplay between these was described in terms of the relationship between core content and surface content.

The section about psychosis wasn’t diagnosis-specific, and it included quasi-psychotic symptoms (which sounds like what I’ve heard referred to as micropsychosis in the context of BPD), dissociation, and dissociative identity disorder (DID). The case study that was given involved an individual who developed a brief psychotic disorder in response to significant stress rather than someone with a chronic psychotic disorder. To me, this section was the weakest, as I found it vague and a bit too much of a hodgepodge.

The chapter explaining PTSD and complex PTSD (C-PTSD), on the other hand, I thought was quite well done. It involved case studies of a war vet with PTSD, someone who had C-PTSD related to childhood abuse, and someone with combined C-PTSD and BPD. I thought the author did a good job of distinguishing the different features and identifying what overlapped and what didn’t.

Overall, I found this book quite interesting. I liked the emphasis on building insight and teasing apart symptoms. Probably most readers aren’t going to have all of the CBPD combinations that the book covers, but I think most readers with BPD will find at least some bits that are more broadly relevant throughout the whole book. This is the first book I’ve come across that deals with BPD and co-occurring conditions, and it’s an important subject area to address.

The author also brings his own conceptualizations to this book; the term complex BPD is his own, and from what I can gather from Google, he’s also come up with the distinction of core content and surface structure content. This offers readers a perspective that’s different from what they’ve read in other books, and I think that’s a good thing. I also think readers will find the book quite validating, and they’ll come away from it with a greater understanding of their condition.

Complex Borderline Personality Disorder 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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The “Good Patient” and Other Mental Illness Stereotypes

By Ashley L. Peterson / 2021-12-14
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Common mental illness stereotypes: image of a person in a straitjacket

Stereotypes are a way that we store knowledge about social categories. When a category is considered by society to be deviant, such as the group of people who are mentally ill, members of that category tend to be viewed as a homogeneous group that is accurately represented by stereotypes.

There may be a grain of truth to stereotypes in some cases, but they’re not accurately when applied uniformly across a group. Those of us with mental illness are all unique individuals, and we’re a very diverse group of people, but for the society that has Othered us, they may only see all stereotype, all the time. They also tend to assume that stereotypes are factual, even though they may be entirely inaccurate.

We all have both implicit and explicit beliefs. Explicit beliefs are conscious and voluntary, while implicit beliefs are unconscious and they come to mind automatically when we’re in a situation where those beliefs apply.

We learn many implicit beliefs through early socialization, including stereotypes associated with mental illness. Even if people express affirming explicit beliefs about people with mental illness, they may still have stereotypes stored implicitly that they’re not consciously aware of.

Some common public stereotypes

Here are some of the common stereotypes that the general public associates with mental illness.

Violence

Every time there’s a mass shooting, people start blaming it on mental illness. In particular, people tend to believe that those with psychotic illnesses are violent. However, a mental illness diagnosis doesn’t have any predictive value in determining who will commit mass shootings.

Most people who have a mental illness are no more likely to be violent than anybody else. There are a few exceptions, like people with antisocial personality disorder, substance use disorders, intermittent explosive disorder, or people experiencing command hallucinations to harm others.

Psychopathy, which isn’t a mental illness, is a significantly bigger risk factor for violence than having a mental illness. So is being male, but you don’t see anyone talking about limiting gun access to angry white men with a paranoid (of the non-psychotic variety) worldview.

Unpredictability, unreliability

Unpredictability and unreliability are also common stereotypes, and they can fuel discrimination in contexts like employment and housing. The unpredictability stereotype often goes hand in hand with the violence stereotype. Watch out, you never know what the scary-crazy person might do!

Moral weakness

Some people see mental illness as a moral failure involving weak character, lack of control, and lack of willpower. They may blame us for the onset and continuation of our illnesses, and see us as undeserving of help as a result.

Moral contagion comes from the belief that spending time around someone who has a mental illness may result in “catching” that person’s presumed moral weakness.

