The study, titled “Estimating the smallest worthwhile difference of antidepressants: a cross-sectional survey,” delves into the challenging decisions faced by individuals considering SSRI and SNRI antidepressants, which are common treatments for depression.

The findings suggest that while one in three people might find the currently available antidepressants worthwhile, the majority seek greater benefits or fewer burdens. This discrepancy underscores the necessity for more effective or less burdensome medications, with a heightened focus on patient perspectives in depression treatment.

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These recommendations were recently published in the scientific journal PLOS ONE by a team of authors from the United Kingdom, including Ruth E. Cooper, Michael Ashman, Jo Lomani, Joanna Moncrieff, Anne Guy, James Davies, Nicola Morant, and Mark Horowitz.

The authors not only documented the current state of deprescribing and tapering but also aimed to identify factors that contribute to successful outcomes for service users who go through the deprescribing and tapering process.

As websites like SurvivingAntidepressants.org grow in popularity, the need for shared-decision making in the prescribing and deprescribing process between patients and their practitioners grows, too. However, barriers on the prescribers’ end can create friction that may leave service users feeling disempowered and unheard. Thus, the UK-based authors crafted a research question designed to document the current state of deprescribing practices and to draft recommendations to improve them:

To answer this question, the study’s authors surveyed 13 deprescribing services across various countries, including 8 in the UK, 1 in the USA, 1 in Norway, 1 in Italy, 1 in Sweden, and 1 in Denmark. Each of the included deprescribing services had to meet the following criteria: 1) the service was specifically designed to support patients withdrawing from prescribed psychotropic medications, and 2) at least one staff member could conduct interviews in English.

A researcher with lived experience conducted structured interviews, and the study lasted only three months. The qualitative analysis of the structured interviews was performed using a rapid qualitative analytical framework.

Most of the service users at the deprescribing centers were prescribed various psychotropic medications, with four centers targeting a specific combination of z-drugs, benzodiazepines, antidepressants, and antipsychotics. The interviews revealed the difficulties and complexities of tapering and discontinuing psychotropic drugs.

For example:

After coding, the results revealed that the most efficacious way to discontinue psychotropic drugs was to taper the medication slowly with patient preference and lived experience as the driver of the taper. The author’s direct recommendations for services are:

• Drugs should be tapered gradually using hyperbolic strategies. “This means that the steps by which the dose is lowered are made smaller and smaller as the dose decreases, for example, reducing the medication by 10% of the prior dose.”
• Tapering should be individualized, flexible, and use shared decision-making.
• Psychosocial support should be provided to patients during and, if required, after withdrawal.
• Lived experience should be integrated at all levels: people with lived experience of successfully and unsuccessfully withdrawing from prescribed drugs of dependence must be involved in the conception, development, and running of services.
• The broader context of a patient’s life should be taken into account.
• Dedicated deprescribing services for prescribed medications of dependence are necessary.

The authors end their recommendations by substantiating their qualitative findings with quantitative findings:

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Cooper RE, Ashman M, Lomani J, Moncrieff J, Guy A, Davies J, et al. (2023) “Stabilise-reduce, stabilise-reduce”: A survey of the common practices of deprescribing services and recommendations for future services. PLoS ONE 18(3): e0282988. https://doi.org/10.1371/journal. pone.0282988 (Link)

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The study, published in the journal of European Neuropsychopharmacology, sought to appraise the most recent literature on ADS and withdrawal from antidepressants. They found that “down-titrating” or tapering is almost always warranted in the clinical setting, especially for antidepressants like citalopram.

Abruptly stopping SSRIs (Selective Serotonin Reuptake Inhibitors) like Zoloft, Citalopram, and Escitalopram can be disruptive and harmful to your day-to-day life—sometimes causing flu-like symptoms, insomnia, nausea, and or anxiety. However, quitting your antidepressant cold turkey may also cause confusion between you and your healthcare provider, as it may be difficult to distinguish between a reoccurrence of symptoms of depression and symptoms of withdrawal and ADS.

The literature review first highlights that the newest version of the Diagnostic Statistical Manual for Mental Disorders, the DSM-TR, does note that ADS “may occur following treatment with all types of antidepressants” and that “the incidence depends on the dosage and the half-life of the medication being taken and the rate at which the medication is tapered.” In particular, the authors found that the most likely culprit of ADS is drugs with high SERT occupancies and drugs with short-half lives.

Citalopram, known best by its brand name Celexa, has a “high SERT occupancy.” Selective serotonin reuptake inhibitors (SSRIs) are thought to stop serotonin from being removed from neuronal synapses. By binding to the serotonin transporter or “SERT,” SSRIs block serotonin transport and thus increase the presence of serotonin in the brain. Researchers and physicians can measure SERT occupancy (that is, how “occupied” or “bound” the serotonin transporters are) of an SSRI through medical imaging like PET scans. The authors explain:

Similarly, paroxetine, commonly known by its brand name Paxil, has a short half-life. Short half-lives increase the likelihood of withdrawal and discontinuation symptoms across all drug types, whereas long half-lives decrease withdrawal symptoms significantly. A drug’s half-life is the amount of time it takes to reduce to half of its original value or potency in your body. The quicker the drug loses potency in your body, the worse withdrawal you may experience. Or, in the case of antidepressants, the shorter the half-life, the higher the likelihood of ADS.

Moreover, individuals who are “already vulnerable” to antidepressant discontinuation symptoms, such as people who experience frequent panic attacks, are more likely to experience ADS if antidepressants are not tapered correctly.

As with all studies, there are limitations to this literature review. Of note, the literature review was conducted using a single database. And, whether it is because the studies reviewed did not contain demographic data or the authors themselves did not note demographic data, there is no mention of race, ethnicity, gender, or socioeconomic status in the review.

As the public grows more informed about depression, the questionable efficacy of antidepressants, and non-pharmaceutical treatment options, individuals deciding to discontinue their antidepressants may find it difficult to do so. Discussing discontinuation with your doctor is recommended to avoid ADS and withdrawal symptoms.

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Fornaro, M., Cattaneo, C. I., De Berardis, D., Ressico, F. V., Martinotti, G., & Vieta, E. (2023). Antidepressant discontinuation syndrome: A state-of-the-art clinical review. European Neuropsychopharmacology, 66, 1-10. (Link)

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Narinder Bansal, Mohammad Hudda, Rupert A. Payne, Daniel J. Smith, David Kessler, and Nicola Wiles utilized over 200,000 individual medical records collected by UK Biobank between 2006 and 2010.

In July, Joanna Moncreiff and Mark Horowitz conducted and published a review of the evidence for the “chemical imbalance theory” of depression, effectively debunking the idea. However, psychotropic medications are still used as the first-line treatment for depression despite questions about their efficacy. Additionally, long-term antidepressant use may have troubling side effects, but public and medical education concerning discontinuation and tapering remain scarce.

Bansal and colleagues sought to document the adverse effects of long-term antidepressant use. The United Kingdom Biobank collected medical records of over 500,000 individuals over four years (2006-2010). After excluding participants for various reasons (e.g., the participant was no longer registered with their general practitioner or was on multiple antidepressants at the start of the study), over 200,000 participants between the ages of 40-69 years old remained 96% of whom were White.

