Depression occurs in the young and the old and in men and women. We do know that the rate of depression in men is less than for women.
The symptoms that men experience can be different from those that women experience. Symptoms including anger, irritability, and feeling discouraged are more common in men than symptoms of hopelessness or helplessness.
Typical symptoms we associate with depression such as depressed mood may not be present in depression in men. This can make it more difficult to recognize depression in men. Many famous men, including President Abraham Lincoln and Winston Churchill, had depression and still lived successful lives.
Unfortunately, men are not as likely as women to admit to having depression. Even if they do admit to having depression, they may be less likely to seek treatment. Men may stuff their feelings instead of verbalizing them. They may work more, gamble, or use alcohol or drugs to avoid their feelings. Their sleep and or appetite may change. They may suddenly begin talking about divorce or separation.
Women attempt suicide more often than men, but the rate of completed suicide in men is 4 times that of women. Suicide rates peak in mid life and again later in life. Men age 85 and older have the highest suicide rate.
Men want and need to be strong for their families; they don't want to appear weak or vulnerable. If they are the primary bread winner, they can feel pressure to provide for their dependents. Of course, these general statements can be applied to women as well.
Depression in men is treatable. If you suspect a friend or loved one may be depressed, urge them to seek a professional evaluation. There are many options, including medication, therapy or a combination of the two.
By Gabrielle J. Melin, M.D.
Panic Disorder, Your Questions Answered
Answers to Your Questions About Panic Disorder
Panic Disorder is a serious condition that around one out of every 75 people might experience. It usually appears during the teens or early adulthood, and while the exact causes are unclear, there does seem to be a connection with major life transitions that are potentially stressful: graduating from college, getting married, having a first child, and so on. There is also some evidence for a genetic predisposition; if a family member has suffered from panic disorder, you have an increased risk of suffering from it yourself, especially during a time in your life that is particularly stressful.
Panic Attacks: The Hallmark of Panic Disorder
it occurs suddenly, without any warning and without any way to stop it.
the level of fear is way out of proportion to the actual situation; often, in fact, it's completely unrelated.
Panic Disorder is a serious condition that around one out of every 75 people might experience. It usually appears during the teens or early adulthood, and while the exact causes are unclear, there does seem to be a connection with major life transitions that are potentially stressful: graduating from college, getting married, having a first child, and so on. There is also some evidence for a genetic predisposition; if a family member has suffered from panic disorder, you have an increased risk of suffering from it yourself, especially during a time in your life that is particularly stressful.
Panic Attacks: The Hallmark of Panic Disorder
A panic attack is a sudden surge of overwhelming fear that comes without warning and without any obvious reason. It is far more intense than the feeling of being 'stressed out' that most people experience. Symptoms of a panic attack include:
racing heartbeat
difficulty breathing, feeling as though you 'can't get enough air'
terror that is almost paralyzing
dizziness, lightheadedness or nausea
trembling, sweating, shaking
choking, chest pains
hot flashes, or sudden chills
tingling in fingers or toes ('pins and needles')
fear that you're going to go crazy or are about to die
You probably recognize this as the classic 'flight or fight' response that human beings experience when we are in a situation of danger. But during a panic attack, these symptoms seem to rise from out of nowhere. They occur in seemingly harmless situations--they can even happen while you are asleep.
it occurs suddenly, without any warning and without any way to stop it.
the level of fear is way out of proportion to the actual situation; often, in fact, it's completely unrelated.
it passes in a few minutes; the body cannot sustain the 'fight or flight' response for longer than that. However, repeated attacks can continue to recur for hours.
A panic attack is not dangerous, but it can be terrifying, largely because it feels 'crazy' and 'out of control.' Panic disorder is frightening because of the panic attacks associated with it, and also because it often leads to other complications such as phobias, depression, substance abuse, medical complications, even suicide. Its effects can range from mild word or social impairment to a total inability to face the outside world.
In fact, the phobias that people with panic disorder develop do not come from fears of actual objects or events, but rather from fear of having another attack. In these cases, people will avoid certain objects or situations because they fear that these things will trigger another attack.
How to Identify Panic Disorder
Please remember that only a licensed therapist can diagnose a panic disorder. There are certain signs you may already be aware of, though.
One study found that people sometimes see 10 or more doctors before being properly diagnosed, and that only one out of four people with the disorder receive the treatment they need. That's why it's important to know what the symptoms are, and to make sure you get the right help.
Many people experience occasional panic attacks, and if you have had one or two such attacks, there probably isn't any reason to worry. The key symptom of panic disorder is the persistent fear of having future panic attacks. If you suffer from repeated (four or more) panic attacks, and especially if you have had a panic attack and are in continued fear of having another, these are signs that you should consider finding a mental health professional who specializes in panic or anxiety disorders.
