The Adolescent Mental Health Initiative is a major, Penn-led effort to address what one expert calls the “chronic diseases of the young.”
By Samuel Hughes | Illustration by Josh Cochran
Mental Health Online
What Is To Be Done?
Spreading the Word
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Before Patrick Jamieson C’97 GEd’99 Gr’03 was able to get his bipolar disorder under control, his life was unraveling. Mania and depression had transformed the rutty road of adolescence into a kind of carnival speedway, one whose surface alternated between rain-slicked blacktop and tire-engulfing mud.
“During one manic episode, I followed the turn signals of the car ahead of me for direction because I thought God was trying to lead me,” he recalls in his 2006 memoir, Mind Race: A Firsthand Account of One Teenager’s Experience with Bipolar Disorder. “But mania sparks second and third interpretations for every action. Alternatively, I thought following the car ahead of me would reveal something important and otherwise unknowable, a mystery unraveled—where that car was going.”
The depression that inevitably dragged his mania to a slogging halt was worse. His body felt like a “nearly lifeless hulk,” he writes. He found himself “weary, purposeless, submerged in a world filled with muffled echoes of my own thoughts and the whispers of others, a dark and desolate world. As my mind congeals, my speech slows. I petrify.”
Jamieson, now 33, declined—politely but firmly—to talk to the Gazette for this article. But his book is a trenchant, harrowing, ultimately uplifting portrait of his adolescent struggles with bipolar disorder, one that led to six hospitalizations and serious stress on his family. It also offers a wealth of practical information about living and coping with that disorder.
What makes his story remarkable is not just that he survived his ordeal but that he triumphed over it. Today, having earned his Ph.D. at the Graduate School of Education, he is associate director of the Adolescent Risk Communication Institute (ARCI) at the Annenberg Public Policy Center (APPC) at Penn. He and his wife recently celebrated the birth of their second child.
More important for this story, he is the editor of a series of books for the Adolescent Mental Health Initiative (AMHI), whose mission is to “synthesize and disseminate scientific research on the prevention and treatment of mental disorders in adolescents.” One of those books is Mind Race, which he describes as “the book I searched for and could not find” when he was finally diagnosed at age 15.
The AMHI is the brainchild of Dr. Kathleen Hall Jamieson, director of the APPC, former dean of the Annenberg School for Communication, and—last but certainly not least—Patrick’s mother. It has been funded, to the tune of nearly $5 million, by the Annenberg Foundation Trust at Sunnylands (whose director is … Kathleen Hall Jamieson), and has been administered by the APPC.
That it emerged from Penn is no accident. It wasn’t until the Jamiesons moved to Philadelphia, and Patrick got into Penn’s Health System, that he was properly diagnosed and treated. Furthermore, Penn is Kathleen Hall Jamieson’s intellectual home, and one of the few universities in the country with the scholarly resources and research capabilities to carry out the mission.
The initiative represents a massive undertaking, involving seven commissions of top-flight scholars from around the United States and Europe—more than 100 altogether. Each commission addressed a different issue: mood disorders (including bipolar), schizophrenia, anxiety disorders, eating disorders, alcohol and drug abuse, suicide, and positive psychology, which could be viewed as the anti-disorder. Five of the seven are led by Penn faculty members, and Penn is represented on all commissions.
They have produced a prodigious amount of resource material, including a definitive, 800-page tome, Treating and Preventing Adolescent Mental Health Disorders: What We Know and What We Don’t Know, which was named the best book in clinical medicine in 2005 by the Association of American Publishers. (It can be viewed online.) Then there are the four resource books for parents and eight firsthand accounts of teenage mental illness (see sidebar on p. 43), all edited by Patrick Jamieson—who also oversees a website for teens, CopeCareDeal (see sidebar on p. 38).
The abundance of material is a response to a problem whose severity is not always recognized. As Dr. Dwight Evans, chair of the Department of Psychiatry and head of the AMHI’s commission on adolescent depression and bipolar disorder, puts it: “Mental illness really is the chronic disease, or diseases, of the young.”
- Suicide is the third leading cause of death among youth (behind only car accidents and homicide). More than one out of every 12 of high-school students have attempted it in the past year, and each year roughly 4,000 young people (ages 15 to 24) succeed in killing themselves. “Mental illness underlies the majority of suicides,” notes Dr. Daniel Romer, director of the ARCI.
- Between 20 and 30 percent of adolescents report “clinically significant” symptoms of depression. The mean age of onset is 15.
