TYPES OF COMMUNITY TREATMENT

There are several options for individuals who wish to receive treatment therapy in a community setting. These include public agencies, therapists in private practice, and community mental health centers.

COMMUNITY MENTAL HEALTH CENTERS

Community Mental Health Centers are government-supported centers, which provide a range of mental health services, regardless of a person’s ability to pay. Services of a Community Mental Health Center include outpatient treatment, partial hospitalization, emergency services, alcohol and drug abuse programs, consultation and education, and many more.

OTHER PLACES TO GET HELP

Partial Listing

Family Service and Private Counseling Agencies: provide counseling and referrals for troubled individuals and families.

Therapists in Private Practice: psychiatrists, psychologists, social workers and others provide treatment in a private office setting.

Help for Special Populations: school and college counseling services help students with emotional and psychological problems. Treatment centers for children with emotional and/or behavioral problems provide screening, diagnosis and treatment for this age group. Children are usually referred to these centers by their school district.

Information and Referral: The Mental Health Association gives information about mental health and illnesses and appropriate services. Visit the Mental Health Association’s website at www.mharochester.org for a Support Group Directory that lists groups in our community.

CHOOSING A THERAPIST

Therapists have different training and credentials, offer various kinds of therapy depending on their qualifications and school of thought and may operate in different settings. (See types of community treatments above).

New York State has expanded the mental health professions it licenses to include psychiatrists, psychologists, social workers, nurses, mental health counselors, marriage and family therapists, creative arts therapists and psychoanalysts. When an individual decides to seek services, licensure is one way to assess the qualifications of a therapist. By obtaining a New York State license the therapist has met certain basic requirements including being a graduate of a licensure qualifying program of study and meeting certain competency requirements. While the relationship that is developed between the client and the therapist is the ultimate determinant of whether the therapeutic experience is a success, licensure provides a certain level of quality control.

The nature of one’s problem may be the most important determinant of the type of therapist that should be chosen. A psychiatrist should see a person with serious mental illness with a probable physical component, such as bipolar disorder or schizophrenia, initially because medical treatment will be required. Persons whose primary problems involve psychological functioning and adjustment to daily living such as relationships and communication issues may choose any of the other professions.

Physicians, clergy and friends can often recommend therapists. Professional organizations such as the Medical Society, the American Psychiatric and Psychological Associations in our area, and the local branch of the National Association of Social Workers may be able to help find a therapist. The Mental Health Association offers a Therapist Referral Service. Individuals can call with their requests and information on up to three therapists taking new patients will be given. The Yellow Pages list therapists under Physicians, Psychologists, Social Workers, Counselors, Marriage and Family Counselors, Social Service Organizations and Psychotherapists.

Clients should remember that they are consumers paying for a service, and thus have a right to be satisfied with the service received.

Clients may want to ask questions about the therapist’s credentials, kind of therapy used, cost and expected length of therapy. As mentioned above, the therapist’s credentials, education, training, licensing, etc. are important, although they alone don’t insure successful therapy. The therapist’s style and the client-therapist relationship should be considered. A person seeing a therapist in a public clinic has less choice than a person seeking a therapist in private practice. Nonetheless clients in public settings may ask to change therapists if they are dissatisfied with the one assigned to them.

WHO’S WHO

Psychiatrist: A medical doctor (M.D.) specialized in the diagnosis and treatment of mental illnesses and licensed to prescribe medications.

Psychologist: A health care professional who diagnoses and treats mental, nervous, emotional and behavioral disorders and ailments. Psychologists’ practices also include industrial/organizational psychology, research and teaching. New York psychologists have earned a doctoral degree in psychology from a program registered or accepted as equivalent by the New York State Education Department. Psychologists with doctoral degrees with the letters Ph.D., Psy.D., and Ed.D. all have met the same educational requirements.

Social Worker: A person who helps individuals and families with personal and practical problems. In New York State, there are two professional licenses for social workers with different qualifications. Only licensed social work professionals may legally use the title Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW). Clinical social workers may provide all social work services, including the diagnosis of mental, emotional, behavioral, developmental, and addictive disorders, the development of treatment plans, and the provision of psychotherapy. The Licensed Master Social Worker may provide these clinical services only under supervision of an LCSW, licensed psychologist or psychiatrist.

