by Jessica Kraft, MSN, PMHNP-BC

 

 

 

 

Anxiety and mood disorders are amongst the most commonly diagnosed mental health conditions in the United States. While many find successful treatment through various psychotherapies or medications targeted at managing anxiety and depression, no medication will magically take away all anxiety or life stressors and it is not uncommon to experience breakthrough anxiety or symptoms of depression even while under the care of mental health professionals.  In today’s hectic world it can be challenging to juggle daily responsibilities and find ways and time to take a step back and practice mindfulness or focus on self-care. This article explores different mindfulness activities and alternative therapies, some of the benefits they illustrate, and how to include them in our day-to-day routines.

Meditation: Meditation has been practiced for thousands of years and is considered one of the oldest spiritual practices in ancient India and China. While it can be challenging to find an agreed upon definition for meditation, in general it is agreed upon that meditation is a practice and form of mental training with the goal of calming the mind (Wang et al., 2022). Meditation can look different to different people and can be practiced in as little as a few minutes every day.

Yoga: Yoga is an ancient spiritual practice with roots in Indian culture and is an alternative therapy often combined with meditation that focuses on breathwork and the adoption of physical postures.  There are multiple style of yoga that differ in intensity and length of time, but multiple individual studies and systematic reviews have concluded that yoga can benefit those struggling with depression with symptom reduction seen with 60-minute sessions per week (Saeed et al., 2019).

Exercise: There are numerous studies and clinical trials showing the benefits of exercise related to mental health, particularly for those who struggle with anxiety and depression. A meta-review examining the relationship between anxiety disorders and physical activity (especially aerobic and resistance exercises) with over 69,000 participants showed that on average participants reported significantly reduced anxiety over a 3-year period when engaging in physical activity on a regular basis. Analysis examining sedentary behavior showed an increased risk of depression over time compared to those who engaged in more physical lifestyle activities (Firth et al., 2020). While there can be limitations in studies related to exercise types, additional therapies, and other variables there is one thing that remains consistent: no trials have shown that physical activity worsens anxiety or depression (Saeed et al., 2019).

While mindfulness activities and alternative therapies sound great on paper, they can be challenging to practice regularly. Below are some tips for squeezing in mindfulness activities into a hectic schedule:

  • Utilizing meditation apps. Most popular meditation apps (Calm, Headspace, Healthy Minds Program) have lengthy daily meditations, but they also include quick 1-3 minute meditations/deep breathing exercises that can easily be practiced before going to bed, before starting the work day, or to take a time out when feeling overwhelmed
  • Find exercise you enjoy doing. Motivation to exercise can be challenging enough, but when it is for an activity you don’t even enjoy this can be even more challenging. Find an activity or sport that you actually enjoy or look forward to doing and this will help with consistency, especially if you are able to engage in the activity with friends or family and turn it into a social or group event
  • Make slow, incremental changes to routine. It’s not uncommon to make a self-care plan including things like exercising daily, meditating daily, and making dietary changes. When we try to make multiple changes like this overnight it is easy to get discouraged if we miss a day and sometimes, we don’t even get back to it. Focusing on one change at a time and incorporating it into your routine more slowly helps with habit changing
  • In short, set yourself up for success with the four laws of behavior change. 1) make it obvious – if you want to go to the gym after work every day pack your bag the night before, 2) make it attractive – get yourself a new pair of shoes or a new workout outfit, 3) make it easy – start with a few minutes per day, and 4) make it satisfying – set up incentives to motivate yourself and keep it going (Clear, 2022)

Sources:

Clear, J. (2022). Atomic habits: An easy & proven way to build Good Habits & Break Bad Ones: Tiny Changes, remarkable results. Cornerstone Press.

Firth, J., Solmi, M., Wootton, R.E., Vancampfort, D., Schuch, F.B., Hoare, E., Gilbody, S., Torous, J., Teasdale, S.B., Jackson, S.E., Smith, L., Eaton, M., Jacka, F.N., Veronese, N., Marx, W., Ashdown-Franks, G., Siskind, D., Sarris, J., Rosenbaum, S., Carvalho, A.F. and Stubbs, B. (2020), A meta-review of “lifestyle psychiatry”: the role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders. World Psychiatry, 19: 360-380. https://doi.org/10.1002/wps.20773

Saeed SA, Cunningham K, Bloch RM. Depression and Anxiety Disorders: Benefits of Exercise, Yoga, and Meditation. Am Fam Physician. 2019 May 15;99(10):620-627. PMID: 31083878.

Wang, Zanyi1,; Rawat, Vikas1; Yu, Xinli2; Panda, Ramesh Chandra3. Meditation and its practice in Vedic scriptures and early Taoism scriptures. Yoga Mimamsa 54(1):p 41-46, Jan–Jun 2022. | DOI: 10.4103/ym.ym_48_22 (https://journals.lww.com/yomi/fulltext/2022/54010/Meditation_and_its_practice_in_Vedic_scriptures.8.aspx)

By Peter White, M.A., LPCC, LICDC, Lindner Center of HOPE Outpatient Therapist

The problem during Bipolar Mood Disorders is a pattern of swings of the essential elements of mood between the two poles, like the North Pole and South Pole, of Mania and Depression. These swings are not moodiness, which are swings of mood throughout a day. A Bipolar swing is a distinct period of at least one week when the full spectrum of mood elements exhibits depressive and/or manic elements.

Although thought of as a subjective experience, mood deeply influences three areas. First is metabolism – sleep, appetite, libido and energy levels. Second, mood influences both motivation as well as the ability to experience pleasure and/or a sense of accomplishment. Thirdly, mood deeply influences interpretations within thoughts from positive to neutral to negative.

So, we can think of this first spectrum of mood disorder along an axis of depression to neutral to manic. Therefore, a depressed mood will depress metabolism. A person will have difficulty with sleep through either excessive or inadequate or disrupted sleep, loss of appetite or excessive eating despite disrupted appetite, loss of libido as well as loss of energy. Depression will hinder motivation making it difficult to experience the drive to initiate activities as well as hinder pleasure or the reward of activity. This is a very difficult cycle when it is hard to get active in the day compounded by not finding any pleasure or reward in the day’s activities. Lastly, depression will darken the flow of thoughts adding many themes of hopelessness, helplessness, worthlessness and guilt into our thought process.

Conversely, mania will elevate the same essentials. It will increase energy levels often in the face of declining sleep hours. It will increase libido, increase excessive and/or absence of appetite. It will increase motivation often leading to excessive engagement of plans or activities and will create a compounding loop of all activity feeling especially pleasurable or rewarding. Again, conversely is will paint thinking with elevated judgements of specialness, invulnerability, and inevitable positive outcomes.

