Today is World Mental Health Day. Help us raise awareness. We are 5 experts on mental health here to answer your questions - Ask Us Anything.

What would be your advice to the vast amount of people that think they may very well have a mental illness but have no way to access a doctor? In my city atleast the lower income options aren't very good at all and even just seeing a therapist regularly can break the bank.

First, this pains me so much to read because I know how true this statement is. We live in the wealthiest country in the world and I’m answering a question about how to provide care to a sick person. I watch politicians talk about “America’s values” and then I try desperately to help people find $50 for one month’s worth of medication. It’s sickening that we are here. I feel incredibly sad that I don’t have a better answer than this:
Try telemedicine via the internet. It’s gaining ground and I’m hearing good things. Use sites like psychcentral.com to find resources via the web and in nearby communities as well as peer communities. It’s not ideal, but it’s a good resource that is available 24/7 to anyone with internet access. -Gabe Howard

I’m going to second Gabe Howard’s recommendation here (again). I’ve provided teletherapy for several years now, and recently switched to doing exclusively tele-sessions, and have been pleasantly surprised by how little seems to be lost in the process. I’ve also been on the receiving end of medical consultations via video conference and found them extremely useful, and of course super convenient. I also understand that many health insurance providers have started to cover teletherapy, which reduces one more barrier to care.  —Seth Gillihan

Sometimes I feel so bad, I don’t want to ‘anything’ or do something worthless. After that time, I feel sadness over that. What is your advice to avoid this kind of vicious cycles?

Some of these cycles can only be avoided with treatment. As much as I’d love to tell you I can manage the cycles of bipolar disorder through force of will or by using coping skills -- I can’t. I have a medical illness that needs medical intervention. I do want to touch on another point of your question -- you said “after that time, I feel sadness over that.” This is something I understand on a very personal level. I, too, feel sadness after a spell of depression or laziness or for sleeping too much. My strategy is to focus on what I’m doing well. Reward myself for the small steps I take to move forward and not focus on what I’ve done “wrong” but keep looking forward. Is it is easy? No. I have a bulletin board where I write my accomplishments and pin them to it and read them for inspiration. And when I say accomplishments I mean “took a shower today” and “cleaned the house for the first time in 2 weeks.” Celebrating little success breeds bigger victories. -Gabe Howard

I really like Gabe Howard’s reply here—it’s so important to focus on what’s going well, and to recognize even “small” accomplishments, which can be huge given the challenge of doing anything when we’re depressed. It can also be useful to keep a list of enjoyable and/or important things to do (important meaning even something as minor as unloading the dishwasher—just something that needs doing), and choosing from them based on what we’re able to do at the time. I always work with people to break tasks down into pieces that are small enough they seem doable. It might be quite small at times, and of course that’s perfectly fine. Any win is a win.  —Seth Gillihan

Everytime I go to the dr to discuss my emotional state, general anxiety and what I feel like they completely brush aside any type of thoughtful diagnosis and just prescribe me the latest version of valium and send me on my way. I have litterally had this experience with 3 separate drs. I cant see a psychiatrist without a referral but they dont give me one, they all seem to think that if I pop a pill a day all my problems will go away. I've tried more anti depressants and anti anxiety medications than I can recall but none of them seem to really do anything.

What can I do at this point to ensure that the doctor either takes the time to properly diagnose and treat my condition, or admits its beyond their scope and give me a referral?

I’m sorry to hear that’s been your experience—that’s very disappointing. Unfortunately a lot of primary care doctors aren’t experts in treating psychiatric conditions, so it would make sense if they would give you a referral. If this doctor is not responsive to your direct request for a psych referral, then I would recommend finding another doctor in your network who would be. It could be a good idea to get a sense from a new doctor early on (even before the first visit, if possible) if they’re willing to provide a referral to a psychiatrist if needed. —Seth

It may also be helpful to talk with a therapist as well.  They can often provide alternatives to medication, like therapy. - Smitha Bhandari, MD

Are we seeing an increase in mental illness? I’ve heard the opinion that people just need to ”toughen up” and that back in the days no one had time to be mentally ill. Or is it the complexity of everyday life that has increased and is putting more burden on people?