The authors then assessed the association between antidepressant use and four different morbidities: diabetes, hypertension, coronary heart disease (CHD), and cerebrovascular disease (CV), and two different mortality outcomes, including cardiovascular disease (CVD) and all-cause mortality. Each morbidity was then assessed utilizing Cox’s proportional hazard model (a regression model commonly used to understand the association between the survival time of patients and one or more predictor variables).

The authors highlight that the experience of the symptoms commonly understood as “depression” is strongly associated with “health risk behaviors” or “cofounders,” such as obesity, smoking, and lack of physical activity, which are also risk factors for both CVD and diabetes. Through multiple statistical analyses, Bansal and colleagues did their best to account for these risk factors.

The authors discuss their findings:

The authors explain why their findings may differ from other studies due to how they accommodated varying cofounders. After the authors adjusted for the risk behaviors that commonly co-occur with symptoms of depression, the increased risk of diabetes seems to be indistinguishable from that of antidepressant use vs. smoking/obesity.

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Bansal, N., Hudda, M., Payne, R., Smith, D., Kessler, D., & Wiles, N. (2022). Antidepressant use and risk of adverse outcomes: Population-based cohort study. BJPsych Open, 8(5),    E164. doi:10.1192/bjo.2022.563 (Link)

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The article is written by John Read, professor of clinical psychology at the University of East London. Read examines how APs are prescribed from the perspective of patients:

The relationship between doctors and patients is a crucial touchstone to the service user’s perception of healing and betterment. Unfortunately, however, previous research indicates that prescribers rarely share the risks of taking and discontinuing psychiatric medication with their patients: what the adverse effects are, when is the right time to discontinue, and what withdrawal feels and looks like. These risks may be especially pronounced for antipsychotics.

One explanation is that the prescribers, too, are unaware of adverse effects, how to distinguish between withdrawal and relapse, and how psychiatric medications work. However, another explanation is that prescribers may feel that sharing psychiatric medication risks may deter patients from taking it or negatively affect outcomes.

An online questionnaire titled, The Experiences of Antidepressant and Antipsychotic Medication Survey, was disseminated via an online research company and social media. The inclusion criteria were: ‘I have been taking or have previously taken antipsychotic medication continuously for at least one month’; ‘I am aged 18 or older’; and ‘I am not currently compulsorily detained in a psychiatric hospital.’ Of the 2,346 individuals who responded to the survey, 757 were included in Read’s analysis.

Of those included, the majority of respondents were women (69.0%), with most hailing from the United States (71.5%), while the rest of the respondents were from 29 other predominantly white countries, e.g., Australia, the United Kingdom, New Zealand, Ireland, Denmark, Norway, and Spain. Six-hundred sixty-three (663) respondents provided their primary diagnosis. About 30% of respondents received a diagnosis of Schizophrenia Spectrum and Other Psychotic Disorders whereas about 28% were diagnosed with bipolar disorder and 25% a ‘Depressive Disorder.’ The remaining respondents received diagnoses of trauma, stress-related, or personality disorder (8.4%).

The participants were asked the following questions:

• “Did the prescribing doctor tell you how the antipsychotic medication works?”
• “Did the doctor inform you of any possible side effects?”
• “Were you offered any other treatment options to consider as alternatives or additions to antipsychotics?”
• “When you were first prescribed antipsychotic medication, how long were you told you could expect to take it for?”
• “How would you describe your relationship with the doctor?”
• “Overall, how satisfactory was the initial prescribing process for you?”

Each question produced notable results: in particular, 75.7% of respondents replied ‘no’ to the question, “did the prescribing doctor tell you how the antipsychotic medication works?” and those that responded “yes” articulated that they were told it alters or fixes a chemical imbalance in the brain.

In response to the question, “did the doctor inform you of any side effects” participants were most likely talked about weight gain and drowsiness/sedation/tiredness. But 70.5% were not told about any side effects, even though many are life-altering, such as diabetes and reduced brain size.

Meanwhile, about two-thirds of respondents (roughly 65%) were not given other treatment options. Those that were offered alternatives cited other psychiatric drugs, with women far more likely to be offered another prescription. Others remembered being offered a form of therapy or counseling; 29 participants mentioned electroconvulsive therapy (ECT) as another treatment option.

Over 70% of respondents were not told how long they would be on the medication or were told they would be on it indefinitely, and this was especially true for those with a psychiatric diagnosis.

Overall, Read found that the satisfaction with the doctor-patient relationship and initial prescribing process was low, especially if the participant had a psychosis diagnosis.

Notably, of those who were in the minority, that is, they were included in the prescribing process and given information about the side effects of their respective medication and given an understanding of how the medication works and for how long they ought to take it actually reported that the medication was more efficacious.

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Read, J. (2022). How important are informed consent, informed choice, and patient-doctor relationships when prescribing antipsychotic medication? Journal of Mental Health. (Link)

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Danish researchers Anders Sørensen, Karsten Juhl Jørgensen, and Klaus Munkholm conducted a systemic review of CPGs from high-income English-speaking countries. Their results highlight severe shortcomings in the guidelines that can mislead practitioners and put patients at risk. They write:

Discontinuing antidepressants is a notoriously challenging and long process. The journey to lowering a dosage, tapering, and discontinuing altogether is not easily done alone—often requiring close contact and support with a care team and prescriber, not to mention a robust network of peer and community supports. Despite this, the current guidelines to taper or discontinue are often vague and imprecise, not only for service users but practitioners too.

The initial guideline collection yielded 21 usable non-repeated Clinical Practice Guidelines proposed by major national or international health authorities and professional organizations. The CPGs were published over  20+ years (1998-2020). Of the 21 unique guidelines: seven were from the United States, five were from the United Kingdom, one each was from Canada, New Zealand, Scotland, Singapore, and Australia, respectively. In addition, three additional CPGs were issued by international organizations.

These guidelines were then combed through for data extraction independently by Munkholm and Sørensen. They were assessed and appraised for quality, i.e., if the current guidelines are comprehensive enough and relevant enough to practitioners in helping their patients manage and discontinue their antidepressants.

After an in-depth review of their extracted data and appraisal screening, the authors found the following:

The results revealed that most CPGs did recommend that antidepressants are tapered slowly and gradually, but very few CPGs specified what “gradual” and “slow” meant.

None of the CPGs explicitly recommended discontinuation or a taper, and none discussed what withdrawal symptoms might look like throughout the taper/discontinuation.

The authors feel that the clinical implication of the research is important, in particular:

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Sørensen, A., Juhl Jørgensen, K., & Munkholm, K. (2022). Clinical practice guideline recommendations on tapering and discontinuing antidepressants for depression: a systematic review. Therapeutic Advances in Psychopharmacology, 12, 20451253211067656. (Link)

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Written by American researchers Sabrina Darrow, Morgan Pelot, Sarah Naeger, and Laysha Ostrow, the article attempts to fill a gap in the literature on psychopharmacology and service user perspectives. The research design was specifically created to examine whether individuals seeking to discontinue their psychiatric medication feel supported by their prescribers and care team.

As psychiatric medications continue to proliferate throughout the United States, the prescribing and overprescribing of these medications have received renewed research interest. Unfortunately, not only do many psychiatric drugs present serious side effects, but researchers have also contested their long-term effectiveness.