The second spectrum of mood disorders, like most other behavioral health problems, is along the spectrum of severity – mild to moderate to severe. If you combine this spectrum of severity along with the first spectrum of depressive to manic, we see how varied and individualized any person’s experience with Bipolar Mood disorders can be.  Most people can relate to some degree of depression during periods of their life with perhaps a few weeks or month of low energy, noticing that they are not getting the same rewards in their regular activity as well as perhaps noticing they are thinking unusually negatively about themselves and their outlook on life. We might call this a mild, brief depressive episode. But the reality is that depression is one of the most disruptive and costly of all health conditions as recognized by the World Health Organization. This mean that depression is often moderate or severe to very severe and can disrupt functioning on every level for weeks to months if not years. A severe depression can make it difficult to get out or bed for days on end both from collapsed energy and motivation. It can destroy the pleasure and rewards of living so that all activity feels like a painful chore at best. Finally, it can turn thoughts dangerously dark with so much hopelessness, helplessness and worthless that suicidal thinking emerges nearly with a sense of relief.

Again conversely, though experienced less often by most people, Manic Episodes can present with mild, moderate, severe and very severe intensity. During a sever episode, a person with manic symptoms is often sleeping little but maintaining very high levels of energy. They are often talking very quickly and sometimes laughing excessively and outside the context of humorous things. Given the very high levels of motivation and the reinforcement of pleasure in all activities, they often initiate an excessive number of activities – starting multiple projects with little awareness of the ability to balance or complete them. They frequently initiate conversations or relationship in an open or disinhibited style very unusual for to their character. With elevated thought patterns, they might believe they have a unique or special purpose, and they are convinced that all their activities will be successful and rewarding. Give the excessive energy, motivation, pleasure and elevated sense of self and success, people in manic states will often engage in behavior patterns much riskier than typical – spending money well beyond their mean, unusually disinhibited sexual decision, reckless driving, shop lifting.

I hope it’s useful to review the way mood symptoms fluctuate along these two spectrums, because like all health care conditions, we are best off when we accurately identify what these behaviors are – symptoms. Mood symptoms are not moral challenges, personality traits or unconsciously desired behaviors. Mood symptoms are symptoms, and fortunately, there are many very effective treatments for all symptoms along both spectrums. Please know if you or a loved one or a client is experiencing any degree of Bipolar mood problems, there will be many ways to help and cope, and experience the satisfaction of effectively treating a behavioral health care condition.

 

Almost everyone has felt “down in the dumps” at times or had a case of “the blues.” In this state, you may have referred to yourself as feeling depressed.  But is this really clinical depression?

An estimated 25 percent of Americans suffer from major depression. So what distinguishes the common “down” feelings felt by most of us with true depression?  Actual depression is different from “the blues” in several key ways.

Symptoms of Feeling Blue vs. Being Depressed

Feeling “blue” or being down in the dumps” are ways we describe feelings of sadness or melancholy.  True depression has a host of other symptoms in addition to sadness.  They may include: significant weight loss or gain, insomnia, loss of interest in daily activities, feelings of guilt, helplessness or hopelessness, fatigue/loss of energy, and poor concentration.

Causes of Feeling Blue vs. Being Depressed

Brief periods of feeling “blue” are usually caused by life events that leave us feeling discouraged.  From a broken date to the loss of a loved one, the causes can range from minor to major events.  Depression can be triggered by a stressful life event, but research indicates that depression is also associated with a variety of genetic and biochemical factors.  Some individuals appear to be more “hard-wired” to get depression.  The “blues,” on the other hand, are feelings with which almost everyone can relate.

Duration of Feeling Blue vs. Depression

To be considered depressed, an individual must be experiencing significant symptoms for at least two weeks on an ongoing basis.  Individuals who are feeling a bit “down” usually shake off these feelings in a few days, if not hours.  The “down in the dumps” sensation we’ve all had is noteworthy for being temporary.  Without treatment, true depression, on the other hand, can last for months or years, or it can re-occur frequently.

Intensity of Depression Symptoms 

In addition to being longer lasting, true clinical depression is also more intense than a case of the “blues.”  Usually, individuals who are feeling “blue” or “down” manage to perform their regular daily activities.  Individuals experiencing an episode of depression often are unable to function normally. The depression interferes with work, relationship, and daily activities.  In extreme cases, depression can lead to feelings of complete hopelessness and suicidal thoughts or acts.

If you or a loved one frequently feels “down in the dumps” or “blue,” consider whether the condition may actually be depression.  A physician or mental health professional can conduct an assessment to determine if depression is present and recommend appropriate treatment.

Understanding the difference between feeling “blue” and being depressed can make a difference in the quality of life for an affected individual.  With proper treatment, depression can be managed, and individuals can live more enjoyable and productive lives.

Danielle Johnson, MD, FAPA
Lindner Center of HOPE/Chief Medical Officer
University of Cincinnati College of Medicine Adjunct Assistant Professor of Psychiatry

Medications are undoubtedly an important tool in the treatment of mental illnesses. Expert application of psychopharmacology is a game changer in improving symptoms of mental illness and helping individuals achieve a manageable baseline. Complex co-morbidities and severe mental illness make prescribing even more complex.

Psychiatric medications can stabilize symptoms and prevent relapse. They work by affecting neurotransmitters in the brain. Serotonin is involved in mood, appetite, sensory perception, and pain pathways. Norepinephrine is part of the fight-or-flight response and regulates blood pressure and calmness. Dopamine produces feelings of pleasure when released by the brain reward system.

One in ten Americans takes an antidepressant, including almost one in four women in their 40s and 50s. Women are twice as likely to develop depression as men.

Selective Serotonin Reuptake Inhibitors (SSRIs) Side Effects

Selective serotonin reuptake inhibitors (SSRIs) increase levels of serotonin. Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro) treat depression, anxiety disorders, premenstrual dysphoric disorder, eating disorders, and hot flashes. Potential side effects include jitteriness, nausea, diarrhea, insomnia, sedation, headaches, weight gain, and sexual dysfunction.

Zoloft Side Effects in Women

Zoloft, also known by its generic name sertraline, is an antidepressant medication that can cause a range of side effects in women. Some of the common side effects of Zoloft include nausea, diarrhea, headache, dizziness, dry mouth, drowsiness, and difficulty sleeping. Women may also experience sexual side effects such as decreased libido, difficulty reaching orgasm, and erectile dysfunction. In some cases, Zoloft may cause weight gain or weight loss, and it can also affect blood pressure and heart rate. Rare but serious side effects of Zoloft in women may include seizures, serotonin syndrome, and suicidal thoughts or behavior.

Prozac Side Effects in Women

Prozac, also known by its generic name fluoxetine, is an antidepressant medication that can cause a range of side effects in women. Some of the common side effects of Prozac include nausea, diarrhea, headache, dizziness, dry mouth, drowsiness, and difficulty sleeping. Women may also experience sexual side effects such as decreased libido and difficulty reaching orgasm. Prozac may also cause weight gain or weight loss, and it can affect blood pressure and heart rate. Rare but serious side effects of Prozac in women may include serotonin syndrome, suicidal thoughts or behavior, and seizures.

