Amanda Williams - Southern Regional AHEC

DEPRESSION, the Black Dog (part 1)

By MICHAEL SHAPIRO, PhD

No blog about behavioral health issues would be complete without a discussion of depression. Winston Churchill (who some think suffered from major depression or bipolar disorder) referred to his episodic dark moods as his “black dog.” He didn’t actually invent this term; in fact, it was a pejorative term used by nannies in the Victorian era to refer to unpleasant or moody children. In any event…we get the idea. Everyone on the planet who claims to be human (which, I suppose, includes pretty much everyone) has experienced low mood, despair, or sadness. If you deny it, you’re either a liar, have very poor insight, are deeply in denial, or literally live in Mr. Rogers’ Land of Make Believe (even then, the rising price of trolley tickets has got to get you down sometimes!).

Sadness is a natural, healthy reaction to loss: loss of a relationship, loss of an opportunity, even loss of physical health. It can even be evoked in response to someone else’s loss. This kind of identification with another person (in other words, feeling sad because someone else is sad) is called empathy: it ties us together as humans and motivates us to help each other. In a way, “normal” sadness gives life meaning by helping us understand our own values. It reveals what’s really important to us. Also, how can anyone appreciate joy and happiness if we’ve never known sadness?

However, there’s a difference between sadness and depression. Typically, sadness is caused by an identifiable event: your favorite team lost in the playoffs, your pet hamster died, or your child went off to college (okay…so maybe sadness and joy can sometimes co-exist). In contrast, clinical depression often appears for no reason. Indeed, people who suffer from depression often feel guilty about being depressed without any apparent cause! The job is going well, the kids are fine, the marriage is solid…what could be wrong? This conflict between a person’s mood and the reality of the situation only makes him or her feel worse.

So if clinical depression is profound sadness that often appears for no reason, what causes it? Excellent question. As with any behavioral health disorder, there is more than one answer. Specifically, depression has four facets: biological, psychological, social, and spiritual.

Let’s start with the biological facet: it is now a known fact that, as with any physical illness, depression is rooted in biology. For one thing, it appears to be hereditary. Since depression runs in families, there must be a genetic predisposition to this disorder. More often than not, someone who suffers from depression has a depressed relative (or relatives) climbing around on some branch (or branches) of the family tree.

It is also known that some kinds of depression are linked to deficiencies in neurotransmitters…the chemicals that allow brain cells to communicate with each other. That’s why treatment of depression often involves medication. Most antidepressant medications cause these neurotransmitters to be more available to the brain (more about that in our next blog!). The important take-away is this: clinical depression isn’t a weakness, a lack of character, or a moral failure! It’s a biological disorder, just like diabetes, hypertension, or the flu!

However, for someone who is biologically predisposed to depression, the first depressive episode is usually triggered by a stressful or traumatic event. Personal catastrophe (loss of a job, financial stress), family stress (divorce, frequent conflicts between family members), trauma (abuse, natural disasters), or any other stressful circumstance can precipitate a depressive episode. Whereas such circumstances would cause anyone to be depressed, the individual with clinical depression doesn’t “bounce back” and may become vegetative (loss of energy, loss of interest in things that used to be pleasurable) or suicidal.

This brings us to the social aspects of depression. This refers to the way you were raised, events of the past, and how you’ve been treated since you were a child. Did you grow up in a “negative,” unloving, or oppressive household where conflicts were the norm, or where certain emotions (like anger) were expressed while others (like love and warmth) were discouraged? If so, you may never have been able to develop the “coping skills” that are necessary to keep minor setbacks from becoming emotionally catastrophic events.

It’s worth mentioning that these social factors appear to have become more prevalent in modern times, such that depression has almost become an epidemic. In fact, it has been shown that at least one out of every five people in the US will experience an episode of major depression at some point in their lives. At least some of this increase in depression can be attributed to the fact that mental health professionals are getting better at describing and identifying this disorder. Also, depression carries less of a stigma than it used to, so people are more likely to admit that they have a problem and seek treatment. However, let’s be realistic: there have been numerous social changes that have contributed to the rise in depression, such as rising divorce rates and the slow erosion of family structure since the 1940s and 50s. Of course, there’s also the impact of social media, which has given millions of people a stage on which to share their sorrow or exploit the sorrow of others. There are even websites and Facebook pages that instruct depressed people on the best ways to commit suicide!