- An estimated 1.1 million teenagers (ages 12-17) needed substance-abuse treatment in 2001. (More than half of all high-school students have used an illegal drug by the time they graduate.) Only 100,000 actually received treatment.
- Schools, the main service-delivery system for 70 to 80 percent of adolescents with mental-health issues, are seldom equipped to deliver the services needed. Nearly half of the 2,000 schools surveyed by the AMHI lacked full-time access to a mental-health professional. “It’s amazing to me how little teachers, even in national conventions, know about the various mental illnesses,” says Dr. Raquel Gur M’80 GM’84, the Rickles Professor and vice chair for research development in psychiatry who headed the AMHI’s commission on schizophrenia. “They’re more familiar with ADD, and how [students] are progressing according to the growth charts.”
- Primary-care physicians are often inadequately trained to identify and diagnose mental-health problems, and “report low confidence in their ability” to do so, according to an AMHI study.
The recent tragedy at Virginia Tech is a grim reminder of the possible consequences for untreated or ineffectually treated mental illness—though only a small percentage of the mentally ill commit acts of violence. “Every time I see a news article in which a killer, or someone who was shot and killed by police, or someone who died by suicide is listed as having bipolar disorder, I remind myself that there are nearly two million of us with bipolar in the United States,” notes Patrick Jamieson. “That’s a lot of people—and very few of them have violent histories.”
Most mental-health disorders first “present” (to use the medical lexicon) during adolescence, which the authors of Treating and Preventing define broadly as ages 10 to 22. Left untreated, those disorders can become permanent, unwanted guests. Using a metric called Disability Adjusted Life Years, which measures the morbidity of a disease, the World Health Organization recently “ranked depression as No. 4 worldwide in terms of disability,” notes Evans. By 2020, “depression alone—not anything else; just depression—will be No. 2 worldwide behind ischemic heart disease. Because these disorders begin so early, they do have significant morbidity and mortality associated with them.”
There’s a “lot of well-respected epidemiologic data” linking depression to different illnesses, Evans adds. “We often say depression is bad for the brain, and it’s bad for the body.”
Thanks to medications and psychotherapy—not necessarily in that order—depression, anxiety, and a number of other mental illnesses are treatable. Yet in many places it is harder to get an accurate diagnosis and good treatment for bipolar disorder than it is for, say, diabetes. Especially when co-morbidity—overlapping disorders—enters the mix, which it often does.
“Experts are aware of the fact that we know very little about adolescents” when it comes to mental illness, says Dr. Edna Foa, the professor of clinical psychology in psychiatry and director of Penn’s Center for the Treatment and Study of Anxiety who headed the AMHI’s commission on anxiety disorders. “We know a lot about adults, especially in anxiety disorders; some about children; and we know next to nothing about adolescents. That still is the case—I think because, for a while, we thought maybe adolescents are like little adults or like big children. We didn’t think about them as having very specific issues that make their stress issues very unique.”
Even when mental illness is properly diagnosed, the logistics of getting treatment for it can be daunting—especially since “at least six separate sectors or administrative structures may be involved in serving youth with mental health problems,” according to Treating and Preventing. Though one important national program—the Comprehensive Community Mental Health Services for Children and Families—receives close to $100 million in federal funding, it only reaches a “small percentage of communities” in the U.S. Most families seeking mental-health care thus face “significant system barriers” to effective treatment.
“You could produce a whole movie on adolescent and child mental-health care that in some ways would easily be more startling than Sicko,” says Dr. Charles O’Brien GM’69, the Appel Professor and Vice Chair of Psychiatry (and director of the Center for Studies of Addiction at Penn), referring to Michael Moore’s documentary about the health-care industry. “Even here in Philadelphia, it’s very hard to find treatment slots for children and adolescents,” adds O’Brien, who headed the AMHI’s commission on substance abuse. “There are problems with service delivery and problems with the knowledge base.”
Not to mention with funding and insurance coverage: Nearly 12 percent of those under 18—and 30 percent of those between 18 and 24—have no health-insurance coverage whatsoever. And those who have health insurance are by no means guaranteed payment, since parity for mental-health issues remains an elusive goal.
“We have interventions that actually work, but now we’ve got a category that says this is ‘mental’ as opposed to ‘physical’—and as a result you don’t get access to the things that work,” says Kathleen Hall Jamieson. “That’s the part of society that’s broken right now in the United States, and it would be good to find a way to get it fixed. My husband and I are upper class; we’re educated; we’re tied into a major research university; we had insurance—and it was difficult for us. Imagine what it would be for someone who doesn’t fall into those categories. That ought to be troubling to society. It’s certainly troubling to us.”