Lexapro Side Effects in Women

Lexapro, also known by its generic name escitalopram, is an antidepressant medication that can cause a range of side effects in women. Some of the common side effects of Lexapro include nausea, diarrhea, headache, dizziness, dry mouth, drowsiness, and difficulty sleeping. Women may also experience sexual side effects such as decreased libido and difficulty reaching orgasm. Lexapro may also cause weight gain or weight loss, and it can affect blood pressure and heart rate. Rare but serious side effects of Lexapro in women may include serotonin syndrome, suicidal thoughts or behavior, and seizures.

Serotonin-norepinephrine Reuptake Inhibitors (SNRIs) Side Effects

Serotonin-norepinephrine reuptake inhibitors (SNRIs) increase levels of serotonin and norepinephrine. Venlafaxine (Effexor), duloxetine (Cymbalta), and desvenlafaxine (Pristiq) are used to treat depression, anxiety disorders, diabetic neuropathy, chronic pain, and fibromyalgia. Potential side effects include nausea, dry mouth, sweating, headache, decreased appetite, insomnia, increased blood pressure, and sexual dysfunction.

Tricyclic Antidepressants Side Effects

Tricyclic antidepressants (TCAs) also increase serotonin and norepinephrine. Amitriptyline (Elavil), clomipramine (Anafranil), desipramine (Norpramin), nortriptyline (Pamelor), doxepin (Sinequan), trimipramine (Surmontil), protriptyline (Vivactil), and imipramine (Tofranil) are used to treat depression, anxiety disorders, chronic pain, irritable bowel syndrome, migraines, and insomnia. Possible side effects include sedation, forgetfulness, dry mouth, dry skin, constipation, blurred vision, difficulty urinating, dizziness, weight gain, sexual dysfunction, increased seizure risk, and cardiac complications.

Other Antidepressants Side Effects

Wellbutrin Side Effects in Women

Bupropion (Wellbutrin) increases levels of dopamine and norepinephrine. It treats depression, seasonal affective disorder, ADHD, and can be used for smoking cessation. It can also augment other antidepressants. Potential side effects include anxiety, dry mouth, insomnia, and tremor. It can lower the seizure threshold. There are minimal to no sexual side effects or weight gain.

Trazodone (Desyrel, Oleptro) affects serotonin and mirtazapine (Remeron) affects serotonin and norepinephrine. They are both used for depression and sleep. Mirtazapine has minimal sexual side effects.

Monoamine oxidase inhibitors (MAOIs) increase serotonin, norepinephrine, and dopamine. Isocarboxazid (Marplan), phenelzine (Nardil), selegiline (Emsam), tranylcypromine (Parnate), and moclobemide are associated with more serious side effects than other antidepressants. There are dietary restrictions and numerous drug interactions. MAOIs are often used after other antidepressant classes have been tried. Other antidepressants need to be discontinued for a period of time prior to starting an MAOI.

Newer antidepressants include Viibryd (vilazodone) which affects serotonin, Fetzima (levomilnacipran) which affects serotonin and norepinephrine, and Brintellix (vortioxetine) which affects serotonin. Brintellix and Viibryd have mechanisms of action that make them unique from SSRIs. Viibryd is less likely to cause sexual side effects.

Excess serotonin can accumulate when antidepressants are used with other medications that effect serotonin (other antidepressants, triptans for migraines, certain muscle relaxers, certain pain medications, certain antinausea medications, dextromethorphan, St. John’s Wort, tryptophan, stimulants, LSD, cocaine, ecstasy, etc.) Symptoms of serotonin syndrome include anxiety, agitation, restlessness, easy startling, delirium, increased heart rate, increased blood pressure, increased temperature, profuse sweating, shivering, vomiting, diarrhea, tremor, and muscle rigidity or twitching. Life threatening symptoms include high fever, seizures, irregular heartbeat, and unconsciousness.

Estrogen Levels With Antidepressants in Females

Varying estrogen levels during the menstrual cycle, pregnancy, postpartum, perimenopause, and menopause raise issues with antidepressants and depression that are unique to women. Estrogen increases serotonin, so a decrease in estrogen at certain times in a woman’s reproductive life cycle can reduce serotonin levels and lead to symptoms of depression. Hormonal contraception and hormone replacement therapy can reduce or increase depressive symptoms; an increase in symptoms may be more likely in women who already had major depressive disorder. During pregnancy, antidepressants have a potential risk to the developing baby but there are also risks of untreated depression on the baby’s development. With breastfeeding, some antidepressants pass minimally into breast milk and may not affect the baby. The benefits of breastfeeding may outweigh the risks of taking these medications.   Antidepressant sexual side effects in women are vaginal dryness, decreased genital sensations, decreased libido, and difficulty achieving orgasm. Women should communicate with their psychiatrist and/or OB/GYN to discuss the risks and benefits of medication use vs. untreated illness during pregnancy and breastfeeding; the use of hormonal treatments to regulate symptoms associated with menses and menopause; and the treatment of sexual dysfunction caused by antidepressants.

It has been observed that some antidepressants can affect estrogen levels in women. The exact mechanisms behind these effects are not fully understood, but it is thought to be related to the interactions between the medication and the hypothalamic-pituitary-gonadal (HPG) axis, which is responsible for regulating estrogen production. It is important for women to discuss any potential effects of antidepressants on estrogen levels with their healthcare provider, especially if they have a history of hormonal imbalances or are taking hormonal therapies.

It is important for women to discuss any potential side effects with their healthcare provider before starting any depression medication.

Lindner Center of HOPE’s Approach

Lindner Center of HOPE’s residential services employ full-time psychiatrists with expertise in psychopharmacology. These prescribing physicians are designated members of each residential client’s treatment team. Medication management within Lindner Center of HOPE’s residential programs is also supported by 24/7 psychiatry and nursing staff, onsite pharmacy and an innovative Research Institute.

In some cases, patients over the course of treatment for mental illnesses accumulate many prescriptions. In cases like this, Lindner Center of HOPE’s residential units can offer a safe environment for medication assessment and adjustment. While the client participates in appropriate evaluation and treatment, their psychiatrist can also work with them on reaching rational polypharmacy — in other words, medication optimization.

For patients with more severe, treatment-resistant mental illness, Lindner Center’s psychiatrists can implement the most complicated, and often hard to use, treatments, in a safe environment, while under their observation.

If medication adjustments result in decompensation on the residential units, a patient can be temporarily stepped up to an acute inpatient unit on the same campus.

By Danielle Beltz, MSN, PMHNP-BC, Psychiatric Nurse Practitioner, Lindner Center of HOPE

Pregnancy and childbirth can be one of the most rewarding and fulfilling things a woman can do in her
lifetime but can hand in hand be one of most challenging and emotionally taxing times.
A female goes through not only physical changes throughout pregnancy but also hormonal, emotional,
and psychological changes. In addition, a pregnancy can bring stress and emotional hardship to their
interpersonal dynamics.