In view of these social aspects of depression, another component of treatment involves individual counseling or psychotherapy. It is the task of the mental health professional (counselor, therapist, psychiatrist, or psychologist) to help the individual come to grips with the social components of depression and untangle the complexities of things like past trauma, abuse, or a fragmented family.

In addition, therapists can be very helpful with the psychological component of depression. This refers to aspects of your own personality…the way you think, the way you view the world, and how you naturally react to circumstances. Have you ever known someone who is a “natural worrier,” or someone who always sees the glass as half empty? These

tendencies are part of your inborn personality and temperament, but they can be changed. Therapists use techniques like Cognitive Behavior Therapy to help the depressed person learn how to change those depressive or negative thoughts that lead to depressed mood.

Lastly, although some people embrace it and other people ignore it, I can tell you that there is always a spiritual component to depression. When someone is depressed, their thoughts invariably turn to some of the “big picture” questions that reveal their spiritual convictions (or lack thereof): “Why am I here?” “Would the world be better off without me?” “Why is God letting me go through this?” Several studies have suggested that religious and spiritual beliefs are protective against depression. Also, although there are certainly some people who are “spiritual” but do not participate in an organized religion, the prognosis is better for people who are involved in a faith community like a church, temple, or mosque. As such, a component of treatment should involve either spiritual guidance from a leader in the faith (pastor, minister, rabbi, priest, imam, or monk, to name a few), or cultivation of a more introspective type of spiritual exercise (meditation, yoga, etc.).

So, it is hoped that you now view depression as an actual disorder that is very common but is more complex than you originally thought. If so, good…because we’re about to make it even more interesting by discussing different types of depression and how to recognize them according to their specific symptoms. However, that will have to wait until next month. See you then!

DEPRESSION, the Black Dog (part 2)

By MICHAEL SHAPIRO, PhD

In my previous blog, I introduced the notion of clinical depression and (hopefully) differentiated this from “normal” sadness due to grief or loss. We then discussed the four-part nature of clinical depression (well, okay, there wasn’t actually much discussion. I did all the talking). Now, did you know that there are several kinds of clinical depression? As with other disorders, you can view depression as being on a spectrum, from mild to severe. The different types of depression can also be distinguished by other factors, such as the underlying cause, or the length of each depressive episode. For this blog, I’d like to confine my observations to the two most “popular” forms of depression; Major Depressive Disorder and Persistent Depressive Disorder.

Major Depressive Disorder (aka major depression) tends to receive the most attention in the popular media, at least partly because it has become less stigmatized and has claimed so many lives. It often comes from out of the blue (no pun intended), with no obvious reason or precipitant. It hits like a truck, overwhelming the person with feelings of sadness, hopelessness, and despair. Necessary for this diagnosis are what are known as “vegetative” symptoms, such as anergia (loss of energy and motivation) and anhedonia (loss of interest in things that used to be fun or pleasurable). Sleep is usually disrupted, such that the person sleeps too little (insomnia) or too much (hypersomnia). Also, there is typically weight gain (as a result of “eating for comfort”) or weight loss (from decreased appetite). In major depression, these symptoms become so severe that they ultimately interfere with one’s ability to take care of the normal day-to-day demands of life, such as going to work and keeping up with family responsibilities.

During a major depressive episode, a person will often feel useless and non-productive. This begins a domino effect of guilt, feelings of worthlessness, declining self-esteem… often culminating in the question, “If the rest of my life is going to be like this, why should I go on living?” Mental health professionals refer to this as a passive suicidal thought. If left unchecked, it may escalate to active suicidal intent, wherein the individual forms an actual plan as to how to take his or her own life. Whether suicidal thoughts are passive or active, they must never be ignored, underestimated, or written off as someone just trying to get attention. Emergency treatment should be sought for anyone who entertains thoughts of suicide, or shows any signs of self-harmful behavior.

A diagnosis of major depression is applicable when someone’s mood and demeanor is distinctly different from the way he or she was before the depressive episode. In contrast, Persistent Depressive Disorder (which is also known by the more intimidating name, dysthymia) is more chronic, less extreme, and often more difficult to recognize. This type of depression is less episodic than major depression. In fact, to have this diagnosis, the individual must have experienced depressed mood (more days than not) for at least two years!

Whereas dysthymia has been shown to be more prevalent in women than in men, my experience tells me that men with this disorder are much more likely to go undetected. Why? At the risk of over-generalizing, men tend to be less sensitive to their…um…what are those uncomfortable things called again? Oh, yeah. “Feelings.” As a species, they seem to be more apt to put their heads down, charge forward, and “soldier on,” even when they are sad and joyless.