In addition, over the past several years, more attention has been paid to the discontinuation and withdrawal effects that can occur when patients attempt to stop taking their medications. Clinicians often mistake these effects as a relapse of the disorder/illness rather than a result of the medication. When the service user chooses to continue discontinuation despite their prescribers’ desire to return to normal or higher doses of the medication, they can be labeled as “non-compliant,” further damaging the patient-provider relationship.

The implementation of shared decision-making (SDM) practices may benefit both service users and providers in scenarios where discontinuation is desired. For this reason, Darrow and colleagues sought to understand better how SDM practices can be incorporated in discussions over discontinuation and withdrawal.

The authors designed a survey with a sample of 250 adults (18 years or older) with a ‘serious mental illness (a lifetime diagnosis of schizophrenia, schizoaffective disorder, schizophreniform disorder, psychosis not otherwise specified (NOS), bipolar I, II, or NOS, or major depressive disorder). Each participant had a goal to completely discontinue using one or two psychiatric medications that they had been taking for more than nine months. Medications included antidepressants, antianxiety, antipsychotics, mood stabilizers, or stimulants.

The data was collected in June of 2016 utilizing an online survey with 105 questions pertaining to current medication, health status, sociodemographic factors, social supports, and clinical services. The demographic makeup of this study is its largest limitation as the majority of respondents were college-educated white women.

The participants were asked if they saw a prescriber or a psychotherapist while discontinuing their medication. The survey aimed to identify the respondent’s relationship with their most recent psychiatric medication prescriber, with questions focusing specifically on the involvement of the prescriber in the respondent’s decision to discontinue their medication(s).

About half of the sample reported that they successfully discontinued a medication (54% total discontinuation). Although some participants reported not receiving mental health care services while they discontinued, about 65% of respondents continued to see either their prescriber or counselor/therapist, or both.

Those diagnosed with a psychotic disorder were most likely to continue seeing a prescriber while trying to discontinue their medication. However, no other demographic, diagnosis, or medication variables were significantly associated with seeing a prescriber while discontinuing.

In response to questions concerning the prescriber-patient relationship during discontinuation, the authors found that these relationships often significantly impacted the process.

In addition to seeing a prescriber and psychotherapist, many sought out online support groups to help throughout the discontinuation process. Indeed, individuals who used these supports while stopping psychiatric medication were more likely to succeed in their tapering and discontinuation.

The authors close the article with an important recommendation regarding shared decision-making (SDM).

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Darrow, S., Pelot, M., Naeger, S., & Ostrow, L. (2022). User Perspectives on Professional Support and Service Use During Psychiatric Medication Discontinuation. Community Mental Health Journal, 1-9. (Link)

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Her recent work focuses on mental health care in Ghana, drawing attention to the need for rights-based approaches to mental health care. In doing so, she questions the movement for Global Mental Health: asking what this movement is doing currently and imagining what it could become.

Her research brings to light how those in the Global North and high-income countries can overlook what rights-based approaches to mental health care may actually look like when incorporated into Global Mental Health and enacted on the ground. She also is deeply concerned with the structural and social determinants of health and mental health and their interconnection with community resources, places of worship, faith, and overall health promotion.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Samantha Lilly: Could you tell us more about what led to your geographical interest in Ghana as a researcher from the UK?

Ursula Read: I initially trained as an occupational therapist. That’s how I ended up working in the mental health field. I was working in parts of London with an over-representation of people of African and Caribbean heritage in the mental health system. It’s been a big question, really, as to why that might be, and various hypotheses have been put forward. Obviously, racism plays a big role, as does structural discrimination and inequalities generally.

So that opened my interest. I began to look at how mental health services operate in a country without many mental health services. In the UK and America, we’re very used to thinking of psychiatry as this big kind of monolithic organization that has a lot of state-sponsored power to incarcerate people against their will and medicate people. And, of course, there is a lot of protest against that and a lot of resistance from organizations like Mad In America and the World Network of Users and Survivors of Psychiatry. So, that was kind of interesting to think about what happened in those places where psychiatry wasn’t so dominant, where perhaps people made more use of traditional and faith-based healing, and where there might be different ways of thinking about mental health and what mental illness is and how you might help people with those difficulties.

I was working alongside a lot of nurses from Ghana. I met Victor Doku, a Ghanaian psychiatrist, and it was those kinds of networks that really led me to think about Ghana as a place where I could do that research.

Lilly: You worked as an occupational therapist and now as a researcher. How do you see these different roles?

Read: I started working in the health and social care fields, and then I trained as an occupational therapist, working in hospitals and community services in London. It really had a massive impact on me to think about my own mental health and my own ways of making meaning. I come from a religious background, so my Christian family and faith were very important in how I was brought up. So, all those kinds of big questions came up.

I also like how the occupational therapy approach thinks about illness not as your pathology but as how it impacts your being in the world. And that, I think, is to me very, very potent.

The other kind of crossover, between occupational therapy and anthropology, is around the methods. And the method is to be with people and to participate in what they’re doing. So, if I were an occupational therapist, I would go into the kitchen with people and cook with them and see—for example, if they had cognitive problems, memory problems, or problems with focusing or attention—how that impacted how they prepared a meal. When I’m doing my research in Ghana, I’m going with people into the kitchen, and I’m looking at the same questions, you know? I’m not looking at it with a kind of clinical instinct, but I am asking what supports do you need to ensure that you’re getting a meal. I am asking how the illness has impacted that, but I wouldn’t necessarily think about how to ameliorate that situation. That would be more to do with the people who support the family or the mental health workers or whatever.

So it is a kind of ‘being with,’ ‘being alongside,’ and understanding what it means physically and bodily to be in these kinds of spaces as well—I find that an incredibly powerful method. I think that method really enriches the data you’re able to put together as a researcher, aside from the interview space, which is a kind of performative space and very constrained in some ways.

Lilly: Tell us more about how power dynamics impact your research encounters in the UK and Ghana.

Read: I think maybe I can illustrate this with an example. For many people in Ghana, psychiatry, the vocabulary of psychiatry, is quite new, and the medical model can, for many people, be a way of making sense of their experience. It takes out a lot of moral judgments that can come alongside ideas of what mental illness is. Often it can be linked to ideas of, you know, taking drugs or doing something spiritually questionable, like witchcraft, or being cursed or all these kinds of connotations, which can be very stigmatizing. And so, a medical model of mental illness, for many people I know with lived experience of mental illness in Ghana, means that they don’t have to deal with all of that stigma. They find it’s a more neutral way of thinking about it. “I’ve got an illness just like any other illness, and I can take medication for that.” Now, obviously, I know that from the history of working in mental health services in the UK, and knowing what I’ve read from the US, that many people with lived experience in those settings contest the medicalization of their experience because the medical model has been stigmatizing and has also sidelined people making sense of their mental illness through spiritual language or other ways of being.

There is space to open up this kind of conversation to think about different ways of making sense of experience and bringing people into conversation across these geographical boundaries—because the question of what mental illness is remains unresolved. In the Ghanaian context, I sometimes see that the education around mental illness often presents things as certainties. And, you know, we like certainties, and public health messages are supposed to be clear.

Lilly: Do you find that there’s a desire to be diagnosed with a mental illness in Ghana? Is that something you’ve experienced?

