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Expanding Use of Technology for Mental Health

More than half of people with mental illness are not receiving the care they need, but technology is offering those in need more ways to access mental health help.  While using technology is not new, it is rapidly changing and expanding.  A June 2015 World Health Organization report notes that 6 six percent of all mobile health apps relate to mental health.



A look at a few examples of the ways technology is improving mental health care:



Assess/ Track Symptoms

Technology is being used to help individuals and their physicians track depression symptoms. For example, one app helps monitor mental health by tracking in real time responses to depression screening questions. Many emergency rooms are now using remote access to psychiatrists to provide psychiatric services  that would not otherwise have been available.



Access to Therapy Remotely

Cognitive behavior therapy (CBT) and other talk therapies are increasingly being provided remotely.  A recent study looking at computer and Internet based CBT found it to be a promising treatment for youth with depression and anxiety.



Connect

Technology allows people to connect to others for sharing, understanding, support and community.  For example, the Love is Louder campaign, a collaboration of The Jed Foundation, MTV and Brittany Snow, has hundreds of thousands of participants in its efforts to address issues such as bullying, discrimination, loneliness and depression. The National Alliance on Mental Illness (NAMI) has developed a support app, NAMIAir (Anonymous, Inspiring, and Relatable), for people looking to connect and talk about mental health. It is designed for use by individuals with mental illines and their families and allows people to share experiences and receive encouragement.







Communicate

Numerous apps are available to help people who have difficulty with communication, such as many people with autism, to express themselves.  The apps are changing the lives of many children and adults with autism.



But experts offer a word of caution when considering using technology to aid in mental health. One recent review of smartphone uses for mental health concluded that “mobile apps for mental health have the potential to be effective in reducing depression, anxiety, stress and possibly substance use.” However, the authors caution that few have been tested and found effective and they call for further research and possibly regulation.(1) Another group of researchers looking at smartphone apps for anxiety concluded that the apps can be useful for self-help and can complement existing treatment. However, they also cautioned that patients should be wary about security, privacy, and effectiveness.(2)





References

(1) Donker T, Petrie K, Proudfoot J, et al. Smartphones for Smarter Delivery of Mental Health Programs: A Systematic Review

(2) Chan S, Torous J, Misra S, et al. Smartphone apps for anxiety: A Review of Commercially Available Apps Using a Heuristic Review Framework. Poster presentation at Annual Meeting of the American Psychiatric Association, 2015.





By Deborah Cohen, Senior Writer, APA

Celebrating the Progress and Promise of the ADA

Twenty-five years ago, on July 26, 1990, President George H.W. Bush signed into law the Americans with Disabilities Act (ADA). The ADA and the subsequent ADA Amendments Act, signed in 2008 by President George W. Bush, expanded opportunities for Americans with disabilities by reducing barriers and changing perceptions.  As a result, our society is more open and accessible to people with disabilities today than it was just a generation ago.

The ADA prohibits discrimination based on disability in employment, services rendered by state and local governments, places of public accommodation, transportation, and telecommunication services.

While the ADA mandates equal access to employment for people with a physical or mental impairment, two-thirds of Americans with disabilities are still unemployed or underemployed, a number that has not changed since the ADA became law. Truly, employment remains the unfulfilled promise of the ADA.



In a recent Catholic News Service article, Marian Vessels, director of the Mid-Atlantic ADA Center in Rockville, Md., suggested the need to address disabilities that may not be apparent or obvious, noting: “accommodations need to be made for people with psychiatric issues, people with PTSD, people with a variety of different learning disabilities.” Addressing these concerns is critical to expanding opportunity for those with mental or intellectual disabilities, as well as those with physical disabilities.



The Interfaith Disability Advocacy Coalition (IDAC), a program of the American Association of People with Disabilities (AAPD), partnered with the ADA Legacy Project, the Collaborative on Faith and Disability, and the ADA National Network to celebrate the progress and recommit to the promise of the ADA. We developed worship and education resources, a proclamation for faith communities to commit to full implementation of the ADA, and hosted an interfaith worship service celebrating 25 years of the ADA, July 26 in Washington, D.C.