This is a great question and one that is often debated. I think you summarized it very well by saying the “complexity of everyday life” has increased. Another very important factor is that our ability to recognize and treat mental health diagnoses has also increased. There have been many programs in place to expand education about diagnoses and symptoms to people and medical providers. That’s thankfully because some of the stigma of mental health treatment has started to decrease. -Smitha Bhandari, MD

Eh. Why not?

Should assisted suicide for people who live with debilitating treatment-resistant depression be an option?

This is a really complicated question with many ethical factors to consider. The American Psychiatric Association published a statement regarding physician-assisted suicide in 2017. They stated that a “psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.” - Smitha Bhandari, MD

This is such a tough question, and I don’t have an easy answer. We seem to understand that certain kinds of suffering—physical agony—should be grounds for medically assisted suicide, but we’re less likely to think the option should be available for mental and emotional anguish. I’ve worked with several people with TRD who said that having suicide as an option actually helped them keep going, because they knew they had an out should they need it. I should also acknowledge that my father’s father chose to end his life a few years before I was born because of the unending pain from untreated combat-related PTSD. I wish more effective treatments had been available in his lifetime, and I also understand he must have been in incredible pain to kill himself. At the same time, making the means of suicide more widely available doesn’t seem like a good idea when they could be used by those who could still find a treatment that helps. So I don’t know what the policy should be, but I do believe we can extend greater compassion and understanding to those who find life intolerably painful. —Seth Gillihan

What would you most like to tell us that no one asks about?

No one asks if people in recovery still suffer symptoms. Society has this general belief that people with mental illness are either perfectly fine (recovery) or very sick (crisis/mentally ill). Most people don’t see the nuance. I’m in recovery but I still have depression sometimes. I still have hypersexuality sometimes. Symptoms crop up and ruin my week! But I’ve learned how to cope with that and the impact is lessened. Because the symptoms never reach crisis for me -- people assume I never suffer the impact of bipolar disorder. Which isn’t even remotely true. - Gabe Howard

A couple years ago I listened to an episode of Invisibilia that explored the argument that cure-directed approaches to mental health are more detrimental to patient outcomes for a variety of reasons. They visited a small community in... Switzerland, I think it was? I can't remember. Anyway, in this community, people with serious mental illnesses like Schizophrenia and Bipolar disorder lived alongside mentally healthy people in an environment of total acceptance. The only "treatment" was no treatment. People even went as far as catering to someone's hallucinations; there was one story where a woman chased away imaginary lions that were plaguing a schizophrenic tenant of hers.

My question is this: what do you think about this approach? Can we really just let the mentally ill be mentally ill, the end? Are there some conditions that could be treated this way, and other that could not?

As a man with bipolar, this disturbs me. Honestly. Without treatment I’d be dead. No question. So maybe I would have lived along side my neighbors for a while… But then I’d go manic and hurt myself -- or accidentally hurt someone else (but driving too fast or taking unnecessary risks as an example). I think, *maybe*, there is a point in here that we should not medicate or treat every single part of a person’s personality we don’t like… But the specific example in your question was bipolar and schizophrenia. No treatment is a death sentence, IMHO, and cruel. - Gabe Howard

My depression symptoms really seem to feed on each other in evil ways: when I'm depressed I genuinely feel like I let everyone down and am a constant disappointment; I also withdraw and *do* disappoint people by not keeping up with social and other obligations. When I'm depressed, I feel like I am a huge burden to people; I also *am* a burden to people because I need people to do basic stuff like buy me food or take over some portion of work. What recommendations do you have for breaking the negative thought loops when actions and thoughts really do reinforce each other like this?

