1. How Mental Health Effects Us and Our Students Larry Scott lscott2@kenton.k12.ny.us

2. I. Current State of Mental Health II. General Characteristics of Anxiety & Depression III. Depression IV. Anxiety V. Self-Harm & Suicide VI. Addiction VII. Mental Health Treatment/Intervention

3.  47% of people killed by police, north of NYC, over a 5 year period suffered from a mental illness or were emotionally disturbed  About 17% of U.S. prison population have mental illness; 3x the rate of the general public  8,000 inmates are cared for by NYS Office of Mental Health  56% of NYS prison population have a “mental health problem” including substance abuse; 5x the rate of general public  Law enforcement have become primary providers to those with serious mental illness  Cuts, consolidations, and closings in mental health continue  In 1955 the U.S. had 558,000 beds for mentally ill; today we have about 40,000  Mentally ill are more likely to be victims of crime, than criminals, and they are more likely to be harmed by police, than harm police

4.  The number of poor in the entire Buffalo Niagara metropolitan area grew from 120,861 in 1970 to 162,917 in 2011  52 percent – of this area’s poor reside in the suburbs  Mobile Safety-Net Team (John R. Oishei Foundation):  Ken-Ton School District is the largest human service of 38 agencies  Free/reduced lunch (#1):  27% in March of 2001 compared to 41% in March of 2013

5.  Question #4  CDC (2012): About 20% of American youth (aged 3 – 17) suffer from a mental health disorder (ADHD, anxiety, depression, and conduct problems)  ADHD= 6.8%  Conduct Problems= 3.5%  Anxiety= 3%  Depression= 2.1%  Autism Spectrum Disorder= 1.1%  ADHD diagnosis has jumped 53% in past decade  Chronic health problems (i.e. asthma & diabetes) are associated with mental illness in adulthood  Question #3  $247 Billion is spent per year for mental health services from medical bills, special education, and juvenile justice  Question #2  Suicide has become the 2 nd leading cause of death among youth (aged 12-17) behind accidents

6.  Everyone experiences varying emotion and mood, including symptoms of anxiety and depression  Mood : sustained emotional state which impacts how we respond on a regular basis; becomes more of an internal state, independent of external circumstances  Emotion : short-term and more influenced by external factors  “Emotion is the weather, mood is the climate.” (C. Smith)  Mood exists across species; the more developed the species the more intensely mood exists independent of external events  Some manage the interaction of mood, personality, and stress well; for others it becomes damaging

7.  Anxiety & Depression often co-exist and influence each  Share a single set of genes, which are also involved in alcoholism  Depression: a response to loss; Anxiety : a response to future loss  Depression with high anxiety increases risk of suicide & complicates recovery  Intervention needed when anxiety and/or depression interferes with a life function (i.e. work, school, family relationships/functioning….).

8. Genetics Environmental Neuropsychological Personality

9.  Brain Plasticity  Between approximately 10 to 18 months of age is a critical period of plasticity and shaping of the brain (right frontal lobe) for attachments & emotional regulation  Neglect/trauma during this time can shape “wiring” for attachments & emotional regulation which can continue into adulthood  Limbic System ( hypothalamus, hippocampus, & thalamus) is involved in emotional regulation Limbic System  Dopamine (pleasure neurotransmitter) likes novelty & enhances brain circuitry

11.  About 19 million Americans suffer chronic depression (over 2 million are children)  About 15% will commit suicide  2.3 million suffer from Bipolar Disorder  Could be leading cause of death when considering its influence on suicide, substance abuse, heart disease, and other health issues  Anger & violence may be symptoms of depression, particularly in males (destructive, but short-term remedy)  Question #5  Leading cause of disability in U.S. for those over the age of 5 and leading cause worldwide (WHO); costs tens of billions yearly in lost productivity

12.  Females are 2x more likely to suffer depression, a ratio consistent throughout Western societies  Males synthesize serotonin 50% more rapidly than females  Rate of depression is about the same among working and non-working married females  Males are more likely to have ADHD, autism, and alcoholism  Closeted people and single people have a higher rate of depression  Question #6  Women who are pregnant or have just given birth are more likely than anyone else to suffer depression, but least likely to commit suicide  Question #7  Poverty & parent depression are highest predictors of child depression  Question #8  GLBT are at increased risk for depression and anxiety problems. Suicide is the number 1 cause of death for this group