While the 25th anniversary of the signing of the ADA has passed, the opportunity to recommit ourselves to expanding access and opportunity for Americans with disabilities remains, whether those disabilities are apparent or not.



By Curtis Ramsey-Lucas, Director of Interfaith Engagement

American Association of People with Disabilities

Why People Don’t Get Help for Alcohol Use

Alcohol misuse is common – more than 16 million US adults (about seven percent) have alcohol use disorder. Yet many people don’t get help.  Less than one in 10 people with alcohol use disorder receiving treatment, according to the 2013 National Survey on Drug Use and Health.



Many people with alcohol use disorder don’t think they need treatment, yet even among people who believe they need treatment, only 15-30 percent receive treatment.  Researchers looking into why people don’t get treatment found barriers related to beliefs and attitude the biggest obstacle.



Among people who believe they need treatment, their attitudes are the most commonly reported barriers, according to research reported  in Psychiatric Services in Advance on August 3, 2015  Financial barriers (e.g., couldn’t afford it) and structural barriers (e.g., didn’t have time, didn’t know where to go) were cited much less frequently.



The top barriers to seeking help for alcohol problems were

• I should be strong enough to handle it alone -  42%

• The problem would get better by itself - 33%

• Not serious enough to seek treatment  - 21%

• Too embarrassed to discuss it - 19%



Previous research has identified some characteristics that make if more or less likely that people will seek treatment: unmarried people are more likely to get treatment than married people and men are more likely to get treatment than women.



One ongoing problem, the researchers note, is that many doctors are still uncomfortable asking about alcohol use.



Concerned about your own drinking?  See an online assessment from NIAAA and learn more problem drinking and getting help in Rethinking Drinking. Find help with SAMHSA’s Behavioral Health Treatment Locator or 24-hour toll-free Referral Helpline at 1-800-662-HELP (1-800-662-4357).





By Deborah Cohen, Senior Writer, American Psychiatric Association

Celebrities Take on Roles as Mental Health Advocates

Actor Jared Padalecki, known for his roles in “Supernatural” and “Gilmore Girls,” has become the latest in a long list of celebrities who are speaking out about mental illness. These famous people are talking about their personal experiences and using their popularity to help raise awareness, fight stigma, and encourage people who are struggling to reach out and get help. Padelecki has talked about his struggles with depression and initiated the #AlwaysKeepFighting campaign to raise awareness and support.



Musician Demi Lovato has been outspoken and public about her experience with bipolar disorder and has become an outspoken advocate for mental health.  She recently joined with several organizations, including the Depression and Bipolar Support Alliance, the Jed Foundation, and others, as part of the  Be Vocal: Speak Up for Mental Health initiative. The campaign encourages individuals to speak up for themselves in asking for help and to learn how to speak out for others in the community.



Actress Glenn Close has been outspoken and active in bringing national attention to the issue of mental illness. After seeing her sister cope with a mental illness and the stigma associated with it, Close founded the nonprofit advocacy organization of Bring Change 2 Mind.  



Actor Joey Pantoliano, has also been active in talking about his personal struggles with depression and substance use. He is raising awareness and fighting stigma through his No Kidding, Me Too! foundation.  Among its many activities, NKM2 promotes messages of empowerments and acceptance through an award-winning documentary of the same name and a series of public service announcements.



Brooke Shields has publicly shared her experience with postpartum depression and written her story of despair and recovery in a memoir, “Down Came the Rain: My Journey Through Postpartum Depression.” Carrie Fisher (Princess Leia of “Star Wars” fame) has taken her advocacy to the stage with her autobiographical one-woman play “Wishful Drinking,” where she tells her story of bipolar disorder and substance use with openness and humor.


As Jeffrey Borenstein, M.D., president and CEO of the Brain and Behavior Research Foundation, noted in a recent interview with CNN, "When celebrities speak publicly about their own experiences with depression or other psychiatric conditions, it's very helpful. It opens up a conversation about these issues. If someone you admire is going through the same thing you might be going through, it makes a difference with people, it causes people to seek help."