The Jamieson family did not think of itself as lucky when Patrick’s bipolar disorder emerged. But for the sizeable swath of American adolescents and families struggling with mental illness, the fact that this happened to a son of Kathleen Hall Jamieson was a stroke of remarkably good fortune. Though she’s not a medical doctor or scientist, it’s hard to imagine anyone better equipped—by temperament, connections, and stature in the academy—to lead an initiative like the AMHI.
“This is the area in which I have the least expertise as a scholar and the most expertise as a mother, and it makes it a different project,” says Jamieson, who was famously protective of her family during her two sons’ adolescent years. “Ordinarily, you’re ill-advised as a scholar or policy-center director to take on anything that you don’t have a fair amount of scholarly expertise in, because you won’t find a niche and you can’t make a contribution,” she says. “What is exciting about this project is that Penn was able to identify the scholars, to find the niche, and to make the contribution.”
As she speaks, she is sitting at the large table in her office in the Annenberg Public Policy Center, where a photo of her first grandchild adorns a glass door. Her jeans suggest a more casual workday environment than she was accustomed to during her years as dean of the Annenberg School, but her speaking style—fast, precise, content-rich—hasn’t changed one bit.
“Am I personally invested in it?” she asks rhetorically. “Yeah. When you see that your child has benefited from access to a body of professionals and a body of knowledge, and then you realize that other parents would not have had the same benefit because they weren’t tied to a research university and might as well have lost their child, you’ve got to be very grateful to the Annenberg Foundation Trust at Sunnylands saying: ‘Yes, you can do this project.’ It’s the story of what happens when the Annenbergs enter your life.
“I am invested in it because I think it is incredibly important,” she adds, “but the real investment, in terms of time and expertise, was the Penn scholarly community.”
“There are five or six places this could have been done, and Penn was one of those places,” says Dr. Martin E. P. Seligman Gr’67, the highly influential professor of psychology who headed the AMHI’s commission on positive psychology. (Seligman founded the positive-psychology movement, and is director of the Positive Psychology Network.) He and Evans were the initiative’s “co-chairs and conceptualizers,” in Jamieson’s words (they also edited their commissions’ chapters and wrote the introduction to Treating and Preventing), but they both point to Jamieson as the AMHI’s catalyst and linchpin.
“This never would have remotely happened without Kathleen and Patrick,” says Seligman. “This is a product of Kathleen’s emotional life and the financial weight that she could throw around. She said she was going to do this adolescent mental-health thing, and whatever she would say, I would do, and trust her taste. Kathleen’s got a real nose for who’s important, and I think she just picks up the phone and people say Yes.”
“It was very interesting—nobody said No,” says Raquel Gur. “All these people who are so busy, from all around the country and even Europe—nobody said No. I thought it reflected the perception of all the participants that this was a really important initiative.”
Two underlying principles are worth mentioning. One is that the initiative’s leaders didn’t want any funding from pharmaceutical companies.
“There’s no drug money,” says Jamieson. “So when the book says, ‘This medicine category works,’ they’re not saying this with any hint that some influence in that decision might have been drug money.”
“This was funded by the Annenberg family, who care about mental illness and want to get the best information out to the public at large, both professionals and a lay audience,” says Joan Bossert, the Oxford University Press editor of Treating and Preventing. “That it was not funded by the pharmaceuticals is very powerful.”
The other principle had to do with “crossing the psychological/psychiatric divide,” in the words of Jamieson. Essentially, that divide lies between psychologists who stress psychotherapy and psychiatrists who emphasize medication. While there are obviously members of both camps who don’t follow that pattern and cross the great divide in their own ways, “in a whole lot of places those areas fight each other, which makes no sense,” Jamieson notes. “Marty [Seligman] and Dwight [Evans] don’t do that. They started out with a broader list.”
“I’ve never had a psychiatric/psychological divide,” says Seligman. “The divides are really more biological vs. psychological, and Dwight and I are both serious about both. I’m closer in mind to Dwight than 90 percent of my colleagues in the psychology department, so I’m an easy fit for a lot of different departments.”
“Our understanding of brain development is rendering the old debates between nature and nurture or biology vs. behavior increasingly irrelevant,” note Evans and Seligman in their introduction to Treating and Preventing. The recent advances in the field “make this a most exciting time for advancing our knowledge and ultimately for preventing the onset and development of mental disorders at the earliest signs of presentation.”
