Season 4 | Episode 6

Title: Mental Health
Merck Manuals Medical Author: Michael B. First MD, is a Professor of Clinical Psychiatry at Columbia University, and is a Research Psychiatrist at the Biometrics Department at the New York State Psychiatric Institute and maintains a schematherapy and psychopharmacology practice in Manhattan, Dr. First is a nationally and internationally recognized expert on psychiatric diagnosis and assessment issues and has conducted expert forensic psychiatric evaluations in both civil and criminal matters, including the 2006 trial of the 9/11 terrorist Zacarias Moussaoui.

Opening Audio: It's so normal that one in four adults actually suffer from some sort of mental illness. So, I want you to take that in, count yourself, the person to the left the person to the right of you, and the person behind her in front of you. That's four, one of you is suffering from mental illness. But we're all high functioning adults.

Joe McIntyre: Mental health affects every aspect of our lives, how we feel about ourselves in the world. How we solve problems cope with stress and overcome challenges. Of course, mental health challenges can be difficult to define and address. On today's episode, we welcome Dr. Michael B. First. Dr. First is a Professor of Clinical psychiatry at Columbia University, and is the editor and co-chair of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders fifth edition text provision known as DSM 5 TR. He joins us today to examine the misconceptions surrounding mental health doctor first we'll also highlight how to help you or someone you know who is dealing with a mental health crisis. Doctor First thanks for coming on the show.

Michael B. First MD: My pleasure.

Joe McIntyre: Now, there are tons of terms and mental health disorders that are thrown around the media. You hear about bipolar disorders, depression, schizophrenia. Let's get to the truth. What is schizophrenia?

Michael B. First MD: Schizophrenia is an illness characterized primarily by psychotic symptoms. Now psychotic symptom is a symptom where you lose touch with reality. So, for example, you hear a voice, and you actually experience it as a real voice talking to you that would be a possible symptom of schizophrenia. Another symptom is delusions believing something with complete certainty is being true when in fact it's not. Those are two of the hallmark symptoms, but other symptoms like disorganized speech and having no motivation. So, it's really a cluster of symptoms, and it's a condition. Unfortunately, it's often lifelong. As it started in the prime of life, adolescence and early adulthood and people with schizophrenia often get derailed and have a very difficult time functioning but there are some treatments it's not hopeless, but it's a difficult condition. So, it's a relatively rare but in some it's something that we do our treatments for, to make life manageable, if you have that condition.

Joe McIntyre: Is it the same as having a so called split personality?

Michael B. First MD: That's, unfortunately, the word skits. So it's where it comes from. And the schizophrenia meant split brain because there was some sense of sense of that there was something split in how you are back. Split Personality, that phrase usually, is what people talk about with multiple personality disorder. That's when you have somebody says split personality. It's usually which is actual condition. There's a condition called dissociative identity disorder that used to be called Multiple Personality sorter so often when people hear the word schizophrenia, they're thinking of multiple personalities. So that's a condition where people actually have different personalities that they switch one to the other.
Joe McIntyre: Is multiple personality disorder different from a bipolar disorder?

Michael B. First MD: Yes, so bipolar disorder is a mood disorder. And it's called bipolar because people with bipolar disorder have both ups and downs. So, depression is everybody certainly familiar with depression. It's normal to be depressed. But depressive disorder is a level of depression in which the severity and the persistence is such that it gets in the way of your life. So that's, that's one of the most common mental disorders as mentioned, depression. Bipolar disorder is like major depression. People with bipolar disorder have the depressive episodes like people with depression. They also have the opposite episodes of elevated euphoric mood, they feel on top of the world, they lose the judgment, they get into trouble. Often the people ended up having to be hospitalized to protect themselves or others. So that's, that's so bipolar really means the bipolar names means the up and down the ups and the downs.

Joe McIntyre: Is everyone affected by a mental health illness in some form, or is that just a myth that that's kind of pervasive now?

Michael B. First MD: Yes, I mean, I think it's important to differentiate between a mental health disorder and symptoms. So, a mental health symptoms or any kind of anxiety, depression, being confused. Those are symptoms that are characteristic of mental health disorders but having a symptom does not mean you have a mental health disorder. It's normal to be depressed you wake up the wrong side of the bed, you're feeling that with that day, that doesn't mean you have a disorder. It means you may have depression or sadness for the day, in order to consider something a disorder. The symptoms have to be around long enough and get in the way for functioning in some way. That's the boundary between a disorder and just symptoms. So if you look at the who has a mental health disorder, that it's definitely not the case that everybody has always had a mental health disorder. It's certainly the case that mental health symptoms are ubiquitous.

