Hear more from TeenScreen Schools & Communities Program Coordinator Deanna Richards as she discusses the steps that educators can take to make a difference in the mental health of teenagers.

Knowing this grim history, I was pleased that NIMH director Dr. Tom Insel invited New York Times science reporter Benedict Carey to speak at a recent gathering of organizations supporting NIMH research. Meeting attendees applauded Ben Carey for his series in the NY Times. “Lives Restored” began running last summer with several stories appearing on the front page. The series profiled people who are functioning well in the community, despite struggling with serious mental illnesses. The stories underline advances in diagnosis, treatment and the research that has revolutionized our understanding of these disorders. More important, they humanize mental illnesses and make plain the strength and resilience of the individuals who shared their life stories. The audience was moved by videos of Ben Carey’s interviews with the people he profiled.

I hope we’re at an important turning point in reducing stigma. For nearly 20 years we’ve seen a steady effort to help people shake off their prejudices and understand that mental illnesses are no-fault brain disorders. Public figures and celebrities have led the way in disclosing their personal struggles. The list includes successful authors William Styron and J.K. Rowling, actors Owen Wilson and Johnny Depp, actresses Patty Duke and Brooke Shields, Washington women Tipper Gore and Barbara Bush, musicians Billy Joel and Eric Clapton, pro football players Terry Bradshaw and Earl Campbell, astronaut Buzz Aldrin and many more. Each time a notable person talks about having a psychiatric diagnosis it emboldens others and chips away at the myths that surround mental illness.

Now we’re learning about everyday people – friends, neighbors and co-workers who are living with mental illnesses including depression, anxiety, bipolar disorder and even psychosis. People we know and love are being diagnosed, treated and are recovering with our help and support. The media, which often demonized mentally ill people as crazy killers or homeless bums, now leads the way in shaping accurate portrayals. I know we have a lot more to do in the battle against stigma, but it’s inspiring to read Ben Carey’s stories of hope and recovery, especially when they focus on “ordinary heroes.”

Hear more from our Executive Director Laurie Flynn on how teen mental health screenings can help parents.

Here, Dr. Olfson shares his thoughts on the controversy and discusses how new research findings may help settle it.

Over the past several years, an increasing number of children and adolescents in the U.S. have been diagnosed and treated for bipolar disorder^1,2. As part of their treatment, a majority receive psychotropic medications, often a mood stabilizer and an antipsychotic medication. A recent meta-analysis suggests that antipsychotic medications may be more effective than mood stabilizers for the treatment of manic symptoms in bipolar youth³. Yet weight gain and other adverse metabolic side effects associated with antipsychotic medications⁴ pose important considerations. As compared with adults, children and adolescents may be more vulnerable to antipsychotic-induced weight gain⁵ and perhaps even to antipsychotic-associated diabetes^6,7.

When the diagnosis is clear, than the benefits of these medications often far outweigh the risks. However, there is growing concern over the accuracy of some of these diagnoses^{8, 9}. Symptoms of increased irritability – often interpreted as symptoms of bipolar — also occur in ADHD and disruptive behavior disorders, and may contribute to a tendency among some clinicians to overdiagnose bipolar disorder¹⁰. Even among child and adolescent psychiatrists, there is variation in the clinical criteria used to make a bipolar diagnosis. Many are either uncertain or reject the concept that a child must have the primary DSM-IV criterion for a manic episode (at least one week of elevated, expansive, or irritable mood) to receive bipolar disorder diagnosis⁸.

Concern over high rates of community bipolar disorder diagnosis in young patients has led the DSM-5 Task Force to propose a new diagnosis: disruptive mood dysregulation disorder. This disorder includes youth with recurrent temper outbursts that are out of proportion – both in duration and intensity — to the stressor that provoked them and that are not connected to an existing mood or psychotic disorder. Although the effects of this new disorder on medical practice remain unknown, epidemiological data suggest that disruptive mood dysregulation disorder occurs in approximately 3.3% of children and adolescents¹¹.

Despite substantial progress in combining psychosocial therapies for adults with bipolar disorder, much less research has focused on child and adolescent bipolar patients. Recently, however, family-focused therapy, which emphasizes communication and problem-solving skills training to enhance family functioning, in combination with pharmacotherapy, has been found to contribute to more rapid and complete remission of depression symptoms than a combination of brief psychoeducation and pharmacotherapy¹². Support also exists for multifamily group psychoeducational therapy for children with bipolar disorder in reducing mood symptoms¹³.

