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Bipolar News

June 21, 2005

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MRI shows up brain differences in bipolar disorder
Reuters - USA
NEW YORK (Reuters Health) - Efforts to define the abnormally activated areas in the brains of people with bipolar disorder could lead to new drug treatments ...

Bipolar Disorder: More Common Than Expected?
FOX News - USA
By Miranda Hitti. A new study says that bipolar disorder, while still rare, may be more common than previously thought. Face-to-face ...

Multi-Modal Integrated Treatment for Youth With Bipolar Disorder
Psychiatric Times - Irvine,CA,USA
Given the hectic pace of clinical practice, it is difficult to keep up with the research on pediatric bipolar disorder (PBD). This ...

Bipolar disorder affects mood and thinking
Hagerstown Morning Herald - Hagerstown,MD,USA
by Dr. Matthew Wagner. In this column, I will describe what bipolar disorder is, how to diagnose it, and what can be done about it. ...

Bipolar disorder more prevalent and costly than believed; Lithium ...
Medical News Today - UK
The incidence of bipolar disorder in the general population is considerably higher than earlier studies have indicated, resulting in significantly less ...

Sexton facing a future of uncertainty
Sun-Sentinel.com - Fort Lauderdale,FL,USA
... the same exhibited by Alonzo Spellman, Dimitrius Underwood and Barret Robbins -- all high-profile cases of football players diagnosed as having bipolar disorder ...

Mental Illness Survivors Demand Parity in Medical Coverage
The NewStandard - Syracuse,NY,USA
... Her son, Nicholas, suffered from chronic depression and severe mood swings associated with bipolar disorder and had been undergoing treatment at a psychiatric ...

Health Plans Pressed to Include Wide Range of Prescription Drugs in Offerings

Federal officials are pressing health insurance plans to make available through Medicare Part D — the new prescription drug benefit that will go into effect Jan. 1— a wide-range of prescription medications, which may include a broad-array of drugs not available in many private health plans. In negotiations with some health plans, which filed their proposed formularies in April, federal officials are asking that the plans include “most or substantially all” drugs available to treat certain conditions. These drugs include anti-depressants and anti-psychotics as well as anti-convulsants, which are also used to treat some mental illnesses. (The New York Times , 6/15/05)

For NMHA’s information about Medicare Part D, click here .

HSA Implementation Hampered in Some Areas by State Laws

Some states’ law and regulations are limiting the availability of health savings accounts (HSAs) to individuals, a situation that’s becoming more evident due to the accounts’ increasing popularity. The federal law that created the accounts in 2003 requires that the accounts be paired with health maintenance organization plans that charge at least a $1,000 annual deductible. Some states, however, bar such charges for some or all medical services. Also, some states haven’t passed legislation that would allow individuals to deduct funds they contribute to their HSAs from their state income taxes, even though it is deductible from their federal taxes. Between Sept. 2004 and March 2005, the number of people who had HSAs increased by about 2.5 times. (The Wall Street Journal, 6/20/05)

Research

Many Older Adults Must Fight for Adequate Care: Older adults tend to share the perception with their physicians that many physical and mental aches and pains are common among people their age, recent research suggests. Among those who do recognize that these complaints may not be normal, many have to fight to ensure that they receive adequate care, according to experts. This is especially true for the treatment of chronic depression. Although older adults, and particularly white men older than 85 years, have a disproportionably high rate of suicide, little research has been conducted on older adults who have chronic depression. (The Wall Street Journal, 6/20/05)

Divorce, Widowhood May Up Risk for Illnesses: The longer an adult who has been divorced or has been widowed remains unmarried, the greater the likelihood that the individual will develop an illness such as heart disease or cancer, as well as mobility problems, a study to be presented this week at the Coalition for Marriage, Family and Couples Education indicates. The study was funded by the National Institute on Aging. The researchers attribute this discrepancy in part to the stresses of divorce and losing a spouse. Divorced people tend to be less active, and smoke and drink more than people who are married, the researchers note. (The Wall Street Journal, 6/20/05)

Nicotine May Share Heroin’s Affect on the Brain: University of Pennsylvania researchers reported in the journal Neuron that nicotine may affect a person’s brain through the same way that heroin and other opiates can. The researchers found, at least in mice, that both nicotine and heroin increase the levels of a protein called CREB that affects the brain’s levels of dopamine, a neurotransmitter associated with feelings of well-being. In addition, the researchers found that CREB levels not only increased when mice were given nicotine or heroin, but also increased when the mice were placed in the same environment in which the drugs were given. (Reuters Health, 6/20/05)

Pharmaceutical News

Lilly Warned Over ADHD Ad: The FDA issued a warning letter to Eli Lilly and Company about a Lilly advertisement for Strattera, a drug used to treat ADHD. The agency complained that the ad is “false and misleading” because it seems to promote the use of the drug to treat attention deficit disorder, which, although similar to ADHD, is not a disorder for which the drug has been approved to treat. A Lilly spokesperson said that the company did not agree with the FDA’s warning but had stopped using the ad before receiving the letter and will no longer use it. (Dow Jones Newswires, 6/16/05)

Researchers Find Possible Link Between Drug and Benign Tumors: A review of an FDA database of adverse drug reactions by researchers has found a possible link between Johnson & Johnson’s antipsychotic medication, Risperdal, and the development of benign tumors of the pituitary gland. The researchers’ findings were to be released last week at a University of Pittsburgh conference. The finding is preliminary and doesn’t prove an actual link, the lead FDA author of the study stressed. Her co-author also pointed out that people should not stop taking their medications until they’ve talked with their doctors about the cost and benefits of any drugs. (The Wall Street Journal, 6/17/05)