Joe McIntyre: Are all mental health disorders permanent?

Michael B. First, MD: No, no, not at all. I mean, the names of them unfortunately go on, but many of them happen as an episode and they go away and they never come back. Most of them respond to some degree to treatment and some are completely relieved by treatment. So mental health disorder used to be thought that having a mental health disorder you'd be stuck with it. That's certainly not the case. There are a couple of disorders that are very generally are considered to be lifelong, but the most common ones are not.

Joe McIntyre: And what is a mental health crisis? Can you define that a little bit? How is that different from a mental health disorder?

Michael B. First, MD: Well, the word crisis implies some emergency need for help right away if you're in a crisis you're on the verge of not functioning, maybe you are feeling suicidal, or homicidal, perhaps and the crisis is the symptoms of a mental health disorder or basically need to be addressed immediately in order for you to continue functioning, not get into trouble. So that's what makes your crisis but that's certainly not most disorders. People are not in a mental health crisis. Like, if you have periods of your life where you're in crisis, and most of the time we're not.

Joe McIntyre: On the topic of depression, what is the difference between having, you know, a bad week you're feeling down, things aren't going your way and being depressed?

Michael B. First, MD: It's really the feeling of depression can be very similar, you know, sadness, pessimism, feel hopeless. So those symptoms which are if you go the diagnostic manual, that is the editor of the finds all sorts of the way to find major depressive disorder, which is a mental health disorder that is the one that's most common for depression. In order to say somebody has that you have to have depression plus a bunch of other symptoms and typical symptoms of depression is you lose interest in things you have trouble sleeping or you sleep too much, you overeat or lose your appetite. If you're worthless can't concentrate that cluster of symptoms together is what defines the major depressive episode. And those steps have to be around nearly every day for at least two weeks. So that you need the duration. You need the cluster of symptoms and the severity so that it's interfering with your life. So that's what differentiates sadness, which is normal, a normal human reaction when things don't go well, it's normal to feel sad or you do someone it's your grief reaction, you feel sad or you get fired from a job or you don't get what you want, whatever it is that those are normal human emotions, anger, I mean all kinds of emotions or anxiety does. It depends upon the context and usually, if it's temporary, we do not consider that evidence in the mental health disorder.

Joe McIntyre: Now are all mental health conditions, something that run in families or only some? How does genetics play a part in mental health?

Michael B. First, MD: Its variable certain disorders are very, very genetic meaning that that one way you can see what genetic the best way to see how much something genetic is, in these kinds of cells you do you find identical twins. So, if you have identical twins, in theory, their genes are exactly the same. So the degree to which you have one twin has one condition and the identical twin has the same condition. If that happened 100% of the time, that means it's completely genetic. That happens 50% of the time that suggests that there's some environmental factors that combined with the genetic, the cause sort of happen. So that's the genetic is a very variable thing, but certain disorders are considered to be more hereditary than others. Things like schizophrenia for example, if you have a relative with schizophrenia, you're much more likely to have schizophrenia yourself. Same is true with Bipolar is same is true with depression. Same is true with substance use. disorders. So most of the disorders, there's at least some genetic component, but the degree to which genetic is very variable from one disorder to another.

Joe McIntyre: Now, we mentioned that not all mental health disorders are permanent, which is great. Can they go away on their own or do all mental health disorders or mental health challenges require some sort of intervention in some way?

Michael B. First, MD: Not always. I mean, if you get an evaluation for a problem, one possible recommendation is let's just see what happens because many disorders, but bad thing happens and you're depressed for example, and you feel very sad, and it's like a week into it. It's very likely then another week goes by it'll go away and so you don't need any treatment at all. But if it if you when it goes on and on and on, you don't get treated. It's beginning it's suggested it probably will not go away on its own you need to have it or bench so that's why it's extremely important. If you have a condition lasting long enough and it hasn't gone away on its own, then seeking help is something we always recommend.