Read: I feel I’m uncomfortable talking on behalf of people, but I think there are many people I’ve spoken with in Ghana for whom receiving the diagnosis has been a big relief because they have been going through these experiences and not really knowing what’s happening. And, you know, it’s caused all sorts of problems at work, in daily life, in their relationships, and their families. So getting a diagnosis and talking with a psychiatrist who can help them make sense of some of what’s happening within that medical frame has been very helpful in a time of huge confusion and ad distress.

Nonetheless, I think it’s true to say that many people I meet are very unhappy with the medication. The drugs that are used to treat psychosis have really terrible side effects and are really problematic. People find that they’re sedated, and the sedating can impact your sexual performance. They can make people feel cut off from their emotions. So the idea of taking medication indefinitely is horrific to many people.

As an occupational therapist and also as a researcher, I’ve sat with people who have been really devastated that when they stopped taking the medication, they had some terrible symptoms—hearing voices or really frightening experiences—then feeling like, “God is this it? I’ve got to keep taking these meds?” And it isn’t easy.

I think there’s a real need to have honest conversations about these issues. Some people have also queried that the level of research that goes into treatments for mental health is nowhere near the same level that it is for physical conditions. So, there are minimal options, really, even in terms of something as basic as medication.

In brief, I think the medical model is helpful for some people to make sense of what’s happening. But I think what’s not helpful is when that drowns out other ways of making sense of experience. It erases all the questions, unresolved issues, and issues still being debated and researched today.

To go back to these questions about power, medicine has massive power compared to other ways of approaching mental illness. And you can see that even in the health systems that international aid organizations fund. They fund medical health systems. They fund psychiatry. They fund psychology, perhaps, sometimes. But, they don’t fund traditional healers. They don’t fund faith-based healers. The state does not sponsor that. Those are private enterprises.

I think it’s important to remember that, of course, places like Ghana and Nigeria, and other countries have their own histories of psychiatry. For example, psychiatry has been around in Ghana for over 100 years. Starting in the colonial period and then in the post-colonial period, there were three psychiatric hospitals in Ghana. Two were built in the post-colonial period. And people were thinking at the time of new mental health models that were not like a colonial asylum or a prison but was more of a therapeutic kind of space.

It’s important that we don’t just think of psychiatry as something that’s been exported from the North and taken to the South. In Ghana, because for so many people, faith is so important to them— even the most diehard psychiatrist will also go to church on a Sunday, pray every day, read the Bible every day—the faith is present in ways that it may not be for many people in the US and the UK. And so, even when people are working in psychology, psychiatry, and mental health, their faith is also there. So, I think this is one of the things that facilitates working alongside traditional and faith-based healers. I think there is a lot of respect for the work that some of these people do. On the other hand, there is also a healthy kind of critique because there are healers who are very exploitative. And obviously, there are a lot of concerns about the use of chains and shackles and other restraints. There’s a lot of mistreatments that go on in some of these places as well.

There are lots of complicated ethical issues to consider. We’ve been researching how traditional and faith-based healers and mental health workers are working together. And the nurses that we were working with in Ghana very much saw it as a balance between the two. So, as mental health workers, they were offering a kind of medical framing and psychiatric drugs but also thinking about how they could support people with their livelihoods and things like that. They were aware of the social factors that were also difficult for people—poverty is a huge part of people’s lives in that part of the world. But then they also recognize that faith-based and traditional healers have expertise in the spiritual realm and that they have insight into these other aspects. The spiritual realm was incredibly important for both patients and their caregivers in making sense of what had happened. And this is, I think, something that we can learn from. It shows how these different approaches can work together.

Lilly: You had recently written a piece called Psychiatry Beyond Fanon. Will you tell us a bit more about it?

Read: The inspiration for that piece came after an article published in The Guardian, which is the UK’s leading progressive newspaper, that had a lot of these pictures of people in chains in Ghana. The whole photo series accompanied this article, and it was talking about Ghana as a mental health void where there was just no access to psychiatry and people were chained up. And I felt very disturbed by that piece. Because I felt it presented Ghana as a place where nothing had ever changed and where there were absolutely no mental health services whatsoever—where everybody was in the dark ages, primitive and just in stasis. It brought up all sorts of tropes of Africa being backward and out of step with nothing changing. So, back when the articles were first published, I got together with a load of people in Ghana, including the head of the mental health services there, and loads of other people, and we wrote to The Guardian. We said, look, you know, there was a misrepresentation of the facts. Even the number of psychiatrists they used was wrong. So, we corrected those, and we said that this was a misrepresentation of Ghana because they had really expanded the number of community mental health workers quite dramatically over the last 10 years. We felt we understood the need to highlight these injustices, and we felt there was a bigger story to tell.

The Guardian completely ignored our letter, which I felt was quite shocking. If the head of psychiatry in Germany, for example, had written to The Guardian, would they have ignored it? I don’t know. But anyway, it was Ghana, so they did.

I think it’s important to say that, of course, I’ve met many people who have been chained in Ghana, and it is horrific. And I don’t want to in any way minimize the suffering that people have gone through. But, still, I think it’s not the only story and that there are other people I have met who are faith-based healers who genuinely care for the welfare of the people who come and use their services, and they do a lot to try and support a very stigmatized group.

These are all abuses in one way or another, and some try to justify them. But we don’t work hard enough to find other ways of approaching these situations. For example, our Mental Health Act permits you to take people against their will to the hospital in the UK. In an ideal world, we want to find some way where that wouldn’t be necessary. We’re at a bit of a crisis point at the moment, actually, because the cuts in mental health services mean that it’s much more likely that compulsion will be used. After all, people are not getting support in the community, and things get to a crisis point. When that happens, it’s much more likely that you’re going to use the Mental Health Act to bring people into the hospital.

I think that’s in my work in a way. That’s what I like to do; try and think of this as kind of the big issue for all of us to grapple with. And I think that we are all learning together how to deal with the central problem of being human.

Lilly: How do you define rights-based approaches in your work, and how does faith-based healing fit into rights-based approaches?

Read: Yeah, it’s an excellent question because I think rights have become central in the discourse around mental health, with the World Health Organization and the UN. There’s a big push to improve rights in mental health. But, often, we tend to think of rights in terms of freedom from abuse. So, particularly in Ghana, we think about rights-based health care as getting rid of the chains, getting rid of the restraints, improving access to mental health services, and evidence-based services. We tend to focus less on what has been called positive rights or the rights to be included.

The research I’ve been doing with the Wellcome Trust, the Mental Health and Justice Project at King’s, is around Article 19 of the Convention on the Rights of Persons with Disabilities. Article 19 talks about the right to live independently and to be included in the community. When we think about rights-based health, mental health care, we often don’t think about that.

We don’t think about the right to have a decent job, the right to family life. A lot of people that I know with mental health issues don’t have kids. They are not married. And you know, in a culture like Ghana, that’s quite unusual. And, I have met women whose children have been taken away from them because they have a mental health problems. So, these are all ‘rights’ issues. And I have to say that some great NGOs in Ghana are really doing a lot to push for rights with civil society organizations. It’s interesting, actually, because the organizations that have been focused on gender equality and domestic violence have become involved in seeing that these are also issues relevant to mental health.