Certainly, those afflicted with mental illness now have a better chance at living a productive life than ever before, especially if they are diagnosed and treated early. Five or six years ago, Raquel Gur recalls, Penn’s Student Health Service called her and asked her to see a student whose behavior suggested psychosis. After evaluating him, she met with his parents, who had flown to Philadelphia. “I asked the mother, ‘Are you familiar with schizophrenia?’ She said, ‘Yes, my husband’s brother is schizophrenic’—that’s why they flew in,” says Gur. “She was crying and saying, ‘Dr. Gur, I wish you were telling me it was cancer! There’s more progress and more potential for curing young people with cancer! I saw what schizophrenia did to his uncle.’”
As it turned out, the woman’s son was successfully treated. “He came back to Penn, and he was able to graduate, and he’s OK,” says Gur. “But their reaction—‘It would be easier for me if it was cancer’—really captures the fear, the feeling of being totally alone and scared. And because the implications can be so significant, it’s important to identify it early, because there’s much more that can be done if it’s identified early rather than late.”
Adolescence is an amazing phase of life. True, there are some who think the phase is overstated, including psychologist Robert Epstein, the founding director of the Cambridge (Massachusetts) Center for Behavioral Studies and the author of The Case Against Adolescence: Rediscovering the Adult in Every Teen. He believes that, as a nation, we are infantilizing our youth by relegating them to the frivolous world of teen culture. Epstein also argues that the teenage brain may well be as much the product of the turmoil around it as the cause, and to some extent the authors of Treating and Preventing agree: “The brain is an eminently plastic organ that develops both in accord with genetic rules and in response to its environment.”
But those same authors also provide a lot of evidence that adolescence is a unique period of “dramatic change in brain structure and function.”
- Synaptic change. Synapses are the small junctions across which a nerve impulse passes from one nerve cell to another (or to a muscle cell or gland cell). Oddly enough, there is a “major reduction in the number of synapses” during adolescence, which appears to reflect “active restructuring of connections and the sculpting of more mature patterns, with a corresponding pruning of connections with very little activity.” That reduction helps the adolescent brain become “more efficient and less energy consuming,” which in turn “may permit more selective reactions to stimuli …”
- Myelination. The process of myelination during adolescence is also thought to contribute to the development of the brain’s “executive functions,” including faster information processing. (Myelination is the formation of a myelin sheath around a nerve fiber; myelin both insulates the nerves and permits the rapid transmission of nerve impulses.)
- Matter. The brain is made up mostly of white matter (whitish nerve tissue containing mostly myelinated fibers) and gray matter (brownish-gray nerve tissue composed of nerve-cell bodies and fibers). Adolescence is marked by an increase in white-matter density and a corresponding decrease in gray matter, especially in the frontal and prefrontal areas; the overall result is a net decrease in volume of the prefrontal cortex. The dorsal lateral prefrontal cortex, which controls impulses, doesn’t reach adult size until the early 20s, by which time there is “improvement in prefrontal executive functions, including response inhibition and organizational and planning skills.” Though more research needs to be done in this area, some studies indicate that adolescents with depression have relatively small frontal lobes, with less white matter in them. The frontal lobes “regulate the capacity to think something through and see the potential adverse outcome—and to say to yourself, No, not just to act impulsively or instinctually,” notes Evans. “Add to that an actual illness on top of it, whether it’s depression or an anxiety disorder, or substance abuse and alcohol, and you have a pretty uneven mix in terms of brain behavior and potential for adverse outcome.”
- Some of the transformations in the adolescent brain have to do with the “hormonal reawakening of puberty,” which leads to sexual maturation and is “characterized by a cascade of hormones,” explains psychologist Linda Spear in another AMHI book, Adolescent Psychopathology and the Developing Brain. There is also a chicken-or-egg component, she notes: While rising hormone levels may be “precipitated” by the brain, they “also in turn may serve to trigger some adolescent-associated brain transformations.”
Though most mental illnesses first appear during adolescence or early adulthood, recent research suggests that those years offer an opportunity for preventing them and even changing the pathways of the brain. That could have far-reaching consequences.
“Mental health has not, historically, been preventive,” says Evans. “We treat conditions once they’re set up, but it’s like a cardiologist who might be studying an established ischemic heart disease—the real bang for the buck, so to speak, is to prevent ischemic heart disease. If one could prevent depression, that could be a real target.”