13.  Fewer social skills and close relationships  Fewer social interactions  Limited interest in activities  Limited motivation and academic achievement  Irritability  Limited energy  Limited affect  Worsened with the presence of learning weaknesses  Most challenging during adolescence

14.  There are particular genes which predispose depression, but whether one suffers depression is dependent on life events/experiences  These genes are involved in serotonin regulation in the brain  There are three possible gene combinations, one from each parent: short/short, short/long, and long/long  A short/short combination with multiple uncontrollable bad life events makes it about twice as likely to suffer from depression than long/long combination  Significant episodes of depression alter brain chemistry and structure  Decrease in serotonin receptors and rise in cortisol (stress hormone) are known to occur with depression  With each episode of depression there is an increased 10% risk depression will become chronic and inescapable

15.  Many studies show that socioeconomic status is the number one predictor of depression  Question #9  Those in poverty represent the highest rate of depression compared to any other class in U.S.  Depression is so common in poor communities awareness that an internal problem exists is lacking; perceived the problems are only due to uncontrollable external factors  Poverty is highly associated with a learned helplessness & passivity  Rate among welfare recipients is about 3x higher  Question #10  85 – 95% of those with serious mental illness are unemployed

16.  Quality mental health care is lacking most among the poor  Investment in addressing mental health needs may be worthwhile, financially and socially  The cost of not treating mental illness, may far outweigh the cost of adequately treating it

17.  Depressed mothers greatly influence the likelihood that a child will suffer depression or other emotional / behavioral issues  Having a depressed mother is often more detrimental than a schizophrenic mother  With a depressed mother, signs of depression can be seen in infants, as early as 3 months  Children are often weepy, angry, & aggressive  If mother’s depression is treated early, children show improvement, reversal becomes more challenging with age

18.  Five potential impacts on child’s emotional / behavioral development (Sameroff, A.): 1. Genetics 2. Empathetic mirroring: repeating back what they experience 3. Learned helplessness : giving up on connecting due to lack of parent approval for emotional outreach 4. Role-playing : taking on the illness role to avoid unpleasant things as observed by parent 5. Withdrawal: consequence of seeing no pleasure/meaning in communication with unhappy parent

19.  Anaclitic depression: occurs in second half of the child’s first year when separated from too much from their mother  May develop in “failure to thrive” starting at age four or five; limited affect & don’t bond  At age five to six show extreme crankiness, irritability, poor sleeping, and poor eating  Low self-esteem, high anxiety, and bed-wetting become common problems

20.  Depressed children usually go on to be depressed adults  The earlier the onset the more resistance to treatment  Occurs in many before puberty, but peaks in adolescence  Early/preventative intervention is critical

21.  Four possible theories of evolution: 1. Served an important purpose in pre-human times 2. The stresses of modern life are incompatible with the brains we have evolved. 3. It serves a useful function. 4. It is a secondary result of other characteristics.

22.  Self-Consciousness: high awareness of self, meta- cognition, and awareness of competing cognitive functions (i.e. rational and emotional thinking) makes us unlike any other species  Humans have the slowest brain maturation and are most plastic at older ages  Humans exhibit significant capacity to regulate emotions  Linguistic-Evolutionary Model (Crow, Timothy) mental illness is on a continuous spectrum and is determined by difference in intensity of symptoms

23.  Out of the Shadows Out of the Shadows

24.  10 – 20% Americans suffer from Anxiety Disorder  About ½ of those with true anxiety disorders develop major depression within 5 years  Anxiety is often overlooked, misdiagnosed as ADHD, left untreated, and sometimes worsened when misdiagnosed  Anxiety is difficult to detect- internal, not easily observed  Worsens with time if untreated  Self-awareness  Medication

25.  The opposite of peace and feeling safe  “Curse” of sensitivity & empathy: capacity for feeling deeply, including emotional pain can be hindering, but also beneficial  Often obsessive thinkers without compulsive tendencies  Anticipatory anxiety  Frightening/gruesome thoughts may be a diversion to facing and dealing with inner and external conflict