The rights-based approach would be looking at these issues around social inclusion, around participation, around creating enabling environments so that you have the supports that you need to make decisions about your care, to live with who you want to live with, to work and have a meaningful role in society. These rights are often not available to people even if they do not have a mental health issue. There have been big protests in Ghana because there’s huge youth unemployment. There are not many work opportunities. There’s rising inequality in Ghana, as there is all over the globe. And obviously, the pandemic has really increased those inequalities. I think we really are at a very critical point, actually.

We’re also working on another project thinking about how to have a more disability-inclusive recovery from the pandemic—where we don’t just go back to normal, but that we think about how services, societies, and communities can be more inclusive for everyone and be more accepting of difference. As human beings were not always very good at that.

Lilly: How do you believe that we can continue to move forward with Global Mental Health in an ethical and efficacious way, especially as inequality arises, especially with the history of Global Mental Health as a field?

Read: I think there are big questions for Global Mental Health. I think one is around decolonizing Global Mental Health and shifting the power dynamics. At the moment, it’s so frustrating because of the way most of the funding networks are set up. Typically, and this is how all my projects are, the funds come from the UK or funders in the UK, and then they get sent to our partners in the Global South. Of course, it’s a really colonial way of doing it. All of those kinds of governance strategies, all the funds, are flowing one way, and that’s not right. And that really must change. We need to see the funding sources coming up within countries to fund their own research without it having to come via institutions in the North. I think these are critical issues, the funding, how funding is set up, how it’s organized, and where it comes from that really must change.

Lilly: Is there anything more that you want to share?

Read: The questions that people always ask me are, what will your research do to help us, to help Ghana? I think it is totally the right question to ask. The other question is more of a personal one, like, how can you support me? How can you help me? I need medication. I want to get a job. I need to earn an income. So, these are the kinds of questions that all of us who work in research need to address.

Because I have worked in mental health services, and I know some things can help, I think it’s often not enough to just intellectualize around these questions and theorize around these questions. It’s not satisfactory to just export models that we have, scale them up, and expect that they will work. We have to be humble about what we know and really listen carefully to what people tell us about what might help or what they know because everybody I’ve spoken to in Ghana is the expert on their lives and what’s happening to them. My job is to listen and learn from what they tell me. And hopefully, I try to share some of that with people in Ghana, but also outside.

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MIA Reports are supported, in part, by a grant from the Open Society Foundations

The post Rights Based Global Mental Health and Social Exclusion: An Interview with Ursula Read appeared first on Mad In America.

Adele Framer, the author, is the founder of the website and virtual support space SurvivingAntidepressants.org. She is also known by her online handle Altostrata. Framer was previously interviewed by Mad in America about her lived experience with protracted withdrawal symptoms (PWS) after discontinuing psychotropic medication.

Framer is not alone. It is estimated that half of the individuals who discontinue psychiatric medication experience withdrawal symptoms. However, these symptoms are often misdiagnosed as a functional disorder or “relapse” back into mental illness. It is believed that withdrawal symptoms result from drug-induced neuro-physiological adaptions and can be curbed with a slow and gradual tapering schedule instead of a sudden termination of the drug.

However, information on tapering and slow cessation of psychotropic drugs is hard to come by, which is why Framer started SurvivingAntidepressants.org years ago.

Framer reports what she has learned from the online community over the years.

• People from all walks of life request assistance tapering off all kinds of psychiatric drugs. However, SurvivingAntidepressants.org came about because of those taking psychiatric drugs (one in six US adults), 95% were/are taking antidepressants.
• Differentiating “relapse” from withdrawal symptoms requires both listening and patience. Emotional symptoms of withdrawal can be confusing. But Framer points out that the emotional symptoms of acute withdrawal are sudden, unlike a relapse which is gradual. Patients often describe their withdrawal feelings as “new or exceptionally severe.” For example: “I’ve never felt this before.” Causing electrical sensations in the brain, often described as “zaps,” among other physiological conditions, including dizziness, pain, nausea, and insomnia.
• The taper can and ought to be adjusted to the individual, as tolerance levels vary widely. The taper also should take into account the trickier drugs to taper and deprescribe, in particular, antipsychotics and paroxetine.
• Often what makes tapering and deprescribing drugs challenging are adverse drug reactions and polypharmacy. These factors make it difficult to determine what drug is causing each symptom. Indeed, there are countless narratives on SurvivingAntidepressants.org recalling the difficulties of prescription cascades, adverse drug reactions, and drug-drug interactions.

• Withdrawal symptoms indicate neurological instability, necessitating more caution when practitioners consider new medications or ameliorative dosages.
• Never skip doses to taper.

Framer’s article, “What I have learnt from helping thousands of people taper off antidepressants and other psychotropic medications,” and her website open up doors for clinicians to understand how to understand psychotropic drug withdrawal better. Her work also gives a unique and powerful scientific authority to the lived experience of those who had visited SurvivingAntidepressants.org seeking advice and community wisdom when more formal channels did not have the answers to help.

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Framer, A. (2021). What I have learned from helping thousands of people taper off antidepressants and other psychotropic medications. Therapeutic Advances in Psychopharmacology, 11, 2045125321991274. (Link)

The post Internet Forum for Tapering Psychiatric Drugs Provides Novel Insights appeared first on Mad In America.

She is a Professor in the School of Child and Youth Care at the University of Victoria in British Columbia, Canada. She has practiced as a counselor, educator, researcher, and advocate. White served for seven years as the Director of the Suicide Prevention Center in the Department of Psychiatry at the University of British Columbia.

She has written numerous articles and book chapters on suicide and self-harm and has co-authored two books: Child and youth care: Critical perspectives on pedagogy, practice and policy (2011), and Critical suicidology: Transforming suicide research and prevention for the 21st century (2016). Her current research focus centers itself around the contemporary discourse of youth suicide prevention, seeking alternatives to one-size-fits-all approaches.

She is currently leading a Wise Practices for Life Promotion project funded by the First Nations and Inuit Health Branch (FNIHB) of Health Canada. This project seeks to curate a series of wise practices for promoting life based on what is already working and/or showing promise in First Nations communities across the country. She is also conducting a study with family counselors to learn more about the challenges and opportunities they face with youth suicide prevention and the organizational conditions that support them to be most effective in their work. 

Samantha Lilly: Young people with lived experience of suicidality are often disregarded or treated as if their thoughts are silly or unfit for their situation. Can you tell me about youth suicide studies as it exists within mainstream understandings of youth suicidology?

Jennifer White: I think we have inherited an adult kind of framework for thinking about suicide in general, that we apply to young people. That is often predicated, as you say, on the idea that young people are fragile and cannot make decisions on their own behalf. Oftentimes, our interventions can feel quite paternalistic. There is a connection between this dynamic and the tendency to apply a more colonial framework when thinking about indigenous suicide.

I’ve certainly been involved in youth suicide prevention efforts like this. At the very beginning of my career—probably 30 years ago—we’d go into classrooms and deliver a very standard package: here are the warning signs, here are the risk factors, etc. You memorize these things.

There was a very scripted sense of what was permissible to say, what was not allowed to be uttered, and the kinds of questions that were allowed. There was a very clear narrative: “If you’re suicidal, you don’t really want to die. You need to get help from a trusted adult, and this trusted adult will link you up with a professional or an expert who will then intervene.”