Antidepressant Patch May Be on Market Later This Year: Somerset Pharmaceuticals — a joint venture between Mylan Laboratories Inc. and Watson Pharmaceuticals Inc. — announced that it expects the FDA to complete its review of Somerset’s antidepressant product, Emsam, by Nov. 27. The FDA issued an approvable letter for Emsam in February. Bristol-Myers Squibb will market and distribute Emsam, which is applied to the skin as a patch. (Dow Jones Newswires, 6/16/05)

Antipsychotic Drug May Help With Aggression: A Spanish study published in the journal Human Psychopharmacology last week indicates that the antipsychotic medication Seroquel may be an effective treatment for the few people with schizophrenia who demonstrate aggression during psychotic episodes. The vast majority of people who have schizophrenia do not become aggressive during such episodes. (Dow Jones Newswires, 6/17/05)

72 HOUR HOLD.(Books)(Review)(Brief Article)(Brief Review)

Entertainment Weekly; 6/24/2005; Watson, Margeaux

Byline: Margeaux Watson

Bebe Moore Campbell

Novel (Knopf, $24.95)

Campbell's fifth novel imagines the well-heeled yet deeply troubled life of Keri, an L.A. boutique owner and divorced single mother who's struggling to get her 18-year-old, Ivy League-bound daughter, Trina, treated for bipolar disorder. Exhausted by Trina's paranoid and violent episodes, and frustrated by the bureaucracy of the medical establishment, Keri enlists the services of an illegal psychiatric program founded by a team of vigilantes who fancy themselves the reincarnation of Harriet Tubman's Underground Railroad. Meantime, Keri is forced to confront her own demons--chiefly, painful memories of growing up with an alcoholic mother, lingering grief over the death of her young son, and unresolved feelings for her ex-husband. Thankfully, Campbell keeps the cumbersome Underground Railroad metaphors to a minimum, producing a captivating examination of mental health in the African-American community. B --Margeaux Watson

COPYRIGHT 2005 Time, Inc.

Mandatory care for mentally ill OK'd ; State House: Some outpatients would have to adhere to treatment plans or risk being hospitalized.

Portland Press Herald (Maine); 6/19/2005; KEVIN WACK Staff Writer

Large majorities in the Maine House and Senate have approved a bill that would require some mentally ill outpatients to adhere to court-ordered treatment plans or risk being hospitalized against their will.

The measure, which deeply split the state's mental-health community and sparked passionate debate in Augusta, faces one remaining obstacle.
The Appropriations Committee, which is expected to meet later this month, must allocate $520,000 to fund the bill, said its sponsor, state Sen. John Nutting, D-Leeds.

"That's the only hurdle left," Nutting said Saturday. "There's not money enough to fund all the bills. So we still have to work very hard to make sure that it's funded."

Nutting is optimistic because both legislative chambers passed the bill by overwhelming margins. The Senate approved it 32-3, while the House vote, held shortly before the Legislature adjourned early Saturday, was 132-15.

Helen Bailey of the Disability Rights Center of Maine, who was one of the bill's most vocal opponents, expressed disappointment with the outcome.

"I don't think we persuaded very many people. So, a terrible loss," Bailey said.

Opponents of the bill, which would take effect July 1, 2006, see it as an effort to medicate sick people into compliance. They say that recovery from mental illness is possible only when patients are participating voluntarily in their treatment.

And opponents, many of whom have mental illnesses themselves, view mandatory care as a violation of basic liberties.

Backers, on the other hand, believe the bill will benefit mentally ill people who resist treatment because they don't understand they are sick. When they receive treatment, these people are more likely to keep their jobs and maintain relationship, and are less prone to violence, supporters say.

The families of people with mental illnesses will also benefit from an improved quality of life, according to supporters.

The proposal has the backing of the Maine Department of Health and Human Services, the Maine Association of Psychiatric Physicians and the Maine Sheriffs' Association.

Nutting credited that diverse coalition with the bill's passage.

"Legislators could see that it wasn't just one interest group working to pass this legislation," he said.

The proposal has changed a great deal since it was introduced in January. It would require some people with severe mental illnesses to follow treatment plans, which often include medication, after being released from the hospital.

It would apply to adults 21 and older with severe and persistent mental illnesses, such as schizophrenia and bipolar disorder, who have previously been committed to a state mental hospital and who are clinically determined to need mandatory care to survive safely in the community.

Estimates of the numbers of people who might initially be affected have ranged from several dozen to a few hundred.

Individuals who meet the criteria could be ordered by a judge to follow a six-month treatment plan that would be administered by a team of mental-health professionals.

These health-care workers would take a proactive role in the patients' treatment, making regular house calls to check on compliance.

If someone subject to a court order stopped cooperating, that person would be involuntarily hospitalized and could be forced to take medication.

Most of the $520,000 in proposed funding would pay for the formation of an Augusta-based team of mental-health professionals to administer treatment, Nutting said.

If the bill gets funding, Maine will become the 43rd state with a law mandating treatment for mentally ill outpatients.

Staff Writer Kevin Wack can be contacted at 282-8226 or at:

kwack@pressherald.com

Copyright 2005 Blethen Maine Newspapers Inc.