Psychiatric Nurse: A registered nurse (R.N.) who has also received an advanced degree in psychiatric nursing and who may have passed a qualifying examination.

Mental Health Counselors have completed a master’s or higher degree in counseling. They work in both agencies and private practice settings and provide evaluation, assessment and treatment by the use of verbal or behavioral methods. In New York State they are referred to as a Licensed Mental Health Counselor or LMHC.

Marriage and Family Therapist: A person who uses mental health counseling, psychotherapy and therapeutic techniques to evaluate and treat marital, relational and family systems, and individuals in relationship to these systems. In New York State they are referred to as a Licensed Marriage and Family Therapist or LMFT.

Registered Therapist: A person who has been trained in a particular aspect of treatment related to the daily living skills of clients. These include occupational (O.T.R.), physical (P.T.R.) and recreational therapists (R.T.R.), as well as rehabilitation counselors (C.R.C.).

Creative Arts Therapists: A person trained in psychotherapy and specific arts disciplines. By guiding patients to create and reflect on art and the artistic process, they help people increase awareness of self and others cope with symptoms of stress, illness and trauma and enhance cognitive abilities. Creative art therapists may be trained in dance/movement therapy, drama therapy, music therapy, poetry therapy and art therapy. Creative Arts Therapists are a licensed profession under New York State Law.

To check the status of a therapist, go to the Office of the Professions of the State Education Department (see index).

TYPES OF THERAPY

There are many kinds of therapy, sometimes used in combination, which can be used in treating a mental illness. Your needs and the background and orientation of the therapist will determine what type of approach is used. One of the first steps is to determine if you need medications to help decrease or stabilize your symptoms. At this point, it is best to be evaluated by a psychiatrist who can prescribe and monitor medication. In recent years, primary physicians have also become a source of drug therapy. However, medications usually cannot address all of your issues and most people find it useful to also see a therapist.

Many people do not need or want medications and enter psychotherapy as a means of handling their emotional problems. Psychotherapy is a general term that refers to the talking therapies where you talk about your condition and related issues with a mental health professional. Psychotherapy varies in length and can take place in individual, couples, family or group sessions. Most therapists use a combination of approaches to therapy.

Types of psychotherapy include:

Psychodynamic: A problem, such as fear of heights, is considered a symptom of a deep, unconscious conflict and therapy is focused on helping you to gain awareness and insight into the repressed conflicts. The goal is then to resolve these conflicts so that you can modify the unwanted thought and behaviors that are the result of the conflict.

Behavioral: The unwanted behavior is identified and the therapist uses a system of rewards, reinforcements of positive behavior and desensitization to help you change the unwanted or unhealthy behavior.

Cognitive: This therapy looks at your thought process and helps you to identify and change the distorted thought patterns that lead to and self-destructive feelings and behaviors.

Cognitive-Behavioral: Combines elements of both approaches. After identification of the dysfunctional thought process, therapy focuses on providing new information-processing skills to allow you to replace the negative thoughts with more positive thoughts and behaviors.

Dialectical Behavior: A type of cognitive-behavioral therapy, that teaches you behavioral skills to help you better tolerate stress, regulate you emotions and improve your relationships with others.

USE OF MEDICATIONS IN PSYCHIATRY

Medications are an important part of psychiatric care. They are rarely successful by themselves and are therefore typically combined with the various psychotherapies. The major reliance on medication is for the simple reason that they work and they can play an important role if used appropriately both in treatment of acute episodes and in the prevention of subsequent difficulties.

It is vital that there be collaboration between the patient, the primary therapist, the physician, and involved family members. Patients who are educated about their medications are far more likely to succeed than those with less knowledge. This section is meant to provide you with an overview of the various medications, their indications and side-effects. If any of the material that follows is disturbing to you, please discuss it with your physician.

Some of the key questions to discuss when medication is suggested might include:

What can we hope for this medicine to accomplish? How will we tell if it is successful?

What information do you need from me for this purpose?

What side effects might I reasonably expect? (NO doctor can list all of the potential problems; there are simply too many possibilities. The common side-effects and suggestions on how to manage them should be discussed.)

What sort of difficulties should I call you for?