Ah, those loops are tough, aren’t they?? “Evil” is a good word for it! Vicious. First I would examine the stories your mind is telling you. It could be that you’re a burden, for example, and it’s also possible that others don’t experience your increased needs as a burden. I know my own mind is very reluctant to let go of the “burden” idea when I’m depressed and not pulling my weight, despite others’ insistence to the contrary. It can be helpful to flip the roles in that kind of situation, and ask if we would consider the other person a burden if they needed extra support from us. Or might we even consider it a privilege to offer love in that way, and to have someone willing to receive it? Mindful acceptance can be hugely helpful here, too, like with the withdrawal and disappointing others. We can practice letting go of our resistance to the way things are—to a reality we don’t like—and instead open to it. This is how things are right now. I’m not able to be as present as I wish I were, and people who care about me wish they could see me more. This is what’s happening. Easier said than done, of course. I know it takes practice. And finally, we can look for ways to not let our thoughts and emotions dictate our actions, when we have a choice. We can acknowledge that we want to withdraw, for example, and choose not to, or choose not to withdraw entirely. We can still do as much as we’re able, even if it’s not a lot. Even if it’s kind of embarrassingly not a lot. When I was deep in a depression that might mean reading a couple pages of a book to my 2-year-old if I weren’t able to read the whole thing. Or maybe it means walking outside to get the mail rather than staying inside all day. There was an excellent recent post on the WebMD Mental Health blog along those lines recently (I didn’t write it, which is why I mention it!). Wishing you all the best. Oh, one final thought—many kinds of therapy can address these loops, and they’re addressed most explicitly in cognitive behavioral therapy. —Seth Gillihan, PhD

Hi, long-time sufferer, first-time commenter. So 20% of the population had a diagnosed mental health issue five years ago, and that's risen since. Many more must be undiagnosed. Is it time to think more public healthishly about broad prevention (like earlier/opt-out screening?) and better systems of care (like increased access and some way to get providers to actually take insurance)? If so, whose arm do I twist?

You make a great point about how high the burden of mental health conditions are (not just in the U.S. but throughout the world). As a mother of young kids, I think about this often. I take my kids to routine dental care and preventive medical check-ups, but the focus on starting early with regard to preventing( or mitigating) mental health conditions or even providing early intervention for mental health conditions gets almost no notice.
I have found that both of my children (kindergarten and 3rd) have “emotional learning” sessions at school run by a counselor to help them think about how they are feeling and who they should talk to if they feel sad or overwhelmed.
Just like preventing medical conditions, I think it needs to be an “all hands on deck” approach where parents, schools, and the healthcare system make mental health assessment a priority as well. -Neha Pathak

Is depression a symptom, or an illness?

Yes. Depression (Major Depression) is an illness all by itself. I live with bipolar disorder and depression is a symptom of bipolar (extreme highs -- mania -- and extreme lows -- depression. And everything in between. -Gabe Howard

That’s a great question. Many people experience depression “out of the blue,” with no obvious trigger. That seems to be what Gabe is describing. If I understand your question, you’re also asking if it can be an indication of something else—a symptom, as it were, of another condition. That is also true. For many people that I’ve worked with in therapy, their depression was a response to life circumstances, like a major loss, overwhelming stress, a lack of direction or engagement, profound loneliness, etc. My own experiences of depression have been of that type, most recently from a prolonged illness that left me isolated and very uncertain about my future. So it’s not really one or the other—it depends on the person, and their particular situation. My own depression helped me see with greater clarity some of the changes I needed to make in my life. But again, it can be very different for different people. —Seth Gillihan

Clinically, when we talk about depression as a diagnosis it is made up of a number of possible symptoms including sad or irritable mood, difficulty sleeping or sleeping too much, low energy or restlessness, suicidal thoughts, poor appetite or weight loss, difficulty concentrating, lack of pleasure or interest in doing things, and feeling worthless or guilty. - Smitha Bhandari, MD

How would you recommend someone deals with starting talk therapy during a “high” time? I have an appointment with a clinician coming up that I made weeks ago when I was at one of my very low points, but now that it’s getting closer, I’m afraid I won’t have anything to say even though I know how scary my thoughts get when I’m in a “low” time.

This often happens in our office as well. Most times we suggest keeping the appointment. Therapists often need a few sessions to get to know you and review important information about your childhood, medical history, history of treatment, relationships, etc. They may also be better able to help you in a crisis if they know how you are during a “high time.” -Smitha Bhandari, MD

I have severe ADHD. I feel that the emotional and anxiety aspect of ADHD in adults is severely understated - what are your thoughts?

About half of adults with ADHD also have some form of anxiety. A lot of adults with ADHD often describe feeling inefficient, ineffective, or stressed because they aren’t keeping up with their demands. Furthermore, since ADHD symptoms often impact so many parts of life and can affect work, relationships, parenting, etc, many people do feel emotional effects as well. -Smitha Bhandari, MD

Other than exercise and diet, are there any natural options or dietary supplements to help stabilize mood, that you recommend?