What Causes Panic Disorder: Mind, Body, or Both?
Body: There may be a genetic predisposition to anxiety disorders; some sufferers report that a family member has or had a panic disorder or some other emotional disorder such as depression. Studies with twins have confirmed the possibility of 'genetic inheritance' of the disorder.
Panic Disorder could also be due to a biological malfunction, although a specific biological marker has yet to be identified.
All ethnic groups are vulnerable to panic disorder. For unknown reasons, women are twice as likely to get the disorder as men.
Mind: Stressful life events can trigger panic disorders. One association that has been noted is that of a recent loss or separation. Some researchers liken the 'life stressor' to a thermostat; that is, when stresses lower your resistance, the underlying physical predisposition kicks in and triggers an attack.
Both: Physical and psychological causes of panic disorder work together. Although initially attacks may come out of the blue, eventually the sufferer may actually help bring them on by responding to physical symptoms of an attack.
For example, if a person with panic disorder experiences a racing heartbeat caused by drinking coffee, exercising, or taking a certain medication, they might interpret this as a symptom of an attack and , because of their anxiety, actually bring on the attack. On the other hand, coffee, exercise, and certain medications sometimes do, in fact, cause panic attacks. One of the most frustrating things for the panic sufferer is never knowing how to isolate the different triggers of an attack. That's why the right therapy for panic disorder focuses on all aspects -- physical, psychological, and physiological -- of the disorder.
Can People with Panic Disorder lead normal lives?
The answer to this is a resounding YES -- if they receive treatment.
Panic disorder is highly treatable, with a variety of available therapies. These treatments are extremely effective, and most people who have successfully completed treatment can continue to experience situational avoidance or anxiety, and further treatment might be necessary in those cases. Once treated, panic disorder doesn't lead to any permanent complications.
Side Effects of Panic Disorder
Without treatment, panic disorder can have very serious consequences.
The immediate danger with panic disorder is that it can often lead to a phobia. That's because once you've suffered a panic attack, you may start to avoid situations like the one you were in when the attack occurred.
Many people with panic disorder show 'situational avoidance' associated with their panic attacks. For example, you might have an attack while driving, and start to avoid driving until you develop an actual phobia towards it. In worst case scenarios, people with panic disorder develop agoraphobia -- fear of going outdoors -- because they believe that by staying inside, they can avoid all situations that might provoke an attack, or where they might not be able to get help. The fear of an attack is so debilitating, they prefer to spend their lives locked inside their homes.
Even if you don't develop these extreme phobias, your quality of life can be severely damaged by untreated panic disorder. A recent study showed that people who suffer from panic disorder:
are more prone to alcohol and other drug abuse
have greater risk of attempting suicide
spend more time in hospital emergency rooms
spend less time on hobbies, sports and other satisfying activities
tend to be financially dependent on others
report feeling emotionally and physically less healthy than non-sufferers.
are afraid of driving more than a few miles away from home
None of this needs to happen. Panic disorder can be treated successfully, and sufferers can go on to lead full and satisfying lives.
How Can Panic Disorder Be Treated?
Most specialists agree that a combination of cognitive and behavioral therapies are the best treatment for panic disorder. Medication might also be appropriate in some cases.
The first part of therapy is largely informational; many people are greatly helped by simply understanding exactly what panic disorder is, and how many others suffer from it. Many people who suffer from panic disorder are worried that their panic attacks mean they're 'going crazy' or that the panic might induce a heart attack. 'Cognitive restructuring' (changing one's way of thinking) helps people replace those thoughts with more realistic, positive ways of viewing the attacks.
Cognitive therapy can help the patient identify possible triggers for the attacks. The trigger in an individual case could be something like a thought, a situation, or something as subtle as a slight change in heartbeat. Once the patient understands that the panic attack is separate and independent of the trigger, that trigger begins to lose some of its power to induce an attack.
The behavioral components of the therapy can consist of what one group of clinicians has termed 'interoceptive exposure.' This is similar to the systematic desensitization used to cure phobias, but what it focuses on is exposure to he actual physical sensations that someone experiences during a panic attack.
People with panic disorder are more afraid of the actual attack than they are of specific objects or events; for instance, their 'fear of flying' is not that the planes will crash but that they will have a panic attack in a place, like a plane, where they can't get to help. Others won't drink coffee or go to an overheated room because they're afraid that these might trigger the physical symptoms of a panic attack.
Interoceptive exposure can help them go through the symptoms of an attack (elevated heart rate, hot flashes, sweating, and so on) in a controlled setting, and teach them that these symptoms need not develop into a full-blown attack. Behavioral therapy is also used to deal with the situational avoidance associated with panic attacks. One very effective treatment for phobias is in vivo exposure, which is in its simplest terms means breaking a fearful situation down into small manageable steps and doing them one at a time until the most difficult level is mastered.