A lot of new moms experience postpartum “baby blues” after giving birth which differentiates from
postpartum depression. Symptoms usually include sadness, irritability, moodiness, crying spells, and
decreased concentration. Baby blues usually begin within 2 to 35 days after childbirth and can persist up
to 2 weeks. When these symptoms last longer than 2 weeks this is when the mother should consider talking
to a healthcare provider.

About one in seven women develop postpartum depression. It most commonly occurs 6 weeks after delivery but can begin prior to
delivery as well. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) a major depressive episode with the onset
of pregnancy or within 4 weeks of delivery is considered postpartum depression. Five of the nine symptoms must be present nearly every
day for at least two weeks and constitute a change from previous functioning to be diagnosed. Depression or loss of interest in addition
to the following symptoms must be present:

• Depressed mood (subjective or observed) most of the day
• Diminished interest or pleasure in all or most activities
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Feelings of worthlessness or guilt
• Loss of energy or fatigue
• Recurrent suicidal ideation, thoughts of death or attempts
• Diminished concentration or indecisiveness
• Change in weight or appetite (5% weight change over 1 month)

Fifty percent of postpartum major depressive episodes begin before
delivery so collectively these episodes are described as peripartum
episodes. Mothers with peripartum major depressive episodes commonly have severe anxiety and panic attacks.

The exact etiology of postpartum depression is unknown. Several factors have been reported to contribute to the development of
postpartum depression. The physical and hormonal fluctuations resulting from pregnancy influence postpartum women to develop
depression when stressful and emotional events coincide with childbirth. Some of these factors include the stress of motherhood, difficult
labor, poor financial and family support, and harmful health outcomes of childbirth. Lower socioeconomic demographic, personal or
family history of depression, anxiety, or postpartum depression, PMDD, complications in pregnancy and birth, and mothers who have
gone through infertility treatments have also all been suggested to be strong contributors.

Postpartum depression not only affects the mother’s health but also the relationship the mother has with her infant and that child’s
development. Studies have shown that children are at a greater probability of developing behavioral, cognitive, and interpersonal problems
whose mothers have postpartum depression. It can also lead to inability to breastfeed and marital conflict.

Postpartum psychosis is another severe kind of depression but is not the same thing as postpartum depression. Around 1 in 500 or 1 in
1,000 women has postpartum psychosis after delivering a baby. It commonly starts the first 2 weeks after giving birth. Women who are
also diagnosed with bipolar disorder or schizoaffective disorder are more prone to have postpartum psychosis than women who are not
diagnosed with other mental health conditions.

Postpartum psychosis is considered a psychiatric emergency with a capacity of suicide and infanticidal threat. Some symptoms include
delusions, hallucinations, unusual behavior, paranoia, and sleep disturbances. If postpartum psychosis is suspected help should be sought
immediately.

Psychotherapy and antidepressant medications are the first line treatments for postpartum depression. Psychotherapy is considered first
line for women with mild to moderate depression or if they have concerns of starting a medication while breastfeeding. For moderate to
severe depression therapy and antidepressant medications are recommended. The most common medication for postpartum depression is
an SSRI or selective serotonin reuptake inhibitor. Once an efficacious dose is reached, treatment should persist for 6-12 months to prevent
relapse of symptoms. Risk versus benefits of treated versus untreated depression while breastfeeding or pregnant should be discussed.
Transcranial Magnetic Stimulation (TMS) is an alternate therapy that can be used for women who have concerns about their child being
exposed to a medication. Although, the risk of taking an SSRI while breastfeeding is relatively low. ECT is another option for women with
severe postpartum depression who do not respond to traditional treatment. It can be particularly helpful with psychotic depression.

Zurzuvae (zuranolone) is the first oral medication approved by the FDA specifically for the treatment of postpartum depression in adults.
Until August 2023, treatment for PPD was only available as an IV (Brexanolone) and was only available at certified healthcare facilities.

People with depression especially new mothers and postpartum mothers may not identify or accept that they’re depressed. They also
may be unaware of the signs and symptoms of depression. If you are questioning whether a friend or family member has postpartum
depression or is developing signs of postpartum psychosis, assist them in pursuing medical treatment and recognize that help is accessible.
References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Commissioner, O. of the. (n.d.). FDA approves first oral treatment for postpartum depression. U.S. Food and Drug Administration. https://www.fda.
gov/news-events/press-announcements/fda-approves-first-oral-treatment-postpartum-depression#:~:text=Today%2C%20the%20U.S.%20Food%20
and,the%20later%20stages%20of%20pregnancy
Guo, L. , Zhang, J. , Mu, L. & Ye, Z. (2020). Preventing Postpartum Depression With Mindful Self-Compassion Intervention. The Journal of Nervous and
Mental Disease, 208 (2), 101-107. doi: 10.1097/NMD.0000000000001096.
Mayo Foundation for Medical Education and Research. (2023, April 14). “I’m happy to be a new mom. but why am I feeling
so sad?” Mayo Clinic. https://mcpress.mayoclinic.org/mental-health/im-happy-to-be-a-new-mom-but-why-am-i-feeling-sosad/?
mc_id=global&utm_source=webpage&utm_medium=l&utm_content=epsmentalhealth&utm_
campaign=mayoclinic&geo=global&placementsite=enterprise&invsrc=other&cauid=177193
Miller, L. J. (2002). Postpartum depression. JAMA : The Journal of the American Medical Association, 287(6), 762-765. https://doi.org/10.1001/jama.287.6.762
Mughal S, Azhar Y, Siddiqui W. Postpartum Depression. [Updated 2022 Oct 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023
Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519070/
Postpartum depression. March of Dimes. (n.d.). https://www.marchofdimes.org/find-support/topics/postpartum/postpartum-depression?gad_
source=1&gclid=EAIaIQobChMIqKLemfTfggMVq0VyCh3ouwGDEAAYBCAAEgKxjPD_BwE
Silverman, M. E., Reichenberg, A., Savitz, D. A., Cnattingius, S., Lichtenstein, P., Hultman, C. M., Larsson, H., & Sandin, S. (2017). The risk factors for postpartum
depression: A population-based study. Depression and Anxiety, 34(2), 178–187. https://doi-org.uc.idm.oclc.org/10.1002/da.22597
Stewart, D. E., & Vigod, S. (2016). Postpartum depression. The New England Journal of Medicine, 375(22), 2177-2186. https://doi.org/10.1056/NEJMcp1607649

 

by Dawn Anderson, LPCCS

Humans are a very resilient species. We have overcome generations of burdens to accomplish family unity, and yet this effort renews with new barriers and challenges each year. A vital component of a thriving family unit is the ability to co-regulate. Co-regulation describes the process in which a parent can identify their child’s need for help, recognize their own emotional reaction, and then help themselves cope to share that gift with their child.