Many of my older male patients with dysthymia apparently decided early on that it was just their lot in life to be unhappy. Interestingly, most of them did not show up in my office on their own accord; they were “urged” to seek help by their wives or other close family members, who had gotten tired of being married to Eeyore (don’t get that reference?Google it).

Interestingly, because dysthymia in an adult is more chronic than acute, it used to be thought of as a “personality problem” and actually went by the (now archaic) name, Depressive Personality. However, in children and teenagers, dysthymia usually appears in the form of irritability rather than outright depression. Has your child ever been irritable? Yeah, I thought so. If he or she has been that way (more days than not) for at least a year, you might think about dysthymia. You might also think about getting help for yourself…because, you know, you’ve been living with a grouchy child for a long time.

Regardless of whether someone is suffering from major depression or dysthymia, the good news is that both conditions are very treatable. As I tell all my patients, treatment of depression usually entails two things: medication and psychotherapy. Although each of these works well, neither alone works as well they do together…rather like the two wings of an airplane. Whereas medicine addresses the biological component of depression, therapy helps address some of the psychological and social issues that we talked about last time.

Antidepressant medications relieve the vegetative symptoms of depression. The most popular antidepressants, called SSRIs (Selective Serotonin Reuptake Inhibitors), have relatively few side-effects and also have anti-anxiety properties. As such, they help to break the cycle of anxious, unwanted, ruminative thoughts that seem so hard to ignore (“Why am I so unhappy?” “Will I always be this way?” “What should I be doing about this?”). Once those symptoms have been relieved and the “dark cloud” has lifted somewhat (or, using our metaphor from the last blog, the “black dog” has been put back on the chain), the patient can apply his or her mind to therapy.

There are many types of therapy, and each type focuses on a different aspect of depression. For example, Cognitive Behavior Therapy (CBT) is a very popular and particularly effective form of therapy that is based on the theory is that your thoughts lead to your depressed feelings, not the other way around. Clinicians who use CBT train patients to recognize and change irrational or unrealistic thoughts that lead to depressed mood. Interpersonal Therapy (IT) focuses on helping a patient navigate and untangle the complicated family and social relationships (got any of those?) that might be contributing to depression. Mindfulness Therapy is a meditation-like technique wherein you learn to calm your mind by being “in the moment,” not thinking about the past (which you can do nothing about) or the future (which isn’t here yet).

Once again, the research robustly suggests that medication and therapy work best as a team. Whenever I propose this two-pronged plan of treatment, the first question the patient usually asks is, “How long?” Let’s face it: almost no one likes to take medication. So, please keep in mind that medication is never intended to be a life-long treatment! However, I usually ask my patients to commit to an antidepressant medication for at least 9 months to a year. That prevents them from giving up too early if they don’t feel better immediately (“See? I knew this wasn’t going

to work!”) or if they do feel better immediately (“Yay! I feel better! Now I

don’t have to take medication anymore!”).

It’s important to understand that antidepressant medications don’t (usually) work overnight. It takes time, sometimes weeks, for them to take effect. Even then, the patient doesn’t just magically wake up “happy” one day. Instead, the changes are subtle: the depressed person slowly discovers that minor things aren’t quite as irritating or bothersome as they used to be. As I tell my patients, medicine will help “increase your ability to tolerate frustration” (sounds wise and scientific, doesn’t it?). If, after about a year, the patient has shown sustained improvement for quite a while, we can talk about slowly tapering medication. It is always a bad idea to go “cold turkey” with an antidepressant, since it takes the brain some time to establish a new neurochemical “normal.”

So, if you have been hounded by the black dog for at least two weeks and have experienced loss of energy, loss of interest in things, and disrupted sleep or appetite, it may be time to seek professional help. If you don’t know where to look, start with your family physician or primary care provider. First, your primary care provider will try to determine if there is some medical reason for your depression, such as hypothyroidism or some other disease. Once all possible medical factors have been ruled out, your PCP may refer you to a psychiatrist, psychologist, therapist, or counselor. Don’t know the difference between those four mental health professionals? You will in about a month…after my next blog comes out. Meanwhile, if you suffer from depression, just remember that there’s always hope: with proper treatment, the black dog can always be tamed.

ADHD and…hey, look! A squirrel!

By MICHAEL SHAPIRO, PhD

In my 36 years as a psychologist who specializes in treating children, there has been no more controversial and confusing issue than the diagnosis and treatment of…um…of…now what were we talking about again?