Joe McIntyre: Now, I think we can probably assume the answer to this question, but maybe you can dive a little bit deeper into it. Is mental health a sign of weakness or there's something wrong with you? Is that actually what the case is?

Michael B. First, MD: Well, that's the big problem with the stigma of mental health. A lot of people amazingly will not take medication for mental health conditions. They won't see a mental health professional because it feels like it's their character is weak and it reflects on them as a person. And because of that they feel so ashamed up and they keep quiet about it used to be a family member who had a mental illness. Nobody ever talked about it because having a mental health disorder was considered to be a sign of shame. Luckily, in the past 50 years that has made some major changes I think part of that has to do with the number of celebrities who come out and share the fact that they've had these conditions that helps to really prove stigmatize issues a person can feel comfortable sharing it, and it really shows that these things are really quite common, and it's often helpful to be able to talk about so I think that the there's unfortunately still large segments by like that. I think a lot of people continue to be very embarrassed and do not want to seek help, because either it's embarrassing, or they just don't they feel that it's a statement of their character.

Joe McIntyre: And they don't want to even according to the CDC, mental health is among the most common health conditions in the US. Like you said, the stigma is still there, and it still remains are there any ways that we can overcome the stigma around mental health? What should people do which society do I know it's a big question, but maybe that's maybe have an answer.

Michael B. First, MD: On an individual level, I think it depends upon one's situation. Very often people assume that if they share the fact that they have a mental health condition that the person is sharing it with will sort of indicate that they disapprove of that. I think that's that that's an assumption that people have, but more often than not, much more often than not, that's not the case people understand. They're empathic and if in fact, you do get the courage to share it with someone who cares about you, and they show you that they don't have a negative reaction. In fact, they want to help you that can be very, very comforting. So I would encourage people, if they're hesitant to share they want to keep a secret. Now certainly there going to be people they did they have a grandmother or something they know what they think about mental health conditions, you may not want to share it with that person. But most people nowadays younger people in particular, understand that mental health disorders are just like medical conditions and you know, that used to be like it used to be to present medical conditions cancer a long time ago was the same kind of thing. You would never say that you had cancer. You wouldn't even tell patients. They had cancer. There was such stigma, that luckily has really improved. I think the mental health disorders are among the last ones to get the stigmatize and I think we've made major project progress, but I think over time, it'll continue to get less and less stigmatizing the other one substance use disorders as the same way. I think those are generally quite stigmatized. I think people are seeking help and getting less stigma from it.

Joe McIntyre: In your eyes, has social media impacted mental health in a negative way and a positive way? They're both you know, good or bad aspects of social media when it comes to mental health?

Michael B. First, MD: Exactly, absolutely. It's good in the sense that people who tell their story about their mental health condition first have to hear somebody if you are suffering from a health condition. You've never told anybody, and you go on social media and somebody's telling their life story. You see, they have the same thing and they tell you, they went and sought treatment, and now they're completely better. That's a huge impact and motivating people to actually get help because people often think that if you have this is hopeless, there's no reason to get help, because it's never going to get better. So, if you hear story after story, and people talking about how they had this, they sought help and got better. That's a positive thing. The negative of course, is a lot of people who are on social media who are not are very critical and make fun of people and bully. You know, this lot of bullying and sharing something that you have a mental health disorder would be true for the physical disorder as well. But sharing something vulnerable that yourself could get some stranger to come after you. So that's the problem with social media that you can't control who reacts to what you post and sometimes it's mostly it's positive people that are very nice. I had that and I really better to get help or the opposite. So I think social media goes both ways.

Joe McIntyre: What are some ways we can combat mental health challenges in our day to day lives, let's say you know, we're, we feel like we're struggling for a little bit. We may want to seek help, or we want to take care of something on our own. What are some ways we can combat these mental health challenges?