Dr. Julia Rucklidge and her colleagues have done some good research showing that certain vitamin and mineral supplements can have a protective effective for our mental health. She has a 2015 article in Clinical Psychological Science that is available online that could be useful. Cognitive behavioral therapy (CBT) is also a “natural” option that is very useful for treating mood symptoms. —Seth Gillihan, PhD

I have family who have been diagnosed with depression, been to counseling, taken the medication, and remained in depression. What are the possible reasons? Wrong medication? Wrong counselors? Unfixable?

It must be difficult to see your family struggle with depression despite treatment.  There are many factors that could be affecting their response to treatment. The first step is to make sure the diagnosis is accurate.  Bipolar depression for example can have symptoms that overlap with depression but needs to be treated differently. Sometimes, it can be helpful to look at co-occurring diagnoses like substance abuse, thyroid disorders, or neurologic disorders. The issue may be with therapy.  A one-size-fits-all approach often doesn’t work and it may be that your family member needs a different type of therapy. Sometimes depression can be so difficult to treat that we call it treatment-resistant depression. Some doctors specialize in this type of treatment and it may be helpful to consult with one of them.  -Smitha Bhandari, MD

What are some of the main symptoms of having any kind of mental illness?

Also what are your thoughts on Dr. Gabor Mate and his ideas of how illness of any form comes from the relationship we have with ourselves and trauma in childhood is a main cause of mental illness?

How can someone without insurance or on a low income status find help without having to spend large amounts of money?

That’s a really giant question -- in fact, it’s like three questions. :) The main symptoms differ depending on diagnosis. It’s a bit like asking “what are the main symptoms of physical illness.” That makes it a bit difficult to answer. In general, something that interferes with the activities of daily living for two or more weeks may quality as a mental illness or mental health issue. I’ll answer the next question next. -Gabe Howard

I’m not familiar with Dr. Mate so I can’t comment but the insurance question keeps me up at night. I know that I’m lucky. Without health insurance, money, supportive family, and so many other things that “went right” for me I would not have survived with bipolar disorder. Without a payer source (insurance, medicare, social services) getting good care for a price the average person can afford is nearly impossible. And I’d like to point out that a sick person is not “the average person” -- they are sick. The best advice I can offer is to utilize your community’s mental health services / social services -- if they exist. Call the Jobs and Family Services or google “mental health services.” I wish I had a better answer but our country doesn’t do a good job helping the sick unless they have resources. :( - Gabe Howard

What would you say are the best key habits to keep mental health issues at bay?

I know sleep, exercise and diet play a massive role (I would also be particularly interested in how we can look after our gut for this). Are there any ways of thinking or attitudes which can particularly help too?

Preventative medicine can play a role in mental health disorders as well. There are many ways to decrease your vulnerability to stressors, including avoiding alcohol and drugs, exercising, sleeping well, eating a well-balanced diet, and having outlets (sports, music, art, reading, etc). Sometimes though, you can be doing all of this right, and still suffer from symptoms. That’s because mental health diagnoses result as an interaction between your genes and your environment. - Smitha Bhandari, MD

I’m really glad you said sleep with diet and exercise. It’s often missed and it plays a vital role. As a guy who lives with bipolar, I know that my outlook changed when I accepted that having this illness isn’t fair -- but it is what it is. My therapist called it “radical acceptance.”

When I was first diagnosed I wasted a lot of time feeling badly about my circumstances. I remember thinking this isn’t fair -- and it isn’t. Once I fully accepted that I’m a man living with bipolar I could spend my time and energy fighting the illness and working toward living my best life. That was a big shift for me. A big one. -Gabe Howard

Thoughts and beliefs can definitely play a really important role. That’s the premise of cognitive behavioral therapy, and it’s what people have taught long before there was CBT (the Stoics of Greece and Rome, for example). In my work I often help people to figure out what their minds are telling them, and then to practice more helpful ways of thinking when they discover biases or distortions that are causing them distress. For example, we might constantly berate ourselves for not being “perfect.” As we get better at recognizing those thoughts, we can practice replacing them with more useful ones, and ones that better fit reality. There are many good books along those lines (search for CBT online, for example), and many therapists who specialize in that approach. —Seth Gillihan, PhD