But seriously, back in the Dark Ages when I started my training (and men still wore bearskins), the term Attention Deficit Disorder was not yet the buzzword it is today. However, there was growing concern about a population of children who were clearly overactive and had trouble paying attention, especially in school. Quite often, there was nothing to explain why these children were having these problems: they were usually quite intelligent, and they came from good families that enforced discipline and tried to properly balance rewards and punishments. Back in 1902, British pediatrician Sir George Still described this syndrome as an “abnormal defect of moral control in children”; but this didn’t really seem to fit, because quite often, these children were not mean-spirited or intentionally disobedient. In fact, many of this children were quite pleasant to be around…if you could only get them to sit still!

As is usually the case with newly emerging medical mysteries, researchers and doctors in the modern age tried to come up with a term that sounded impressive and implied that we knew exactly what we were talking about. Hence the term “Minimal Brain Dysfunction,” which was actually a junkyard term that included several disorders that were assumed to be due to abnormal neurological development, such as learning disabilities and “hyperkinesis” (hyperactivity). This term was further refined in 1968, when the Diagnostic and Statistical Manual of Mental Disorders (aka the DSM, which is the catalog of all known psychiatric diagnoses) first recognized a disorder called “hyperkinetic impulse disorder.” The three key symptoms of this disorder were overactivity, inattention, and impulsiveness.

The term Attention Deficit Disorder (ADD) made its first appearance in 1980, when the DSM went through its third revision. However, by that time, there was already some debate about whether or not all kids with ADD were hyperactive: some had problems with attention and concentration, but they were not usually climbing the walls or shaving the pet cat. Therefore, the diagnosis was split in two: ADD with hyperactivity, and ADD without hyperactivity.

Never ones to be happy with the status quo (and always looking for ways to shake things up), psychiatrists and psychologists decided to remove this distinction when the DSM was revised (yet again) in 1987. On that go-around, the two subtypes were re-united into a new stand-alone term: Attention Deficit Hyperactivity Disorder (ADHD). And so it was to remain for the rest of all eternity…or at least until 2000, when the DSM was revised for the fourth (but certainly not yet final) time.

From that year until this, we have labored under the most modern terms for this disorder: ADHD, predominantly inattentive type (which refers to children who are inattentive but not particularly hyper or impulsive); ADHD, predominately hyperactive-impulsive type (for children who can’t seem to sit still and sometimes endanger themselves by being so impulsive), and ADHD, combined type (which is the most common). Oh, and I almost forgot…there’s also Unspecified ADHD, which can be used when a child (or adult, for that matter) exhibits some of the characteristics of ADHD but doesn’t seem to fit the entire clinical picture. At long last, we have all the diagnostic bases covered…at least for the next year or two.

Unless you’ve been living under a rock or are under the age of 20, you may have noticed the steep increase in this diagnosis over the last several decades, mostly since the ‘80s and ‘90s. Population surveys have found that about 5% of all children (and 2.5% of all adults) qualify for this diagnosis. Why? Is this some kind of epidemic? Is this just a function of widespread misdiagnosis? Has something changed with our children? Are aliens commandeering the minds of our kids? I would have say “yes” to all of the above (except maybe the last one).

Certainly, things have changed with our children since Dr. Still’s politically incorrect implication that ADHD children are “immoral.” Children now start school earlier and are expected to sit still and remain largely inactive in a highly structured environment for six to seven hours a day (depending on the state in which you live), about 180 days per year. Oh, and then they have to come home and do homework. Consider that the next time your child gets off the bus and you ask him (and I say “him” because ADHD is 75% more prevalent in boys than in girls…see my earlier blog on the differences between male and female brains) to “…get all your homework done before you can go out and play.” It would be wise to reverse that order and let your child run off all that pent-up energy before expecting him to sit down and tangle with more schoolwork!

In addition to higher expectations for concentration and achievement in school, we now throw in the modern epidemic of electronic entertainment, which satisfies the ADHD child’s need for constant stimulation but removes the beneficial effects of exercise (and actual social interaction)…more on that in a future blog. Another reason for the proliferation of ADHD has to do with making a correct diagnosis. Sure enough, more children are being diagnosed with ADHD because we have a better definition of the disorder and are getting better at recognizing it. However, what confuses the picture is the myriad of other disorders that cause the same symptoms in children—inattention, overactivity, and impulsiveness—but are not actually ADHD! Take depression, for example. We all know what that looks like in an adult. Depressed adults cry, lose interest and energy, and often want to “escape” depression by sleeping all day. In contrast, kids with depression may become irritable, inattentive, sullen, and aggressive. In fact, the same can be said of anxiety disorders and many other psychiatric problems that look one way in adults but another way in children. There are also neurodevelopmental disorders, like learning disabilities and developmental delays, which cause children to be inattentive in the classroom because the level of schoolwork is over their heads.