“There are opportunities to intervene early,” says Daniel Romer. “If the brain is still forming, then we still have the opportunity to use that plasticity to our advantage.”
If we don’t, that same plasticity can be a curse.
“It is dangerous because kids learn very well,” says Charles O’Brien. “Drugs can activate the brain’s reward system,” which is more fully developed at that age than the inhibitory or executive-function systems. “Many kids start smoking when they’re 12 to 14 or 16, and they develop addiction more rapidly than adults. That very plasticity, which can be good when learning a language or music, can be very bad when learning a bad habit.”
Patrick was 11 when he first began showing the manic symptoms of bipolar disorder during his family’s six-month stay in Hawaii. Two years later, the Jamiesons moved to Austin, where his mother chaired the Department of Speech Communication at the University of Texas. There his condition morphed into a “mixed state” in which both manic and depressive symptoms—fast thoughts, lack of focus, and low energy—reared their heads. After some months of “little sleep and still less focus,” Patrick “crashed out of the mixed state and into a five-month depression,” sleeping up to 18 hours a day and missing more school than he attended. But despite getting “poked and probed, scanned and scrutinized … as if every bodily fluid of mine that could be extracted was tested for diseases both rare and common,” no one could figure out what was wrong.
“We were in a town [Austin] that is highly educated,” recalls Kathleen. “It’s a university town. But the doctors there were one degree removed from a medical-research hospital. I’m sure doctors try to stay in touch with their own literature. But we went from doctor to doctor—who never, in the time that we confronted any of them, said, ‘This could be bipolar disorder.’ Which led me to think that maybe there are a lot of people out there who don’t have the benefit that we had of being tied to a major research hospital, whose children are not getting the treatment that they should have, as quickly as possible, simply because the doctors don’t know.”
When the Jamiesons moved to Philadelphia and Kathleen became dean of the Annenberg School, Patrick’s mania kicked back in. The move also put the Jamiesons into the orbit of a “local medical teaching hospital”—feel free to connect the dots—and with it “experts who not only recognized but also studied adolescent bipolar disorder.” They quickly diagnosed it as such.
Patrick was not, at the time, pleased with the diagnosis. “I wanted an illness caused by a bacterium that could be treated with an antibiotic or one produced by a splinter that could be removed by surgery,” he writes. A psychiatric illness “wasn’t real,” he felt; “it was ‘all in your head’—the ultimate form of self-indulgent hypochondria.” (One of the “insidious things about stereotypes is that you think they are facts,” he points out, and the stigma of mental illness is something he helped address in Treating and Preventing as well as in Mind Race.)
Nor was he keen on taking lithium for the rest of his life—or having to forgo such customary adolescent mood-enhancers as beer. But as he soon found out, doing so was a lot better than the alternative.
For Kathleen, the diagnosis meant that now she knew what she was dealing with and could start to address it. Or so she thought.
“The first impulse of an academic when you’re confronted with a problem is to try to find research,” she says. “So when we finally got into the Penn system and Patrick was diagnosed, we did a literature review. We pulled everything we could find.”
At that time, apart from one “excellent” book—Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, by Frederick Goodwin and Kay Redfield Jamison (no relation)—there was nothing. “That was an Oxford University Press book, and I am an Oxford author, so I could very easily go to Oxford and ask, ‘Is there anything else in the pipeline?’” says Jamieson. “There was virtually nothing for Patrick to read. What we found was that one excellent book, but it wasn’t written for lay people and it certainly wasn’t written for a teenager.
“Nevertheless, Patrick read it, and kind of clutched at it all the way through this process, because it provided something that looked like systematized knowledge.”
It was at that point that she realized that the intellectual resources available to her son and her family were not adequate. If she wanted something done, she would have to start it herself.
When Edna Foa first heard about the AMHI, she recalls, “My first reaction was, ‘Wow—this would be of great help to a lot of people.’”
“The goal of bringing together a broad range of real expertise in the most important mental-health topics relating to adolescence was unprecedented,” says Dr. B. Timothy Walsh, the professor of pediatric psychopharmacology in psychiatry at Columbia University Medical Center and a former president of the Academy for Eating Disorders who headed the AMHI’s commission on eating disorders. “It really served a very important goal of summarizing both the information available and, as importantly, of underlining the need for new information.”