Relaxation techniques can further help someone 'flow through' an attack. These techniques include breathing retraining and positive visualization. Some experts have found that people with panic disorder tend to have slightly higher than average breathing rates, learning to slow this can help someone deal with a panic attack and can also prevent future attacks.
In some cases, medications may also be needed. Anti-anxiety medications may be prescribed, as well as antidepressants, and sometimes even heart medications (such as beta blockers) that are used to control irregular heartbeats.
Finally, a support group with others who suffer from panic disorder can be very helpful to some people. It can't take the place of therapy, but it can be a useful adjunct.
If you suffer from panic disorder, these therapies can help you. But you can't do them on your own; all of these treatments must be outlined and prescribed by a psychologist or psychiatrist.
How Long Does Treatment Take?
Much of the success of treatment depends on your willingness to carefully follow the outlined treatment plan. This is often multifaceted, and it won't work overnight, but if you stick with it, you should start to have noticeable improvement within about 10 to 20 weekly sessions. If you continue to follow the program, within one year you will notice a tremendous improvement.
If you are suffering from panic disorder, you should be able to find help in your area. You need to find a licensed psychologist or other mental health professional who specializes in panic or anxiety disorders. There may even be a clinic nearby that specializes in these disorders.
When you speak with a therapist, specify that you think you have panic disorder, and ask about his or her experience treating this disorder.
Keep in mind, though, that panic disorder, like any other emotional disorder, isn't something you can either diagnose or cure by yourself. An experience clinical psychologist or psychiatrist is the most qualified person to make this diagnosis, just as he or she is the most qualified to treat this disorder.
This Article is designed to answer your basic questions about panic disorder; a qualified mental health professional will be able to give you more complete information.
Panic disorder does not need to disrupt your life in any way, you are not alone and there are both those who can help and those who understand. Contact me for information on a No Panic Service offered both in Ireland and the UK
Staying Sane May Be Easier Than You Think
As modern pressures take their toll doctors preach relaxation
"Rule No. 1 is, don't sweat the small stuff. Rule No. 2 is, it's all small stuff. And if you can't fight and you can't flee, flow."
—University of Nebraska Cardiologist Robert Eliot, on how to cope with stress
It is the dawn of human history, and Homo sapiens steps out from his cave to watch the rising sun paint the horizon. Suddenly he hears a rustling in the forest. His muscles tense, his heart pounds, his breath comes rapidly as he locks eyes with a saber-toothed tiger. Should he fight or run for his life? He reaches down, picks up a sharp rock and hurls it. The animal snarls but disappears into the trees. The man feels his body go limp, his breathing ease. He returns to his darkened den to rest.
It is the start of another working day, and Homo sapiens steps out of his apartment building into the roar of rush hour. He picks his way through the traffic and arrives at the corner just in time to watch his bus pull away. Late for work, he opens his office door and finds the boss pacing inside. His report was due an hour ago, he is told; the client is furious. If he values his job, he had better have a good explanation. And, by the way, he can forget about taking a vacation this summer. The man eyes a paperweight on his desk and longs to throw it at his oppressor. Instead, he sits down, his stomach churning, his back muscles knotting, his blood pressure climbing. He reaches for a Maalox and an aspirin and has a sudden yearning for a dry martini, straight up.
The saber-toothed tiger is long gone, but the modern jungle is no less perilous. The sense of panic over a deadline, a tight plane connection, a reckless driver on one's tail are the new beasts that can set the heart racing, the teeth on edge, the sweat streaming. These responses may have served our ancestors well; that extra burst of adrenaline got their muscles primed, their attention focused and their nerves ready for a sudden "fight or flight." But try doing either one in today's traffic jams or boardrooms. "The fight-or-flight emergency response is inappropriate to today's social stresses," says Harvard Cardiologist Herbert Benson, an expert on the subject. It is also dangerous. Says Psychiatrist Peter Knapp of Boston University: "When you get a Wall Street broker using the responses a cave man used to fight the elements, you've got a problem."
Indeed we have. In the past 30 years, doctors and health officials have come to realize how heavy a toll stress is taking on the nation's well being. According to the American Academy of Family Physicians, two-thirds of office visits to family doctors are prompted by stress-related symptoms. At the same time, leaders of industry have become alarmed by the huge cost of such symptoms in absenteeism, company medical expenses and lost productivity. Based on national samples, these costs have been estimated at $50 billion to $75 billion a year, more than $750 for every U.S. worker. Stress is now known to be a major contributor, either directly or indirectly, to coronary heart disease, cancer, lung ailments, accidental injuries, cirrhosis of the liver and suicide—six of the leading causes of death in the U.S. Stress also plays a role in aggravating such diverse conditions as multiple
Studying such kids for more than a decade, the researchers discovered that those who became schizophrenic were most often from families that, when first interviewed, displayed "communication deviance" (unclear, unintelligible or fragmented speech) and highly critical and intrusive parenting. These weren't merely families that argued with difficult sons and daughters; they were families that had lost all ability to cope.