Incompetence

Another common stereotype is that people with mental illness are incompetent, unable to work or function independently, and need others to make decisions for them. This stereotype may be approached in an authoritarian or a benevolent manner. An authoritarian approach can limit the rights and freedoms of mentally ill people, while a benevolent approach can mean the mentally ill person is treated like a child.

One of the beliefs that can go along with incompetence stereotypes is that people with mental illness are unhygienic. This is a good example of something that has a kernel of truth, but isn’t true when applied broadly to all people with mental illness. Depression can make showering hard. So can negative symptoms of schizophrenia. The fact that hygiene deficits can sometimes occur as a result of symptoms does not in any way mean that everyone and their goat who has a mental illness is dishevelled, dirty, and/or smelly. Some of us are goaty. Most of us are not.

The “good patient” stereotype

I consider the “good patient” stereotype to be the expectations that many mental health treatment providers have about how a psychiatric “should” behave in the context of the treatment relationship. This stereotype isn’t universally endorsed by all treatment providers, but it’s pretty common, especially in hospital settings.

The specific expectations associated with the good patient can vary depending on the setting, but they can include:

  • being cooperative and accepting whatever the treatment provider thinks is best
  • not asking too many questions
  • treating the health care provider as the authority
  • not challenging the treatment provider(s)
  • being willing to tolerate side effects
  • being willing to tolerate symptoms that aren’t being addressed
  • operating on the treatment provider’s timeline rather than the patient’s
  • in hospital: not making requests outside of designated times, accepting without question the various arbitrary limits that have been created

The graphic below is a good example of the “good patient” stereotype in the context of chronic pain.

https://www.pinterest.ca/pin/846958273678636105/

While these expectations aren’t necessarily conveyed verbally, they often exist as unwritten, unspoken rules. When patients don’t conform to these expectations, they may be brushed off by treatment providers as being difficult.

We are not stereotypes

I’ve been hit with the unpredictability/unreliability stereotype in the past in work contexts. Coworkers were fine, but management clearly saw me as unreliable.

I’ve encountered the incompetence stereotype from health care providers. The worse my psychomotor slowing has gotten, hence the more overt my illness is, the more I tend to be treated like I’m a complete dolt.

When I was in hospital, I encountered the good patient stereotype a lot. I was not interested in meeting the expectations of that stereotype, which definitely created friction.

Have you experienced stereotyping? What particular stereotypes seemed to be the most prominent?

Now available: A Brief History of Stigma

This is part of a series of posts on topics that are addressed in my new book, A Brief History of Stigma.

You can find it on Amazon and Google Play.

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Workplace Accommodations for People with Mental Illness

By DNW Contributors / 2021-12-13
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Reasonable accommodations in the workplace (also known as reasonable adjustments in the UK) are a human right for people with disabilities. However, it may not be immediately obvious to employers or employees how that applies to people with mental illness. For those of us living with mental health conditions, it can be helpful to get some familiarity with what accommodations are and how they work before it starts getting to the point where it feels like you’re flailing at work.

When I requested an accommodation at my job as a nurse a few years ago, I waited until the flailing stage. I was only vaguely familiar with accommodations, and trying to do research on the topic was hard while I wasn’t feeling well and was really stressed out about work. When my employer started putting up roadblocks after I made my request, it all just seemed too overwhelming, and I ended up just giving up on it. Had I been more prepared ahead of time and had a better idea of what my options might be, I think I would have been more comfortable standing my ground.


Contributed by Ashley Peterson, you can contact her at: @MH_at_home


Even if you don’t  think of your mental illness as a disability, entitlement to an accommodation is based on functioning rather than diagnosis. Just because some people might experience depression without being disabled doesn’t mean that you can’t experience disability with the same illness. A reasonable accommodation is not an advantage that’s being given to you, much as the mental illness voice in your head might tell you that it’s something you don’t deserve; rather, it’s about helping you do your job functions and putting you on the same level as workers who don’t have a disability.