What... What are some ways the people who know they have a mental illness, and will have it for the rest of their lives, can cope knowing that? It's... It's so much harder knowing I can't just... Make it stop. That this is me, my brain, how it functions, and i may never be able to be functionally ok or happy without medications in my life, which have a whole host of risks and life shortening consequences. I have such trouble coming to terms with that, and I have such strong feelings of frustration and guilt about it. I cannot live without mind altering medications, and SO many people would see that, and see me as a drain on society, a sicko weirdo, or any number of derogatory descriptors, and it weighs on me so much. I know it's stupid to let social pressures affect you, but I can't help feel like this. It affects every situation I'm in, from work to the doctor's to going some place for fun... Im lost on how to reconcile and cope knowing I'll never "get better" or "be cured", and will have to face that stigma the rest of my life.

That’s a tough pill to swallow, isn’t it. (Definitely no pun intended.) Living with any kind of illness that won’t go away can be dispiriting. Mindful acceptance as a practice can be very useful. I’ve also been introduced to Meaningful Life Therapy, which emphasizes moving toward what we find important and … meaningful … in life, even through whatever limitations we’re dealing with. I would recommend looking into that kind of approach, and of course seeking out the support of others who are dealing with similar challenges. Wishing you the best. —Seth Gillihan, PhD

I’m literally about to drive to my first therapist appointment. Life has been pretty cruel the last year and I’m feeling insanely low. I’ve accepted that I’m just completely broken and I need help, but I also know there’s a small portion of these issues that are stemming from the loved ones in my life and how they act towards me. They refuse to own anything. What can I do to finally open their eyes instead of them turning it around blaming it all on me and telling me I’m too sensitive?

I’ve literally been told suck it up, that’s what a man does. It’s let me to thinking about my own death 3-5 times a day. I put on a face every day but deep down I’m so insanely sad, lonely and in pain.

Please know that you are not alone. I understand the desire to want the people around you to understand you and be supportive. It may be best -- for the time being -- to focus on yourself and your needs and care and accept that you can’t make them do anything. You can only control yourself.
The toxic trope of “man up” is hurting men all over the country -- all over the world. Please know that fighting through your pain, seeking help, and admitting that you can’t control your loved ones is very hard. It takes guts and internal fortitude to move forward like you are. I believe in you and you are not alone. -Gabe Howard

I am a budding author of a life skills book for high schoolers. what should we teach young adults about mental health? specifically: how to manage their mental health, recognise mental illnesses in themselves or loved ones, learn good „home remedies“ and learn when to seek professional help? Any good books or resources that will help me teach these skills?

So much pain is caused by people simply not discussing mental illness and mental health issues. I really think we need to have meaningful and hard conversations surrounding these topics. If a young person is simply empowered to discuss their feelings, symptoms, emotions, concerns with an adult who has some level of understanding -- think of how much better we would be. 

In my opinion, your book needs to contain a chapter on why it’s okay to reach out. Why it’s okay to need help. And, perhaps, a chapter on why adults shouldn’t push children’s mental health under that rug. We tend to dismiss children’s mental health concerns because we think they can’t suffer... because we forgot that being a kid isn’t as easy as we seem to think it is. -Gabe Howard

What a great question. I would emphasize three areas for training young people to manage their mental wellness. They should learn about how the mind works and the stories our minds tend to tell us. When we can recognize the stories, we can evaluate whether they’re really true, and can consider alternative interpretations. Second, we should be teaching the behaviors that keep us well, mentally, physically, emotionally, and spiritually. This would include many things that aren’t obviously for our “mental health,” but are increasingly recognized as being important for it—things like a nourishing diet and regular physical movement, not to mention time with people we care about. And finally, I would want young people to learn about the importance of tending their Spirits, through the practice of being present (the kinds of things mindfulness teachers emphasize). This kind of training could provide students with a set of tools for staying well—mind, body, and spirit. Additionally, as you mentioned, learning the basics of the signs of psychiatric conditions in oneself and others, and how to respond, would be very valuable, too. I imagine books and other resources along those lines exist, but I don’t know offhand what they might be. One option could be to find an approach you like—that includes the skills and knowledge you think would be helpful—and work to adapt it for young people. All the best to you in this important endeavor. —Seth Gillihan, PhD