McFarlane and others began working with some of the families to address their interactions and teach them how to communicate better — more slowly, with less anger and intrusion. Even after they are on medication, people with schizophrenia have a difficult time tracking rapid, highly emotional speech, yet that's the kind they often hear from frustrated family members. These patients would improve in hospitals but relapse once they got home, even when they continued to take antipsychotics.
For several years, McFarlane developed and tested the Multi-Family Group approach, which brought several families together at a time to learn from one another how they sounded to outsiders. In twice-monthly sessions, the families modeled greater clarity and compassion and troubleshot daily-living problems like kids' marijuana use or sexual activity. It was a simple intervention that, when combined with antipsychotic drugs, worked to reduce schizophrenic relapse rates significantly more than the drugs alone.
McFarlane wondered if the treatment could work even earlier, to help prevent the illness in largely asymptomatic kids who were at risk for schizophrenia. Such prediagnosis would not be easy, but McFarlane knew that once a patient's perception of reality has cracked for the first time, it becomes exceedingly hard to walk back to normality. Indeed, a major study just published in the journal Neuropsychology shows that the signature cognitive problems of schizophrenia — deficits in verbal learning and memory along with processing speed — actually begin days or weeks before a first psychotic episode, making the earliest possible detection all the more urgent.
And so in the 1980s, McFarlane began canvassing schools in the New York City area to try to get the staffs excited about preventing schizophrenia among their students. A number of the superintendents "practically threw us out the window," he says. "They just kept saying, 'We don't have mental illness in our high school.'" It was dispiriting: based on the epidemiological data, McFarlane knew that each year about 12 in 10,000 young people suffered a first episode of psychosis. Some of the kids were clearly in those schools, but if he couldn't get through the door to screen them, he couldn't prevent any illness.
A Theory Goes WideEven as McFarlane was exploring his schizophrenia-prevention idea, other researchers were having similar what-if moments with respect to other, more routine conditions. Suppose irritable infants who become fearful toddlers who become shy children somehow could be stopped from becoming adults with anxiety disorders. Suppose men and women who go to war or become cops in inner cities could be helped before developing posttraumatic stress disorder. Could you, similarly, identify the children of depressed parents early and give them skills to prevent their own first depressive episode?
In any given year, approximately 17% of Americans under 25 have a mental, emotional or behavioral disorder. (Over our lifetime, 46% of us will receive such a diagnosis.) If we reduce the proportion of young people who become mentally ill by even one-quarter, that would mean about 3.8 million saved each year from what can turn into a lifelong struggle.
But if most mental illnesses have a genetic origin, isn't even that modest 25%-reduction goal unlikely? The science can get tricky here, but the simple answer is that genes aren't destiny. You can't do anything to change your genome, but your environment and experiences have powerful effects on the way those genes are expressed. A susceptibility to cancer may remain just a susceptibility — until you start smoking and kick the disease process into motion. Similarly, change a child's emotional experiences for the worse and you can trigger mental illness; change them for the better and you may hush the problem genes. One concrete example of this: in 2003, a study in Science found that the larger the number of copies an individual carries of a serotonin-transporter gene called 5-HTTLPR the greater the risk of developing major depressive disorder and suicidality — but only if the individual suffers stressful early-life experiences like abuse.
How long is the window between first symptoms and actual diagnosis? The National Academies report says that across several mental illnesses — including obsessive-compulsive disorder, depression and substance dependence — we have about two to three years to intervene and keep short-term symptoms from becoming long-term afflictions.
Depression offers particularly good evidence of this idea at work. Currently, about 5% of adolescents experience an episode of clinical depression in any given year. Rates of depression are three to four times as high among the children of depressed parents as among those whose parents aren't depressed. Dr. William Beardslee of Children's Hospital Boston, one of the authors of the National Academies report, has spent more than 25 years studying how some kids of depressed parents avoid the illness, and he has found that resilience is key. The kids who don't develop depression are "activists and doers," Beardslee says. Even growing up in the darkness of a depressed home, they muster the capacity to engage deeply in relationships. They also are likelier than other kids to understand that they aren't to blame for their parents' disorder — and that they are free to chart their own course.
