Article by Dr. Olseth printed in MN Healthcare News
May- Mental Health Awareness Month
“Cogito, ergo sum.” -Renee Descartes
What is mental health? It might be more than you think. Mental Health is the essence of our very existence, for without our mental health, we may not be able to understand ourselves or the world around us. It is from our seat of consciousness- our brains- that we interpret and interact with our environment in the most humanistic of ways. Mental illness can literally make life unbearable or incomprehensible to those who suffer from it, but treatment can help people get better, just like any other medical condition.
The US Department of Health & Human Services defines it as such: Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood.[i] Many factors can influence our mental health, including our physical health and wellness as well as our life experiences. This is best understood from the “bio-psycho-social” model of mental health, which emphasizes the fact that no single factor is clearly the cause or contributor to mental health and wellness. This idea was first proposed in the 1970’s by George Engel, a Psychiatrist who realized that previous concepts of mental health failed to encompass the complex interplay between organism and environment. [ii] Much progress is being made in the field of mental health and treatment of mental illness today.
So, Whats New & Where Are We Going from Here?
In 1990, President George H.W. Bush declared the 90’s as the “Decade of the Brain” and founded a project with the Library of Congress and the National Institute of Mental Health (NIMH) to “enhance public awareness of the benefits to be derived from brain research,” and promoted multiple projects involved in furthering our understanding of various topics; these included the science of cognition, the science of emotion, brain development and children’s mental health, and mental health parity, amongst many others.[iii] This research was associated with an explosion in the field of Psychopharmacology, with large numbers of new medications emerging to treat various forms of mental illness that were now better understood. The Decade of the Brain was followed by a proclamation in the 2000’s of a “Decade of Behavior Project,” and in 2010, a proclamation of the Decade of the Mind- the most recent topic to focus research on the concepts of neuroscience and psychology, and much more international effort has evolved.
Part of the Decade of the Mind project came from the United States in the form of the BRAIN (Brain Research through Advanced Innovative Neurotechnologies) Initiative, announced by the Obama administration in 2013 and advanced $110 million USD in annual expenditures for research in the field. Various agencies- including DARPA, NIH, and NSF- received the funding to direct further research into brain mapping, neuroinformatics, and nanobiotechnology. [iv] The European Union founded their own Human Brain Project (HBP) and involves multiple research organizations in various countries across Europe, including academic as well as government organizations. Their total budget for the 10 year plan is estimated to be about $1.5 billion USD with goals of using supercomputers to create a complete map of the human brain and its intricate connections, also known as “whole brain simulation”.
In fact, there is even a local connection to this exciting area of mental health research at the University of Minnesota. The Center for Magnetic Resonance Research (CMRR) houses some of the most advanced magnetic resonance imaging (MRI) instruments in the world, and is conducting several studies on Brain Function and Connectivity using ultra-high strength magnetic fields to look at the function of the brain in various mental states.[v] These scans, called functional MRI (fMRI) and resting-state (rs-fMRI) are helping to elucidate when a mental disorder is present, and has even shown evidence in helping to guide treatment. For example, fMRI scans have been found to be helpful in determining which patients may respond to repetitive Transcranial Magnetic Stimulation (rTMS) for the treatment of Major Depressive Disorder; this facility is also doing research on developing direct visualization of Deep Brain Stimulation electrode placement for conditions like Parkinson’s Disease and others.
The medications available to treat various disorders is also expanding rapidly; more than 2 dozen antidepressants are available for depression, working in many different ways, and new treatments are arriving every year.[vi] Greater understanding of the science behind use of medications is arising as well; an array of companies have developed “pharmacogenomics testing” to evaluate a person’s response to various medications based on their DNA and known mechanism of action of medications, sometimes this is called “personalized medicine.” This is an area of hot research right here at Medica, as a number of different vendors are seeking to become part of our network. [vii]
The science of mental health is taking great leaps forward, but at the same time we are also realizing the profound impact of our daily activities on our mental health, and there is a great number of things that we all can do on a regular basis to improve our own mental health as well as those around us. Moderation in all activities is a cornerstone to our sanity. Self-care, such as a healthy diet and exercise and regular check-ups with health care providers and therapists, have profound impacts on our mental health and wellness. Spirituality and involvement with church or community organizations can be effective antidepressants; and having a healthy relationship with our families and coworkers can be contributors to our well-being, or causes for our illness. Peer supportand sensitivity towards others mental state can be as therapeutic to the giver as well as the receiver; for as our minds interact with the minds of others, we find out what it really means to be human.