Processes of mental health service use by adolescents with depression.(Health Policy and System)

Journal of Nursing Scholarship; 6/22/2005; Draucker, Claire Burke

Purpose: To begin development of a substantive theory of the processes of mental health service use by adolescents who are depressed and by their families.

Design: Grounded theory.

Methods: Open-ended interviews were conducted with 52 young adults who were depressed as adolescents, four of their parents, and eight professionals who work with adolescents who are depressed. The constant comparison method was used to analyze the data.

Findings: Adolescents who are depressed and their families perceived several "treatment pitfalls" associated with formal mental health services: (a) "They'll (mental health clinicians) think I'm crazy," (b) "They'll tell my business," and (c) "They won't have a clue." The adolescents and their families interacted with the mental health care providers by engaging in the psychosocial process of "venturing through the system," that is, proceeding despite possible dangers and risks by steering clear, holding back, and letting it take hold.

Conclusions: Mental health service use by adolescents with depression involved complex and fluid interactional processes among the depressed adolescents, their parents or caretakers, and mental health care providers. Strategies are needed to avoid creating the pitfalls that concern adolescents and their families.

[Key words: depression, adolescents, mental health service utilization]

**********

Although depression is a serious mental health problem that affects the health and well being of many adolescents, few receive mental health treatment. Between 10% and 15% of children and adolescents in the United States show some symptoms of depression. The 1-year prevalence of major depression disorder (MDD) in adolescents is thought to be as high as 8.3%; the prevalence of dysthymic disorder is estimated to be 3% (U.S. Department of Health and Human Services [USDHHS], 1999). From 20% to 40% of depressed children have another depressive episode within 2 years, 70% will relapse in adulthood, and 20% to 40% of adolescents with depression will develop bipolar disorder (USDHHS, 1999).

Adolescent depression is associated with family and personal distress, problems with socialization, missed educational and employment opportunities, increased risk for suicide during the teen years (USDHHS, 1999), and multiple psychosocial impairments in young adulthood (Lewinsohn, Rohde, Seeley, Klein, & Gotlib, 2003). In 2001, the suicide rate for 15- to 19-year olds was 7.9 per 100,000 (Centers for Disease Control & Prevention, 2003). Despite 2 decades of significant advancements in the development of psychotherapeutic and pharmacological approaches for children and adolescents with depression (Kazdin, 2004; Silva et al., 2004), only 20% of children with a serious emotional disturbance receive mental health specialty services; 40% receive some form of mental health intervention; and 40% to 60% of children and adolescents who receive treatment terminate it prematurely (Kazdin, Holland, & Crowley, 1997; USDHHS, 1999). The purpose of this research is to begin development of a substantive theory to explain the processes by which adolescents with depression and their families use mental health services.

Background

Several factors contribute to the underutilization of mental health services by children with psychiatric symptoms and their families (Kazdin, 2004). Children and adolescents typically do not perceive themselves to have mental health problems and they rarely initiate treatment. Adolescent behaviors that may alarm adults, such as substance abuse, sexual behaviors, eating problems, or talk of suicide, are often not perceived by teens as problematic or requiring intervention. Adolescents who are depressed, therefore, are typically dependent on parents and other caretakers to initiate treatment. Yet, many adults fail to perceive a need for treatment even when the teen displays overt psychiatric symptoms (Kazdin, 2004). Even in cases when a need for treatment is identified, children and their parents might not use mental health services because they do not perceive them to be relevant, effective, or affordable; in addition, seeking mental health care continues to be stigmatizing (Kazdin et al., 1997; Wisdom & Green, 2004).

Research has indicated that underutilization of services by children with mental health concerns is associated with economic disadvantage and unfavorable family situations, including parental psychopathology, family stress, and adverse child-rearing practices (Flisher et al., 1997; Kazdin, Stolar, & Marciano, 1995). Use of services has been associated with parents' beliefs that their child has problems and their perceptions of the effect of the child's symptoms on others (Farmer & Burns, 1997; Teagle, 2002). African American children are less likely than are Caucasian children to receive outpatient treatment or inpatient psychiatric care; they are also more likely to receive publicly funded residential treatment and to drop out of treatment earlier and at a greater rate (Kazdin et al., 1995; USDHHS, 2001). Experts suggest that these differences might be attributable to service delivery factors, such as bias in diagnosis or mismatch of ethnicity between client and service provider (Kazdin et al., 1995).

Although little is known about the experience of service use from adolescents' perspectives, one study showed that severity of behavioral problems, positive expectations about services, and perceived choice in seeking services were associated with adolescents' satisfaction with mental health services (Garland, Aarons, Saltzman, & Kruse, 2000). In semistructured interviews, teens and young adults who had been diagnosed with mental illness by a psychiatrist made a variety of positive and negative comments about their mental health treatment; the major theme of their responses was the value of an understanding and supportive clinical relationship. They appreciated caregivers who had good interpersonal skills and could put them at ease, as well as systems that provided easy access and continuity of care. They were particularly critical of treatment that consisted solely of "doling out" medication (Buston, 2002).

Although specific factors that influence the use of mental health services by children have been identified, no reports have provided an in-depth description of the processes by which services are used by this group. Thus, the following research questions were addressed in this study: (a) How do depressed adolescents and their families decide whether to use mental health services? (b) What are common processes of mental health service use by adolescents with depression and their families? and (c) Do service use processes differ for African American and Caucasian adolescents who are depressed and their families?