Therefore, the diagnosis of ADHD cannot be made quickly or capriciously. Making a correct diagnosis is a complex process that considers all aspects of a child’s life. There are also psychological tests that can be used to sort out how much is ADHD and how much might be something else, like a learning problem, an emotional problem, or a family problem. However, I feel my and concentration waning as I write, and there’s a shiny thing over there on my desk that I want to look at. So, you’ll have to wait until my next blog for a discussion on the cause, diagnosis, and treatment of ADHD…or whatever it is that we’ve been talking about!

ADHD, Part 2 (or was it 3? I don’t know…I wasn’t really paying attention)

By MICHAEL SHAPIRO, PhD

As I was saying at the end of our last episode, because of the myriad of things that look like ADHD but are not, a diagnosis of ADHD should never be made casually, and should never be based solely on opinion, observation, comparison (“My other kids were never this much trouble!”), or a cursory evaluation in a doctor’s office. A proper evaluation for ADHD involves many painstaking components, beginning with a complete history. Since so many things could predispose a child to hyperactivity and attention problems, the skilled mental health professional will be careful to ask about a child’s health history (“Were there any problems with pregnancy and delivery? Does the child have any chronic health problems or take any medications?”), educational history (“Have there been any learning problems?”), family/social history (“Is this an intact family? Has there been any trauma or abuse? Is there anyone else in the family with similar problems?”), and any history of previous behavioral or mental health issues.

Once a thorough history has been obtained, specific tests will be administered in an attempt to verify an attention problem and rule out any other developmental, emotional, or educational issues. The first of these should be a test of intelligence, which will help the psychologist decide whether or not the child’s behaviors are consistent with his level of intellectual development. For example, children who are intellectually gifted may find it difficult to pay attention in a “normal” classroom because they’re bored. Conversely, children with a developmental delay may act impulsive or immature, but those behaviors might actually be

appropriate for their “mental age.”

Next, tests of academic achievement (reading, writing, and arithmetic) should be administered in order to rule out a learning disability, or to determine the degree to which a child’s inattention in the classroom has interfered with learning. Last but not least, tests of emotional functioning should be administered to assess the child’s feelings about school, himself, his family, other children, and the world in general. The clinician may ask the child to draw pictures or respond to some open-ended questions. Also, there are surveys and behavior rating scales that can be administered to parents, teachers, and the child himself for the purpose of comparison. In this way, we can get a “360 degree” picture of a child’s behavioral and emotional functioning from many viewpoints.

Once a history has been obtained and all the data has been collected, a proper diagnosis can be made. However, even with all this information at hand, there still may be some overlap with other diagnoses. For example, a child can suffer from both an attention deficit disorder AND a conduct disorder, an anxiety disorder, a learning disability, or a mood disorder like depression! Quite often, a good evaluation will reveal several issues that will need to be addressed at the same time! A good treatment plan will take all of these into account.

Speaking of treatment…let’s start with the Big Kahuna of contentious issues: medication. Typically, ADHD is treated with stimulant medication. Stimulants all work essentially the same way, by “activating” or energizing the brain. To give you a good point of reference, caffeine is a stimulant. The activating effects of caffeine are why we (or is it just me?) can’t even begin to face the day without a healthy dose of morning Joe (injected, preferably, directly into my veins).

Of course, when I propose stimulant medication to parents, their first reaction is something like, “A stimulant? Really? Don’t you think my kid is stimulated enough?” Although no one is entirely certain why stimulants help children with ADHD, the theory is that these medications actually stimulate the self-control centers of the brain to work more efficiently. Another theory is that the brains of ADHD children don’t receive enough stimulation from within, so they crave stimulation from without (by watching fast-changing cartoons, playing stimulating video games, or going from one thing to another). Stimulant medications satisfy the needs of these under-stimulated brains.