26.  Strong episodes of anxiousness and panicky feelings  Racing heart and chest discomfort  Dizziness or lightheadedness  Feelings of bewilderment and unreality  Inner nervousness  Scary, uncontrollable thoughts  Nausea, upset stomach, diarrhea  Hot and cold flashes  Numbness or strange aches and pains, muscle tension  Feelings of depression and hopelessness  Restless feelings, insomnia, sleeping too much  Difficulty breathing  Picking at self or objects  Uncontrollable bouts of anger/crying  Obsessive-compulsive tendencies  Withdrawing

27. Control Anxiety Anxiety Control

28.  Experiencing severe panic attacks can be debilitating  Often develop from life events where there is a loss of security or perceived loss of security  Most difficult factor- it is not volitional, feelings occur for absolutely no reason  About 1/3 of panic attacks related to depression occur during deep, dreamless sleep  Gives a sense that you have a serious medical condition

29. Cognitive Symptoms:  “I’m going to have a heart attack.”  “I’m about to die.”  “I can’t breathe properly. I’m going to suffocate.”  “I’m about to pass out.”  “I’m going to lose control and go crazy.”

30. Hot / cold flashes Numbness / tingling Chest pain / tightness Trembling Tight, tense muscles Pounding heart Shortness of breath Nausea / dizzy Feeling unreal or detached

32.  Anxiety is one of the most basic emotions found in almost all animal species  Is a response to danger or threat- perceived or real  It’s primary purpose is to protect us, not harm us  “Fight/Flight/Freeze” response  Sympathetic nervous system releases energy to respond to threat  Parasympathetic nervous system restores the body to normal function

33. Physical Symptoms Fear Physical Symptoms Fear

34.  People with high anxiety lock onto worry and can’t let go  Their brains are haunted with horrific scenarios that present as quite real and can’t be ignored  Norepinephrine and serotonin are neurotransmitters which play a role in anxiety  Locus coeruleus controls norepinephrine production & the lower bowel Locus coeruleus

35.  Early childhood trauma causes major changes to the brain’s hippocampus, shrinking it & inhibiting new, long-term memories  A stress hormone, glucocorticoid, kills cells in the hippocampus  Depression, high stress, and childhood trauma all cause the release of glucocorticoid.  The longer someone is seriously depressed or under high stress the smaller their hippocampus.  Antidepressants have been found to increase stem cells that become new neurons in the hippocampus  It takes about 3-6 weeks on an antidepressant for new neurons to mature and connect with other neurons  Psychotherapy has been shown to decrease activation in prefrontal cortex (less blood flow) in patients who suffer from past trauma and/or panic attacks

37.  Obsessive-Compulsive Disorder (OCD) can be most severe with frequent worrying about harm to self and/or loved ones  Excessive fear of health is common- with frequent scanning of body for symptoms & doctor visits  OCD often worsens with time, slowly shaping brain structures/functioning  Certain thoughts are persist even when it is known that they are meaningless

38.  The brain of OCD does not move or transition easily. It becomes “locked.”  3 major areas are hyperactive in those who suffer from OCD: 1. Orbital frontal cortex: the more obsessive the more activity in this area 2. Cingulate gyrus: seems to play a role in triggering the sense of impending dread which then activates physiological responses (pain in stomach, pounding heart, etc…) 3. Caudate nucleus: plays a role in transitioning our thoughts  OCD can be inherited, but infections can swell the caudate nucleus leading to OCD symptoms

39.  Dr. Jeffery Schwartz ( Brain Lock ) and his research have discovered much about the brain’s role in OCD  Uses a form of psychotherapy to restructure the brain with a success rate of about 80% when combined with an antidepressant medication  The 3 major parts of the brain which are hyperactive & “locked” begin to function normally and separately, relieving the brain lock  Uses 2 major methods: 1. Identify & accept that an obsessive worry is a symptom of OCD & not something else (i.e. chronic disease) 2. Focus on something desirable & pleasurable (about 30 minute intervals) when faced with the obsessive thoughts