Just like the airplane metaphor- you must put on your own oxygen mask before you can help others. As a parent, we are bombarded with requests for our time, resources, and attention. We have a certain amount of emotional energy in the day, and this is a renewable resource! Taking the time to take care of your own emotional health allows you to be more responsive in the ways we’d like to show up with our children. Another huge burden on parents is the one we place there ourselves- guilt. We fret about the choices to be made, the amount we’re able to give our children, and the perpetual feeling we aren’t enough. The reality is we all bring different types and amounts of skills and talents to the table.

Some of us have different capacities for stress, and that doesn’t make us good or bad. Sometimes it’s helpful to think of your stress tolerance as a cup- is yours a 12 oz picnic cup? A 2 oz bathroom water cup? An Olympic swimming pool? Whatever the size, we must take ownership of knowing where we are throughout the day, and how we are showing up in interactions with our children. We also need to be intentional about emptying said cup proactively throughout the day, so it doesn’t overflow. Overflow here is where we see the unintentional screaming at our precious ones, storming off, or being unable to play with them after our long day.

Lastly in explanation, its valuable to consider the way language impacts our thoughts, feelings, and behavior. In common language, we say things about children such as “they’re a mess,” “they’re not listening to me,” “they’re being a brat.” In all humans, we have a system in our brain that takes in information and decides if it’s safe or not, and then sends it to either the thinking part or the survival part of our brain. What our brains decide as safe depends on the person. Some of us have different themes that activate the threat systems in our own bodies, and with careful observation, you might be able to pin these down for your loved ones. If this feels difficult, a licensed clinical therapist can help.

Once the “threat center” of your brain decides something isn’t safe, we have survival reactions: our heart rate picks up, heavy breathing, we feel shaky, and/or we have a hard time thinking clearly due to the process where your brain diverts power from the thinking brain to the survival brain. That said, that’s part of why it’s hard to talk to someone who doesn’t feel safe. It’s hard for them to hear you, and hard for them to express how they feel in words. If we use compassionate language, it removes blame from the driver seat. Try “they look like they need help” or “they are having some big feelings” You and your child are a team, and teams are stronger when they work from the operating point that we win when we work together with our strengths.

That said, here are some helpful tips to regulate with your child:

  1. When you identify that your child needs help, first check in with yourself on what you need to be best able to respond to them. Its valuable to practice the breathing skills when you don’t need them, so you can use them in the moment when you do. Trying to only use them in a moment of crisis is like expecting yourself to learn to swim in the choppy ocean.
  2. Get on their level. Kneel, squat, or sit down if necessary. Looking up at someone activates the “threat” center of our brain and makes it harder to calm down.
  3. Use a low, consistent tone. If I want someone to hear me, I need to be quieter, not louder. Especially if they are yelling. Keep your messages concise and direct, such as “I want to hear you, and it’s easier when you’re at a level 2” or “Let’s take a deep breath together then we can put your toy back together.”
  4. Take a full, deep breath in your nose and exhale slowly out your mouth. Imagine feeling like you’re smelling something super pleasant and trying to cool off hot cocoa with the exhale. Even if they are not in the place to participate because they’re too dysregulated, their body will unconsciously mirror yours.
  5. If you’re not able to offer your child 1:1 proximity, or their bodies are not safe for you (i.e. hitting) consider regulating in the room by counting items together. Redirection is a powerful tool for the right moment. Again, a licensed therapist can help you catch these windows of opportunity.
  6. If appropriate, leave the room and regulate yourself before returning. Use your words to announce the intention “I need two minutes to regulate myself and I will be back to work on this with you.” Stepping away from the situation is a tool that can give teenage parents the break we need to not ground our child for the next 100 years when we’re both stuck in an argument.
  7. With any strategy, it’s important to come back together and process Use the compliment sandwich: Identify one thing that went well, offer constructive feedback, and close with another positive thing you noticed or future oriented reconnection point. “I’m proud of you for breathing with me. Next time, do you think it would help if we used the feelings chart? I’m glad I have you.”

 

 

 

 

 

 

 

 

 

 

By: Laurie Little, PsyD
Chief Patient Experience Officer and Staff Psychologist,
Lindner Center of HOPE

In recent years, there has been a growing interest in exploring alternative and innovative treatments for mental illness. Among these novel approaches, ketamine has emerged as a promising treatment for various mental health disorders. Traditionally known as an anesthetic and pain-relieving medication, ketamine has shown potential in treating mental health disorders such as depression and anxiety.

History of Ketamine

Ketamine was originally discovered by chemist Calvin Stevens in 1962 for Parke Davis Company and was Food & Drug Administration (FDA)- approved for medical use as an analgesic and anesthetic in 1970.  It is considered a “Dissociative Anesthetic” with different dosages leading to differing effects. Lower dosages can lead to a psychedelic experience and higher dosages can lead to complete dissociation or analgesia. When using Ketamine as an analgesic, researchers noticed an intriguing off-label effect: a rapid and pronounced improvement in mood and depressive symptoms in some patients. This discovery sparked interest in exploring ketamine’s potential as a novel treatment for mental health disorders.

To curb its illicit and recreational use, the United States categorized Ketamine as a Schedule III federally controlled substance in 1999, however research into its mental health benefits continued to flourish. In 2019, the FDA approved the first ketamine derived therapy, called Esketamine, as a therapy for treatment-resistant depression.

Ketamine and Depression

Ketamine’s antidepressant effects are unique compared to traditional antidepressant medications, which typically take several weeks to produce noticeable results. Ketamine often provides immediate relief to patients who are suffering. Ketamine promotes the release of Glutamate, an essential neurotransmitter that is related to cognition, memory and mood.  Traditional antidepressants often affect neurotransmitters such as Serotonin and Dopamine and take longer to notice an improvement in symptoms.

A recently published large, systematic review of published journal articles on Ketamine treatment found “support for robust, rapid and transient antidepressant and anti-suicidal effects of ketamine. Evidence for other indications is less robust but suggests similarly positive and short-lived effects. “ The findings suggest that ketamine facilitates rapid improvements in symptoms among patients with major depressive disorder (MDD), bipolar disorder and suicidality, lasting up to 7-14 days after treatment. In some cases, effects last up to four weeks, depending on the number of ketamine sessions and the underlying mental health conditions.

There is also preliminary but growing evidence base supporting the efficacy of ketamine therapy for substance use disorders, anxiety disorders (generalized, social, OCD, PTSD)  and eating disorders.  However, just like its antidepressant effects, ketamine’s reductions in anxiety are also short-lived, and symptom recurrence is common after several weeks.

Patients who receive adjunctive psychotherapy appear to achieve the most long-lasting benefit compared with ketamine administration alone.