Back in the day, there were very few stimulant medications, Ritalin being the most famous and easily recognized. Nowadays, there are many stimulants on the market, as well as non-stimulant medications (which work a little differently and may be better for children with other issues, like aggression). There are also some “natural” preparations that claim to be effective, but please be aware that few of these claims are actually supported by research. In a child whose ADHD has been confirmed by an evaluation (and who has no other “complicating” issues), stimulants can be very effective, and improvement can be seen very quickly, because these medications are rapidly absorbed by the body. On the other hand, these medications don’t usually last very long, and some children may experience a “rebound” (irritability, tearfulness, or fatigue) when they wear off towards the end of the day. If this is the case, there are some long-acting stimulants that can be helpful, or the child’s doctor can make adjustments to the dosage.

I am always careful to tell the parents of children with ADHD that medication is never intended to be a “forever” thing. Because of the way the human central nervous system matures and develops, many children grow out of some of the symptoms of ADHD. After all, you don’t see many 30 year-olds running through Walmart knocking over displays and playing hide-and-seek in the clothing section (or do you?). However, they may still struggle with inattention and feelings of restlessness as an adult. For children on medication, we are careful to re-evaluate periodically, in the hopes that there will come a day when the child—usually at some point in adolescence—no longer needs medication (only 30 to 60 percent of patients diagnosed with ADHD in childhood continue to require treatment as adults).

How old does a child have to be to start medication? Most doctors are hesitant to medicate preschoolers. However, I usually make two exceptions: the first of these applies to children who are so impulsive that they endanger themselves or others…for example, by jumping off tall things or throwing rocks (often not out of maliciousness…just to see if the rocks can fly). The other exception involves preschoolers who are getting in so much trouble that no one likes them; not their preschool teachers, not the other children…and sometimes not their parents. With these children, if their symptoms are not managed with medication, they might develop social problems, a hatred of school, or problems with self-esteem. So, in the cost-to-benefit analysis, it may be advisable to treat these little ones now in order to prevent some more severe problems in the future.

Of course, medication represents only one tool in the ADHD treatment tool kit. It tends to yield the fastest improvement, which is why it’s usually the first to be recommended. Once a child’s symptoms have been brought under control with medication, individual psychotherapy can be used to help the child develop some self-control and self-regulation skills. Also, the research strongly suggests that the prognosis is best when therapy for the child is paired with training for the parent! EVERY parent can benefit from coaching on parenting skills like communication, discipline, encouragement, and the proper balancing of age-appropriate rewards and punishments. So, no therapist, counselor, or psychologist should treat only the child! The best mental health professionals are those who are skilled in both child therapy and parent training.

That brings us to the topic of how to choose an appropriate mental health professional, because the list of degrees, certifications, and titles can be absolutely bewildering. However, I see by the clock on the wall that it’s time for my afternoon Starbucks, without which I will lose my concentration, fall asleep, start daydreaming, or a combination of all three. So, this will have to wait until next month. See you then!

July is National Minority Mental Health Awareness Month

July is National Minority Mental Health Awareness Month. It is observed to bring awareness to the unique struggles that racial and ethnic minority communities face regarding mental illness in the United States.

Specific community health awareness efforts have been centered around the COVID-19 pandemic. The US Department of Health and Human Services, Office of Minority Health (OMH), focuses on promoting tools and resources to address the stigma regarding mental health among racial and ethnic minority populations.

OMH encourages state, tribal, and local leaders, healthcare providers, community-based organizations, faith leaders, and individuals who educate their communities regarding mental health stigma.

The first week in June honored health professionals in hospital settings and professionals who work closely with communities during the Community Health Improvement week. This national event was created to raise awareness and recognize community health professionals’ dedication and passion for improving the health of the communities they serve.

Some key highlights within Community Health Improvements are:

Engaged leadership with hospitals and health systems can play vital roles internally and externally within these organizations.

Community endorsement and support can come in the form of remembering all organizations are not alike, but all organizations can be involved in partnerships within the community.

Innovative coordination and funding will help communities optimize the use of existing resources while building on existing strengths.

Provide valuable care and optimize delivery through standard processes and handoffs, connecting through common screening and assessment tools, and coordinating all levels of follow-up care.

Leveraging technology will help people in a mental health crisis and be a support line for immediate help. Leverage technology can connect an electronic referral system to efficiently triage patients and coordinate care, while telehealth offers an additional avenue to expand behavioral health services.

Measurable and Actionable can be used in Community Health Improvement to have transparency in data reporting identified outcomes to demonstrate value to community partners. These standardized screening tools and quality measures will assist in improving data integrity.

Community Health Improvement is an ongoing goal to build connections between the whole person and integrated care. This process not only highlights the medical part, but also connects the community supports of all Americans, including additional resources for racial and ethnic minority communities.