What will the medication cost?

What should I do if I miss a dose?

How will we decide when it is time to stop the medicine?

ANTIPSYCHOTICS

Antipsychotic medications can be divided into two groups: the older “conventional” agents and the newer “atypical” medications. The newer agents have different side effects from conventional agents and are generally better tolerated. But, some of the toxicities associated with the newer medications can be serious. Also, the newer medications tend to be more expensive. Some of the newer medications are reserved for patients who are intolerant or non-responsive to the conventional agents, while some are now used as first line medications.

The newer antipsychotic medications will be discussed in the section on Atypical Antipsychotics. The indications for antipsychotics, discussed next, are largely the same for both classes of medication, though there is a suggestion that negative symptoms of schizophrenia (difficulty with motivation, energy, and social interaction) may be more responsive to the newer agents.

Common Indications: used to treat hallucinations, delusions, agitation, thought disorder (difficulties with thought, language, and communication), and acute mania. Some of the diagnostic indications include schizophrenia, schizoaffective disorder, psychotic depression, and mania.

Examples of older antipsychotic medication ranked from low potency to high potency (see side effects for explanation): chlorpromazine (Thorazine), mesoridazine (Serentil), loxapine (Loxitane), molindone (Moban), trifluoperazine (Stelazine), fluphenazine (Prolixin), thiothixene (Navane), haloperidol (Haldol).

Side-effects: all antipsychotic medications, with the exception of clozapine (Clozaril) and risperidone (Risperdal), which will be discussed separately, are the same in terms of their mechanism of action and what can be reasonably expected. The selection of a particular medication is based on which side effect can be most readily accepted. High potency agents require fewer milligrams to have the same effect; thus 2 mgs. of haloperidol, a high potency agent will have compatible effects to 100 mgs. of chlorpromazine. High potency antipsychotic medication will pose a greater risk of Parkinsonian side-effects and less risk of lowering blood pressure, sedation, or anticholinergic difficulties. Parkinsonian side effects can include tremor, stiffness, akathisia (a sense of restlessness and difficulty sitting still) and lessened facial expressions. Selecting a different antipsychotic, lowering the dose or taking another medication for the side effects usually manages these. Anticholinergic problems might include dry mouth, constipation, visual blurring, and difficulty with urination, sexual difficulties, and confusion.

Unusual and more serious side effects include tardive dyskinesia (TD) and neuroleptic malignant syndrome (NMS). TD is the occurrence of involuntary (not under conscious control) movements that might involve any part of the body, but which most often involve the mouth, arising from prolonged use of antipsychotics. NMS also results from exposure to antipsychotics and may be early or late in treatment. Patients develop a sudden fever, stiffness, and may become profoundly confused or lose consciousness. There is often extensive damage to muscle. This is a real medical emergency and may lead to death. It should be kept in mind, though, that NMS is rare. A physician should promptly evaluate sudden fevers or stiffness.

SPECIAL ANTIPSYCHOTICS

Depot Antipsychotic: the most commonly used are haloperidol (Haldol) decanoate and fluphenazine (Prolixin) decanoate. These are medicines given by injection from once a week to once a month. They are used when patients are having difficulty in taking daily doses by mouth. Injectable antipsychotics have, unfortunately, been subject to manufacturing shortages and your physician may have to switch you to an oral medication or a different medication, depending on the situation.

Atypical Antipsychotics: clozapine (Clozaril), risperdidone, (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon) and aripiprazole (Abilify). Geodon is the first to market a quick acting intramuscular preparation.

The effects of these medications are very like those for conventional antipsychotics, but they differ in terms of side effects (usually less), price (usually more), the possibility that they may do a more effective job of treating the (negative) symptoms (lack of interest, difficulty in initiating activities, and social withdrawal) that can plague some people with schizophrenia. There are also data indicating that as many as a third of schizophrenic patients who have not responded to conventional agents will respond to these atypical agents.

The newer medications can be expensive. The typical cost of a year’s medication with clozapine will be in excess of $5,000. Risperidone will cost about half as much. Clozapine will not be expected to cause parkinsonian side effects or tardive dyskinesia, although one cannot guarantee this. It will cause many other SIDE EFFECTS mentioned for low potency agents. Risperidone at low doses (most typically around 6 mg. per day) should also be free of these difficulties, but there is no guarantee. If the dose is advanced much more it starts to be very like a conventional antipsychotic and the benefit tends to be lost. Olanzepine has been effective in the 10 mg. to 20 mg.dose range.