There are so many great areas your could focus on.  I think talking to teens about managing their vulnerabilities to stress is important.  This can include things like avoiding drugs and alcohol and having good outlets for their stress.  Studies have shown that teens who feel connected to things can have an easier time managing stress.  This could be a connection to family, friends, teachers, coaches, or a particular activity. For this age group, ways to reduce the stigma of mental illness is also really important. - Smitha Bhandari, MD

Is there any discussion in the mental health profession about reaching people who avoid treatment out of fear? I know the threat of involuntary hospitalization (and its accompanying loss of personhood) kept me entirely away from treatment until I was in crisis myself, and I could have had a much better late-20s otherwise.

I think one of the best ways to address this type of fear is to build trust in your treatment team. I would mention your fears to them and ask them to help you come up with a plan to address it. As a psychiatrist, one of the ways we try to help people who are afraid to come in for treatment is to work with primary care physicians. If someone is afraid to make an appointment with a psychiatrist, the only doctor they may be seeing is their primary care doctor. If we can help primary care doctors screen patients for symptoms and talk about referrals, it can help the individual feel more comfortable. As a child psychiatrist, I also give educational talks to the community. Sometimes kids and parents are more likely to see a psychiatrist if they have had a chance to ask questions in a less-threatening setting. -Smitha Bhandari, MD

It’s a really important question. I know many people I’ve treated have been relieved that they can mention having suicidal thoughts without my calling 911 and having them locked in a psychiatric ward. So yes, there is definitely discussion around this topic. Actually one of the most read blog posts I’ve written was about how mental health professionals are trained to respond to mentions of suicide in therapy, which speaks to the importance of this issue. I think it’s important to educate those who might be considering psychiatric treatment that involuntary commitment is not an automatic outcome from being in deep mental and emotional distress. —Seth Gillihan, PhD

I've had issues for my whole entire teenage years,I was very afraid of people,like deathly afraid. I've broken out of it but I find myself alienated and incapable of truly trusting others. what do I do?

I'm already going to group therapy BTW

That is fantastic to hear that you’ve broken out of the deathly fear you had of others. I can’t imagine that was easy. And being in group therapy is probably a great idea. At this point I would recommend looking into the thoughts that might underlie the lingering alienation and mistrust. For example, we might internalize beliefs like, “It’s dangerous to let others really know me,” which we’re not really aware of but may be driving our feelings and behaviors. It’s also good to be aware of the thoughts we have in social situations. A lot of the time we’re telling ourselves really unhelpful stories about how others perceive us (like, “They can see I’m anxious and awkward,” or, “They think I sound stupid”), which make social contact a punishing experience. Most of the time we’re much harder on ourselves than others actually are—chances are they’re thinking about themselves, not us! (I’m sure you’ve been told that before.) Finally, if you have a history of trauma it would be important to address that, probably with a therapist. Untreated trauma tends to make it harder to connect with others. I’m not suggesting your struggles mean you must have been traumatized, just that if you have been through trauma, that’s another factor to consider. Wishing you the best. –Seth Gillihan, PhD

Is there anything outside of medication to help tone down the symptoms of bipolar? I finally got diagnosed with BP2 after two decades of being told I had only depression and since starting treatment, I haven't had any of those extreme highs or mania episodes that were becoming more and more frequent, which is amazing. Would CBT be able to help combat some of the lows and occasional mediocre high?

It’s great to hear that you are considering therapy. Oftentimes, patients feel better when they are using a combination of therapy and medication. Therapy can be more helpful if the fit with the therapist and the type of therapy match the individual. CBT, or cognitive behavior therapy, is a combination of using techniques to restructure inaccurate thoughts or distortions, and work on improving problematic behaviors. Another type of therapy, DBT, dialectical behavior therapy, is a skills-based therapy that is often taught in groups. You can ask your current therapist or psychiatrist for suggestions on which type of therapy may be best suited for you. - Smitha Bhandari, MD

I’m living in a country abroad and don’t fully know the language.