May is Mental Health Month

Mental Health Month was established in 1949 to celebrate recovery from mental illness and increase awareness of the importance of mental health and wellness in all lives. This month raises awareness of trauma and helps to reduce the stigma so many people experience. Mental Health Month highlights the impact trauma can have on communities, children, and families’ emotional, physical, and mental well-being.

Maternal mental health conditions such as anxiety, depression, and substance use disorders affect 1 in 5 women and are prominent in pregnancy, childbirth, and postpartum complications. Women at an increased risk of maternal mental health may have a personal or family history of mental illness; may lack social support, especially from their partner; may have experienced traumatic birth or previous trauma in their lives; may have a baby in the neonatal intensive care unit (NICU). Maternal mental health challenges are temporary and treatable with proper care. Recovery from maternal mental health includes social support, self-care, medication, and talk therapy, as a combination approach.

Child and adolescent mental health are also essential to consider during this month. 1 in 7 children and adolescents aged ten to nineteen years old experience mental health conditions, but these largely remain unrecognized and untreated. Emotional, social, and physical changes, including exposure to abuse, poverty, or crime, can make adolescents vulnerable to mental health problems. Anxiety, depression, and behavioral disorders are the leading causes of disability and illness among adolescents. Children and adolescents can feel supported about their diagnosis by the people in their lives learning about their diagnosis, exploring stress management techniques, and praising the child’s abilities and strengths.

Mental health prevention and promotion interventions aim to strengthen an individual’s capacity to regulate emotions, build resilience for managing difficult situations and adversity, enhance alternatives to risk-taking behaviors and promote supportive social environments and social networks. Enhance alternatives to risk-taking behaviors and promote supportive social environments and social networks.

National Healthcare Decisions Day

National Healthcare Decisions Day (NHDD) is represented annually in April and is an initiative created to inspire, educate, and empower the public about the importance of advance care planning. NHDD was designed to encourage someone to express their wishes regarding healthcare and for providers and facilities to respect those wishes, whatever those wishes might be.

The pandemic has been a reminder that healthcare affects everyone of all ages. It impacts that patient, the person’s family, and the facility taking care of the person. The focus on advance care planning has been highlighted through these unique times.

Advanced care planning includes completing an advance directive (living will), appointing a healthcare power of attorney (someone to make healthcare decisions if the person can not speak for themselves), and the person sharing their choices with their family and loved ones.

Another aspect of advanced care planning is Psychiatric Advanced Directives (PADs). PADs are legal documents detailing a person’s preference for future mental health treatment, including specific choices about medications and hospitalizations and the refusal of consent to either. PADs help the person identify an individual to make treatment decisions if that person is in a crisis and unable to make decisions. In NC, PADs are also known as an “Advance Instruction for Mental Health Treatment .”An Advance Instruction for Mental Health Treatment remains valid until the person who created it revokes it.

There are numerous benefits to having and completing advanced care directives, including enabling proper care and possibly preventing involuntary treatment. When families are informed, and up to date on a person’s advanced care directives, the family can better advocate for their loved ones.

Medicaid Managed Care Updates

NC Medicaid Rate Reductions Effective Oct. 1, 2025

Fee schedules impacted by rate reductions will be released.

Oct. 1, 2025. Rates are subject to change if additional appropriations are

made.

North Carolina has expanded health care coverage to more people. You might be one of them. Check to see: North Carolina Expands Medicaid | NC Medicaid

NC Medicaid Managed Care Overview Video: Watch this brief video to learn more about the different health plan types for NC Medicaid Managed Care beneficiaries. These include Standard Plans, Tailored Plans, EBCI Tribal Option, the Children and Families Specialty Plan and NC Medicaid Direct.

New Primary Care Provider Change Request Form for Members in Managed Care Prepaid Health Plans: In collaboration with primary care providers (PCPs), the NC Medicaid Managed Care Prepaid Health Plans (PHPs) have created a new standardized PCP Change Request Form for members who wish to change their primary care assignment throughout the year. A link to each health plan’s form can be found here:

AmeriHealth Caritas North Carolina
Carolina Complete Health
Healthy Blue
United Healthcare Community Plan of North Carolina
WellCare of North Carolina

As a reminder, beneficiaries can change their PCP/Advanced Medical Home (AMH) without cause twice each year. For more information, please see New Primary Care Provider Change Request Form for Members in Managed Care Prepaid Health Plans.

NC DHHS

The Children and Families Specialty Plan will launch December 1, 2025. Visit health plan types to learn more at Health plan types | NC Medicaid Managed Care.