Methods

Grounded theory methods (Glaser & Strauss, 1967) were used to develop the theoretical framework. A basic assumption of grounded theory is that human experience is interpreted through social interactions and is influenced by the sociocultural environment. An assumption in this study was that adolescents who are depressed have a common problem, and the ways in which they and their families use mental health services are best understood as a series of complex interactions that change over time and that are influenced by sociocultural context. Grounded theory methods include overlapping processes of data collection, categorization, reduction of data, and hypothesis formation.

Setting and Sample

The sampling area for the study was a midsize city in the midwestern region of the United States. This city has considerable ethnic and socioeconomic diversity because of its history as a manufacturing hub. Women and men from age 18 to 21 who experienced depression as adolescents and, when possible, their parents or other interested adults were sought for the sample. Because the goal of the research was to identify patterns of mental health service use throughout adolescence, we recruited young adults rather than adolescents because young adults could reflect on their adolescence in its entirety while still being "close" enough to their teenage years to remember how they experienced the depression and any mental health treatment they received. Because we were interested in ethnic influences on service utilization patterns, we sought a sample with equal numbers of Caucasian and African American participants.

After obtaining institutional review board approval, adaptive sampling techniques (Campbell & Salem, 1999) were used to obtain a diverse community-based sample of young adults. Demographic data were obtained for all zip codes in the sampling area so that neighborhoods of varying demographic characteristics could be sampled. Particularly intensive recruitment efforts were made in neighborhoods of typically hard-to-recruit participants (e.g., low socioeconomic communities and communities with large minority populations). Fliers announcing the study were placed at locations where young adults live, work, and pass through as part of their daily activities. In addition, youth workers and religious and community leaders in the selected neighborhoods were informed about the study; some of these leaders provided information about the study to young adults with whom they worked. A small group of professionals who worked with troubled youth in the schools and communities in the recruitment area were also included in the study. The research team became acquainted with some of these professionals during the recruitment phase of the study and we had prior professional contact with others.

The fliers listed common symptoms of depression and indicated that we sought men and women from ages 18 to 21 who had experienced depression or depressive symptoms as adolescents. Interested individuals were asked to call a toll-free telephone number and leave contact information. Research associates contacted potential participants, did a brief screening to ensure that they were not currently experiencing a psychiatric crisis that would make participation risky, and scheduled interviews at a site that was convenient for participants.

Data Collection

After obtaining informed consent from the participants, data were collected by open-ended interviews. The participants were asked to describe their perceptions of their experiences with depression as adolescents, with a special focus on any mental health treatment they might have received or considered. If the participant agreed to have an adult family member or caregiver participate, that person was contacted and interviewed about his or her experiences related to the child's depression. The professionals were asked to describe their experiences in working with adolescents who were depressed and to share their observations or perceptions of mental health services received by teens. Each participant was interviewed one time.

Data Analysis

All interviews were audiotaped and transcribed. The research team held six team meetings dedicated primarily to data analysis. To answer the research questions related to service use processes, all of the participants' descriptions of their experiences with, thoughts about, or recommendations regarding formal mental health treatment services (e.g., counseling or psychotherapy, medication management, psychiatric inpatient treatment, therapeutic programming) provided by any mental health or health care professional (e.g., psychiatric nurse, counselor, psychologist, social worker, psychiatrist, primary care practitioner) were examined. Constant comparison analysis was used to form the beginning of the substantive theory (Glaser & Strauss, 1967). This technique yields codes, categories, hypothesized relationships among categories, basic psychosocial processes (e.g., common changes in action or interaction patterns of individuals who have a similar experience or problem), and a core category that explains much of the variation in the data.

Sample

Data were collected from 63 participants, including 52 young adults, 4 parents, and 7 professionals. Of the young adults, 17 were male (9 African American and 8 Caucasian) and 35 were female (15 African American and 20 Caucasian). Almost half of the young adults (n=23, 44%) were students, 13% (n=7) were unemployed, and the rest reported a variety of occupations including retail sales, health care worker, food service worker, and entertainer. The majority (n=47, 90%) reported incomes under $15,000 a year. Most (n=47, 94%) were single. Five of the young adult participants had one child and three were pregnant. Of the parent participants, three were mothers (two Caucasian and one African American) and one was a father (Caucasian). Of the professional participants, three were men (one African American, one Caucasian, and one "other") and four were women (two African American and two Caucasian). Their professions were teacher and coach, case manager, youth mentor, choir director, youth minister and coach, social service program coordinator, and nurse.

Findings

The young-adult participants described experiences of adolescent depression that varied considerably in course and severity. Some had been depressed as long as they could remember; these participants typically had grown up in chaotic family situations that included violence and abuse, serious mental illness, substance abuse, or criminal activity. Others described significant interpersonal disruptions through devastating life tragedies (murder or suicide of parents), painful losses (being abandoned by a parent), and significant upheaval (becoming homeless). Some described a happy home life, but they felt isolated, ignored, ridiculed, teased, or tormented by peers. A few described a stable childhood but they experienced depression in response to their parents' divorce, a geographic move, or the break-up of a romantic relationship. Some of the young adult participants indicated that they were no longer depressed, but others said they continued to struggle with mood or other emotional problems.

The mental health treatment experiences described by the participants varied greatly. The majority of the young adults (n=42) had received mental health services at some time in their lives, ranging from a brief medication evaluation to intensive treatment throughout childhood and adolescence with multiple hospitalizations. Many received prescriptions, but few took medication consistently for any length of time. Ten participants had no formal mental health treatment. All the family members and professionals who were interviewed provided some description of their experiences with, or perceptions of, mental health services for adolescents with mental health concerns. All participants are identified here with pseudonyms.