The major problem with clozapine is bone marrow suppression. This occurs with about one percent of patients and can be fatal if not addressed. The result of this is that weekly, biweekly or monthly (depending on how long one has been on the medication) blood tests are required so long as patients are taking the medication.

Most of the newer antipsychotics can affect glucose (blood sugar) regulation and lipid levels, and weight gain. Weight gain tends not to be related to the dosage. A collection of signs (diabetes, increased lipids, hypertension and weight gain) has been called Metabolic Syndrome. People taking atypical antipsychotic medication need to have their weight, lipids, blood pressure and blood glucose monitored by their doctor.

Of note: antipsychotic medication may affect the body’s ability to regulate temperature. This is important to keep in mind for the summer months when people tend to spend more time in the sun.

AGENTS FOR SLEEP

These are almost exclusively benzodiazepines (see the comments about anti-anxiety agents). The important thing to remember is that these medicines will lose their impact after a couple of weeks, so use should not be on a nightly basis for much more than a week. It is possible to create considerable confusion since there will often be a kind of withdrawal effect after prolonged nightly use which will lead to more difficulty with sleep and the mistaken belief that the appropriate response is to increase the hypnotic. It is also possible to become psychologically dependent on taking something to fall asleep. The other worry is if you are a heavy snorer. This might indicate that you have sleep apnea, which would worsen if you used a benzodiazepine. Examples: flurazepam (Dalmane), temazepam (Restoril), triazolam (Halcion), zolpidem (Ambien) which is not a benzodiazepine, but works the same way. There are many over the counter (OTC) sleep aids, the majority of whose active ingredient is diphenhydramine (Benadryl), essentially an antihistamine that makes you drowsy.

Many doctors prescribe trazedone (Desyrel) for sleep. This is actually an antidepressant with some anti-anxiety effect. The dosages for antidepressant effect are around 150 to 400 mg. a day in divided doses. Unfortunately, many people complained of drowsiness. When better medications came along it was rarely used as an antidepressant, but instead prescribed as a sleeping aid. Doctors like it because it has no real abuse potential (as do benzodiazepines) and very little, if any, problems with drug interactions.  One potential side effect of trazedone is call priaprism, a sustained erection.  If this occurs the patient should stop the medication and alert the prescribing provider.

ANTIDEPRESSANTS

Common Indications: not surprisingly, the main indication is for depression. This is not the same as sadness, but is, instead, an illness that includes depressed mood, difficulty with sleep and appetite, diminished interest in sex, guilt, limited energy, difficulty in enjoying previously pleasurable activities, suicidal thoughts, hopelessness, and helplessness in its classical form. Other reasons for antidepressants include panic disorder, obsessive-compulsive disorder, some chronic pain syndromes, and some eating disorders.

General Comments: it is important to realize that it is quite common for someone to fail to respond to a good trial of one antidepressant and to do quite well with another, so do not give up if the first agent fails to help. Unfortunately, all of these medications take from 1 to 5 weeks before anything worthwhile happens. To make things worse, side-effects can be immediate. The typical pattern of response is for sleep, appetite, and energy to return before mood starts to improve. Curiously, your friends or family might notice some improvement before you are aware of it, so ask for feedback. It is vital that you let your prescriber or therapist know if you are experiencing suicidal feelings. Many of these medications (paradoxically) can cause suicidal thoughts, but this is not common and there is no good information to prove that they actually cause anyone to harm themselves.

Examples: The traditional tricyclics include imipramine (Tofranil), amitriptyline (Elavil), desipramine (Norpramin), nortriptyline (Aventyl, Pamelor), clomipramine (Anafranil) and doxepin (Sinequan), among others.

Newer agents called Serotonin Selective Re-Uptake Inhibitors (SSRI) include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), escitalopram (Lexapro), and citalopram (Celexa). Lexapro and Celexa are very similar.