How do you foster resilience in order to prevent depression? Over the past 17 years, Beardslee's team has developed an early intervention that targets kids from families in which at least one parent is depressed. Like McFarlane, he uses a family-based approach because a bad home environment tends to be more predictive of adolescent mental illness than dysfunctional peer relationships are. Beardslee's Family Talk Intervention includes both separate meetings with parents and kids as well as family meetings with social workers or psychologists that focus in part on demystifying depression — explaining that it is a treatable illness, not a beast that will necessarily crush a family. In a randomized trial, Beardslee found that just seven sessions of this intervention decreased predepression symptoms among the kids and improved the parents' behavior and attitudes. All this makes kids more resilient.
Tackling SchizophreniaMcFarlane hadn't gotten far with the New York City schools in the 1980s, and his prevention work waned for a few years as he taught at Columbia University and wrote articles on his Multi-Family Group approach to treating psychosis. Eventually, he moved to Portland, Maine, where he had been offered the chairmanship of Maine Medical Center's psychiatry department. There, he settled into quieter, less paradigm-changing work.
It wasn't until 1996 that his prevention work resumed. That year, a team of researchers in Norway — one that included Dr. Thomas McGlashan of Yale — approached McFarlane about training therapists to use the Multi-Family Group approach with patients who had just suffered a first psychotic episode. These patients already had the illness, so it was too late for prevention. But the Norwegians had succeeded where McFarlane had failed in New York: they had connected with schools and other local institutions to identify the first signs of psychosis and refer patients to the team immediately.
In October 1998, the picture grew still more promising when NATO sponsored a major psychotic-disorders conference in Prague, where McFarlane learned that several groups around the world, including one in Australia, had also been trying to prevent first episodes of psychosis. He returned from Prague and tried again to set up an early-detection system with schools, this time in Portland. By now, the stigma against mental illness had eased a bit; schools had seen a dramatic rise in emotional and behavioral problems during the '90s. Unlike their New York counterparts, Portland school superintendents welcomed McFarlane.
At about the same time, McGlashan's team at Yale was working on a screening interview that might distinguish kids who would become psychotic from those who wouldn't. McGlashan tested his questions at various sites in North America, including with teens who sought treatment in McFarlane's department in Portland. By 2001, McGlashan and his team had completed their "Structured Interview for Prodromal [pre-disease] Symptoms" (SIPS) — a two-hour assessment involving various oral tests and a family history. Those who meet SIPS criteria for risk are about 30 times as likely as the general population to develop a diagnosable psychotic disorder. SIPS allows for the careful scoring of warning signs, some of which are obvious (hearing mumbling that isn't there) and some of which are less so (changing your behavior because of a superstition).
McFarlane and his team connected with most of Portland's principals and pediatricians. The message was simple: If you encounter kids who seem slightly off — prone to jumbled thoughts, maybe even hearing voices — send them our way. Among those referred to him, McFarlane found that 80% of those who met SIPS criteria for prodromal psychosis would receive a diagnosis of schizophrenia within 30 months. He put kids who met a certain SIPS threshold into Multi-Family Group psychoeducation. At first, he intended not to use drugs with these prediagnosis kids, particularly since the meds can cause side effects like weight gain, acne and uncontrollably shaky legs. But McFarlane found that once symptoms like auditory hallucinations started, he couldn't correct them with only psychosocial interventions. (Today, virtually everyone enrolled in his Portland Identification and Early Referral prevention program is prescribed psychiatric medication.)
The combination of the family approach and drug support seems to be working well. The National Institute of Mental Health is funding a trial of McFarlane's work, and while he is still writing up his data for publication, his anecdotal results are promising: most of the kids are so far avoiding a first psychotic episode. Even those who have heard voices and nearly dropped out of high school are going to college and getting jobs.
But this approach doesn't come cheap. The kids who are enrolled are bombarded with care: social workers help them at school or work; therapists guide them and their families in individual and group sessions; a psychiatrist or nurse practitioner carefully calibrates their medication based on response rates and side effects.
When members of McFarlane's clinical team gather each day to discuss cases, they know virtually everything about their kids: they know about boyfriends, girlfriends and summer plans. They know the kids' grades in English class, how much pot they smoke, what they did on a recent trip to Disneyland. They know whether Dad just lost his job and if Mom's grandmother killed herself. This is what prevention of mental illness looks like: unwavering, sweeping, complicated. But it works.
One Family at a TimeThe Robert Wood Johnson foundation is so impressed with McFarlane's program that it has devoted $15 million to its national expansion. It is the foundation's single largest mental-health initiative. McFarlane's approach costs about $3,500 per patient per year, but compare that with the $150,000 a year to care for a hospitalized schizophrenic or severely bipolar patient.
