Mental Illness

Carolyn Robinowitz, M.D., was online Thursday, June 1, at 11 a.m. ET to field questions and comments about mental illness and a nationwide survey recently released by the APA that showed a widespread lack of knowledge and understanding about the warning signs, causes, and effective treatments for mental illnesses. Robinowitz is president-elect of the American Psychiatric Association (APA).

Read About the Study (pdf) | Survey Fact Sheet (pdf) | healthyminds.org

Robinowitz is a former dean of the Georgetown University School of Medicine, where she also served as associate dean for students and professor of psychiatry. She has served as president of the American Board of Psychiatry and Neurology, the American College of Psychiatrists, the Council of Medical Specialty Societies, the Group for the Advancement of Psychiatry and the Association for Academic Psychiatry.

The transcript follows.

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Carolyn Robinowitz, M.D.: Good morning, welcome to our chat about mental health.

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St. Paul, Minn.: Are health care providers getting better at recognizing where some manifestations of mental illness are in part attributable to underlying and undiagnosed treatable physiological conditions, such as hypothyroidism or sleep disorders?

Carolyn Robinowitz, M.D.: Psychiatrists' training as physicians includes evaluating physical and physiologic conditions as well as emotional problems. Your primary care physician also is aware of the psychological aspects of your overall health. Research has expanded our awareness of the connection between mind and body--physical and emotional functioning.

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Richmond, Va.: Dr. Robinowitz,A friend of mine has recently been treated for depression, anxiety, and paranoia. Apparently, this has happened before and runs in the family. He was treated and eventually chose to stop taking the medications because he felt he didn't need them anymore. Fast forward a few years later and he's right back to square one. What are the chances of this person having to stay on this medication for the rest of his life? Also, what kind of support is out there for the caregivers?

Carolyn Robinowitz, M.D.: Thank you for bringing up such an important issue. Mental illnesses can be more like high blood pressure and diabetes, in that they require longer term treatment; however, combinations of medication and talking therapies have proven to be quite effective. Support for friends and families can be found through organizations such as the National Alliance on Mental Illness (NAMI) with local chapters throughout the country, as well as support groups.

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Washington, D.C.: Although I am sure the study is correct -- that people are relatively ignorant of the warning signs and causes of psychiatric problems (I just hate the phrase "mental illness") -- don't you think that a bigger problem is access to resources?

I spent all of my twenties without health insurance, and although I was able to find free psychiatric clinics and access to free drugs, medical tests, sliding scale therapy, etc., it was such a hassle that I never stuck with it.

I somehow managed to be extremely industrious about finding these resources, but I just can't see most depressed persons being able to do that.

Now that I have a relatively fancy job, I have health insurance that covers my care, and that makes all the difference in the world to my ability to stick with treatment.

Any practical advice on how to get actual treatment out there in the communities to the people without health insurance who need it? One only need walk down the street to see the need.

Carolyn Robinowitz, M.D.: Unfortunately, mental health care has not been covered well through most health insurance plans, despite the clear need and the recognition that treatment works. Local resources include community health centers as well as the National Alliance on Mental Illness (NAMI) and the National Mental Health Association (NMHA). These advocacy groups can help refer to low cost care settings.

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Washington, D.C.: I think one of the barriers to seeking treatment for mental illness is knowing the line between normal every day problems and actual mental illness. For example, I don't know if people understand the distinction between unhappiness and depression. Also, insurance coverage for mental health can be very limited and thus make treatment expensive. Finally, many government workers are hesitant to seek treatment because of concerns about security clearances. What is the APA doing about these things?

Carolyn Robinowitz, M.D.: Stigma surrounding mental illness has prevented many people from seeking care, in spite of very effective treatments. Now more than ever, the public is aware that mental illnesses are real disorders, not disorders of will or morality, and as public figures have spoken out about their own illness and treatment, people have become more open and comfortable with seeking treatment.

The American Psychiatric Association has worked to diminish stigma and to improve access to care.

For more information, and to see what else APA is doing, go to WWW.healthyminds.org

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Columbia, Md.: What do you say to a person who may clearly benefit from psychotropic medications, but refuses to seek such treatment due to the stigma and/or a past negative experience with medication?

Carolyn Robinowitz, M.D.: I would encourage this person to speak with his/her primary care physician as a first step. There are many resources providing information about the treatment of depression, which includes a personalized approach involving medication and/or talk therapies. Just as there are many medications to treat high blood pressure, there are many different medications that have been shown to be effective in treating depression. Your doctor can help.

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New Market, Md: There's a tendency in psychiatry to assume that we understand more about mental illness than we really do -- and to assume that all mental illness is the result of something inside the brain. For example, many people have heard that depression is a "chemical imbalance," and so billions of prescriptions for anti-depressants are written, most of which do not help, or barely help, the people who get them, because depression usually has many factors other than biological. By over-emphasizing the idea that depression is a "chemical imbalance," psychiatry may even be misinforming the public and harming many people. Where do you stand on this?