Requesting an accommodation

Disclosing a mental illness at work can be a difficult decision, especially when there’s so much stigma around mental health conditions. While silence can be appealing, it can also be the source of a lot of stress, especially if your employer starts raising concerns about your performance.

One thing to keep in mind is that you don’t need to give your employer your diagnosis when requesting an accommodation, since the accommodation is based on functional impairment rather than your specific diagnosis. The employer is only entitled to enough information to establish what your functional limitations are so that they can figure out what can be done about them. If your employer is pressuring you for more personal medical information than you feel comfortable giving them, try consulting with a local disability charity to see if they can give you some guidance on what exactly employers are allowed to ask for based on the laws where you live.

You can start the process by notifying your employer in writing that you are requesting an accommodation because you have a disability (or medical condition, chronic illness, invisible illness, mental illness, or however else you’d like to phrase it) that’s making it difficult to do your job. If you are disclosing that you have a mental illness and you’re concerned about that being an excuse to brush you off, you might want to demonstrate right from the get-go that you’ve done your research.

You may not be sure what accommodations would be reasonable to ask for, and your employer might be just as clueless about reasonable adjustments for a mental health condition. However, there are some good resources available that can provide a good jumping off point both for you and for the employer; some of these are listed at the end of this article. When you make your initial request, lay out the particular areas of your job functioning in which you need support and provide some initial suggestions about accommodations you think would be helpful and how they would allow you to work better. Also, request that they review particular resources/websites that seem particularly relevant, so that these can be used as a starting point for your discussions moving forward.

Possible areas for accommodations

There are several areas where accommodations for mental illness-related disabilities can be implemented. One possibility is making changes to the work environment to support concentration, like modifying the physical workspace to reduce distractions, using noise-cancelling headphones, or working from home.

Another common area for accommodations is flexibility around scheduling. This may involve changes in start/end times, allowing more frequent breaks and access to a quiet area for them, allowing time off for medical/therapy appointments, allowing for a temporary reduction in hours, or allowing unpaid leaves.

Accommodations may also relate to the way that tasks are assigned and performed. This might involve giving written rather than verbal instructions, breaking large tasks into smaller pieces, allowing extra time for orientation or task completion, or restructuring job tasks to focus on things that are the best fit for your abilities.

Changes in supervision and feedback style could also be helpful, although this is perhaps one of the hardest things to ask for. The site Workplace Strategies for Mental Health has a section on supportive performance management that may be helpful: https://www.workplacestrategiesformentalhealth.com/resources/performance-management

Disclosure to colleagues

Depending on what particular accommodations you have in the workplace, colleagues may notice and wonder why you’re getting what appears to be special treatment. They’re not entitled to know why you have an accommodation or what your disability is; the choice is yours whether or not to disclose. However, when people don’t have actual information, they may start to create their own stories, which can make the work environment uncomfortable for you.

Selective disclosure may allow you to have more control over the narrative. My own experience has been that colleagues were always more supportive than managers, and if you’ve gotten an accommodation, you’ve already had to disclose at least some bits to managers. While I never did end up getting accommodations, I did take time off for medical appointments and  several extended periods of time off due to my mental illness over the course of my career. I liked that being open with colleagues allowed me to take control of my story; there was nothing to gossip about if I was telling people what was actually going on.

Your rights matter

Knowledge truly is power when it comes to knowing your rights and your options as a worker with a mental illness. Connecting with peers can also be really empowering. You’re not the only one dealing wit this. You have a lot to contribute, and even if stigma throws up barriers, you deserve to succeed, whatever success looks like for you. Again, an accommodation is not an advantage that you have to earn; it’s a human right.

Resources

Australia:

Canada:

New Zealand

United States:

There’s also more information on workplace mental health and challenging stigma in other contexts in the Mental Health @ Home stigma reduction toolkit. https://mentalhealthathome.org/mhh-books/a-brief-history-of-stigma/

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