Still, not all the kids McFarlane sees can be helped. Patti White is a plainspoken 47-year-old Mainer who works for McFarlane as an administrative coordinator. She has a son who began experiencing psychotic symptoms a few years ago, and he might have seemed like a perfect fit for her boss's program. He wasn't; prevention isn't that easy. Instead, White's son Tyler, who turns 20 this month, was too far along in his illness — eventually diagnosed as schizoaffective disorder, a relative of schizophrenia — to benefit from prevention therapy. A social worker on McFarlane's team helped Tyler get into treatment, and he is doing better and holding down a job in food service.
But White has another son, Jacob, who causes her to worry. A few months ago, Jacob, 10, started to withdraw. He was getting paranoid. At school, he started seeing complicated machinations where none existed. And even though White works for one of the world's leading prevention experts, she at first resisted having Jacob take the SIPS test. "If his brother had had diabetes, I wouldn't have thought twice about having Jacob screened for diabetes," she says. "But I just couldn't deal with the idea that another one of my kids would have" — she pauses — "this enormous thing."
Three weeks ago, Jacob took SIPS. The good news: he showed no red flags for psychosis. He does have depressive symptoms and is now taking a low dose of Prozac to help prevent a full-blown depression. But for Jacob — and millions of other Americans with all manner of mental ills — intervention can now come in time
"Rule No. 1 is, don't sweat the small stuff. Rule No. 2 is, it's all small stuff. And if you can't fight and you can't flee, flow."
—University of Nebraska Cardiologist Robert Eliot, on how to cope with stress
It is the dawn of human history, and Homo sapiens steps out from his cave to watch the rising sun paint the horizon. Suddenly he hears a rustling in the forest. His muscles tense, his heart pounds, his breath comes rapidly as he locks eyes with a saber-toothed tiger. Should he fight or run for his life? He reaches down, picks up a sharp rock and hurls it. The animal snarls but disappears into the trees. The man feels his body go limp, his breathing ease. He returns to his darkened den to rest.
It is the start of another working day, and Homo sapiens steps out of his apartment building into the roar of rush hour. He picks his way through the traffic and arrives at the corner just in time to watch his bus pull away. Late for work, he opens his office door and finds the boss pacing inside. His report was due an hour ago, he is told; the client is furious. If he values his job, he had better have a good explanation. And, by the way, he can forget about taking a vacation this summer. The man eyes a paperweight on his desk and longs to throw it at his oppressor. Instead, he sits down, his stomach churning, his back muscles knotting, his blood pressure climbing. He reaches for a Maalox and an aspirin and has a sudden yearning for a dry martini, straight up.
The saber-toothed tiger is long gone, but the modern jungle is no less perilous. The sense of panic over a deadline, a tight plane connection, a reckless driver on one's tail are the new beasts that can set the heart racing, the teeth on edge, the sweat streaming. These responses may have served our ancestors well; that extra burst of adrenaline got their muscles primed, their attention focused and their nerves ready for a sudden "fight or flight." But try doing either one in today's traffic jams or boardrooms. "The fight-or-flight emergency response is inappropriate to today's social stresses," says Harvard Cardiologist Herbert Benson, an expert on the subject. It is also dangerous. Says Psychiatrist Peter Knapp of Boston University: "When you get a Wall Street broker using the responses a cave man used to fight the elements, you've got a problem."
Indeed we have. In the past 30 years, doctors and health officials have come to realize how heavy a toll stress is taking on the nation's well being. According to the American Academy of Family Physicians, two-thirds of office visits to family doctors are prompted by stress-related symptoms. At the same time, leaders of industry have become alarmed by the huge cost of such symptoms in absenteeism, company medical expenses and lost productivity. Based on national samples, these costs have been estimated at $50 billion to $75 billion a year, more than $750 for every U.S. worker. Stress is now known to be a major contributor, either directly or indirectly, to coronary heart disease, cancer, lung ailments, accidental injuries, cirrhosis of the liver and suicide—six of the leading causes of death in the U.S. Stress also plays a role in aggravating such diverse conditions as multiple
Studying such kids for more than a decade, the researchers discovered that those who became schizophrenic were most often from families that, when first interviewed, displayed "communication deviance" (unclear, unintelligible or fragmented speech) and highly critical and intrusive parenting. These weren't merely families that argued with difficult sons and daughters; they were families that had lost all ability to cope.
McFarlane and others began working with some of the families to address their interactions and teach them how to communicate better — more slowly, with less anger and intrusion. Even after they are on medication, people with schizophrenia have a difficult time tracking rapid, highly emotional speech, yet that's the kind they often hear from frustrated family members. These patients would improve in hospitals but relapse once they got home, even when they continued to take antipsychotics.
For several years, McFarlane developed and tested the Multi-Family Group approach, which brought several families together at a time to learn from one another how they sounded to outsiders. In twice-monthly sessions, the families modeled greater clarity and compassion and troubleshot daily-living problems like kids' marijuana use or sexual activity. It was a simple intervention that, when combined with antipsychotic drugs, worked to reduce schizophrenic relapse rates significantly more than the drugs alone.