Borenstein is also host of a PBS series on mental health issues called Healthy Minds.  You can view past episodes on topics such as bipolar disorder, autism, schizophrenia, and more online at WLIW – Healthy Minds.



By Deborah Cohen, senior writer, American Psychiatric Association

Mental Illness Alone is Not a Risk for Gun Violence

While media coverage of gun violence often leaves us with the perception of close link between violence and mental illness, extensive research tells us that many other factors are associated with a greater risk of gun violence. Most people with mental illness are not violent, and most violent acts are committed by people without mental illness.


New research adds to the wealth of evidence that mental illness is not a risk for gun violence. Research published in June in Psychiatric Services in Advance  found that prior violence, substance abuse, and early trauma are more likely to contribute to future violence than mental illness. The study authors conclude that public safety will not be improved by policies “shaped by highly publicized but infrequent instances of gun violence toward strangers.”


A 2006 report from the Institute of Medicine concludes that "… the contribution of people with mental illnesses to overall rates of violence is small, and further, the magnitude of the relationship is greatly exaggerated in the minds of the general population."


People with mental illness are far more likely to be victims of violence—people with serious mental illness are more than 10 times more likely to be

victims of violence than the general public.



And while mental illness is not a major risk factor for gun violence, mental illness is a significant risk factor for suicide.  Some 39,000 people die by suicide in the United States each year—more than 50 percent by firearm (56 percent of men and 31 percent of women), according to the Centers for Disease Control and Prevention.  Among the major risk factors for suicide are a prior suicide attempt, substance misuse, mood disorders (depression or bipolar disorder), and access to lethal means.  However, research has also identified key protective factors—factors that make it less likely that a person will attempt or die by suicide.  Protective factors include effective mental health care and connection to family, friends and community.


By Deborah Cohen, senior writer, American Psychiatric Association

Diversity, Culture, and Mental Health

Diverse Populations and Mental Health

July is the American Psychiatric Association’s Diversity Mental Health Month, a time to appreciate the diversity among us and to focus on the unique mental health issues of diverse populations and efforts to reduce mental health disparities.  It’s clear we live in an increasingly diverse society, but how does that diversity relate to mental health and receiving quality mental health services?



Cultural background, including race/ethnicity and other aspects, can greatly influence how we think and feel about mental health and illness, how we experience symptoms, how we communicate about mental illness, and how and where we seek help.  Some people may be reluctant to talk about mental health concerns out of fear or shame, some people may seek help from faith leaders, while others may turn to a family doctor or a mental health professional.  (See the infographic from APA:  Mental Health and Diverse Populations.)

Extensive research tells us that ethnic and racial disparities in mental health care exist. A new report from Substance Abuse and Mental Health Services Administration (SAMHSA) notes that among adults with mental illness, whites, American Indian/Alaska Natives, and adults reporting two or more races reported higher mental health service use than black, Asian, and Hispanic adults. (See chart.)

Being aware of differences in the use of mental health services among different ethnic/racial population groups is critical for mental health professionals. That is part of what Diversity Mental Health Month is about – increasing understanding among psychiatrists about the influences of cultural diversity in their practices.



The SAMHSA report also looked at why people don’t use mental health services.  Adults across all racial/ethnic groups cited the same reason most frequently for not using mental health services:  the cost of services cost or lack of insurance.  Other reasons included:  low perceived need; stigma; and structural barriers. Concern about whether mental health services would help was the least cited reason by all racial/ethnic groups.


The top barrier to care, cost, may at least be partly addressed as more people gain access to mental health care with the Affordable Care Act and the Mental Health Parity Act. Many organizations, including the APA, are working to improve cultural sensitivity and to reduce the stigma of mental health, particularly among racial and ethnic minority populations.


By Ranna Parekh, M.D., M.P.H., Director

APA Division of Diversity and Health Equity



This post is part of an ongoing series spotlighting diversity from APA’s Division of Diversity and Health Equity.

Marijuana: Legal Doesn’t Mean Safe

Twenty-three
states and the District of Columbia have laws legalizing some form of marijuana
use, and recreational use of marijuana is legal in four states and D.C.