Although the professional literature indicates that researchers and clinicians advocate increased use of mental health services for youth who are depressed, our findings indicate that many adolescents and their families perceived mental health services to be troublesome and perhaps dangerous. All the narratives, even from participants describing positive therapeutic experiences, contained some discussion of the risks of mental health treatment for adolescents who are depressed. We refer to the risks described by the participants as "pitfalls," unapparent sources of trouble or danger. The term pitfalls was chosen because these dangers or risks might not be obvious to those who provide services or to the general public, but they are salient concerns for the adolescents and their families. The three treatment pitfalls identified by the participants were: (a) "They'll (mental health clinicians) think I'm crazy," (b) "They'll tell my business," or (c) "They won't have a clue."

The core category to describe how adolescents with depression and their families interacted with the mental health community, given the common problem of fear of treatment pitfalls, was a psychosocial process we have labeled "venturing through the system." To venture is to proceed despite possible danger or risk, and a system is the prevailing social order, the establishment. Venturing through the system is the process of getting help for an adolescent's depression while attempting to avoid, manage, or overcome the actual or perceived pitfalls of the mental health system. The participants described three processes used for venturing through the system: (a) steering clear, (b) holding back, and (c) letting it take hold. The Table shows the three venturing processes and provides an exemplar from the narratives to depict each process. The pitfalls and processes are described below.

Pitfalls

Few participants indicated that pragmatic barriers (e.g., cost, no services available in their community, no transportation) or lack of awareness of available services influenced their service use; many participants indicated that their service use was strongly influenced by fears that they would be seen as emotionally disturbed, that information obtained about them or their family would be used against them, or that clinicians would be unable to g.php the true nature of their experiences. The three main fears or pitfalls identified by the participants are described below.

"They'll think I'm crazy." A major pitfall of mental health treatment is the belief that mental health clinicians will view the depressed adolescent as "crazy." Several participants indicated that they feared that if they got treatment, they would be treated as "seriously disturbed" or as a "head case." Krystal, a 22-year-old Caucasian student, described her reluctance to seek treatment: "I really didn't like it [counseling] because at that age ... you think [the counselors think] you're crazy and I didn't want that...." Participants reasoned that if a teen were seen by a clinician as "crazy," the teen would be hospitalized (e.g., "put in the crazy house," "locked up," "sent to the funny farm") or medicated (e.g., "put on drugs"). Teens and their families who are concerned that the teens' problems will be viewed as a "severe psychiatric problem" are especially leery of medication, which many believe will not solve the teens' problem and will cause them to be "messed up" or "turned into a zombie." Matthew, a 21-year-old African American hospital worker, suggested that teens might be more likely to get help if "they know you aren't going to strap them up and pump drugs in their system."

"They'll tell my business." Another pitfall of mental health treatment is the belief that private information will be revealed and used against the teen or the family. Several participants said that mental health care providers "run their mouth," "tell [our] business," or "say something to somebody." Teens who live in chaotic or abusive homes are likely to be concerned that if they seek help for their problems, the "authorities" (e.g., child services) will be contacted. The fear of a mental health care provider "telling my business" was especially predominant in the narratives of African American participants. Maris, a 21-year-old African American mother, described how her first therapist "had me smiling, talking, and stuff," but then shared information about her home life with child protective services. Marls said, "I try to be honest, but it's like I was telling her [the therapist] too much information. She did help me, but she was against me. Childrens' Services was always there. I decided to never tell her everything [again]."

Minors in therapy have a unique burden because some of "their business" may be revealed to the adults who care for them. Several participants had shared information with a therapist, thinking it was confidential, only to find out that the therapist had divulged some of the information to a parent. Other participants bemoaned the common practice of including parents in some, if not all, of the therapy sessions because teens often do not want to discuss some of "their business" with a parent present. Adolescents and their caretakers who are seen by the same therapist often wonder whether the therapist is on the "side" of the teen or on the side of the adults, and they wonder whom the therapist primarily "blames" for the problems in the family. Brittany, a 21-year-old Caucasian student and child care worker, described her reaction when her long-term therapist began to include her family in her sessions. She said, "When my mom got married the second time to the doctor, we actually all started seeing her [a therapist].... I was like 'Oh yeah, I can talk now.... I DON'T THINK SO' [with emphasis]."

"They won't have a clue." A third pitfall is the belief that the teen will be assigned a clinician who is "clueless," that is, a clinician who has no understanding of the teen's thoughts, feelings, or experiences. Several participants suggested that clinicians are "clueless" because they are from a different generation ("the bald guy with a mustache, which was gray") or because they are "just doing their job" and have no interest in trying to understand the adolescent. Therapists' behaviors associated with being "clueless" included "constantly checking his watch," "writing in the secret notebook," "having me play games," "asking dumb questions," "folding his hands and saying, ummm," "providing crappy advice," and "condemning my lifestyle."