What kind of things can I do to ensure I have a stable mentality?

A couple notes:

• I have 0 connection with family

• I don’t have many friends because I’m kind of picky that way

• I’m a homebody and introvert

• I’m a ‘functioning’ alcoholic

It can be hard to make the adjustment to life in a new country. Sometimes it helps to think of ways to feel more connected. Maybe work is a good place to meet people. Or see if the country you are in offers any good outlets for your interests whether through sports, food, art, history, or culture. Whether you are introverted or extroverted, it’s often a good idea to take inventory of your week to make sure you have a balance of alone time for self care and interaction with others. - Smitha Bhandari, MD

I have pretty significant depression. I can’t afford a therapist and my insurance requires I use my entire deductible before they’ll help. What are my options?

I’m sorry it’s been tough for you to find help. Some counties have community mental health centers that can provide therapy at an affordable rate. Or you may be able to find a therapist who can offer a sliding-scale rate. If you live near a university, many of their training programs offer therapy at a reduced rate as well.  -Smitha Bhandari, MD

Some companies offer a certain number of therapy visits for free. Have you asked HR if they have a wellness program? I’m not sure where you work, but if you work for a larger company it may be an option as well. - Gabe Howard

Gabe makes a great point- a lot of us work for companies and universities that offer free counseling services (anonymously). HR departments are a great way to find out what type of services are offered (generally through wellness programs) so you can feel safe accessing without concern that your employer will find out. -Neha Pathak

What SSRIs do you reccomend for people who have libido issues on them? Lexapro killed the drive, Prozac makes it rough. Non ssris buspirone and welbutrin both gave me horrible reactions.

Need some to being up to my dr to try. Ive tried viibryd as well, didnt do anything but make me sick. Not even help my depression in the slightest. And I guess my doc is "running out of options" since viibyrd, prozac, lexapro, buspar, and wellbutrin are all nogos.

Currently on prozac 20mg, doc and me agree It works the best out of what we tried and is the best for libido besides viibyrd but not cutting it. An increase in dose would neuter me. For GAD and Severe Panic Disorder, according to my doc.

This is unfortunately a problem for some people on SSRIs (they can be a great medicine to help lift the dark cloud of depression) but the side effects can affect your sex life- reducing interest in sex, making it difficult to become aroused, and to reach orgasm.

For some people, the sexual problems can be a part of untreated major depression- so you want to think about whether you experienced any of these problems before you began treatment with medications.

If you’ve tried a lot of different medicines, here are some things that might help- lowering the dose (you should be kept on a dose that helps your condition, but finding the lowest effective dose might help.) Think about scheduling sex. Some of the side effects are most pronounced within a certain window of taking the medicine (like a few hours) so scheduling a time outside of that window might help.

It sounds like you have tried a lot of different meds-- there are some that are known to be less likely to cause sexual problems- but it sounds like you’ve already had some trouble with some of these.

The other thought is to talk to your doctor about medicine that can treat erectile dysfunction - some have been found to be helpful in treating SSRI-related sexual problems.

The most important thing is to continue to work closely with your doctors to make sure that both your mental health conditions are treated along with managing the side effects.

-Neha Pathak

about 1 in 5 U.S. adults had a mental health issue in 2014

How do you think this percentage changed up until 2019? Do we have a higher percentage of people with mental issues?

I don’t know if we have specific numbers yet for 2019, but there does seem to be a steady trend upward for mental health diagnoses. Rather than focus on the specific numbers, I think what they point to is that psychiatric conditions are not rare aberrations. They’re common conditions that anyone can experience. Hopefully this awareness will reduce some of the stigma that persists around mental illness.  —Seth Gillihan

Can you be severely depressed off and on, with some weeks being good or bad, and still have only clinical depression?

The medical definition of depression indicates that 5 symptoms must be present during the same 2-week period to qualify for an episode of depression.  Most episodes of depression, however, last longer than that, even up to a year. - Smitha Bhandari, MD

I am a 24 year old adult living on the autism spectrum. I received this diagnosis about a year and a half ago. Looking online, there aren't really a lot of resources for adults on the spectrum is there anything you could recommend?