Provider Resource Requirements

1. The North Carolina Medical Board (NCMB) allows you to access The Licensure Gateway portal to apply for a North Carolina medical license, complete a license renewal, manage licenses, and update licensee information.

2. Were you successful with getting signed up for the NCDAVE System? All clinicians in NC should register with NCDAVE. Register for NCDAVE today

3. NC Tracks Training

4. MLNConnects newsletter

5 MOC IV NC Maintenance of Certification : The North Carolina AHEC Practice Support Program is an approved Project of the North Carolina Maintenance of Certification (NC MOC) Program, an approved sponsor of the American Board of Medical Specialties’ (ABMS) Multi-specialty Portfolio Program (MSPP). Most ABMS Member Boards recognize this participation as an option to meet Part IV requirements. The National Commission on Certification of Physician Assistants (NCCPA) also accepts NC MOC credit for physician assistants. Through this approval, physicians and physician assistants who work with an NC AHEC Practice Support coach to improve care for patients will meet the requirements of their specialty boards to maintain certification in their specialties.

NC Med Board CME

Financial Sustainability Training Events

A Primer for Practice Managers

Part 1 Highlights Strategic Planning, Budgeting, and Financial Reports with Key Performance Indicators.
Part 2 includes education on Effective Payer Management, Revenue Cycle Management, and how to conduct a financial projection for a new program or service.

Find more training opportunities

Sleep Awareness Week is March 13 – 19, 2022

Sleep Awareness Week is March 13 – 19, 2022, and it is a period to use as a call to action for personal well-being. It is the perfect time for everyone to recognize the importance of sleep as a crucial measure of overall health and wellness.

Please use this vital reminder to implement healthy sleeping habits and reflect on practices to help you have a good night’s rest. It is not a coincidence that sleep awareness week begins on March 13th, which is the beginning date of Daylight-Saving Time, when most Americans change their clocks and lose an hour of sleep.

The National Sleep Foundation stresses that adults need seven to nine hours of sleep per night and any less could pose serious consequences to a person’s health and safety. Sleep helps people recover from illness or injury, cope with stress, and solve problems. Common sleep-wake disorders include insomnia (having problems falling or staying asleep which can lead to anxiety and depression), nightmares (this usually happens during Rapid Eye Movement sleep and brings up feelings of distress or terror generally related to a traumatic event), sleep terrors (any single image memory – not like a nightmare but these single images can be so terrifying that you may shake or scream. When the sleep terror ends, you calm down and return to normal sleep.)

The complex relationship between sleep and psychiatric disorders means that treatment for both issues can go hand-in-hand. There are steps to improve sleep which may even form part of a preventive mental health strategy. A medical doctor or psychiatrist can review the potential benefits and risks of different types of treatments, including prescription medications. They can provide tailored care, including in situations with multiple co-occurring physical or mental health issues. Good sleeping habits, relaxation techniques, sleep restriction (limiting the amount of time in bed) and exercise are treatment options for sleep..

February 14th is Designated Congenital Heart Defect Awareness Day.

February 14th is designated Congenital Heart Defect Awareness Day. This is an annual campaign to remember and honor anyone born with a heart defect. This campaign also honors all of the families and friends touched by children with heart defects along with the medical professionals caring for and conducting research to treat and prevent children born with heart defects.

1 out of every 100 newborns are affected by Congenital Heart Defects / Disease. CHDs are conditions that are present at birth and can affect the structure of a baby’s heart and how that baby’s heart works. These conditions can range from a small hole in the heart (considered mild) to missing or poorly formed parts of the heart (severe). Generally, the cause of CHD is not known but if a child has CHD is becomes evident during the first few months after birth during a routine medical checkup. Some babies have very low blood pressure shortly after birth and some babies have breathing difficulties, poor weight gain, or feeding problems.

An article published in Everyday Health noted “pediatricians should consider screening children with CHD and other chronic health illnesses for mental health problems”. This article also stated CHD patients are significantly more likely to have depression, anxiety, and attention deficit hyperactivity disorder than children not diagnosed with CHD. Dr. Lopez reported “that non-Hispanic Black, Hispanic, and Asian American children were significantly less likely to be diagnosed or treated for anxiety and depression than white children, despite the fact that the prevalence of these conditions are thought to be the same across all races and ethnicities in the general population”. Most children with simple defects survive into adulthood. Their exercise capacity may be limited, but these children grow up to live normal or nearly normal lives. Children who had more complex problems had more developmental delay or other learning difficulties.