Atypical anti-depressants include nefazodone (Serzone), mirtazapine (Remeron), and bupropion (Wellbutrin), venlafaxine (Effexor), Trazodone and duloxetine (Cymbalta). A new medication, desvenlafaxine (Pristiq), is essentially a metabolite of venlafaxine.

MonoAmine Oxidase Inhibitors block an enzyme, increasing levels of serotonin, norepinephiine and dopamine. They include tranylcypromine (Parnate), phenelzine (Nardil), and isocarboxazid (Marplan). MAO inhibitors require a special diet and caution about other medications taken while on an MAOI. The diet excludes almost all cheese and aged meats, but is not usually a great problem. The MAO’S are usually used for patients who fail to respond to other antidepressants or for those who have atypical depressions. They are rarely prescribed today, but are very helpful to a select group of patients.

Side effects: there is considerably more variation here than with antipsychotics. Some medicines lead to dry mouth and decreased blood pressure with changes in position, others lead to anorgasmia or difficulty in achieving sexual satisfaction. All carry the risk of inducing mania in those with a propensity for mood swings. As with antipsychotics, weight gain is common with many of the antidepressants. Weight gain is not inevitable, but you will have to watch your intake more closely than usual.

Of note: sometimes if an SSRI medication is stopped abruptly, the person can have a “withdrawal” syndrome of anxiety, agitation, stomach upset and flu-like symptoms that can last a few days. This is not a sign of addiction, just the body readjusting to a different level of serotonin. To avoid this (or if it starts), one can taper the use/dose of the medication. It is best to ask the prescriber about this.

MOOD STABILIZERS

Indications: these medicines can act to prevent recurrent depression or mania and also act acutely to help control a manic episode. In addition, lithium is often used to increase the effect of an antidepressant.

Examples: lithium is the old standby. More recently anticonvulsants including carbamazepine (Tegretol), clonazepam (Klonopin), valproate (Depakote), topiramate (Topamax), oxcarbazepine (Trileptal), and tiagabine (Gabitril) have also been used. Valproate is considered more effective for “rapid cycle” mood disorders (a series of highs and lows).

Side effects: lithium side effects are usually predictable and related to the dose. For this reason, your doctor will probably want to follow your blood levels closely while trying to establish the right dose for you. Problems at relatively low levels may include a fine tremor and increased thirst. As levels climb you may notice diarrhea and nausea. (Lithium will irritate your stomach if it is empty, so always take it after eating something). As levels increase further you might notice difficulties with coordination or speech and your muscles starting to twitch. If you reach this point, it is important for you to be seen by a doctor. Lithium levels climb when people lose salt with situations such as sweating profusely or fever. Sprinkling a little extra salt on your food before a summer outdoor workout is probably prudent. Long-term use of lithium can be associated with kidney damage, so your doctor will want to get a blood test to check for this once or twice a year. Similarly, there is a chance of thyroid damage, especially in women; a blood test will help to monitor for this.  If this were to occur, the prescriber and patient would discuss the pros and cons and could decide to switch to a different mood stabilizer or to just add some thyroid hormone to the regimen.

Weight gain is distressingly common. Some patients feel as if their thinking slows with lithium, although it is sometimes difficult to know whether this is associated with the loss of mania or the medicine itself.

Carbamazepine has significant side-effects. There may be problems in the beginning if it is increased too rapidly. These problems might include problems with coordination, walking, or speech. If these occur, let your doctor know, so the dose can be decreased. The major problem is a rare suppression of the bone marrow. Your doctor may want to get a blood test to monitor for this. Valproate may cause tremor, but is usually well tolerated, and has less side effects than Lithium or Tegretol. Weight gain is a major side effect. Also, occasionally it might cause pancreatitis which presents with significant abdominal pain. Oxcarbazepine (Trileptal), a relative of Tegretol, has fewer side effects. Topamax (Topiramate), which is as effective as Depakote without the significant weight gain should not be used for patients with glaucoma or history of kidney stones. Neurontin has been used but is less effective in studies. Lamotrigine (Lamictal) has been used but has a serious side effect in a small group of people (a skin rash which can be lethal). All individuals should have a thorough discussion about potential side effects with their treating physician. While most patients can take these medications safely, liver function should be monitored

ANTIANXIETY AGENTS

There are two general medication approaches to treating anxiety: Benzodiazepines and buspirone, and antidepressants. Barbiturates and other related compounds should not be prescribed, as they are significantly more dangerous.