Uncertainty and controversy often surround the diagnostic boundaries of bipolar disorder for children and adolescents. In this clinical context, it is important that mental health professionals apply the DSM criteria in a standard and consistent manner, approach pharmacotherapy with an understanding of its efficacy and risks, and seek to take advantage of emerging evidence that interventions that work on family communication and functioning may play an important supporting role in improving the course and outcome of children and adolescents with bipolar disorder.

1. Olfson M, Blanco C, Liu L, Moreno C, Laje G: National trends in the outpatient treatment of children and adolescents with antipsychotics. Arch Gen Psychiatry 2006;63:679-685.

2. Blader JC: Acute inpatient care for psychiatric disorders in the United States, 1996 through 2007. Arch Gen Psychiatry 2011; doi:10.1001/archgenpsychiatry.2011.84

3. Correll CU, Sheridan EM, DelBello MP: Antipsychotic and mood stabilizer efficacy and tolerability in pediatric and adult patients with bipolar 1 mania: a comparative analysis of acute, randomized, placebo-controlled trials. Bipolar Disorders 2010;12:116-141.

4. De Hert M, Dobbelaere M, Sheridan EM, Cohen D, Correll CU: Metabolic and endocrine adverse effects of second-generation antipsychotics in children and adolescents: a systematic review of randomized, placebo controlled trials and guidelines for clinical practice. Eur Psychiatry 2011;26:144-158.

5. Correll CU, Lencz T, Malhotra AK: Antipsychotic drugs and obesity. Trends Molec Med 2011;17 (2):97-107.

6. Hammerman A, Dreiher J, Klang SH, Munitz H, et al.: Antipsychotics and diabetes: an age-related association. Ann Pharmacother 2008;42:1316-1322.

7. Andrade SE, Lo JC, Fouayzi H, Connor DR, Penfold RB, Chandra M, Reed G, Gurwitz JH: Antipsychotic medication use among children and risk of diabetes mellitus. Pediatrics 2011;128:1135-1141.

8. Galanter CA, Pagar DL, Oberg PP, Wong C, Davies M, Jensen PS: Symptoms leading to a bipolar diagnosis: a phone survey of child and adolescent psychiatrists. J Child Adolesc Psychopharmacol 2009;19:641-647.

9. Pogge DL, Wayland-Smith D, Zaccario M, Borgaro S, Stokes J, Harvey PD. Diagnosis of manic episodes in adolescent inpatients: structured diagnostic procedures compared to clinical chart diagnoses. Psychiatry Res. Feb 14 2001;101(1):47-54.

10. McClellan J, Kowatch R, Findling RL. 2007. Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. J Am Acad Child Adolesc. Psychiatry 46(1):107–25

11. Brotman MA, Schmajuk BA, Dickstein DP, et al.: Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children. Biol Psychiatry 2006; 991-997.

12. Miklowitz DJ, Axelson DA, Birmaher B, George EL, Taylor DO, Schneck CD, et al. Family-focused treatment for adolescents with bipolar disorder: results of a 2-year randomized trial. Arch Gen Psychiatry 2008;65(9):1053–61.

13. Fristad MA, Verducci JS, Walters K, Young ME. Impact of multifamily psychoeducational psychotherapy in treating children aged 8 to 12 years with mood disorders. Arch Gen Psychiatry 2009;66(9):1013-21.

Working with TeenScreen National Center, I have seen the impact of this artificial separation on our youth. Not integrating mental health into overall health can contribute to adolescents not getting the care they need. They struggle with depression and other mental disorders that can worsen over time, often with serious consequences.

When I learned that Mental Health America of Colorado (MHA CO) was offering the Mental Health First Aid Training Course in my area, I was compelled to learn more. Could the complexities of mental disorders lend themselves to straightforward and rapid first-aid? Could we use the standard emergency protocols to intervene until appropriate treatment or support arrived? The answer is yes.

In the 4-week class we learned to respond to the warning signs of a range of mental health concerns, including depression, anxiety, psychosis, self-injury, substance abuse and eating disorders. We discussed in-depth how to recognize and address suicide risk. And, we learned how to offer assistance to those experiencing a mental health problem, while understanding that our role is not to diagnose or treat.