[vi] Next Generation Antidepressants: Moving Beyond Monoamines to Discover Novel Treatment Strategies for Mood Disorders Chad E. Beyer, Stephen M. Stahl Cambridge University Press, May 20, 2010
[vii] Principles of Pharmacogenetics and Pharmacogenomics edited by Russ Altman, Russ B. Altman, David Flockhart, David B. Goldstein
Many patients are referred to me as a psychiatrist to treat their depression. The new patients that come to me for depressive symptoms usually expect that I will be recommending and prescribing an antidepressant for their depressive symptoms because that is what a psychiatrist does, right? Not always.
Often times these patients come to me having gone through several antidepressant trials without any successful resolution of their depressive symptoms. Well sometimes the symptoms are caused by something other than depression. This morning I reviewed labs that I ordered on a young woman patient that I saw earlier this week for depression. Sure enough, her labs show she has iron-deficiency anemia. Prescribing an antidepressant in her case would not do anything about relieving all of the fatigue that she has been experiencing. She has a long history of depression, but that does not mean it should be assumed that her current episode of fatigue should be attributed to depression. I will prescribe iron for her at this time and coordinate care with her primary care doctor for further assessment of the cause of her iron-deficiency anemia. We will meet to monitor her response to iron treatment and continue to assess for psychiatric symptoms.
There are many other physical illnesses that can present similar to how depression is experienced in some patients. For example, this past winter there must have been an increase in cases of mononucleosis locally, as I picked up a couple cases of mono when doing labs on patients. For patients with a history of depression, the patient and their providers may be inclined to think that whenever symptoms of fatigue occur that it is due to a recurrence of their depression. My patients appreciate that we are thorough in assessing for other conditions before starting any psychiatric medication.
Another example this past year was of a young woman who was referred to me because she was suicidal. She reported to me that the main reason for her suicidal thinking was unbearable facial pain. She had been diagnosed with TMJ syndrome but wasn’t experiencing any relief of her pain. I did the usual psychiatric assessment of her and also assessed her facial pain symptoms. I advised her that her facial pain symptoms are more consistent with a diagnosis of Trigeminal Neuralgia than of TMJ syndrome. Although skeptical, she agreed to let me start her on Tegretol to treat Trigeminal Neuralgia. When she returned for her follow-up a week later, she started to cry when she expressed gratitude for relieving her facial pain. She was frustrated that her Trigeminal Neuralgia was never diagnosed before and that she was unnecessarily put on many pain medications in attempt to bring her relief of the pain. That was six months ago and her facial pain has not returned. She now wants to try tapering the antidepressant that she was put on previously and I agree that it is time to make this change.
These are just a few of my recent examples of how a thorough assessment of my patient’s symptoms reveals that there is more to their subjective complaints of depression than the patient thought. I am sure that many psychiatrists have similar examples of how other pathologies, such as thyroid disorders, cancers, neurological disorders, to name a few, have been the cause, or at least a contributing factor, to symptoms perceived by the patient as depression. As physicians, we as psychiatrists look beyond just symptoms and carefully look for cause and contributing factors of the presenting chief complaint of depression. An antidepressant isn't always the answer to what appears to be depression.
Sometimes the onset of depression is gradual and insidious. So gradual that an individual doesn't see it in themselves while it is happening. I can think of many patients who came to me for depression who didn't originally recognize it in themselves. A patient of mine recently described how his wife helped him recognize his depression. No he wasn't suicidal or crying all the time. In fact, he was rather unemotional and he wasn’t relating to others in his usual way. He was not really expressing joy or obvious sadness. With further discussion he recognized he was clearly anhedonic. He did not think he felt bad enough to seek treatment without a nudge from his wife. He just thought he was bored all the time.
As often happens it is easier to recognize the severity of symptoms after recovery. I treated his depression with medications while he saw my therapist for CBT. A couple months later he as his symptoms were resolving, he recognized that the "boredom" he experienced was depression. It was easier for him to see in retrospect what his wife was seeing all along.
He described that now he is more engaging in conversations. He now experiences joy in living his daily life. He describes getting his sense of humor back and being able to laugh again. He takes particular pride in being able to make others laugh. I thought he captured things quite well when he said "I got my Woo Hoo back!." I think we all know what that means.
With a little "Woo Hoo" in life we can find pleasure in life even in tough conditions. Depression is experienced differently by different individuals. We all deserve to experience the "Woo Hoo" moments of life..
What a joy to hear from my patient today that she is able to "just be a normal mom." She had struggled with ruminations for years of thoughts that she would harm others. She couldn't enjoy closeness with her children as she was afraid she would harm them. I can't imagine how horrible that would be for a mother. Ruminations of harming others is actually a common rumination for people with OCD. It has been a joy to successfully treat my patients with this illness so they can start enjoying and experiencing normal interactions with the ones they love.