Carolyn Robinowitz, M.D.: Research has shown that the causes of depression and other mental illnesses are a combination of genetic and environmental factors, traumatic events, and other physical illnesses and injuries that have psychiatric side effects. We know that talking therapies as well as medication can produce changes in brain function (as measured by scans) as well as in well-being. As in physical disorders, psychological and biological factors are important in diagnosis and treatment.

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Bethesda, Md.: Good morning, Dr. Robinowitz. My question is about depression. It seems to encompass a lot. Are there different degrees or stages of depression?

Carolyn Robinowitz, M.D.: We use the word depression to describe a number of emotional states as well as the illness "depression."

Everyone can have down days when they feel sad, tearful, or lethargic. When these symptoms persist and interfere with daily functioning over time, we begin to consider the diagnosis of depression.

Fortunately, depression is highly treatable; NIH data show that some 70-80% of people treated for depression get better.

For more information, visit www.healthyminds.org

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Dear Dr. Robinwitz: What can a person do if they are beginning to suspect that their elderly parent is suffering from mental illness but the parent refuses to get an evaluation?

I'm not trying to get her locked up, but she's certainly extremely depressed, and lately her ideas and perceptions seem very confused and a little paranoid.

Many thanks.

Carolyn Robinowitz, M.D.: As you know, depression is not a part of normal aging. Your best resource is her primary care physician, with whom she may feel more comfortable discussing her mood and feelings. That physician probably knows her well and can do an evaluation as part of a routine visit as well as help her receive needed treatment.

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Washington, D.C.: Why is most insurance coverage for mental health services lacking? There is either no coverage, limits to number of visits, or low reimbursement. Many providers are moving to only self-pay patients pricing many people out of the services.

Carolyn Robinowitz, M.D.: Unfortunately, the history of stigma has influenced the availability of non discriminatory coverage, and now, even when there are highly effective treatments, many insurers and even the Federal government through Medicare, limit access to appropriate mental health care. The American Psychiatric Association collaborating with advocacy groups such as NAMI, has been working to educate Congress and insurers about the need for parity. Some progress has been made, but there is still a long way to go. We depend on the public voicing these concerns to employers and legislators.

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Bethesda, Md.: A few years ago, having suffered from chronic depression for a number of years, I went to my new Primary Care physician and asked for a prescription for the anti-depressant I had been on (which had been helping). He looked at me with a straight face and asked, "what are you depressed about?" It was all I could do not to ask him whether he'd actually been to medical school. Do you think GP's are getting at least more vaguely aware now of the nature of different psychiatric conditions? Is there any organized effort by the AMA to make this happen?

Carolyn Robinowitz, M.D.: The American Psychiatric Association has been working closely to ensure that medical school curricula offer comprehensive up-to-date education about mental illnesses for all physicians. We also have been working with our colleagues in primary care (family doctors) to assist them in keeping up to date with the scientific advances in diagnosis and treatment. In my own experience, such collaboration improves care and helps patients lead healthy lives.

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Washington, D.C.: What strides, if any, are being made in working toward eliminating the stigma that comes with mental illness?

Carolyn Robinowitz, M.D.: Mental health advocacy groups and the media have helped reduce stigma. In addition to the many public figures and celebrities who have spoken candidly about their illness and treatment, widely available public information as well as positive portrayals of people with mental illnesses in TV programs and movies have had an impact. Knowing the facts that mental illnesses are real, no fault, and treatable, people are more comfortable speaking about their illness.

Two or three decades ago, cancer suffered from a similar stigma, and people with malignancies felt they had to keep silent about being ill. Knowledge and effective treatments have changed how cancer is viewed, and can do the same for mental illness.

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Alexandria, Va.: What hope is there for those that become depressed due to life events that no pill can change? My only desire now is to have a spectacular death of my own.

Carolyn Robinowitz, M.D.: I would encourage you to seek help immediately--through a general physician or psychiatrist, counselor, or clergy and to turn to a family member or trusted friend to help you. Depression--even in response to highly traumatic life events--is treatable. Do not be discouraged. There is help available and you can feel better.

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Pittsburgh, Pa.: Hello, My sister was diagnosed with borderline personality disorder and bipolar disorder. I'm not sure exactly what medications she's taking, and I know she (half-heartedly) goes to therapy, but...nothing seems to help. She has been suffering for years and it is obviously very difficult to have a relationship with her. Do you have any words of advice (or, at least, comfort)? Thank you!

Carolyn Robinowitz, M.D.: The National Mental Health Association (NMHA) and the National Alliance on Mental Illness (NAMI) sponsor local support groups for family members and friends. I encourage you to contact your local chapter.

Local medical centers and universities may be engaging in research programs to develop new and more effective treatment options, so you may want to pursue that possibility as well.

Additionally, it is important to view the difficult behavior or interactions as symptoms of the illness, and not take it personally. Treatments do help, so encourage her to continue to seek care.

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Carolyn Robinowitz, M.D.: Thanks to everyone for your thoughtful questions. As we can see, there is a lot of interest in mental health issues. For more information, please go to www.healthyminds.org.

Remember mental illnesses are real, no fault, and highly treatable.

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