Common Indications: these agents are typically given for anxiety. They are also effective for insomnia and are sometimes used for alcohol withdrawal.

Examples: alprazolam (Xanax), chlordiazepoxide (Librium), clonazepam (Klonopin), diazepam (Valium), lorazepam (Ativan), and oxazepam (Serax) are all benzodiazepines. Buspirone (Buspar) is not a benzodiazepine, instead being a member of a unique class. There is some question about how well buspirone works. It is clear that it cannot be used on an as needed basis, but must instead be used regularly since it may take weeks to become effective.

Side effects of benzodiazepines: these are clearly sedating agents. As a result, motor abilities for such activities as driving decline. Similarly, there is a subtle decrease in people’s cognitive (thinking) performance when tested on these medications. There is an interaction with alcohol, so that the effects of alcohol are increased. The major issue is that of dependence on these medications (not buspirone). Regular use of high doses will lead to withdrawal effects if you stop them suddenly. Withdrawal symptoms can range from being edgy, to increased anxiety, to tremor, increased heart rate and blood pressure, to seizures.

If you have been on significant amounts of these medications for a long time, it would be wise to have a physician guide you in discontinuing their use. It is not possible to list specific guidelines for when you should be concerned about this, so be sure to discuss this with your physician or prescriber. New York State’s concern about the potential for abuse of these medications led them to be listed as controlled substances.

Some antidepressants (for example, paroxetine (Paxil) work very well with anxiety. A common strategy is to begin with a benzodiazepine to treat acute anxiety and then switch to an antidepressant with good antianxiety effect, discontinuing the benzodiazepine when the other medication begins to help.

COST OF COMMUNITY TREATMENT

The cost of treatment varies depending on whether you are seen in a public agency or by a private therapist. Agencies charge fees based on a person’s income known as a sliding scale. All agencies and some private therapists will accept Medicaid and/or Medicare.

Insurance plans offered through a person’s employment vary with some plans requiring a referral from a primary care physician if mental health services are to be covered. All public mental health providers accept these plans as a form of payment. If you plan on seeing a private therapist, you should discuss whether or not they accept your insurance coverage before beginning therapy.

As of January 1, 2007, New York State implemented Timothy’s Law. This law requires that health insurance policies include coverage for the treatment of mental illnesses at the same levels as treatment for physical illness or injury. This is referred to as mental health parity.

Specifically, Timothy's Law requires that businesses in New York State with over 50 employees provide health insurance that covers at least 30 days of active inpatient (hospital) care and at least 20 days of active outpatient treatment. Treatment may be provided in either a public mental health setting or privately by certain mental health professionals. The cost of deductibles and co-payments cannot be higher than those charged for other benefits under the same policy. For businesses under 50 employees, the law states that the employer will be required to make the enhanced coverage available for purchase upon request of an employee.

Timothy’s Law covers only certain biologically-based mental illnesses. These include schizophrenia/psychotic disorder, major depression, obsessive-compulsive disorders, bulimia, anorexia, and certain serious emotional disturbances in children.

To determine if your services will be covered, we recommend you contact your insurance company and discuss how Timothy’s Law will impact your insurance coverage.

SELF-HELP AND PROFESSIONAL TREATMENT: A COLLABORATIVE RELATIONSHIP

Both self-help and professional treatment play an important role in aiding consumers and families. Self-help groups provide mutual support from peers who have experienced similar feelings and concerns. They stress the ability of an individual to solve his or her own problems with the aid of others in the same situation; they offer education and information in an informal setting, and the chance for people to explore various alternatives to living with their common concern.

Mental health professionals stress the importance of a particular therapeutic program delivered in a one-to-one relationship by a trained practitioner. Professionals are a valuable resource for information, and can offer a consumer the opportunity to discuss various forms of treatment. They can also offer, to self-help groups, their expertise and perspective as consultants and speakers. Through developing a collaborative relationship with self-help groups and group members, mental health professionals may gain a greater understanding of the emotional issues people face.

There is no one correct type of help that is best for all; some may benefit most from self-help, others from professional treatment, and many from using both.

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