Kathleen had agreed to direct the programming, and while she freely admits to having no expertise in the area beyond being Patrick’s concerned and plugged-in mother, once she had Seligman and Evans on board, they were quickly able to recruit the other commission chairs. Three were from Penn: Raquel Gur, Edna Foa, and Charles O’Brien. When Jamieson approached Dr. Thomas Wadden, professor of psychology at Penn and director of its Weight and Eating Disorders Program, to head the commission on eating disorders, he recommended Timothy Walsh, who quickly signed on. Chairing the commission on adolescent suicide prevention was Dr. Herbert Hendin, professor of psychiatry at New York Medical College and director of the American Foundation for Suicide Prevention.
Walsh, a Princeton alumnus who was “very impressed by the Penn folks” involved, says that the “leadership of Kathleen Hall Jamieson, along with the excellence of Penn’s mental-health departments, makes Penn a very logical place” for the initiative to be based.
For Jamieson, the “unsung genius of the process” was Joan Bossert. “She is just a superb editor, and she really cares about this,” Jamieson adds. “By the time we had these commissions created, we had a partnership with Seligman, Evans, and Bossert.”
“I was instantly taken with the project,” says Bossert. “I thought it was brilliant. People were applying adult and child [mental-illness] literature to adolescents and thought it would work. It doesn’t.”
Using another Oxford reference work as a template—A Guide to Treatments That Work, by Peter Nathan and Jack Gorman—most of the AMHI commissions divided their work into four chapters: Defining, Treatment, Prevention, and a Research Agenda. One was significantly different: Seligman’s commission on positive youth development, whose section is titled “Beyond Disorder” (see sidebar on p. 41).
In January 2004, after the seven commissions (each composed of roughly 15 scholars) had their organizational meetings to determine how to approach their sections, they attended a three-day conference at the Annenbergs’ Sunnylands estate in Rancho Mirage, California. “It was a pretty free-wheeling set of debates, an attempt to give everybody a chance to challenge everything in the book,” says Jamieson. “I thought the process was fantastic. If you’ve got that level of expertise locked in one hotel, you’re not going to give up the possibility of saying, ‘Are there other things?’”
Some 32,000 copies of Treating and Preventing, along with the parents’ and teen books, were sent to mental-health professionals, librarians, and others. More than a few of those professionals wrote back.
A social worker in upstate New York called Treating and Preventing a “great overview of the field,” adding that the parents’ books about the disorders were most helpful in “updating current research and treatment modalities.” A school psychologist who had read Mind Race and was now reading If Your Adolescent Has Schizophrenia wrote: “I cannot tell you how helpful these books are. I just recently had to evaluate a 17-year-old male who is an emerging schizophrenic. I think I did a MUCH better job and was able to be far more understanding thanks to your books.”
“Please, please, please forward my heartfelt thanks on to the person who decided to write a book about adolescent schizophrenia,” wrote a librarian in Missouri whose son had been diagnosed with the disorder two years before at age 20. “When he came home and told me the diagnosis, we were both terrified. Being a librarian, the only thing I could think of to do was to read up on the disease. I’ve always felt that knowledge is the best defense against fear … I was appalled at how little print information is available to the general public about schizophrenia.”
Several people wrote in praising Mind Race, including a school psychologist who said it was “instrumental in placing a young girl in therapy,” and another who said it helped her understand bipolar disorder “better than anything I’ve read before on the subject.”
There is a “hope and a possibility” that by 2010 the online version of Treating and Preventing will be updated regularly, says Kathleen Jamieson. In the meantime, the printed version is still the definitive word.
“My personal hope is that parents who come to a doctor someplace that doesn’t have the advantage of being tied to a research hospital, with a child who is frighteningly troubled, [that doctor] may now increasingly have the chance to say, ‘This may be what it is. If I don’t know how to deal with it, I know how to get you a referral to get help for your child.’”
It wasn’t smooth sailing for the Jamiesons, even when Patrick was in the relatively good hands of Penn’s Health System. Though he had been taking his lithium with “almost religious fervor,” he suffered a serious manic episode that led him, late one night, to the hospital emergency room, then to the “unlock unit” of the psychiatric ward—where, after being observed by the staff “talking back to the overhead pager” and “somewhat violently” throwing his clothing on the floor, he was “transferred to the locked unit ‘upstairs’ for potentially dangerous behavior as well as possible elopement risk.” (Elope, in psych-ward jargon, means “escape,” another example of why, in Jamieson’s wry view, a lot of mental-health providers suffer from an ailment he terms compulsive euphemization.)
“My mother found out that I had been transferred when she showed up for visiting hours the next afternoon and instead of locating me on the open ward was directed to the locked ward,” he writes. “Drugged into a deep sleep, I didn’t know she was there.”