40.  With obsessions & compulsions the more you do it, the more desire to do it; the less you do it, the less you desire to do it  Intensive therapy which compels patients to think or do something pleasurable triggers dopamine release, rewarding new brain activity and growth of healthy neural circuitry and connections  One needs to be distracted and “change the channel” for a period of time when experiencing obsessions & compulsions  Anxious feelings will remain for some time (may initially increase) but by changing behavior & how one responds, brain restructuring can occur & with time anxiety will reduce

41. The man who kills a man, kills a man. The man who kill himself kills all men. As far as he is concerned, he wipes out the world. G.K. Chesteron

42.  Depression is not always the primary reason or only reason; often committed after coming out of a depression or long after recovery  Suicide is more a response to anxiety and a tortured mind, rather than a solution to depression and purposeless mind  Question #12  Prior attempt to commit suicide is highest predictor of suicide  Although suicide can coincide with depression, it should be viewed independently just like substance abuse  Many unknowns  There is a significant difference between wanting to die and wanting to kill yourself

43.  Statistics:  Most often on Mondays, between late morning & noon, and spring  Evidence suggests that the best-intentioned prevention programs introduce the idea to a vulnerable population & increase the rate  Suicide rate for age group of 10 – 14 increased by 120% between the early 80’s to the mid-90’s; 85% use aggressive means (guns, hanging, and poisoning)  Question #13  U.S. is the only country where guns are the primary means of suicide; more Americans are kill themselves with guns than murder with guns, yearly  10 states with lax gun-control laws have a suicide rate 2x that of states with the strongest gun-control laws

44.  Deliberate Self-Harm (DSH) has been on rise since 1980’s  Question #11  Average age of onset is about 13  Eating disorder & substance abuse are commonly associated  Females are 3x more likely than males  Reasons from an Inpatient Population:  53% to stop bad feelings  34% to feel something even if it was pain  32% to punish themselves  31% to relieve feeling numb or empty  14% to get help or attention out of desperation

45.  Stereotypic Harm : includes behaviors like head- banging/hitting self associated with mental retardation and severe autism  Major mutilation: involves a great deal of tissue damage associated with psychosis  Superficial/moderate mutilation : most common and usually includes skin cutting & burning

46.  Self-harm: intentional, non-life threatening bodily harm or disfigurement while in a state of distress  Suicidal behavior: act of self-inflicted, self-intended cessation of life  Question #14  Less than 1% kill selves from cutting  Self-harm is usually life sustaining act associated with the following:  Impulsive- thought about for less than an hour  Relieve inexpressible feelings  Body alienation  “Life preserver” rather than exit strategy  May become angry if described as suicidal

47.  Substance abuse  Eating disorder  Physical risk taking  High risk sexual behavior  Unauthorized discontinuation of medication

48. 4 Broad Types of Suicide: 1. Impulsive : sudden act triggered by specific external event without much thought 2. Revenge: poor awareness that death is the end 3. Faulty logic : death is the only escape from unbearable problems 4. Reasonable/logical: as a result of physical illness, mental instability, or change in life circumstances- do not wish to experience pain of life which outweighs remaining pleasure

49.  Low levels of serotonin in brain areas associated with inhibition and freedom to act impulsively on emotion (similar to impulsive murders/arsonists)  Excessive number of serotonin receptors (possible brain compensating)  Stress reduces serotonin making the combination of stressful events and depression high risk for suicide

50.  A cognitive-behavioral treatment empirically supported to treat self-harm in patients with Borderline Personality Disorder  Views self-harm behavior as a combination of dysfunction in emotional regulation in the brain & invalidating social environment, causing confusion of self, impulsivity, emotional instability, & interpersonal problems  Provides a comprehensive structure for treatment providers in dealing with a complex behavior

51. Mental Illness Substance Abuse

52.  Alcohol is appealing for reducing anxiety short-term, but often worsens depression  Alcohol decreases serotonin  Self-medication is common with alcohol and marijuana  Long-term use can alter brain structure and chemistry  Dopamine plays a role in addiction, requiring the need for more  It is typically thought that addiction should be addressed first, then the mental illness, but role of mental illness should not be ignored