It’s great to know that you are looking for resources.  Many autism centers (particularly those affiliated with colleges and universities) have specialized programs for adults.  There are many national organizations as well with specific programming for adults living with autism spectrum disorder. Bestbuddies.org, for example, has programs to help develop friendship and job skills.  Autism Speaks autismspeaks.org also has an online resource area devoted to job development and post-secondary education. Hope this helps! -Smitha Bhandari, MD

Thanks for your question. You may have come across these already, but the Autism Spectrum Program of Excellence at Penn offers many resources on its website: https://aspe.med.upenn.edu/resources/. Penn also is one of the centers, as Smitha Bhandari said, that has an adult autism program: https://www.med.upenn.edu/aas/about.html.  —Seth Gillihan, PhD

What is your advice for somebody seeking out professional help for the first time? Meaning things to look out for, prepared questions to be certain to ask, what to expect going in, etc. It's a daunting task, especially while likely being in a highly vulnerable state.

It is daunting, isn’t it? I would want to know that the person had the qualifications to treat what I’m experiencing, to start. That would be an obvious minimum. It’s especially important for some conditions (in my world, OCD comes to mind) in which many professionals are not trained in the evidence-based approaches. Once you know you’re in the right ballpark, I’d want to get a feel for the person. Do they listen to you? Do they seem to understand you, or at least try to? Do you and they have a shared understanding of who you are and of what the goals for treatment will be? And finally, pay attention to your reactions to the person. Do you feel reasonably comfortable with them? Do you dread your meetings? Do you feel worse after talking with them? Better? Of course, sometimes we feel worse after seeing a professional not because of them but because the subject matter is difficult. That’s a different issue. All the best to you if you’re seeking treatment for the first time. —Seth Gillihan, PhD

The first time we do anything it is scary, generally. I remember my first day of work at a big company. I was a grown man, married, owned a house and all I could think of was “who will I eat lunch with.” All this to say -- being nervous I think is normal. To prepare I recommend writing down why you are going. Top three concerns, top three symptoms, and top three goals.
When it comes to choosing a provider be honest. I remember when I told someone that I wanted to see a woman therapist because I was afraid of men. I was certain they’d laugh or “correct me.” They did not -- they were very understanding. But I had to raise the subject first. It can be hard to advocate for yourself, but be direct. If you have trouble, ask a friend/family member to stand with you or help you make an appointment and drive you. My first psychiatric appointment my best friends sat with me in the waiting room and rubbed my back. It made all the difference. - Gabe Howard

I was diagnosed with GAD. My doctor put me on Paxil 10mg. Is this normal? I hate the thought of having to take a pill to feel better. But, I understand that I have to do something because I can’t keep living life this way. Another doctor recommended CBD oil as an alternative. What is the general consensus on using that to treat anxiety disorder?

It’s hard to know whether CBD will end up being another wellness trend or a treatment that can withstand further research. As of now, the American Psychiatric Association has a statement saying there’s no evidence for the use of cannabis products in the treatment of mental health disorders but that more research is needed. There is some anecdotal evidence for the use of CBD in anxiety as well as some very small animal and human studies. The other issue is that CBD is not currently regulated so it’s hard to know exactly what you are getting and how much. - Smitha Bhandari, MD

What advice do you - Seth - have to an aspiring Clinical Psychologist? I am 3 semesters away from my undergraduate degree and am considering applying for programs that go from a Bachelor's degree to a PsyD. I want to work with either adolescents or veterans - haven't decided yet.

How exciting! It’s a great field to be in. A couple thoughts: One is to follow as closely as you can what you actually want to do in the field. You might not know the specifics at this point, as I hear you’re still deciding the population you might want to work with. As you move through your career, you’ll have opportunities come your way, some of which will be things you’re passionate about and some of which are just what’s there. As much as you can, move toward the things that really excite you, even if it’s not the easiest path and even if you have to the create the opportunities yourself. I would also recommend finding a treatment approach that really resonates with you. For me that was CBT and mindfulness; others are drawn to more psychodynamic or other approaches. And finally, it’s emotionally demanding work, so take good care of yourself. Start today! Learn more about yourself and what you need, and how to work in a way you can sustain, and that will sustain you. The world needs you, and the world needs you well. All the best to you in this journey. —Seth Gillihan, PhD