Several African American participants questioned the wisdom of seeking help from the "mostly White" mental health care providers because they believed Caucasian therapists could not understand their experiences. Many spoke of relying on family, close friends or clergy for support because they "know you best." Jadyn, a 20-year old African American retail sales worker, discussed her experiences talking with a Caucasian therapist:, "It is not a good experience. When I leave I feel [terrible].... I mean I just can't relate to it. I just can't sit and talk to her [the therapist] for an hour." In contrast, her experience with group therapy was positive because she was with "peers." She said, "Just to be able to talk to them and get their advice, what they would do, would help me more. I don't mind talking around those girls--it was cool." Some African American participants indicated that depression originates in the oppressive environment and cannot be solved by "talking to someone." Aaron, a 20-year old African American who was an.phpiring rapper, stated that he did not consider getting mental health treatment for his depression because he believed that his life circumstances and the racism he encountered caused his low mood. He said counseling made no sense because "the man is the problem."

Venturing Through the System

Because discussions of the pitfalls were so salient in the narratives, we concluded that the interactions of adolescents who are depressed, their families, and the mental health care providers are best understood as responses to the pitfalls. Teens and their families venture through the system by (a) steering clear of treatment, thereby avoiding the pitfalls; (b) holding back during their treatment experiences, thereby managing the pitfalls; or (c) letting the treatment take hold, thereby overcoming the pitfalls.

Steering clear. For some adolescents and their families, the fear of treatment pitfalls was so strong that they refused any contact with the mental health system. Steering clear is a process of bypassing any involvement with mental health clinicians in order to avoid the treatment pitfalls. Steering clear is common when a teen, at least one parent or caretaker, or the family experienced a treatment pitfall in the past, or when they adamantly believed that the pitfalls are inherent in established mental health services. Some young adult participants indicated that they wanted to avoid treatment so badly that they hid their distress from, or pretended to be "normal" around, anyone who might insist they get treatment. Others indicated that a parent was opposed to mental health treatment. They explained, "My parents were really negative about counseling," "My dad just refused to go," "My mother is highly against it," "My father thinks therapy is a farce," or "My father just doesn't believe in it."

Steering clear was especially evident in the narratives of African American participants, who were concerned about all three pitfalls. One of the professionals, an African American youth worker, explained, "I don't think we (African Americans) go to psychologists like Whites.... As a culture, we deal with it. You might talk to your pastor. But paying someone, being diagnosed ... I don't think we think like that." Several African American participants indicated that they never considered mental health treatment; rather, they got help from extended family and church members; other informal networks, such as neighborhood community centers or faith-based programs; or God. They said, "I don't mess with mental health people," "My peers are my psychiatrist," and "God is the best counselor."

Holding back. Many teens and their families who were leery of the mental health system nonetheless received some form of mental health treatment. Holding back involves receiving treatment without allowing oneself to become fully immersed in the process in order to manage the pitfalls. Participants described holding back by not revealing all their symptoms to the clinicians, being selective about sharing personal information, and remaining detached from the "clueless" therapist.

Holding back is common when the adolescent does not want treatment, but a parent or caretaker insists the person "get help." Several young adult participants talked about "lying," "playing along," "leading the therapist," "talking enough to get him [the therapist] off of me," or "giving little responses, but without being too cooperative." Robert, an 18-year-old Caucasian who was unemployed, described holding back in a relationship with a therapist whom his father insisted he see: "Eventually I got in to see a volunteer girl, real nice.... Eventually I started talking to this girl but I didn't tell her about the drug use. Some things I had to make up...." His mother, who was interviewed separately, described the holding back, but with different terms: "The first time [in counseling] he [bluffed] his way out of all that [drug abuse]. He'd get in the car and start going on and on about the things he said and I thought, 'Robert, none of this is going to help you if you don't tell the truth.'"

Another holding-back strategy used by teens who did not want to be in treatment was going to a few treatment sessions but "getting out of it [treatment]" as soon as possible. Young adult participants described having "gotten out of it" by persuading their parents that (a) they would rather confide in them than in a stranger, (b) the few sessions had rendered them cured, or (c) their parents were "just wasting their money." Some participants revealed that "getting out of it" was "relatively easy" if one's parents were ambivalent about mental health care or if one got a clinician who would not follow up or was "easy to fool." The parent and the professional participants confirmed that parents are often wary of "nagging" a teen who does not want treatment, fearing they may push away an already aloof teen, and that some mental health professionals do seem to "give up" too quickly on teens who resist treatment.

The process of holding back is common when medications are prescribed for depression. Many young adult participants indicated that they agreed to take medication when it was prescribed, but they maintained control over this component of their treatment by "playing with" their dosage, "taking the medication two or three times and then just stopping," and "taking it for a month and then throwing the pills down the toilet." Few parents checked to see if the teen was taking the medication as prescribed. The practitioners who prescribed the medications often failed to establish a relationship with the teens or persuade them that a medication could be helpful. One health care provider described working for a long time to persuade a reluctant family that a teen needed mental health care, only to have the clinician "drop the ball" by just providing medication and failing to engage the family in more comprehensive treatment.

If the process of holding back continues for any length of time, the treatment often "fizzles out," "dies on the vine," or "just goes nowhere." Holding back is associated frequently with a service use pattern whereby an adolescent sees several different clinicians over time or sees the same clinician but with frequent interruptions ("in and out," "off and on" counseling). These patterns might result in some relief of distress or short-term symptom management, but they do not facilitate significant recovery or result in any major life changes.

Letting it take hold. Despite awareness of and concern about the pitfalls, some adolescents and their families nonetheless received mental health treatment that they perceived to be helpful. The participants described how, despite the adolescents' initial wariness of mental health professionals, some nonetheless let the treatment "take hold," "click in," or "get somewhere." Treatment took hold if an adolescent connected in a substantial way with at least one mental health clinician in the system. All the participants who reported positive treatment experiences described "clicking with," "connecting to," "bonding with," "relating well to," or "feeling comfortable with" a clinician. The young adult participants described these professionals as cool, funky, persistent, passionate, or determined people who could "relate at our level," "tell jokes, but have a serious therapy style," "not talk down to us," and "take time to really get to know US."