McFarlane wondered if the treatment could work even earlier, to help prevent the illness in largely asymptomatic kids who were at risk for schizophrenia. Such prediagnosis would not be easy, but McFarlane knew that once a patient's perception of reality has cracked for the first time, it becomes exceedingly hard to walk back to normality. Indeed, a major study just published in the journal Neuropsychology shows that the signature cognitive problems of schizophrenia — deficits in verbal learning and memory along with processing speed — actually begin days or weeks before a first psychotic episode, making the earliest possible detection all the more urgent.
And so in the 1980s, McFarlane began canvassing schools in the New York City area to try to get the staffs excited about preventing schizophrenia among their students. A number of the superintendents "practically threw us out the window," he says. "They just kept saying, 'We don't have mental illness in our high school.'" It was dispiriting: based on the epidemiological data, McFarlane knew that each year about 12 in 10,000 young people suffered a first episode of psychosis. Some of the kids were clearly in those schools, but if he couldn't get through the door to screen them, he couldn't prevent any illness.
A Theory Goes WideEven as McFarlane was exploring his schizophrenia-prevention idea, other researchers were having similar what-if moments with respect to other, more routine conditions. Suppose irritable infants who become fearful toddlers who become shy children somehow could be stopped from becoming adults with anxiety disorders. Suppose men and women who go to war or become cops in inner cities could be helped before developing posttraumatic stress disorder. Could you, similarly, identify the children of depressed parents early and give them skills to prevent their own first depressive episode?
In any given year, approximately 17% of Americans under 25 have a mental, emotional or behavioral disorder. (Over our lifetime, 46% of us will receive such a diagnosis.) If we reduce the proportion of young people who become mentally ill by even one-quarter, that would mean about 3.8 million saved each year from what can turn into a lifelong struggle.
But if most mental illnesses have a genetic origin, isn't even that modest 25%-reduction goal unlikely? The science can get tricky here, but the simple answer is that genes aren't destiny. You can't do anything to change your genome, but your environment and experiences have powerful effects on the way those genes are expressed. A susceptibility to cancer may remain just a susceptibility — until you start smoking and kick the disease process into motion. Similarly, change a child's emotional experiences for the worse and you can trigger mental illness; change them for the better and you may hush the problem genes. One concrete example of this: in 2003, a study in Science found that the larger the number of copies an individual carries of a serotonin-transporter gene called 5-HTTLPR the greater the risk of developing major depressive disorder and suicidality — but only if the individual suffers stressful early-life experiences like abuse.
How long is the window between first symptoms and actual diagnosis? The National Academies report says that across several mental illnesses — including obsessive-compulsive disorder, depression and substance dependence — we have about two to three years to intervene and keep short-term symptoms from becoming long-term afflictions.
Depression offers particularly good evidence of this idea at work. Currently, about 5% of adolescents experience an episode of clinical depression in any given year. Rates of depression are three to four times as high among the children of depressed parents as among those whose parents aren't depressed. Dr. William Beardslee of Children's Hospital Boston, one of the authors of the National Academies report, has spent more than 25 years studying how some kids of depressed parents avoid the illness, and he has found that resilience is key. The kids who don't develop depression are "activists and doers," Beardslee says. Even growing up in the darkness of a depressed home, they muster the capacity to engage deeply in relationships. They also are likelier than other kids to understand that they aren't to blame for their parents' disorder — and that they are free to chart their own course.
How do you foster resilience in order to prevent depression? Over the past 17 years, Beardslee's team has developed an early intervention that targets kids from families in which at least one parent is depressed. Like McFarlane, he uses a family-based approach because a bad home environment tends to be more predictive of adolescent mental illness than dysfunctional peer relationships are. Beardslee's Family Talk Intervention includes both separate meetings with parents and kids as well as family meetings with social workers or psychologists that focus in part on demystifying depression — explaining that it is a treatable illness, not a beast that will necessarily crush a family. In a randomized trial, Beardslee found that just seven sessions of this intervention decreased predepression symptoms among the kids and improved the parents' behavior and attitudes. All this makes kids more resilient.
Tackling SchizophreniaMcFarlane hadn't gotten far with the New York City schools in the 1980s, and his prevention work waned for a few years as he taught at Columbia University and wrote articles on his Multi-Family Group approach to treating psychosis. Eventually, he moved to Portland, Maine, where he had been offered the chairmanship of Maine Medical Center's psychiatry department. There, he settled into quieter, less paradigm-changing work.
It wasn't until 1996 that his prevention work resumed. That year, a team of researchers in Norway — one that included Dr. Thomas McGlashan of Yale — approached McFarlane about training therapists to use the Multi-Family Group approach with patients who had just suffered a first psychotic episode. These patients already had the illness, so it was too late for prevention. But the Norwegians had succeeded where McFarlane had failed in New York: they had connected with schools and other local institutions to identify the first signs of psychosis and refer patients to the team immediately.