Ketamine Assisted Psychotherapy

Research shows that Ketamine is most beneficial when it is combined with psychotherapy. There is no current standard for how therapy and Ketamine should be combined. Some practitioners combine lower doses of Ketamine and engage in therapy during the treatment. Other practitioners use higher doses of Ketamine and have the patient engage in therapy either the following day or later in the week. Since patients notice an immediate improvement in their mood, they are more able to benefit from therapy and are more open and receptive to thinking about their current circumstances in a new, helpful way.

The Benefits and Challenges of Ketamine Treatment

The most notable benefit of ketamine treatment is its rapid and profound antidepressant effect. Unlike traditional medications, ketamine can provide relief within hours. This immediate response is particularly crucial for patients in crisis, who are suicidal or those struggling with treatment-resistant mental health conditions.

Moreover, ketamine treatment may benefit individuals who cannot tolerate or have not responded well to other standard treatments. Unfortunately, a significant percentage of patients do not find relief from standard therapies and it is important to have multiple treatment options available.

However, ketamine treatment does come with its challenges and risks. One major obstacle is the lack of long-term data on the safety and efficacy of ketamine as a mental health treatment. While research has shown short-term benefits, the question of how long the benefits last requires additional investigation.

Due to its powerful impact, Ketamine is also often misused. Research is still needed on the abuse potential of Ketamine. Interestingly, there is some evidence to suggest that Ketamine itself can be effective in the treatment of other substance use disorders such as alcohol and heroin. There is still much more to be learned.

Lastly, ketamine treatment is often not covered by insurance for mental health conditions, making it financially inaccessible for many patients. The cost of treatment, coupled with the need for repeated administrations to maintain benefits, raises concerns about equitable access to this innovative therapy.

Ketamine treatment represents a groundbreaking shift in the approach to mental health treatment. Its rapid and transformative effects on depression, anxiety and other mental health conditions have sparked hope for those who have exhausted conventional therapies. While ketamine shows immense promise, ongoing research is needed to fully understand its long-term safety and efficacy.

As the field of mental health continues to evolve, ketamine treatment has the potential to offer a lifeline to those who struggle with treatment-resistant conditions. It is crucial for the medical community, researchers, clinicians, policymakers, and insurers to collaborate in ensuring equitable access to this promising therapy.

References

Banoff, MD, Young, JR, Dunn, T and Szabo, T. (2020). Efficacy and safety of ketamine in the management of anxiety and anxiety spectrum disorders: A review of the literature. CNS spectrums, 25(3), 331-342.

Berman, R. M., Cappiello, A., Anand, A., Oren, D. A., Heninger,

  1. R., Charney, D. S., & Krystal, J. H. (2000). Antidepressant effects of ketamine in depressed patients. Biological Psychiatry, 47(4), 351-354.

Feder, A., Rutter, S. B., Schiller, D., & Charney, D. S. (2020). The emergence of ketamine as a novel treatment for posttraumatic stress disorder. Advances in Pharmacology, 89, 261-286.

Krupitsky, E. M., & Grinenko, A. Y. (1997). Ketamine psychedelic therapy (KPT): A review of the results of ten years of research. Journal of Psychoactive Drugs, 29(2), 165-183.

Mia, M. (2021) Glutamate: The Master Neurotransmitter and Its Implications in Chronic Stress and Mood Disorders. Front Hum Neurosci. 15: 722323.

Murrough JW, Iosifescu DV, Chang LC, Al Jurdi RK, Green CE, Perez AM, Iqbal S, Pillemer S, Foulkes A, Shah A, Charney DS, Mathew SJ. (2013). Antidepressant efficacy of ketamine in treatment-resistant major depression: a two-site randomized controlled trial. Am J Psychiatry. 2013 Oct;170(10):1134-42. doi: 10.1176/appi.ajp.2013.13030392. PMID: 23982301; PMCID: PMC3992936.

Chadi G. Abdallah and Lynnette A. Averil

Ragnhildstveit, A., Roscoe, J., Bass, L., Averill, C., Abdallah, C. and Averillhe, L.. (2023). Potential of Ketamine for Posttraumatic Stress Disorder: A Review of Clinical Evidence. Ther Adv Psychopharmacol, Vol. 13: 1–22, DOI: 10.1177/.

Reznikov L. R., Fadel J. R., Reagan L. P. (2011). “Glutamate-mediated neuroplasticity deficits in mood disorders,” in Neuroplasticity, eds Costa e Silva J. A., Macher J. P., Olié J. P. (Tarporley: Springer; ), 13–26. 10.1007/978-1-908517-18-0_2

Walsh, Z., Mollaahmetoglu, O., Rootman, J., Golsof, S., Keeler, J., Marsh, B., Nutt, D., and Morgan, C. (2022). Ketamine for the treatment of mental health and substance use disorders: comprehensive systematic review. BJPsych Open (2022) 8, e19, 1–12. doi: 10.1192/bjo.2021.1061

Witt K, Potts J, Hubers A, et al. Ketamine for suicidal ideation in adults with psychiatric disorders: A systematic review and meta-analysis of treatment trials. Australian & New Zealand Journal of Psychiatry. 2020;54(1):29-45. doi:10.1177/0004867419883341

Wolfson, P., & Hartelius, G. (Eds.). (2016). The ketamine papers: Science, therapy, and transformation. Multidisciplinary Association for Psychedelic Studies.

Zarate, C. A., Singh, J. B., Carlson, P. J., Brutsche, N. E., Ameli, R.,

Luckenbaugh, D. A., … & Manji, H. K. (2006). A randomized trial of an N-methyl-D-aspartate antagonist in treatment-resistant major depression. Archives of General Psychiatry, 63(8), 856-864.

 

By: Zachary Pettibone, MD
Staff Psychiatrist, Lindner Center of HOPE
Assistant Professor of Clinical Psychiatry
University of Cincinnati

Bipolar depression has been gaining attention recently in popular culture and the profession of psychiatry. New medications have emerged to manage this often difficult to treat illness. Bipolar depression denotes a specific type of “depression,” a distinction often unknown to patients seeking treatment and not always appreciated by clinicians. One of the most difficult challenges in clinical psychiatry is characterizing a depressive episode as falling within the diagnosis of major depressive disorder (MDD, sometimes referred to as “unipolar depression”) or bipolar disorder (BP, occasionally referred to as “manic depression”). The distinction is of critical importance because pharmacotherapy for BP and MDD differ significantly. Misdiagnosis and subsequent mismanagement can lead to years of suffering from adverse medication side effects and inadequate stabilization of symptoms.

A major depressive episode, as defined by the American Psychiatric Association (APA), is “a period of at least two weeks in which a person has at least five of the following symptoms (including at least one of the first two symptoms): intense sadness or despair, loss of interest in activities the person once enjoyed, feelings of worthlessness or guilt, fatigue, increased or decreased sleep, increased or decreased appetite, restlessness (e.g., pacing) or slowed speech or movement, difficulty concentrating, and frequent thoughts of death or suicide.” This same definition is used for depressive episodes in both MDD and BP. Despite the diagnostic overlap, depressive episodes in MDD and BP are considered distinct entities with their own indicated treatments. This leads to the question: given the same diagnostic criteria, how does one distinguish MDD depression from BP depression?