53.  Regular marijuana use mimics symptoms of depression  Marijuana may have short-term relief of anxiety and agitated- depression  Cocaine: 15% of those who try it become addicted, but for those 15% it is highly addictive and associated high risk of depression  Cocaine produces immediate gratification, acting on multiple neurotransmitters (serotonin, dopamine, and norepinephrine)  48-72 hours after cocaine use usually elicits an intense depression; depression can become the baseline with long-term use when not high

54.  Two Broad Treatment Methods: 1. Medical (medication and/or electroshock) 2. Therapy (counseling)  Evidence that behavior modification, talk-therapy, & medication can change brain chemistry, structure, & functioning  Medication & therapy should be complimentary, not competitive; used together or separately depending on the situation and individual  Large study by NIMH (2004) on moderately to severely depressed youth (aged 12 – 17):  CBT: 69% success  Prozac: 65%  A combination of Prozac and CBT: 85%

55.  U.S. use of psychiatric medications is far higher than any other country  Question #15  Anti-depressants have become the most used drug in U.S. (about 10% of adults)  About 28 Million Americans are on SSRIs (Selective Serotonin Reuptake Inhibitors)  About 16% of females, compared to 6% of males  About 5% of adolescents (aged 12 – 19) take an antidepressant  White adolescents are 5x more likely to use antidepressants than black adolescents and 2x more than Latino  1996 – 2005: 40% drop in those receiving therapy

56.  Selective Serotonin & Norepinephrine Reuptake Inhibitors (SSRI’s & SNRI’s) act on serotonin and some also act on norepinephrine  Are useful in treating chronic anxiety  Are relatively safe drugs, but do have side effects and unpleasant withdrawal symptoms (sometimes dangerous)  Efficacy in children has not been conducted  Only Prozac has been approved for children by the FDA, but others under generic labels can be prescribed

57.  Benzodiazepine (tranquilizers) are intended for short-term use, and not regarded as safe drugs for long-term treatment of anxiety  Physical tolerance and dependence requiring the need for more of the medication can lead to addiction and abuse  Dangerous when mixed with alcohol  Withdrawal symptoms can be very unpleasant and dangerous

58.  In isolation, does not address a psychological understanding of anxiety and depression  Limited research and education on long-term use and effectiveness  Suicide risk in adolescents (FDA found a 4% increase in suicidal thoughts and behavior)  Weaning off medication can be a challenge and withdrawal can be unpleasant  Side effects, stigma, and uncertainties make medication a challenging decision for parents

59.  Question #16  1997: FDA permitted drug companies to advertise prescription drugs directly to the public  1997 – 2004: Money on advertising quadrupled to $4.35 Billion  2000: Every dollar spent on advertising translated to an additional $4.20 in sales  Profiting off of benefit and not just need  Most funding for mental health research comes from pharmaceutical companies  Few psychiatrists provide therapy, just prescribe medication  Payments from drug companies to doctors sways prescription patterns  Perpetual increase in “ polypharmacy ”

60.  Research shows strong evidence that talk therapy can be effective  About 75% report improvement: diminished symptoms and greater length of time between episodes  Two most critical predictors of success: 1. Rapport 2. Trust in framework being used by patient & therapist

61.  Cognitive-Behavioral Therapy  Based on theory that negative thinking and habits drive anxiety/depression  Alter thinking, self-beliefs, and behavior  Limited focus on emotion  Youth anxiety  Psychodynamic Therapy  Builds self-awareness and understanding of hidden/unresolved conflict & denied feelings to elicit change  Deeper understanding of emotion and it’s meaning  Less intensive than psychoanalysis  Interpersonal Therapy  Communication  Relationships  Family Therapy

62.  Keeping secrets may be unhealthy for the brain  Study- when subjects shared intimate secrets- health improved, doctor visits and stress hormones decreased  Competing operations (telling and withholding) may influence stress/inner tension  May explain the need for some to vent to strangers and the appeal of prayer/confession amongst religions  Venting a secret to an open year (human or human-like) is the intervention and advice is not intended/needed

63.  Fosters positive therapeutic relationship  Reduces self-blame & guilt  Instills hope  Increases motivation  Reduces anxiety  Promotes self help & reliance

64.  Primary objective is stop avoiding and face fears (negative reinforcement)  Gradual or sudden exposure to fear  Cognitive Exposure  Reality Exposure  With youth it should be done gradually and not be forced