A parent can only wince in empathy on reading the hospital’s notes on the Jamiesons’ reaction, which appear in the book: Mother and father [express] discomfort with son being on a locked ward with “bizarre people” … Parents express anger, frustration and feelings of abandonment by medical staff/system.
Ultimately, Patrick was hospitalized six times, but he has learned how to control his disorder with lithium and other medication, and doesn’t expect to be hospitalized again. Though writing about that time in Mind Race can’t have been easy, his sense of humor emerges even when he’s explaining why he was hospitalized—and why patients aren’t always the best judges of their own condition.
“Once when hospitalized, I informed a doctor that I thought I was ready to go home. Deadpan, she responded, ‘Perhaps we should wait for a day in which you did not take a shower with your clothes on.’”
Despite his frustration with life in the locked ward, Jamieson did come to appreciate how lucky he really was.
“I had the ‘choice’ of getting even sicker or checking into the hospital and getting better,” he writes. “I was very fortunate to have this option, and like many other patients my condition improved during each hospitalization. Though I am thankful for the opportunity to heal, after being discharged six times, I vowed that I would do everything I could to ensure that I would not need to be readmitted. Ever.”
Patrick Jamieson’s significant role in the AMHI will almost certainly ensure that a lot of people get helped. It is also one from which he—and everybody else involved—can derive a good deal of satisfaction.
“I’m very proud of this project,” says Kathleen Hall Jamieson, “and proud in a way that I’m not proud of other projects, because this is in some ways for me a Penn project. A lot of what we do in the policy center makes no use whatsoever of the rest of the Penn community, and as a result, I could have done it anywhere. I couldn’t have produced this—even if I had the money from the foundation and the support of Mrs. Annenberg—if I’d been in Texas [the site of her previous academic home]. I couldn’t have done it at the University of Maryland [her first academic appointment]. I look at this book and think, ‘I’m lucky to be at Penn.’”
Mental Health Online
CopeCareDeal (www.copecaredeal.org), “a mental health site for teens,” is not just a resource that is available 24/7; it’s also the AMHI’s way of keeping up with changes in a way that regular publishing can’t.
“We’re moving out of a world in which books are going to be the mode of dissemination—although you still want them on people’s shelves—to a world in which somebody can go online and type in” their question or concern, says Kathleen Hall Jamieson, referring both to CopeCareDeal and to the online version of Treating and Preventing Adolescent Mental Health Disorders.
The website is broken into three sections:
- Cope, which offers tips for coping with everyday stress and larger issues.
- Care, for learning about warning signs that a teenager may need help, and to locate mental-health resources.
- Deal, which contains important information about depression, schizophrenia, eating disorders, and other illnesses that can affect teenagers. There is also a section with links to New York Times health stories relevant to mental illness, such as “Suicide Findings Question Link to Antidepressants,” “Psychiatrists Top List in Drug Maker Gifts,” and “In the Classroom, a New Focus on Quieting the Mind” (which is about mindfulness training, drawn from Buddhist meditation).
What Is To Be Done?
The final chapter of Treating and Preventing Adolescent Mental Health Disorders is titled “A Call to Action on Adolescent Mental Health.” After laying out the mostly good news about the success rate for mental disorders when treated effectively, and discussing the current debate about the safety and efficacy of antidepressants, the authors—Kathleen Hall Jamieson and Daniel Romer—make a number of recommendations, including:
- Increase the number of psychotherapists trained in cognitive behavioral therapy and interpersonal therapy.
- Improve access to results of clinical trials evaluating effects of all therapeutic interventions.
- Treat substance-abuse issues and mental-health issues within the same service system, since drug dependence is often “co-morbid with other mental conditions” and would benefit from “treatment as a medical problem rather than as criminal behavior.”
- Increase and improve early detection and treatment, especially in the area of substance abuse.
- Achieve “full parity” in mental-health insurance coverage.
- Reduce the stigma of mental illness by educating the public about the effectiveness of treatment “and the reality that persons with mental disorders can lead productive lives.”
- Increase research, both about “appropriate protocols and systems for treatment” and to “increase our understanding of the multiple pathways to both healthy and unhealthy development.” While a study that follows a “large and representative sample of children and twins” into adulthood would be quite costly even for the National Institute of Mental Health, it would “greatly advance our understanding of the emergence of mental disorder and resilience in youth,” and pave the way for more tests of intervention strategies.