The primary differentiating factor is the presence or absence of manic or hypomanic episodes. A manic episode is defined by the APA as “a period of at least one week when a person is extremely high-spirited or irritable most of the day for most days, possesses more energy than usual, and experiences at least three of the following changes in behavior: decreased need for sleep (e.g., feeling energetic despite significantly less sleep than usual), increased or faster speech, uncontrollable racing thoughts or quickly changing ideas or topics when speaking, distractibility, increased activity (e.g., restlessness, working on several projects at once), and increased risky behavior (e.g., reckless driving, spending sprees).” These behaviors must represent a change from the person’s usual behavior and be clear to friends and family and cause significant impairments in occupational and social functioning that frequently necessitate psychiatric hospitalization. Hypomania is a milder form of mania that lasts for a shorter period and does not disrupt daily functioning.

If such an episode has occurred, the diagnosis is clear: BP depression. However, depressive episodes pre-date manic/hypomanic episodes in most cases of BP. In some instances, previous manic/hypomanic episodes were overlooked. And in other cases, a patient may mistake symptoms of mania for other psychiatric diagnoses, such as ADHD, borderline personality disorder, anxiety, and drug abuse. Further complicating the picture is the fact that these illnesses commonly coexist with BP.

Laboratory tests and imaging modalities have yet to be developed for diagnosing MDD and BP. The diagnosis is based on clinical interviews and observations. There are validated self-report symptom questionnaires that can help diagnose and facilitate discussion among patients and mental health providers. One frequently used instrument is the Mood Disorder Questionnaire (MDQ). Collateral information from friends, family, and coworkers can be invaluable for supplementing a patient’s recollection of symptoms and behaviors.

Some studies suggest there may be subtle differences in the way depression manifests clinically in BP and MDD, such as more severe motor slowing and predominance of atypical symptoms (hypersomnia and increased appetite) in BP depression. Other clues from a patient’s history may help point to BP over MDD, such as early onset of depressive episodes, the presence of psychotic features, severe and frequent depressive episodes, high anxiety, episodes that have not responded to traditional antidepressant therapy, substance misuse, a history of ADHD, and suicidality. No single feature is diagnostic, however. Each piece of the history must be considered in the context of the entire presentation.

The medications used to treat each type of depression are very different, and often ineffective or even harmful if used for the incorrect type of depression. For someone seeking treatment for undifferentiated depression with no history of mania or other strong indications of BP, an antidepressant medication is typically recommended. Commonly used antidepressants include selective serotonin reuptake inhibitors (SSRIs) and selective serotonin norepinephrine reuptake inhibitors (SNRIs). Other antidepressants with different mechanisms of action may also be used to treat MDD. There is debate among experts about the efficacy and safety of antidepressants for treating BP depression, and while antidepressants may have a place in the treatment of BP depression, the risk of precipitating manic episodes, causing rapid cycling mood episodes, and inadequately treating the illness often relegate antidepressants for use in MDD.

Medications indicated for the treatment of BP depression include second-generation antipsychotics and mood stabilizers. Lithium and the anticonvulsants lamotrigine (Lamictal) and valproate (Depakote) are mood stabilizers that are sometimes used “off label” to treat bipolar depression. Second-generation antipsychotics approved for BP depression are cariprazine (Vraylar), lumateperone (Caplyta), lurasidone (Latuda), olanzapine (Zyprexa) in combination with fluoxetine (Prozac), and quetiapine (Seroquel).

Differentiating BP depression from MDD depression represents a critical decision point in clinical practice. BP can go unrecognized or misdiagnosed as MDD for many years in a large proportion of patients seeking treatment for depressive episodes. Depression can be well managed when the appropriate treatment is chosen. Once a diagnosis is made and treatment is initiated, symptoms should be closely monitored, and the diagnosis reevaluated periodically to ensure effective treatment.

References:
Etain B, Lajnef M, Bellivier F, Mathieu F, Raust A, Cochet B, Gard S, M’Bailara K, Kahn JP, Elgrabli O, Cohen R, Jamain S, Vieta E, Leboyer M, Henry C. Clinical expression of bipolar disorder type I as a function of age and polarity at onset: convergent findings in samples from France and the United States. J Clin Psychiatry. 2012 Apr;73(4):e561-6. doi: 10.4088/JCP.10m06504. PMID: 22579163.

Fogelson, D., & Kagan, B. (2022). Bipolar spectrum disorder masquerading as treatment resistant unipolar depression. CNS Spectrums, 27(1), 4-6. doi:10.1017/S1092852920002047
Howland, M., & El Sehamy, A. (2021, January). What are bipolar disorders?. Psychiatry.org – What Are Bipolar Disorders? https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders 

Mitchell, P., Frankland, A., Hadzi-Pavlovic, D., Roberts, G., Corry, J., Wright, A., . . . Breakspear, M. (2011). Comparison of depressive episodes in bipolar disorder and in major depressive disorder within bipolar disorder pedigrees. The British Journal of Psychiatry, 199(4), 303-309. doi:10.1192/bjp.bp.110.088823

Nestsiarovich, A., Reps, J.M., Matheny, M.E. et al. Predictors of diagnostic transition from major depressive disorder to bipolar disorder: a retrospective observational network study. Transl Psychiatry 11, 642 (2021).

Perlis RH, Brown E, Baker RW, Nierenberg AA. Clinical features of bipolar depression versus major depressive disorder in large multicenter trials. Am J Psychiatry. 2006 Feb;163(2):225-31. doi: 10.1176/appi.ajp.163.2.225. PMID: 16449475.

Swann AC, Geller B, Post RM, Altshuler L, Chang KD, Delbello MP, Reist C, Juster IA. Practical Clues to Early Recognition of Bipolar Disorder: A Primary Care Approach. Prim Care Companion J Clin Psychiatry. 2005;7(1):15-21. doi: 10.4088/pcc.v07n0103. PMID: 15841189; PMCID: PMC1076446.

When someone is suffering from depression, a family member is often called upon to help make important treatment decisions.  In the midst of a major depression, your loved one may be too disturbed to make practical decisions about his or her care.

One of the most important decisions to make is the selection of the right depression treatment center to meet your loved one’s needs.  During the screening process, we recommend that you ask the following questions to potential providers:

1. Is the inpatient depression treatment program individualized?

No one wants a cookie-cutter approach to a loved one’s care.  For depression treatment, one size does not fit all. Varying levels of care and types of treatment modalities should be available. Individuals with imminent suicidal risk may require inpatient care, while others may be treated on an outpatient basis. Some patients may respond well to counseling, while others may also need antidepressant medications. The availability of a full treatment menu, with an individualized approach to care, is critical to finding the best treatment options for your loved one.