65.  Challenge to get all involved on the same page  Varying agendas and sense of urgency  Respect youth’s pace/comfort level  Communication and clear plan is needed for gradual exposure

66.  Adjusted school schedule  Staff support person  Lunch support group or social skills group  Time away in safe place  In-school counseling  Test accommodations/program modifications through 504 Plan/IEP  In severe cases: Home Instruction (short-term with plan for reintegration, only part-time if possible)  Special education programming

67.  Yoga / Meditation  Deep Breathing  Progressive Muscle Relaxation  Pleasant Imagery  Visualization

68.  Children & most adolescents don’t seek help on there own  Therapy cannot begin to be successful until a patient willingly accepts help  Alternative therapies (i.e. play therapy) can be helpful with young children  Asking a child to provide wishes or things they wish they had the power to change can provide much insight into a child’s view of self, life, and others  Parent anxiety and resistance

69. Exercise Diet Sleep

70. ThoughtsBehaviors Physical (Body) Symptoms Emotions

71.  The way we think effects the way we feel, behave, and how our bodies operate.  The opposite is also true- if we are physical ill or in pain it effects how we think, feel, behave.  Neurotransmitters:  chemicals in our bodies that play a role in our thoughts, feelings, and behaviors

72. The most successful people I know have gotten there by choosing to underact to stressful conditions and keep moving forward. Lucinda Bassett

73.  What is it?  Our response to external conditions (stressors) which effect our thoughts, feelings, and bodies  Stressors:  Adrenaline & Cortisol: chemicals that are released in our bodies when we experience stress

74.  Nervousness  Irritability  Crying  Anxiety  Lack of motivation or excitement  Angry outbursts  Feeling powerless  Easily upset  Loneliness

75.  Trouble thinking clearly  Forgetfulness  Lack of creativity  Memory loss  Inability to make decisions  Constant thoughts of worry  Racing thoughts or mind going blank  Lack of sense of humor

76.  Bossiness  Compulsive tendencies- repeating something over & over (eating, chewing gum, playing video games…..)  Critical attitude of others  Grinding teeth  Not able to complete important tasks  Smoking or abusing alcohol and drugs

77.  Headaches  Stomach aches and indigestion  Sweaty palms  Difficulty sleeping  Dizziness  Back pain  Tight neck and shoulders  Feeling nauseous  Hot & Cold Flashes  Numbness or strange aches/pains  Chest pain  Racing heart  Restlessness  Tiredness  Frequent illness

78.  Change the way we think about certain situations or events  Eat healthy and get good SLEEP  Physical activity: exercise, sports, walking, weightlifting, etc…  Relaxed breathing techniques  Meditation  Yoga / Tai Chi  Talk to a trusted person  Listening to or playing music  Reading, drawing, & writing  Spending time having fun with self or others

79.  Doidge, N. (2007), The Brain that Changes Itself.  Eagleman, D. (2011), Incognito: The Secret Lives of the Brain.  Pearrow, M. (2013), Students who Self-Injure: School-based Strategies Based on DBT, NASP Convention, Seattle, WA, Februay 15, 2013.  Solomon, A. (2001), The Noonday Demon  Burns, D. (2006) When Panic Attacks  Bassett, L. (1995), From Panic to Power  www.nydailynews.com (2013), One in five U.S. kids has a mental disorder; ADHD the most common: CDC, May 17, 2013 www.nydailynews.com  The Buffalo News (2013), Today’s Mental Health Squad: The Police, May 19, 2013.  The Buffalo News (2013), Does Training Prepare Cops for the Mentally Ill, August 4, 2013.  The Buffalo News (2013), Suburban Poverty on the Rise, June 8, 2013.  Sharpe, K. (2012), Coming of Age on Zoloft: How Antidepressants Cheered Us Up, Let Us Down, and Changed Who We Are.  Rapee, R., Craske, M., & Barlow, D. The Causes of Anxiety and Panic Attacks, http://algy.com/anxiety/index.php.http://algy.com/anxiety/index.php  Pratt, D. (2012), Anxiety Disorders in Children & Adolescents (power point)