Does
this growing trend to legalize marijuana mean we don’t need to worry about it?  About
one in 10 people who try marijuana will become addicted to it which means that
they most likely will use it in increasing quantities, develop tolerance (less
effect from it as time goes on), will have withdrawal symptoms if they try to
stop, and will find that the marijuana use is causing them to neglect other
important areas of their life like work, relationships and leisure
activities. 

Even
occasional use of marijuana can have negative effects.  hen someone has marijuana in his/her system,
short term memory is impaired, reflexes are impaired and judgment is
impaired.  These impairments can last 24
hours or longer after the use of the marijuana so it is certainly not safe to
drive after using marijuana. Most people will not be able to perform other
demanding tasks (work-related activities, childcare) at the level they are
accustomed to after using marijuana. 

All the
evidence that we now have indicates that marijuana is possibly permanently damaging
to the developing adolescent brain. All
children should be strongly discouraged from using it at all until they are at
least 21 years of age. If marijuana is
smoked there are also potential physical health risks, such as damage to the
lungs or cardiovascular system.

For more information, see American Psychiatric Association’s  Resource
Document on Marijuana as Medicine.

By Andrew Saxon, MD

Professor and Director, Addiction
Psychiatry Residency Program

University of Washington

Director, Center of
Excellence in Substance Abuse Treatment and Education

VA Puget Sound Health
Care System

Seattle, WA

Transgender: A Diverse Group of Individuals

With the recent spotlight on people who identify as transgender, it’s important to keep in mind that transgender people are as diverse as the general population and express themselves in a number of ways.



On a very basic level, a transgender person is born as male or female, but identifies as either the opposite gender, both genders, or no gender at all.  Some who are labeled as transgender may also decide not to even use that term. There is plenty of evidence that transgender people have existed as long as there has been a concept of male and female. Only recently have they received enough support from society to express themselves in a more open way.  This new recognition and support has opened the door for transgender people to pursue life in a body that feels on the outside the way they have always felt inside.



People who identify as transgender usually start to notice their differences early in life. However people can identify and come to understand themselves to be transgender at any point during their life.  Along the lines of discovering one’s sexual orientation, there are no clear “rules,” and identifying as a transgender individual is a very personal and unique process.  This means that those who identify as transgender may decide to dress as the opposite gender, take hormones to change their bodies, and even have surgical procedures to change their appearance to fit how they feel on the inside. There are also many transgender people who decide that these options are not right for them and express themselves in other ways.



Because society has traditionally been unaccepting to those who identify as transgender, they are at higher risk of depression, anxiety, substance abuse and even suicide. Symptoms can generally improve once the person is in a more supportive and accepting environment. Being supportive can be as simple as using the person’s preferred name and pronoun. Traditionally, even this level of support has not been reached in the health care industry because lack of education and training. It’s important that health care providers become more educated about this diverse group of individuals so that all transgender people can receive appropriate health care for their minds and bodies.



For more information on the historical and psychological evolution of transgender Individuals, please see Association for Gay and Lesbian Psychiatrists (AGLP).

More information and medical guidelines can be found at World Professional Association for Transgender Health (WPATH), www.wpath.org/



By Eric Yarbrough, M.D.

President, Association of Gay and Lesbian Psychiatrists

Director of Psychiatric Services, Callen-Lorde Community Health Center

New York City

This post is part of an ongoing series spotlighting
diversity from APA’s Division of Diversity and Health Equity.

Human Trafficking: Modern Day Slavery

Human trafficking is one of the fastest-growing global crimes according to the United Nations. No country is immune to this modern-day slavery. According to one estimate, some 15,000 people are trafficked each year in the U.S. for either forced labor or sexual exploitation. Though governments across the world have declared slavery illegal, more than 20 million people worldwide are victims of forced labor. Human trafficking is the second largest source of illegal income, second only to drug trafficking. This inhumane business cuts across gender, age and ethnicity.