In October 1998, the picture grew still more promising when NATO sponsored a major psychotic-disorders conference in Prague, where McFarlane learned that several groups around the world, including one in Australia, had also been trying to prevent first episodes of psychosis. He returned from Prague and tried again to set up an early-detection system with schools, this time in Portland. By now, the stigma against mental illness had eased a bit; schools had seen a dramatic rise in emotional and behavioral problems during the '90s. Unlike their New York counterparts, Portland school superintendents welcomed McFarlane.
At about the same time, McGlashan's team at Yale was working on a screening interview that might distinguish kids who would become psychotic from those who wouldn't. McGlashan tested his questions at various sites in North America, including with teens who sought treatment in McFarlane's department in Portland. By 2001, McGlashan and his team had completed their "Structured Interview for Prodromal [pre-disease] Symptoms" (SIPS) — a two-hour assessment involving various oral tests and a family history. Those who meet SIPS criteria for risk are about 30 times as likely as the general population to develop a diagnosable psychotic disorder. SIPS allows for the careful scoring of warning signs, some of which are obvious (hearing mumbling that isn't there) and some of which are less so (changing your behavior because of a superstition).
McFarlane and his team connected with most of Portland's principals and pediatricians. The message was simple: If you encounter kids who seem slightly off — prone to jumbled thoughts, maybe even hearing voices — send them our way. Among those referred to him, McFarlane found that 80% of those who met SIPS criteria for prodromal psychosis would receive a diagnosis of schizophrenia within 30 months. He put kids who met a certain SIPS threshold into Multi-Family Group psychoeducation. At first, he intended not to use drugs with these prediagnosis kids, particularly since the meds can cause side effects like weight gain, acne and uncontrollably shaky legs. But McFarlane found that once symptoms like auditory hallucinations started, he couldn't correct them with only psychosocial interventions. (Today, virtually everyone enrolled in his Portland Identification and Early Referral prevention program is prescribed psychiatric medication.)
The combination of the family approach and drug support seems to be working well. The National Institute of Mental Health is funding a trial of McFarlane's work, and while he is still writing up his data for publication, his anecdotal results are promising: most of the kids are so far avoiding a first psychotic episode. Even those who have heard voices and nearly dropped out of high school are going to college and getting jobs.
But this approach doesn't come cheap. The kids who are enrolled are bombarded with care: social workers help them at school or work; therapists guide them and their families in individual and group sessions; a psychiatrist or nurse practitioner carefully calibrates their medication based on response rates and side effects.
When members of McFarlane's clinical team gather each day to discuss cases, they know virtually everything about their kids: they know about boyfriends, girlfriends and summer plans. They know the kids' grades in English class, how much pot they smoke, what they did on a recent trip to Disneyland. They know whether Dad just lost his job and if Mom's grandmother killed herself. This is what prevention of mental illness looks like: unwavering, sweeping, complicated. But it works.
One Family at a TimeThe Robert Wood Johnson foundation is so impressed with McFarlane's program that it has devoted $15 million to its national expansion. It is the foundation's single largest mental-health initiative. McFarlane's approach costs about $3,500 per patient per year, but compare that with the $150,000 a year to care for a hospitalized schizophrenic or severely bipolar patient.
Still, not all the kids McFarlane sees can be helped. Patti White is a plainspoken 47-year-old Mainer who works for McFarlane as an administrative coordinator. She has a son who began experiencing psychotic symptoms a few years ago, and he might have seemed like a perfect fit for her boss's program. He wasn't; prevention isn't that easy. Instead, White's son Tyler, who turns 20 this month, was too far along in his illness — eventually diagnosed as schizoaffective disorder, a relative of schizophrenia — to benefit from prevention therapy. A social worker on McFarlane's team helped Tyler get into treatment, and he is doing better and holding down a job in food service.
But White has another son, Jacob, who causes her to worry. A few months ago, Jacob, 10, started to withdraw. He was getting paranoid. At school, he started seeing complicated machinations where none existed. And even though White works for one of the world's leading prevention experts, she at first resisted having Jacob take the SIPS test. "If his brother had had diabetes, I wouldn't have thought twice about having Jacob screened for diabetes," she says. "But I just couldn't deal with the idea that another one of my kids would have" — she pauses — "this enormous thing."
Three weeks ago, Jacob took SIPS. The good news: he showed no red flags for psychosis. He does have depressive symptoms and is now taking a low dose of Prozac to help prevent a full-blown depression. But for Jacob — and millions of other Americans with all manner of mental ills — intervention can now come in time
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