Connections with professionals allowed the adolescents to overcome the pitfalls and secure therapeutic gains. When teens discovered that they were not considered "insane," that their disclosures would be protected, and that they were respected, they could begin to "deal with real stuff" or "deeper issues" in treatment. Participants indicated that "deeper" issues for them included "checking back into childhood," "tapping into things in me that I didn't see in myself," and "going back to where it started from [usually childhood maltreatment]."

Our data indicate that when an adolescent was initially resistant to getting help, as was often the case, treatment took hold under three conditions: (a) a parent or caretaker was persistent and proactive in ensuring that the teen continued with the treatment, (b) the clinician was nonjudgmental, trustworthy, and receptive to the teen's concerns, and "hung in there" until the treatment took hold, and (c) the teen decided to let down his or her guard.

Discussion

Researchers have attempted to study child mental health service utilization by investigating the relationships among discrete predictors (e.g., demographic variables, indices of family distress or dysfunction, measures of the family's perceptions of the effects of the child's depression on others), and dichotomous measures of utilization (e.g., unmet need, premature termination; Farmer & Burns, 1997; Flisher et al., 1997; Teagle, 2002). Our findings showed, however, that service use for adolescent depression involved complex and fluid interactional processes among adolescents, their parents or caretakers, and mental health care providers.

The two-dimensional nature of the model presented in the Table might appear to indicate that the three venturing processes are sequential and that progressive stages occur so that teens, families, and clinicians gradually overcome pitfalls and obtain or provide optimum mental health care. All participants in this study engaged in one or more of the processes, but their trajectories varied. Some described trajectories in which the processes unfolded in the sequence depicted in the model; others described trajectories that were regressive or circular. For example, a trajectory in which a teen forms a strong relationship with a therapist (letting it take hold) but decides not to get close to a second therapist after the first moves away (holding back) would be a regressive trajectory because the teen is moving away from, rather than toward, helpful treatment. An example of a circular trajectory would be one in which a teen relates well to a clinician (letting it take hold), refuses further treatment because the clinician reveals information to the parents (steering clear), and develops a good relationship with a therapist as an adult when the parents would no longer be involved in treatment (letting it take hold).

Regardless of the complexity of the trajectories, the theoretical model indicates that mental health professionals who work with or plan programs for adolescents who are depressed should be aware of the pitfalls most likely to deter a successful course of treatment. To avoid creating pitfalls, mental health care providers should develop specific strategies to (a) convey to adolescents and their families that the adolescents will not be treated as "crazy," nor will the clinician "only push drugs," (b) address the issue of information-sharing directly with teens and give them as much input as possible over when and how "their business" is shared either with the "authorities" or with their families, and (c) relate to teens in ways that reflect an appreciation of their age, their ethnic background, and their specific life circumstances. If behaviors typically viewed as resistant are instead viewed as strategies to avoid pitfalls, interactions among teens, their caretakers, and mental health clinicians might be more likely to facilitate successful treatment. In our sample, the pitfalls were of special concern to African Americans and the process of steering clear was particularly common in this group. This finding is consistent with federal reports calling for increased alternative and culturally competent mental health services for minority adolescents and young adults (USDHHS, 2000, 2001).

A limitation of the study is the small number of parents we were able to recruit. The young adults were reluctant to have their parents included in the study, either because they had conflicted relationships with them, or because the young adults had "moved on" from their families physically or emotionally. The data we collected from the four parent participants were nonetheless helpful because we could compare their perspectives with those of their young adult children. Because the professionals we interviewed work with youth and their parents in the community and the schools, the professionals were able to share their observations and perceptions of interactions among teens, their parents, and mental health care providers, thereby supplementing the narratives of the parents. In addition, some of the professionals had themselves been parents of depressed teens. Because multiple perspectives enrich descriptions of service use processes and could enhance development of a substantive theory, we recommend that future researchers obtain data from all groups of people involved in service use, including mental health care providers who treat children. Another direction for research could be prospective studies to follow children judged to be at risk for mental health concerns throughout their teen years to determine what sociocultural factors influence the course of the illness and either facilitate or hinder successful use of mental health services.

Conclusions

Adolescents with depression and their families perceived several pitfalls associated with mental health services. They interacted with mental health care providers by engaging in the psychosocial process of venturing through the system.

Mental health service use by adolescents with depression involved complex and fluid interactional processes among the depressed adolescents, their parents or caretakers, and mental health care providers. Strategies are needed to avoid creating the pitfalls that concern adolescents and their families.

Table. Venturing Through the System

Venturing processes Exemplars

Steering clear: Matthew, a 21-year-old African American
To avoid the hospital worker; he had moved to a school
treatment pitfalls that was "mostly White" and became depressed
while at the new school. He experienced
ostracism by peers and racist remarks by the
teacher. The interviewer asked him if he
would have liked to have received mental
health services for his depression.
"No, not at all. It was just, I associated
that with being crazy. And I wasn't crazy.
I just hated my situation, there was nothing
they could say to me, and then you know ...
they would just try and put me on drugs, and
I don't need to be put on drugs. I just need
to get out of this school ... I guess that
has a negative connotation, when you say,
would you like mental help, you know, and
you start to think, well, you know, oh no,
they're going to lock me down. I don't think
I would have wanted it."