A number of factors—poverty, child abuse, adverse social conditions, gender inequality—make people susceptible to trafficking. Children and youth are among the most vulnerable. Long and short-term physical and mental torture endured by victims leads to many health consequences. Physical health consequences can include traumatic brain injuries and other physical injuries, gastrointestinal problems, infectious diseases, poor nutrition, and reproductive health problems. Psychological consequences can include shame, grief, fear, distrust, self-blame and self-hatred, drug and alcohol addiction, suicide, suicidal thoughts, and post-traumatic stress disorder (PTSD).


Though this business operates in our communities, we don’t see these victims in day-to-day life as they are often kept behind locked doors. However, there are things we can do to fight human trafficking—educate ourselves, spread the word, become involved with groups fighting human trafficking and, take a closer look in our communities. With little knowledge about the human trafficking indicators and few follow-up questions, one can identify incidences of victimization and report them to the relevant authorities. Below is a list of indicators and questions from the U.S. Department of State which may help spot a victim.


Human Trafficking Indicators

   • Living with employer

   • Poor living conditions

   • Multiple people in cramped space

   • Inability to speak to individual alone

   • Answers appear to be scripted and rehearsed

   • Employer is holding identity documents

   • Signs of physical abuse

   • Submissive or fearful

   • Unpaid or paid very little

   • Under 18 and in prostitution


Questions to Ask


Assuming you have the opportunity to speak with a potential victim privately and without jeopardizing the victim’s safety because the trafficker is watching, here are some sample questions to ask to follow up on concerns:

• Can you leave your job if you want to?

• Can you come and go as you please?

• Have you been hurt or threatened if you tried to leave?

• Has your family been threatened?

• Do you live with your employer?

• Where do you sleep and eat?

• Are you in debt to your employer?

• Do you have your passport/identification? Who has it?


For more information, visit Stop the Traffik, a global movement of activists working to stop human trafficking.





By

Sejal Petal, Sr. Program Coordinator, and

Ranna Parekh, M.D., M.P.H., Director

APA Division of Diversity and Health Equity



This post is part of an ongoing series spotlighting diversity from APA’s Division of Diversity and Health Equity.

Stigma: Changing the Conversation and Changing Lives

Renee Binder, MD
APA President

I was reminded recently of the death of an acquaintance who was at the top of her career when she died suddenly after complications from surgery, according to her obituary. I later learned that she had died from suicide, possibly in response to her struggle with chronic pain and resulting depression. 


Stigma serves as a barrier to seeking treatment often because of fears of discrimination. A few years ago, a patient requested that I not keep any records and wanted to pay me in cash. He was concerned that if his psychiatric records were ever discovered, his career could be negatively impacted. Were this man’s concerns legitimate? In a more public incident Sen. Tom Eagleton was forced to withdraw as a candidate for vice president in 1972 after it became public that he had suffered from depression and undergone ECT (electroconvulsive therapy). 


According to the Merriam-Webster Dictionary, the definition of stigma is a set of negative and unfair beliefs that a society or group of people has about something; it is a mark of shame or discredit. 


How can we begin to address mental health stigma? Here are several ideas: We need courageous spokespersons who are willing to come forward and talk about mental health issues that they or their families are experiencing. Former Rep. Patrick Kennedy is one such champion. He has openly discussed his struggles with mental illness and substance abuse and how treatment has helped him lead a productive and rewarding life.

We can learn from the LGBT community and their struggles with stigma and negative stereotypes. They have taught us that “coming out” by public figures and celebrities can decrease stigma.




Another way of combating stigma is for my fellow mental health professions, psychiatrists and others, to take responsibility for examining the language that is used by the media and in our society. Words such as “lunatic,” “crazy person,” or “maniac” convey images of people who are out of control and dangerous rather than people who are experiencing a mental illness and deserve our compassion and support in getting effective treatments. 


Mental health professionals and others can take an active role in drawing attention to language and advocating for more appropriate, compassionate and less stigmatizing language. Mental health care is an essential part of health care. Almost everyone will suffer from a mental health problem at some point in his or her lifetime.. But for people to be willing to access the mental health care they need, we have to continue the fight against stigma.


If we are successful in addressing stigma, and we must be, then not only will we change the conversation, we will also change people’s lives and change the culture. We will finally reach the point where all of us can openly talk about someone’s death by suicide and encourage people with mental health problems to seek the help they need without fear of judgment or harmful repercussions.