ALGEE, an acronym for a 5-step action plan that models the kind of step-by-step for traditional ‘first aid,’ gave us the action plan we needed. It stands for:

1. Assess for risk of suicide or harm – we watched two of the class members perform an emotional role-play (co-worker and a concerned boss); the role play focused on how to ask directly about suicidal thoughts, plans and actions, and how to identify and handle crisis situations.
2. Listen non-judgmentally – we learned verbal and nonverbal strategies and listening skills that engage and offer support to individuals in crisis.
3. Give reassurance and information – we discussed how to approach someone with a mental health concern with respect and how to offer helpful information, resources and practical help.
4. Encourage appropriate professional help – we learned about the variety of professionals who can offer help, including doctors, mental health professionals, peer groups, and a variety of local and national resources to connect individuals to care.
5. Encourage self-help and other support strategies – we discussed the importance of self-help and other supports, like exercise, relaxation, peer support groups, books and web sites, etc.

If someone were experiencing symptoms of anxiety disorder or panic attack, for example, we would make sure there was no immediate possibility for suicide or harm, and then listen to what the person was saying (or not saying) about what they were going through. Were they dizzy, feeling breathless, nauseous, sweating or trembling? Since we learned that these are the symptoms of a panic attack, we could then offer assistance, reassurance, and information on how they could get help.

The course provided me with important tools and background that allowed me to feel equipped to intervene when someone is experiencing a mental health concern, whether family member, co-worker, friend or stranger. I see this as an important step in the integration of physical and mental health, and a way to minimize the stigma associated with mental illness. With mental health disorders being one of the most prevalent of all adolescent health problems, this expanded view of first aid can make a difference in the lives of our at-risk youth.

For more information on Mental Health First Aid, visit http://www.mentalhealthfirstaid.org/cs/.

Leslie McGuire, MSW, TeenScreen National Center’s Deputy Executive Director discusses the impact of these troubling trends, and how TeenScreen is working to reverse them.

I recently participated in an hour-long webinar hosted by TeenScreen National Center on Eating Disorders in Adolescents: Strategies for the Primary Care Provider, now available on-line. During the webinar, I review the key clinical features of eating disorders, their complications and treatment approaches. In addition to offering pediatricians and other primary care providers the latest information for identifying and co-managing these disorders, I discuss what parents need to know. Behavior that begins as a ‘good diet’ can develop into an eating disorder, and intervening early is crucial.

As the latest research reminds us, anorexia and bulimia are complex and difficult to treat. For the primary care provider, the study underscores the importance of recognizing these complexities and referring cases to specialist centers. With regard to anorexia, we need to promote awareness of the dangers of refeeding “too slow” or “too fast”. The research also reminds us of the need for more specific, evidence-based guidelines for treating the range of individuals diagnosed with anorexia and other eating disorders.

Despite these challenges, we are making progress, continually learning what approaches are most effective in helping patients regain their health and avoid relapse. Parents can be assured that through ongoing research, we are gaining greater understanding about the factors contributing to eating disorders and how best to treat young people who struggle to overcome them.

B. Timothy Walsh, MD, is the Ruane Professor of Pediatric Psychopharmacology, Department of Psychiatry, Columbia University and Director of the Division of Clinical Therapeutics at the NY State Psychiatric Institute

He quickly found TeenScreen and connected with our office. Soon after, Tulsa became the first community in the US to implement a voluntary depression screening program for adolescents.

After more than 10 years, the Tulsa program is still going strong. As Mike points out, every school – whether public or private — is aware of TeenScreen and they’ve all requested that his office make mental health screening available to their students.

Throughout, his commitment to teen suicide prevention has remained constant, with his focus on communicating with parents.

“There’s a continued effort to try to stress the importance of prevention and screening, so that we protect our teens and keep them safe,” he says.

Hear more from Mike about his community’s journey: the challenges, the successes and what he believes is most important.

Our colleagues at the American Academy of Child and Adolescent Psychiatry echo their concern, calling the shortages “devastating” for children. People with ADHD typically need so-called stimulant medications (i.e. Ritalin, Adderall) to concentrate and feel calm. However, these medications are also abused by people without ADHD, when they can have a very different effect. To stem the illegal abuse of these drugs, the Drug Enforcement Administration (DEA) places quotas on manufacturing. These quotas and their impact on supply are at the center of the controversy.

Parents of children and adolescents with ADHD have more than their share of stressful days. As the DEA, the Food and Drug Administration and manufacturers work to address this problem, parents are confronting yet another level of stress in the management of this difficult disorder. The organization CHADD (Children and Adults with Attention Deficit/Hyperactivity Disorder), offers information and resources to support parents struggling with this issue.

Like our colleagues in mental health, we urge all involved to find a speedy solution to this problem — one that protects our young people from the dangers of drug abuse, while ensuring that those with ADHD have access to the medication they need, without worry.