Michael B. First, MD: Well, some conditions actually can be improved by lifestyle changes, getting enough sleep and exercising and eating around. It sounds like a cliche, but that's a huge amount of data that shows that all three of those are very, very important to calm if you're feeling down or anxious. If you make corrections, there you can actually have a positive impact on what you're suffering from. So that's for starters, and you're reducing stress, if that's possible, and you'll be reaching out to other people you have one of the things that happened during COVID was people's being cut off. I think the rates of depression anxiety went up largely because people got very isolated and that kind of proves the point. That social interaction with people who care about you is very, very helpful and making you feel grounded and will help usually improve most mental conditions. So, I think seeking out help seeking out activity of depressions ability to stay in your room and brood about it all day and avoid doing the kinds of things that normally would give you pleasure, that's a recipe for not getting better than forcing yourself to go out and get together with friends. That usually helps. What happens is people with depression, have a distorted thinking they're very pessimistic, they assume that nobody wants to be with them that they're a drag. So, they won't even call anybody up or if somebody called them up to go Apple said no, no, I don't want to, if they could force themselves to go after actually show that in fact, it's helpful to go out. If you get past that barrier of thinking negatively. You get to disprove that negative attitude by doing it and seeing in fact things go very, very well.

Joe McIntyre: What should someone do? If they are having a mental health crisis or they think they may be having a mental health crisis? What should they do?

Michael B. First, MD: Well there a couple of options. I mean, I think there are hotlines, I mean, suicides, the number of suicide hotlines and there are people who are trained and those lines are open. And the point is when you call those hotlines, that person will talk with you and help you listen to what you have. And if they think that you need professional help, they would, would suggest perhaps it would be really helpful to go seek that out. So that's one thing your primary care doctor has. They are trained to use. Many of the medications that we use for psychiatry, and they're capable of I mean, because it's so common in primary care doctors are basically see all kinds of conditions. They're in a way the first line for getting help. So primary care doctor either will treat the person on their own or they'll have a network of other counselors or other people that they could refer to. So that's one and the other is family members. I mean, telling us one of the advantages actually of sharing. If you're depressed and you've never told anybody that you tell a family member, a friend of God that they may say, oh, actually therapy is the best and then they could help you find a referral as well. So, there's many, many things you can do to try to get help. The important thing is to feel that it's okay to get help and try to seek it because help it can be very, very effective.

Joe McIntyre: Let's say a family member or friend comes to you telling you that you had that they have some sort of mental health challenge or they're dealing with some depression or anxiety, whatever it may be. Is there a way that you would recommend that person react? How would they go about helping them? What are some of the strategies there?

Michael B. First, MD: Well, one of the things if a family member tells you that the first thing to do is to is to destigmatize it by wanting to get Tell Me More and then when they start telling you empathy, oh, that sounds really terrible how you feel you know that that kind of interaction that is itself can be therapeutic. So I think that reacting with with wanting to help is probably one of the most important things and just being accepted thing because again, many people with mental health threats because they've been so stigmatized. I think people just assume that if you share this with someone you're going to get a negative reaction. So if a family member does tell you and you actually show them that you're welcoming, hearing about and you'd like to do anything that could help that could be very, very helpful because many people feel very alone and isolated and that many mental disorders are made worse by this feeling of isolation. And then sometimes, I think if you feel the person is in danger of hurting themselves, then I think that you would might want to recommend that they get held very strongly. And if they are in danger of hurting themselves and they don't want to get treatment, the last resort is to call for EMS or somebody to take that person and get them help in a safe environment.

Joe McIntyre: When it comes to mental health challenges, do you need to use medication? How does that process go from? As a psychiatrist? How does that process go about prescribing someone medication to assist with their mental health?

Michael B. First, MD: It kind of depends on the condition. There are certain conditions like schizophrenia and bipolar disorder where it's widely accepted that it the only way to really get better is to be taking medication. But there are many conditions even depression. I mean, a lot of people take antidepressants, but there are many, many studies show that certain kinds of psycho psycho therapies for depression and cognitive behavioral therapies, that study that works equally well as taking medication. So it's really your choice. So good. Psychiatrist, when somebody were to come, I would give them both choices or you know, medicine could work very well. But if you'd rather do psychotherapy, viveza psychotherapy for depression is you actually learned skills that you can take forward. If you are seeing the world in a negative way. One of the aspects of the treatment is to identify your negative thoughts and sort of counter them with positive thoughts. And that's a whole thing you learn that skill which is one of the big advantages to depression. And taking a pill. On the other hand, you don't learn anything other than the fact that the pill will help which is good, but you can't really carry that. So I think there's a big difference like a therapy over medication in the back that it's a skill that you learn it can help prevent future episodes of depression.