2. How involved are the patient and family with the inpatient depression treatment program?

Effective treatment programs tend to be ones that actively engage the patient and family in the assessment, planning, and treatment process. Terms like “person-centered” and “family involvement” mean that a center understands the importance of including everyone in the process – not just the professionals.  Even though they are troubled, patients with depression can contribute to an understanding of their illness and are better motivate if they are actively involved in treatment.  Family members can learn ways to better support a loved one coping with a depressive disorder, and they can also benefit from support for their own concerns and frustrations.

3.  What are the depression treatment center staff qualifications?

A professional’s best treatment tools come from a combination of training and experience.  Check the credentials of professional staff on your loved one’s treatment team.  Generally, you should look for clinical staff to have licensure in a professional field such as psychiatry, psychology, social work, marriage and family therapy, or counseling.

4.  What types of counseling and therapy for depression are provided?

When most lay people think about psychology, the first name that comes to mind is Sigmund Freud.  While he may have been a pioneer in the treatment of mental disorders, counseling and therapy have come a long way in the past century.  Many counseling techniques developed in the last few decades are designed to work with the negative feelings and self-defeating individuals with depression often have. Current therapeutic approaches considered the most effective with depression include:

  • Cognitive behavioral therapy (CBT);
  • Dialectical behavioral therapy (DBT);
  • Insight oriented therapy (IOT).

Beware of any provider that considers medication to be the sole method for treating a loved one’s depression. While modern antidepressants can have a very beneficial effect upon resistant depression, treatment should usually include other modalities such as counseling, training, or peer supports.

5.  What is the inpatient depression treatment program’s overall treatment philosophy?

A treatment center should have a clear philosophy about appropriate treatment. In discussing a program’s treatment approach, listen for terms such as the following:

  • Person-centered or patient-centered planning and care (see above);
  • Family involvement (see above);
  • Symptom management – provides patients with tools to help manage their own feelings and behaviors;
  • Least restrictive environment – provides the least intensive level of treatment necessary, while respecting the patient’s freedom;
  • Wellness and recovery – focuses on a total wellness approach to healthy living and a belief that recovery is possible.

Getting the right answers to the above questions can be a productive step in setting your own loved one on a journey to recovery.

By Jennifer Farley, PsyD,
Lindner Center of HOPE, Staff Psychologist

There are a number of reasons someone may undergo a psychological evaluation or assessment. The type of testing that is done depends on the individual’s functioning and the setting in which testing may be pursued. This article will look at the different settings of mental health assessments.

Types of Mental Health Assessment Settings

  • Outpatient
  • Inpatient
  • Residential
  • Children’s Assessments

Psychological Assessment in an Outpatient Setting

Testing from a clinical psychologist in a clinical outpatient setting can be pursued on their own or they may be referred from another clinician (such as a primary care physician or psychiatrist). This type of assessment is for patients with non-immediate mental health concerns. In this case, testing is pursued with the referral question in mind (such as whether someone has Attention Deficit/Hyperactivity Disorder, depression, anxiety, a learning disorder, dementia, cognitive problems due to a medical condition, etc). The psychologist tailors the tests to help determine the person’s functioning in the areas that could be affected by a cognitive or emotional disorder. Tests can range from intellectual assessments to personality measures to behavioral questionnaires (which can be completed by the patient themselves, parents, and/or teachers) to academic achievement measures. Clinicians such as neuropsychologists and developmental psychologists can do all these tests and then add additional measures specific to their specialization (such as when documenting problems related to a head injury or when evaluating for Autism Spectrum Disorder). The psychologist can use this information to make a diagnosis and provide recommendations for treatment of the condition. Often, such as for school-age or college-age patients, recommendations for academic accommodations are also provided.

Psychological Assessment In An Acute Inpatient Unit

Sometimes, psychological testing is completed for patients during an acute inpatient psychiatric hospitalization (when the patient is in a mentally unstable condition). In these cases, testing is often used for diagnostic elucidation to help guide decisions about types of medication to use. Recommendations may also be made about additional assessments or resources to pursue following one’s discharge from the hospital. The clinical psychologist completes these evaluations within a short time, since these acute hospitalizations last (on average) about 7 days, and there are usually just a few measures that are administered. Tests are specific to the question about the individual’s diagnosis and may only include emotional/personality measures.

Psychological Assessment in a Residential Setting

Another setting in which psychological testing may occur is within a residential psychiatric setting. This setting is for patients who are experiencing psychological distress that is not severe enough to warrant an acute inpatient hospitalization. Length of stay in a residential setting can vary from 10 days to several months, depending on the purpose of the stay (i.e., evaluation and/or treatment). The purpose of testing in a residential setting is to help comprehensively understand – by way of several different measures – one’s personality functioning, cognitive functioning (which can include neurocognitive skills such as attention, memory, and executive functioning), and other factors (such as external stressors, substance use, medical conditions, etc.) that have contributed to the patient’s condition(s). The patient’s internal strengths and weaknesses are explored, with the intention of making recommendations for how treatment can be tailored to work with the patient’s strengths to compensate for their weaknesses. The clinical psychologist works closely with the other members of the treatment team (such as the psychiatrist, social worker, and the therapists) to understand the patient, develop a treatment plan, and (if a longer stay) to begin implementing the recommendations. The patient’s progress is then monitored and, if needed, further testing can be done to help assess changes in the patient’s functioning as a result of the treatment.

Psychological Assessment in Childhood

In childhood, early observations of potential problems may come from teachers. Teachers may observe struggles in behavior such as impulsivity, talking or interrupting others during times when there is an age-appropriate expectation of silence, and/or oppositional behaviors towards others. Teachers may also be the first to wonder if a child has an underlying learning or attention disorder. If the teacher’s attempts to help the child are unsuccessful, the teacher may recommend testing in the form of a Multi-Factored Evaluation (MFE). Psychological testing may be part of this evaluation and can include intellectual testing and academic achievement testing by a school psychologist. Parent and teacher questionnaires may also be included in the MFE. Depending on the nature of the child’s observed difficulties, others (such as speech and language therapists and physical therapists) may do their own screening. If findings reveal that the student experiences problems that would make learning difficult, accommodations are then recommended and interventions and/or accommodations are then put in place through a 504 Plan or an Individualized Education Plan. It is noteworthy that clinical diagnoses are NOT made from this type of evaluation and findings and recommendations are specific to helping the child learn better.

Prior to any psychological testing, the patient (and/or his/ her family) should understand the purpose of psychological assessment and how it can be useful for guiding treatment and other recommendations.

Find out more information on what psychological assessment is here and why it is a critical step of the process towards finding a diagnosis and treatment plan.

Finding Help and HOPE

If you, or someone you know, is experiencing a mental health crisis, there is help available. The first step would be to consult with a health care provider or mental health care specialist. To see how Lindner Center of HOPE can help you decide on the best mental health assessment setting, reach out to us today. We can help you take the next steps.