In some cases, that’s probably life-saving for some young people. I’ve never been one to say that those things don’t work for anyone. But what I’ve had a problem with is the suggestion that those are the only ways to offer help. We know lots of young people do not avail themselves of formal mental health services. Even if they do show up and get help, they don’t stick around for very long. So I think it’s important that we have a whole range of things to offer that map onto the young person’s needs at the time and their own sense of what’s going to be useful, without us predetermining it.

Lilly: What harms arise when a one size fits all model is applied to youth?

White: Mainstream suicide prevention is very much rooted in a risk paradigm. Everybody gets read through this register of risk and pathology. We see it in how we talk about risk factors and “low, medium and high risks,” and there are certain protocols to follow when people fall into these risk categories. But, of course, people are so much more than risk factors.

In some ways, these approaches can dehumanize people and create distance from the very people who can be most helpful. Because of all the fear and anxiety attached to the topic of suicide, well-meaning adults often feel afraid when it comes up in the conversation. Then we get this kind of message: “If you are ever worried about someone, call 911. Or go to the hospital.”

So, I think some of the limits of it are that these scripts—young people as bundles of risk factors that need to be acted upon by another. They become objects to be acted upon or intervened upon.

I think it risks the very possibility of creating a relational connection where you can have an honest, open conversation about what’s leading someone to feel like they don’t want to live anymore.

What’s going on? Let’s try to understand that. But we put that category on someone, and then we’re off to crisis management mode, and sometimes those strategies can be quite coercive. People don’t want to be in a hospital. People don’t want to have their freedoms taken away in some cases.

Lilly: It sounds like is this one size fits all approach to youth suicide funnels young people through a system, and the funnel may not fit them. We could be pushing people—pushing a round peg into a square hole. As one of the leaders in Critical Suicide Studies, can you talk a little bit about how this critical thinking about suicide and suicidality might alter that funnel or make it fit more people?

White: I think your metaphor of the funnel is a good one.

I think that is what happens because there is so much anxiety about the topic and how people are professionally trained to deal with it that there’s this illusion of control that we know what to do. We feel like, “OK, someone’s suicidal…I know what to do. I know that I assess them as high-risk, and then we send them off to another expert or a more intensive kind of treatment context.”

In critical suicide studies, we are trying to disrupt thinking about people in terms of their risk to see them as more than their risk factors. That is a part of what is going on.

It is also about situating their distress in a context. What mainstream suicidology often misses is the context of the experience of distress and suffering. It zeroes in on their interiority—their feelings, their histories, and their intentions.

We, in the general population, get very careful about asking, “are you thinking about suicide? How long have you been thinking about it? How are you going to kill yourself?” We have all of these techniques we’ve learned to assess risk, which ignore a whole bunch of a person’s humanity and experience. Sometimes that can lead people to feel unheard and misunderstood.

Then again, I don’t ever want to suggest that these things can’t be useful. But for some people, for some young people, it feels like it’s a closing down of possibilities—of ways to be human. Because, in some ways, it signals that people don’t want to talk about suicide. Killing yourself isn’t an option, and there aren’t things that we can’t even explore together about that option. We have to constantly be redirecting you to life, to living.

Many people are writing about this. There’s this exhortation to live and this requirement to live that we often also don’t question in suicide prevention. We think, yes, everybody must live. I think it’s good to interrupt that and ask, “do we want to start from there, or do we want to start somewhere else? Is suicide a part of living?”

Other things external to the person might be contributing to the distress. Sometimes when you reframe or rethink what’s causing the pressure or the distress, people can feel like there are things that they’re up against that are not of their own making. That can sometimes be quite helpful. It can give you a little bit of space to think: “Oh, it’s not me, necessarily, that’s the problem. I’m only a part of this problem.”

There is a whole context here! It makes room for practices of solidarity, for involving other communities, for seeing it as a site of resistance against injustice.

There are a lot of ways we can think about suicide other than as a form of pathology. It can be a question. It can be a refusal. “I refuse to live under these circumstances.” There are lots of ways we could think about suicide that does not characterize it as a psychopathological condition.

Lilly: A lot of folks at home might think, for good reason: “We don’t want to give our young people the wrong idea, that suicide is an act of protest.” Perhaps one of the key questions of critical suicidology is: What if they were “mentally ill”? What if they were just depressed? Can’t they be saved? How do you answer these types of questions?

White: I’m glad you asked because I think it helps to reinforce that I don’t want to get into a situation where it’s either this or that. Suicide is multiple. It is co-constituted with our contexts, our relationships with other people, and our histories.

I don’t want to get into a pattern where we say: “Well, mainstream suicidology thinks about it this way, and we’ve got the answer.” Or, “If only we were just thinking of it this way, we’d solve the problem.”

I think what we’re attempting to do is to create more possibilities and more room for creative ways to understand suicidality so that there are a whole plethora of ways that we might think about it.

Young people experiencing symptoms of depression are encouraged to get help at a mental health clinic. They do get help either through CBT or DBT, which are often thought up as evidence-based practices, and they benefit. I don’t have any problem with that. I think that’s great! It’s great that people are getting help, and that is matching what they need. But I think there are lots of folks for whom those practices don’t work, and they don’t feel like that feels like a good fit.

I’ll give you an example of someone I was speaking with recently who was in a group, and she kept saying, “I want more to life than just being safe.” There was a constant focus on her “safety plan.” She was constantly being asked to create a safety plan to assure people that she was “safe.” And, she said, “there’s more to life than a safe life.” This is an example where some of our tools and instruments that we think are helping people to stay alive felt, for her, like they were diminishing the idea of what is possible for the life she wanted to lead.

To answer your question, we can keep thinking about possibilities that expand our notions of what counts as a livable life. We can continue to engage young people in meaningful conversations about that.

I think we can also say that what we have been doing so far is clearly not working. I mean, suicide rates are going up in many places, including in the states where they were previously stable. We do not see dramatic declines despite all of the efforts where we’ve put into prevention. I think that it also opens up possibilities for thinking about suicide differently.

Lilly: I am grateful for you mentioning this kind of reimagining or expansion of how suicide prevention can look and how our thinking about suicidality can change. Regarding the Critical Suicide Studies Network, can you give us a brief overview of some of the work you and your colleagues are doing across the world?

White: There are scholars worldwide that are disenchanted with the mainstream approach to suicide prevention, and they’re looking for alternatives. I think one of the things we haven’t talked about too much, but it’s important to mention is the inclusion of people with lived experience.

That is something that Critical Suicide Studies is committed to, and we also want to be careful about thinking about people in terms of these identity categories. We can get into this trap of thinking, “well, they’re a professional, and they’re a researcher, and they’re a counselor, etc.” People can have multiple identities.

We also came out with an ethics statement that we wanted to circulate for input at a conference we were supposed to have here in Vancouver in June (it was canceled due to the COVID-19 pandemic). It asked, what does ethics in critical suicide studies mean? How do we want to work?

We take a lot of account of people’s political context, forms of oppression, and intersectional identities. We explicitly recognize that some people, despite others’ wishes for them to be alive, will continue to choose death. We write that right into the ethics statement, which I think is important.

As for my colleagues, there are many examples of people doing amazing work in this area, whether it’s around queer youth suicide, austerity suicides, or critiquing psycho-centric views of suicide.