Asked why positive psychology is an appropriate field to apply to the issue of adolescent mental health, Martin Seligman (who founded the field) responds:
“People have used the words mental health forever to talk about what these initiatives are about, but what they really meant was mental illness, and the relief of mental illness. But I’m serious about mental health. I think it’s a real thing. If you want to grow roses, it’s not enough to weed and clear underbrush; you have to plant something. If you want exemplary adolescents—if you want happy people—you have to do more than just fight the disorders. You have to plant other stuff—skills of positive emotion, of good physical health, of engagement, of meaning.”
Positive psychology’s “two justifications for adolescent mental health,” he says, are: “One, it’s about health, not about the relief of illness. And second, building the positive [side] of life may be the best therapeutic and preventative weapon we have against disorder.” Or, as he puts it in the “Positive Perspective on Youth Development” chapter of Treating and Preventing: “Attention to what is good about a young person provides a foundation on which to base interventions that target what is not so good.”
While conceding that there is probably less room for a person to change plasticity on the “negative side of life,” such as deep-rooted fears and anxieties, “evolution might be a little more permissive about the positive side of life—who we marry, who we love, about sexuality,” Seligman suggests. “I’ve been asking questions: Are there interventions, lessons, in children, that move people—not just from minus-six to minus-two, but from plus-two to plus-eight? My hypothesis is that there’s a much lower upper limit to changing depression or anger than there is for changing meaning and engagement or joy and gratitude.”
The “Positive Perspective” chapter examines individual psychological characteristics, including “positive emotions, such as joy, contentment, and love”; “flow, the psychological state that accompanies highly engaging activities”; “life satisfaction, the overall judgment that one’s life is a good one”; “character strengths, which include positive traits such as curiosity, kindness, gratitude, hope, and humor”; and “competencies, or skills and abilities in social, emotional, cognitive, behavioral, and moral domains.” It also examines “youth development programs that work.”
Believing that schools are the “fulcrum for teaching positive psychology in adolescents,” Seligman recently convened an invitation-only (no press allowed) conference for some 80 educators, psychologists, and “special guests” to discuss:
- What are our expectations vis-à-vis character and well-being? What are our ultimate hopes for our children? How will we measure our success as educators? Can nonacademic outcomes be rigorously assessed?
- How can positive psychology be incorporated into—or at least inform—what goes on in the classroom?
- Outside of the classroom, how can character and well-being be cultivated? Can an entire school culture be pervaded with positive psychology?
- How should positive psychology be applied to faculty selection, development, and assessment?
Spreading the Word
In addition to its massive reference book, Treating and Preventing Adolescent Mental Health Disorders: What We Know and What We Don’t Know, the AMHI has produced two series of books about adolescent mental health, both edited by Patrick Jamieson (see main story).
The Parents series contains four books: If Your Adolescent Has an Anxiety Disorder (by Edna Foa, head of the AMHI’s commission on anxiety disorders, and Linda Wasmer Andrews), If Your Adolescent Has an Eating Disorder (by B. Timothy Walsh, head of the eating-disorders commission, and V. L. Cameron), If Your Adolescent Has a Mood or Bipolar Disorder (by Dwight Evans, head of the commission on depression and bipolar disorder, and Linda Wasmer Andrews), and If Your Adolescent Has Schizophrenia (by Raquel Gur, head of the commission on schizophrenia, and Ann Braden Johnson). Each offers the latest information on:
- Warning signs to watch out for.
- Getting a diagnosis.
- The latest treatments.
- Coping at home and school.
- Prevention strategies.
Four firsthand accounts of teenage mental illness have already been published: Patrick Jamieson’s Mind Race (bipolar disorder), Cait Irwin’s Monochrome Days (depression), Carrie Arnold’s Next to Nothing (eating disorder), and Emily Ford’s What You Must Think of Me (social anxiety disorder). Four more will be published within the next six months: Kyle Keegan’s Chasing the High (substance abuse), Jared Kant’s The Thought That Counts (obsessive-compulsive disorder), Kurt Snyder’s Me, Myself, and Them (schizophrenia), and DeQuincy Lezine’s Eight Stories Up: An Adolescent Chooses Hope Over Suicide. In addition to the personal narratives, each of the books weaves current medical information on diagnosis and treatment; all are co-written with mental-health professionals.
Finally, another reference book put out by the AMHI, Adolescent Psychopathology and the Developing Brain, edited by the ARCI’s Daniel Romer and by Elaine Walker (professor of psychology and neuroscience at Emory University), emerged from a 2005 conference at Penn.