By Renée Binder, M.D., APA President 

Know Your Rights: Fair Insurance Coverage for Mental Health

Federal
law is clear that health insurance companies cannot discriminate against people
seeking care for mental illness or addiction. But how do you know if your insurance
company is not complying with the law? What can you do if you suspect a
violation?

The
American Psychiatric Association (APA) created a tool to help answer these
questions. The poster titled, “Fair Insurance Coverage: It’s the Law”
(Spanish-language version), clearly and
simply explains the law and the steps to take if you suspect a violation.

The
poster is intended to help enforce federal law and end discrimination.  Print it out and share the link (www.psychiatry.org/parity).

By
understanding your rights and taking action you can help ensure fair coverage
for yourself and your family, and you can help others by holding insurance
companies accountable.

What Federal Law Requires

The Mental Health
Parity and Addiction Equity Act requires any group health plan that covers more
than 50 employees and offers mental health and/or substance use disorders
coverage to provide that coverage with no greater financial requirements (such
as co-pays, deductibles, annual or life-time dollar limits) or treatment
limitations than the requirements the plan applies to medical / surgical
benefits. 

Also,
under the Affordable Care Act, new individual and small group plans in and
outside of the mandated health
insurance exchanges are required to offer mental and substance use
disorder coverage similar to medical/surgical benefits.

In addition to federal law, 49 states
and D.C. currently have laws relating to insurance coverage for mental health
and substance use.  More information,
including a summary table of state laws, is available from the National Conference of State Legislators.

By Deborah Cohen, senior writer, American Psychiatric Association

Racism, Discrimination, and Microaggressions: Effects on Mental Health

We know from extensive research that racism can cause significant harmful effects to the victim’s physical and mental health. In 2006, the American Psychiatric Association (APA) established a formal position against racism and discrimination, which partly states that the APA “recognizes that racism and racial discrimination adversely affect mental health by diminishing the victim’s self-image, confidence and optimal mental functioning…. APA believes that attempts should be made to eliminate racism and racial discrimination by fostering a respectful appreciation of multiculturalism and diversity.”

However, racism—prejudice or discrimination directed against someone of a different race based on a belief that one’s own race is superior—is not a mental disorder (it is not included in APA’s diagnostic manual*).

Racism may not appear in the form of clear and obvious acts, it may be in the form of less obvious, “every day” racism.  These acts, termed “microaggressions,” by psychiatrist Chester Pierce, M.D. in 1970, are subtle, often automatic, and nonverbal exchanges with negative overtones. Originally the concept referred to put-downs of blacks by whites in the post-Civil Rights era, but it has since evolved to include people with many differences.  

These subtle and even unintentional acts, can none-the-less be harmful. The effects of this on children are especially pronounced. Victims of racism often display signs of physical and emotional stress. Some victims even start behaving in self-destructive ways that conform to the negative stereotypes they are facing.

Even perceived discrimination can affect health and mental health in several ways, according to an analysis of more than 130 medical studies.** For example, the stress of ongoing perceived discrimination can lead to an increase in unhealthy behaviors, such as smoking or drinking, and decrease in healthy behaviors, such as exercising and healthy eating. If a person has a sense of hopelessness, and low self-esteem, they may be more likely to engage in risky behaviors.  

So how can people protect themselves?  Research suggests several ways to help protect yourself, including having a supportive network of friends and family you can talk to about problems; taking action to address a situation of discrimination, rather than ignoring or avoiding it; and having strong ties to the group(s) with which you identify.

We can all be more mindful of the existence and impact of even subtle and unintentional racism and racial discrimination in the lives of patients and their families and in their everyday practice.

Read more on the Microaggressions Project blog which provides many examples of everyday microaggressions from people across the country.

By Ranna Parekh, M.D.

Director, Division of Diversity and Health Equity\

American Psychiatric Association

References:

*American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.) 2013. Washington, DC:  Author.

**Pascoe EA, Richman LS. (2009). Perceived Discrimination and Health:  A Meta-Analytic Review. Pscyhol Bull; 135(4):531-554.