In my own work, right now, I’m doing a study where I’m interviewing counselors who are working with young people who access mental health services because of suicidality. I’m trying to elicit the counselors’ narratives about the standard approach that their organization and institution expect of them.  Then, asking, what other methods are they also doing at the same time?

They each have this way of speaking about their practice: “Well, here’s the standard, which I’m supposed to do, and then there’s this other thing I’m doing.” These additional steps are less formal, less public, and had a kind of a critical quality to them. They were working with young people in ways that were challenging some of these norms around what counts as a worthwhile life, for example.

They were adhering to the standards and doing what is required—meeting the standards of care in a good and ethical way—but there is another layer of practice where they’re working, I think, in a way that’s getting at some of these critical conversations with young people. They ask different kinds of questions that do not position young people as fragile, discredited knowers but capable people. And the counselors find that there are sites of solidarity that they can connect with them over. It is a way of artfully re-crafting the conversations, inviting young people into a conversation instead of acting upon them.

Lilly: What are some examples of these questions that invite the autonomy of the young person that these clinicians and counselors ask?

White: Because young people are coming for counseling, they’re able to see that there is a part of them that is wanting to get help. Sometimes it is that they want their parents off their back, so they are willing to come. The counselors work very hard to understand what the goals are for the young person and understand what kind of life they would like to be living.

Some of this comes out of a lot of narrative therapy where you can ask questions like, “With your suicide attempt, what are you taking a stand against?” Here, you’re asking a value related question. It can reveal that they care about something in this world that they’re living in right now that is not forthcoming. It opens up the possibility for a different kind of conversation when you ask that question versus, “When did you last try to kill yourself?” or “How did you last try to kill yourself?”

Again, I am not saying these kinds of questions are not useful. But they can become quite predictable for young people. They’re a little bit stale because they’ve been asked those many times if they’ve seen counselors. It is the standard line of questioning.

Many young people will say, “do we have to go through those questions again?” Can we just get on with them?” Some of those conversations need to be fresh and offer a different way of thinking about themselves and the world.

Lilly: How would you advise parents to talk to their child about suicidality if their own child is suicidal, or if they are asking about suicide and what it means? If there was a suicide in their friend group or at school, how would you advise a parent to address suicidality in a way that does encourage an understanding of context and reduces the “stale” nature of the conversation?

White: I am always interested in these kinds of conversations that are driven by curiosity and honest questioning about what is going on for someone without letting anxiety take over. I think that’s the hardest thing for parents and for people who care about young people because their fear and anxiety get the better of them.

Sometimes the fear closes down the possibility for curiosity and a collaboratively generated conversation. When young people feel, “this is someone I can actually have this open conversation with,” it is when someone can acknowledge that suicide is a possibility and that it is part of our human existence to have thoughts of death and suicide.

Many suicidal people will say that through talking it over and thinking it through with another person, they sometimes come to the desire to live again. It’s not a technique. It’s just that sometimes when you’re given permission to honestly express what you’re feeling, you can come to some different understandings for yourself.

Lilly: Can you share your current thinking on the debates about whether suicide is a problem.

White: I think my own thinking has evolved so much over the course of my career. I’ve been working on suicide prevention for over 30 years. I started out in a very traditional way, doing things by the book, producing evidence-based documents, and transmitting knowledge from this “expert place.” I’ve done that.

My own questioning emerged through my work with young people, seeing that this wasn’t always what felt useful. It didn’t always feel like a useful conversation. In some ways, it positioned them in a way that I didn’t feel good about —I was the expert, and I was telling them what they should and shouldn’t do.

So, I accepted the idea that, yes, all suicides should be prevented. I accepted that suicide was a problem that should be stopped, and I’m not sure that I’ve stopped thinking that it’s a concern.

I think that the suffering that I’m concerned about is tied in with suicidality. I wonder if there is a different response that we can give to this suffering that may be different from prevention. Prevention has this quality of stopping, disallowing, intervening, and there are maybe other ways of framing it.

If we think about responding to suicidality as an invitation, as an opening to possibility, then, when people make a suicide attempt, we’re called to respond with curiosity, to engage in some kind of joint meaning-making about what it means. I cannot assume that I know what it means, and I’m not going to put it in a predetermined category.

This gestures toward the kind of world that I want to be a part of where we recognize each other’s humanity, and we see each other. We’re not putting people into categories, assuming I know who you are without even having a conversation with you. It is also about changing the structures and the context and the forms of colonial violence and racism and transmisogyny—all things that we know lead many people to feel distressed and suffering.  We have got to work at all those angles.

Lilly: What does Critical Suicide Studies have to offer about the current cultural moment as it relates to suicidality?

White: I do think it is important to say that Critical Suicide Studies must turn the critical gaze on ourselves. We have to constantly be reflexive about what we’re doing and the effects of our work.

I wrote something recently about the need to include people from the Global South and more racialized Black and Indigenous folks in these conversations. It is an important move we need to make so that we do not continue to replicate a Euro-Western-centrism in this work —a lot of the theoretical resources drawn on by Critical Suicide Studies scholars are from Western scholars.

I think we have work to do. I think we need to constantly be problematizing where we need to go and how we need to be accountable. It’s definitely not a perfect arrangement, and I think we need to constantly be on the move and thinking about what we need to do to be accountable.

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MIA Reports are supported, in part, by a grant from the Open Society Foundations

The post Rethinking Suicide Prevention: An Interview on Critical Suicide Studies with Jennifer White appeared first on Mad In America.

The Congressional Black Caucus Emergency Task Force On Black Youth Suicide and Mental Health recently published a comprehensive report designed to not only educate but to sound the alarm on Black suicidality. Attempting to push back on the trite belief that Black youth simply “do not kill themselves,” this group of Black scientists, Black mental health care practitioners, Black organizers, and Black activists are working to bring Black youth suicide into focus during conversations concerning mental health care in the United States. This blog post is largely informed by the report—please consider reading the report before reading the rest of the blog post.

It is not surprising that this may be the first time you are reading exclusively about Black suicidality. Given the pervasive and prevalent systemic racism found within academia, alongside the insidious and covert discrimination (racism) found in both the nation’s greater science community, (the NIH, the NIMH, the American Psychological Association, and the American Psychiatric Association) and the United States of America writ large, Black scientists and practitioners have been trying to sound the alarm with little to no avail.

The reason for their lack of success is twofold. 1. White and non-Black researchers and practitioners are not doing the work nor are we listening to those who are doing the work— evidenced by your surprise at the 73% increase in suicide attempts made by Black youth in the past thirty years. And 2. Black researchers are 10% less likely to be awarded research funding in comparison to their white counterparts, leaving the important work concerning race and mental health unfunded, unfinished, and undone.

Moreover, media of all kinds fails to address race statistics when reporting and disseminating information surrounding suicidality. Indeed, even in popular media, Black youth are rarely depicted on the big screen as dealing with thoughts of suicide. Black pain and suffering, particularly Black mental pain and suffering, is made invisible and invalidated as it does not fit in with the white racist oeuvre of what it means to be Black in the United States. Typically, it is the frail, misunderstood, chain-smoking white teenage boy or the bullied white teenage girl.

Rarely, if ever, are we given any insight as to what specific lived experience of suicidality Black youth deal with day-to-day in the 21^st century—and based off of the statistic above, it is obvious they are dealing with it.