Joe McIntyre: If you're on you know, some anti depression medication is it best to combine that with actual you know, talking to a to a therapist or psychiatrist regularly to make sure you're not only?

Michael B. First, MD: would always I mean, I unfortunately see many, many people who I'm a psychiatrist and I, people come to me, usually they come to me, they are expecting to get medication because that's why they're coming. Because the way it works in the mental health field is psychiatrists are the only ones who are allowed and I guess nurse practitioners only when those who are allowed to prescribe medication social workers psychologists can to generally if somebody comes to a psychiatrist, that usually because they know that that person is often a tilt towards medication I yield. Back the combination of psychotherapy and medication in VR believed the best but there's some people who prefer to just take a pill, they do work very well. It's like I can't really argue with that plan. But if they want to take the pill and get better, that's fine. But the best possible thing is usually some psychological issue that is triggering whatever the condition is, that could be helped by psychotherapy and again, prevented from hurting

Joe McIntyre: Dr. First, is it ever too late to get help? We feel like we've exhausted all options and nothing's working. And if you get to that point, what do you think are the best resources to find that help that you desperately need?

Michael B. First, MD: One of the challenges in treating mental health disorders a lot of the medications work for some people and not others. So, if you've had some lack of success, I would not there's lots of reasons that may have nothing to do with your condition being untreatable. You may be given the wrong treatment, you may not enter, connect well with the therapist, so I wouldn't I mean, it's certainly understandable. Somebody's been in three different therapies, people fail, the person may forget it, I'm just never going to get better but the therapies are so different and the interactions with the therapists can be so different, that I think it's important to continue to look for good therapists and if you just randomly call people up, you're going to have a hard time finding necessarily somebody better but sometimes things just don't click or the right medication hasn't been tried or maybe the wrong diagnosis was made. If you get the wrong diagnosis, you may be getting the wrong treatment. So there's always you know, I would I would assume that there's something that wasn't done right or that you're not that somehow the treatment isn't optimize this. Find a different person and often just getting a different treatment a different person will be enough to to make it better than others without being too late. A lot of people who've never ever gotten help, had depression for let's say somebody's in their 70s and they're depressed and they've been depressed. All the lechlade never gotten help. Somebody may say, Well, if I haven't gotten help now, forget it's too late. It's never too late. Is depression is very common in the elderly. And I see this a lot when somebody's older, and they get depressed and you speak to them as well. If you are old and had arthritis, you'd be depressed, too. That's a very common issue with with depression, wherever you say, Oh, you have X. You'd be depressed too. But that's not the case. You can be sad, but to actually have a clinical depression shows that it's gotten out of hand and it's not the case that if you had that anyone would be depressed. So I always try to counter that idea that it may feel that way that your feelings are connected and reasonable given how stress but that's often a distortion. So, I would always counter the idea that the whatever the thing that appears to be triggering it is explains it all. And therefore there's no need to get cheap.

Joe McIntyre: That's your first finally, where should people go if they have questions, or looking for more resources about mental health?

Michael B. First, MD: One of the things that is available now that wasn't available 3040 years because the internet the good which is good and bad, but this is a lot of bad information on the internet. I've had patients in fact, tell me all kinds of things they see and they're completely wrong. And that can be very discouraging, or send them in the wrong direction. So the internet's both good and bad if you go to a reputable site that's usually run by an organization but the National Alliance, Nami national alliance for mentally ill they have good sites, the National Institute of Mental Health in particular, has an entire section at that every single condition with the treatments are in and then just educating yourself about the conditions. One place to look is the Merck Manuals. That's an amazing resource. For not just mental health issues, and all medicine, but I think the section on mental health really try hard to explain all the disorders, what they're like, and what the treatment options are. You still need to ultimately go to a healthcare professional to decide I mean, you're not the problem with looking over the internet or opening up a book is your you that's helpful, but often it really requires the experience and knowledge of the actual medical professional to really pick what optimize the right treatment for a particular person.

Joe McIntyre: Well, Doctor first, thank you so much for joining us. On today's episode. It was a super enlightening conversation, covered a lot of topics, but obviously there's plenty more that to still be uncovered when it comes to mental health. So as we do, always on this podcast here, I'll leave our listeners with the one statement.

Michael B. First, MD: Medical knowledge is power. Yes. Thanks so much.