Holding back: Brittany, a 21-year-old Caucasian student and
To manage the day care worker; she had been physically
treatment pitfalls abused as a child and had a severe eating
disorder and depression as a teen.
"I felt very suicidal and asked a guidance
counselor at the time for help. I was
then paired with a psychologist in the
surrounding area and things would get
progressively better. My mother was highly
against me getting help, didn't feel there
was any reason for it so she would have a
very difficult time with me going and would
yell and say aren't you done yet, you've got
to be done with this, aren't you better yet?
So then I would end up quitting, saying ok,
I'm done, I'm ok, I can handle this. Four
to six months would go by and I'd hold it
together pretty well and then I'd just crash
and I'd end up even in a deeper depression
the next time and would have to build back
up. And it just kind of went that pattern
for years... The psychologist really helped,
but there was still that line that I
couldn't ... I didn't feel at the time that
I could tell her what was going on."

Letting it take hold: Alexis, a 21-year-old Caucasian customer
To overcome the service representative; she had been
treatment pitfalls severely depressed and engaged in cutting
behavior since she was a child.
"First of all, it [treatment] made me see it
as a fixable problem, where at first I
thought that was kind of a joke, I was like
'Oh these silly mental health professionals
think they're going to make me better, what
are they thinking, they don't know what's
going on inside my head.' But you know just
their perseverance and everything and like
their calm determination. It was really
annoying at first because I could not make
them break down and just leave me alone.
And ... at the beginning I felt like, 'You
don't really care about me, you're just
doing this because it is your job.' But I
had really good therapists. I ... remember
seeing [one who] just tapped into things
about me that I didn't see. Just involved
enough to say the right thing and make
me change a little."
References

Buston, K. (2002). Adolescents with mental health problems: What do they say about services? Journal of Adolescence, 25, 231-242.

Campbell, R., & Salem, D.A. (1999). Concept mapping as a feminist research method: Examining the community response to rape. Psychology of Women Quarterly, 23, 67-91.

Centers for Disease Control and Prevention. (2003). Health, United States. Retrieved April 10, 2004, from http://www.cdc.gov/nchs/fastas/ suicide.htm

Farmer, E., & Burns, B.J. (1997). Impact of children's mental health problems on families. Journal of Emotional & Behavioral Disorders, 5(5), 230-239.

Flisher, A.J., Kramer, R.A., Grosser, R.C., Alegria, M., Bird, H.R., Bourdon, K.H., et al. (1997). Correlates of unmet need for mental health services by children and adolescents. Psychological Medicine, 27(5), 1145-1154.

Garland, A.F., Aarons, G.A., Saltzman, M.D., & Kruse, M.I. (2000). Correlates of adolescents' satisfaction with mental health services. Mental Health Services Research, 2(3), 127-139.

Glaser, B.G., & Strauss, A.L. (1967). The discovery of grounded theory: Strategies for qualitative research. Chicago: Aldine.

Kazdin, A.E. (2004). Psychotherapy for children and adolescents. In M.J. Lambert (Ed.), Handbook of psychotherapy and behavior change (543-587). New York: John Wiley & Sons.

Kazdin, A.E., Holland, L., & Crowley, M. (1997). Family experience of barriers to treatment and premature termination from child therapy. Journal of Consulting and Clinical Psychology, 65, 453-463.

Kazdin, A.E., Stolar, M.J., & Marciano, P.L. (1995). Risk factors for dropping out of treatment among Black and White families. Journal of Family Psychology, 9(4), 402-417.

Lewinsohn, P.M., Rohde, P., Seeley, J.R., Klein, D.N., & Gotlib, I.H. (2003). Psychosocial functioning of young adults who have experienced and recovered from major depressive disorder during adolescence. Journal of Abnormal Psychology, 112(3), 353-363.

Silva, S., Petrycki, S., Curry, J., Wells, K., Fairbank, J., Burns, B., et al. (2004). Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression. JAMA, 292(7), 807-820.

Teagle, S.E. (2002). Parental problem recognition and child mental health service use. Mental Health Services Research, 4(5), 257-266.

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services,

National Institutes of Health, National Institute of Mental Health. (1999). Mental health: A report of the Surgeon General. Rockville, MD: Author.

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health. (2000). Report of the Surgeon General's conference on children's mental health. Rockville, MD: Author.

U.S. Department of Health and Human Services. (2001). Mental health: A report of the Surgeon General--supplement: Culture, race, and ethnicity. Rockville, MD: U.S. Department of Health and Human Services, Substance abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

Wisdom, J.P., & Green, C.A. (2004). "Being in a funk:" Teens' efforts to understand their depressive experiences. Qualitative Health Research, 14(9), 1227-1238.

Claire Burke Draucker, RN, PhD, CS, Delta Xi, Distinguished Professor and Director, Graduate Program in Psychiatric Mental Health Nursing, Kent State University, Kent, OH. The research reported in this article was funded by the Ohio Department of Mental Health, Grant 02.1179. The author acknowledges the research team: Tom Rusk, Laura Paisley Mullen, Karen Strickland, and Andrea Warner. Correspondence to Dr. Draucker, College of Nursing, Kent State University, Kent, OH 44242-0001. E-mail: cdraucke@kent.edu

Accepted for publication October 5, 2004.

COPYRIGHT 2005 Sigma Theta Tau International Honor Society of Nursing

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