If we are to be authentic in our chants and ever-changing profile pictures, all proudly proclaiming that Black Lives Matter, we must take seriously all the ways Black people die and are at risk to die at disproportionate rates to non-Black people, inclusive of suicide.

The risk factors for suicidality outlined in the Congressional Black Caucus Emergency Task Force’s report are all inextricably intertwined with inequality and modernity.

Each “risk factor” outlined is a non-dominant identity—showcasing that we force Black people in the United States to pay a mental toll for each of their deviances from whiteness, the patriarchy, heteronormativity, and neoliberalism.

For example, LGBTQIA+ Black youth, Black youth hailing from a low socioeconomic status, and Black youth who are targets of bullying i.e., racism, are all considered at high risk for a suicide attempt.

Sure, all queer people in the U.S. pay a mental toll for their identity. It is already dangerous to be transgender and live in the United States, but couple that identity with Blackness, it is not just dangerous, it is deadly….

#SayHerName Nina Pop

#SayHisName Tony McDade

#BlackTransLivesMatter

Similarly, socioeconomic stress is known to have deleterious effects on mental health and wellness. From slavery, to redlining, to gentrification, this country has always been designed to keep Black people socioeconomically disadvantaged—taking yet another mental toll.

Another toll must be paid whenever a Black person logs into Facebook, Twitter, or Instagram. Will today be another day where they are forced see one of their peers lynched by police? In fact, a recent survey of young people of color suggests that exposure to “online racial traumatic events” is associated with depression and post-traumatic stress symptoms, both of which have been associated with suicide risk.

Even outside of the scope of race, suicide can largely be understood as a symptom of inequity, caused by the compounding negative effects of all sorts of structural injustices: racism, classism, sexism, and ableism, rather than a direct tie to a diagnosable mental illness or an unexpected one-off crisis.

What is the first step that mental health care practitioners and so-called allies can take to meaningfully push back against the rising rates of completed suicides and suicide attempts for Black youth? By understanding suicidality as a complex and nuanced social justice issue, rather than solely an issue of mental illness fixed only by pharmaceuticals and Cognitive Behavioral Therapy, we are given the framework to critically understand, speak truth to, and breathe nuance into Black suicidality. In other words, we are given the framework to begin to fix it.

To reiterate once more, young Black people who have attempted to take and have taken their lives did not lack resiliency nor were they necessarily mentally ill.

No.

The young Black people who are killing themselves live in a society where their Black peers are fearful every day. They live in a society where the odds are systemically and methodically stacked against them. They live in a society where Black people are murdered for going on a run in Georgia. #SayHisName Ahmaud Arbery. They live in a society where Black people are shot dead sleeping in their bed. #SayHerName Breonna Taylor. They live in a society where Black people cannot breathe. #SayHisName Eric Garner. #SayHisName George Floyd. They live in a society where a traffic stop is life or death. #SayHerName Sandra Bland. They live in a society where young boys are murdered for walking with their hoods on, with Skittles in their hand. #SayHisName Trayvon Martin.

They live in a society where this is nothing new. #SayHisName Emmitt Till.

These young Black people live within the confines of a culture that continues to foster and perpetuate such an insidious form of racism that we will never be able to say all the names of those lost senselessly to horrifying inequity and bigoted ignorance and indifference. These young Black people live in a country where they are told day-in-and-day-out that their lives do not matter. And yet, we have the audacity to be surprised when faced with a statistic that demonstrates exactly what we have told them.

So, let’s call it like it is: The suicides that have transpired and will ensue in Black communities can be understood to be caused by an institutionalized inequality that requires Black folks to negotiate their quality of life with life itself. And, to only speak to their suicide and suicide attempts as a “mental health issue” not only underestimates their resiliency, but grossly discounts the emotional toll racism continues to take on Black people in the United States.

And, even if Black suicidality were solely accounted for by the biomedical model of mental health, Black people are disadvantaged there as well. Indeed, Black people are less likely to have access to mental health services, less likely to seek out services, less likely to receive needed care, more likely to receive poor quality of care, and more likely to end services prematurely. This inaccessibility is rooted in systemic racism, too.

What is even more frustrating is that when Black people do seek out and acquire mental health care, the Black psyche has been historically portrayed as “unwell, immoral, and inherently criminal” (read The Protest Psychosis by Jonathan Metzl and see for yourself), rendering Black anger and sadness as needing mental health care but limiting quality and meaningful access to it.

Therefore, the implicit bias (racism) toward Black minds, in conjunction with a dominantly white mental health workforce, is yet another emotional and mental toll society takes from Black people daily.

It is my hope that by now, the statistic at the beginning of the blog post is unsurprising. So, what are you going to do about it?

Here are five easy things you can do today to address Black youth suicide and Black mental health.

1. Listen to and learn from Black practitioners, researchers, and organizers. (Below is a reading list.)
2. Question, always, how systems of oppression are so obviously detrimental to mental wellness and health.
3. Acknowledge and own your privilege if you are not Black; be proactive in finding ways to use your privilege to push back against anti-Black racism in mental health care.
4. Stop reposting Black death.
5. Sign petitions to defund the police and other petitions organized by Black people.

Black Mental Health Resources That Are Accepting Donations

BEAM Collective: We are a collective of advocates, yoga teachers, artists, therapists, lawyers, religious leaders, teachers, psychologists and activists committed to the emotional/mental health and healing of Black communities. https://www.beam.community/whatwebelieve

The Okra Project: The Okra Project is a collective that seeks to address the global crisis faced by Black Trans people by bringing home cooked, healthy, and culturally specific meals and resources to Black Trans People wherever we can reach them. https://www.theokraproject.com/

The Loveland Therapy Fund: With the barriers affecting access to treatment by members of diverse ethnic and racial groups. Loveland Therapy Fund provides financial assistance to Black women and girls nationally seeking therapy. https://thelovelandfoundation.org/loveland-therapy-fund/

Harriet’s Apothecary: Harriet’s Apothecary is an intergenerational, healing village led by the brilliance and wisdom of Black Cis Women, Queer and Trans healers, artists, health professionals, magicians, activists, and ancestors. Our village, founded by Harriet Tubman and Adaku Utah on April 6, 2014, is committed to co-creating accessible, affordable, liberatory, all-body loving, all-gender honoring, community healing spaces that recognize, inspire, and deepen the healing genius of people who identify as Black, Indigenous and People of color and the allies that love us. http://www.harrietsapothecary.com/who-we-are

Educational Resources on Black Mental Health Written by Black People

The Unapologetic Guide to Black Mental Health: Navigate an Unequal System, Learn Tools for Emotional Wellness, and Get the Help you Deserve – Dr. Rheeda Walker

Black Pain: It Just Looks Like We’re Not Hurting– Dr. Terrie M. Williams

Too Heavy a Yoke: Black Women and the Burden of Strength– Dr. Chanequa Walker-Barnes

Un-Ashamed – Lecrae

Invisible Man, Got the Whole World Watching, A Young Black Man’s Education  – Mychael Denzel Smith

Willow Weep For Me: A Black Woman’s Journey Through Depression – Meri Nana-Ama Danquah

Heavy – Kiese Layman

My Grandmother’s Hands: Racialized Trauma and the Pathway to Mending Our Hearts and Bodies –  Resmaa Menakem MSW, LICSW, SEP

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