Mental and Substance Abuse Disorders And Their Impact On Veterans

Santa Monica Psychiatrist Katherine Watkins, MD, has substantial experience researching mental and substance abuse disorders suffered by veterans. In fact, focusing on the frequency of disorders in relation to vets reveals both good news and situations that can be improved upon. 

Recent research focuses on returning US service members with symptoms indicative of serious mental disorders. It elaborates on the difficulties of providing high-quality treatment to this population. Although returning service members are only 4.1 percent of the total veteran population, their complex psychological needs have made delivering high-quality treatment for mental and substance use disorders a national priority.

“Care For Veterans With Mental And Substance Use Disorders: Good Performance, But Room To Improve On Many Measures” is an in-depth article that covers the subject. It is available on KaterineWatkinsMD.com as a downloadable PDF.

Consequently, in 2006 the Department of Veterans Affairs commissioned the Altarum Institute and the RAND Corporation to do an evaluation of its mental health treatment system. We published the results of our evaluation in the November 2011 issue of Health Affairs, and the findings are as relevant today as they were at the time of the study.

In our evaluation, we found that veterans with mental illness and substance use disorders represented 15.4 percent of all veterans using Veterans’ Health Administration (VHA) services in 2007 and that they accounted for 32.9 percent ($12 billion) of VHA costs, of which the majority was for non–mental health conditions. The average cost for a veteran with mental illness and substance use in our study was $12,337, or 2.7 times the cost for an average veteran without these conditions. The quality of care for the veterans in our study, although similar to or better than the care given to comparable privately insured patients or those enrolled in Medicare or Medicaid, varied by as much as twenty-three percentage points among regional service networks. Performance on some indicators, such as whether those with alcohol dependence received pharmacotherapy, was low. There is a need for substantial improvement in the care of these veterans, particularly with respect to ensuring the delivery of evidence-based treatments.

Co-Occurring Disorder Research

Katherine Watkins, M.D. — Santa Monica Psychiatrist

A number of my colleagues and I recently completed a study based on the fact that individuals with co-occurring mental and substance use disorders have increased rates of mortality in relation to the overall population. We were struck by the fact that studies until now have shown what the relationship between measures of treatment quality and mortality for these individuals is.

Consequently, we were led to focus on a single objective: to examine the association between a number of quality measures and mortality based on a range of one to two years.

Design, setting and participants: To conduct the survey, we focused on a number of patients with co-occurring mental illness — including but not limited to such illnesses as schizophrenia, bipolar disorder and major depression — also suffering from substance use disorders.

We used the latest techniques such as logistic regression models to examine the association between one- to two-year mortality and various quality measures, while risk-adjusting for patient characteristics. Quality measures included receipt of psychosocial treatment, receipt of psychotherapy, treatment initiation and engagement, and a measure of continuity of care. We also examined the relationship between number of diagnosis-related outpatient visits and mortality, and conducted sensitivity analyses to examine the robustness of our findings to an unobserved confounder.

Results: All measures except for treatment engagement at 24 months were significantly associated with lower mortality at both 12 and 24 months. At 12 months, receiving any psychosocial treatment was associated with a 21% decrease in mortality; psychotherapy, a 22% decrease; treatment initiation, a 15% decrease, treatment engagement, a 31% decrease; and quarterly, diagnosis-related visits a 28% decrease. Increasing numbers of visits were associated with decreasing mortality. Sensitivity analyses indicated that the difference in the prevalence of an unobserved confounder would have to be unrealistically large given the observed data, or there would need to be a large effect of an unobserved confounder, to render these findings non-significant.

This study had a number of conclusions and of particular relevance. It is the first study to show an association between process–based quality measures and mortality in patients with co-occurring mental and substance use disorders, and provides initial support for the predictive validity of the measures.

If you would like more information on co-occurring disorders, please visit my website. There you will find a number of downloadable PDFs with the complete text of the research. 

Katherine Watkins, M.D. is a psychiatrist with offices in West Los Angeles on the border of Santa Monica. 

What Is The Advantage Of Combining Medication With Psychotherapy For People With Major Depression?

As a psychiatrist with a practice located in West Los Angeles, between Santa Monica and Beverly Hills, I often see patients who require a variety of therapies. One common question involves the advantage of combining medication with psychotherapy.

Both antidepressants and psychotherapy can be effective for major depression or dysthymia, a chronic, low-level form of depression. One of the most fascinating findings is that both medication and psychotherapy produce similar changes in the brain of patients who respond to treatment. We don’t understand why, but it suggests that ultimately psychotherapy — which involves new learning— is working to change the underlying structure and function of the brain.

About two-thirds of all patients with major depression will improve on antidepressant medication alone, although only one-third will become symptom-free. In general, the longer you have been suffering from depression, the harder it is to achieve a full remission with just medication. How you were before you became depressed also matters: people with stable jobs and relationships tend to have an easier time of it than people who have struggled more or who have more stress in their lives. Combining medication with psychotherapy improves recovery rates by as much as 33% over medication alone, and seems to be particularly beneficial for people with more severe or more chronic depression, or for people who also have medical illnesses. On the other hand, there are some intriguing research results that suggest that for people with a history of childhood trauma (such as the early loss of a parent or physical or sexual abuse), therapy alone is more effective than medication, and receiving both together is not significantly better than psychotherapy alone.

The best-studied types of therapies for depression (and the ones most often combined with medication) are cognitive-behavioral therapy and interpersonal therapy, although we don’t know yet if one is better than the other, or if success is related to patient characteristics. These types of therapies are typically focused on improving symptoms rather than looking at unconscious patterns of behavior and increasing self-knowledge.

Ultimately the decision about which type of therapy and whether or not to take medication should be based on what the research literature says and your personal preference. There is almost always more than one right choice — the goal is to find the choice that most closely matches your needs and preferences and which is consistent with what the research literature suggests.

What Is The Advantage of Combining Medication With Psychotherapy for People With Bipolar Disorder?

News & Insights From Santa Monica Psychiatrist Katherine Watkins, M.D.
Although mood stabilizers, such as lithium, Depakote or Tegretol, are the mainstays of treatment for bipolar disorder, therapy can be critically important, particularly for individuals newly diagnosed with bipolar disorder or those with significant life stress. Although bipolar disorder usually begins in teenagers/young adult hood, the average age of diagnosis is in the late 20s, which usually means that people have been suffering from it for many years before first getting treatment. Therapy can help people come to terms with the illness, which has often played havoc with their work and relationships in the years between first onset and treatment, learn to recognize the early warning signs of relapse and develop healthy habits to prevent recurrence. Therapy can also help people learn how to manage or decrease stress, which frequently is a precipitant of a new episode.

There are three types of therapies which seem to be particularly helpful in the treatment of bipolar disorder: cognitive behavioral therapy, where you examine how your thoughts affect your emotions and learn how to change negative thinking patterns; interpersonal and social rhythm therapy, where you learn to manage current relationship difficulties and stabilize your social rhythms such as when you wake up, go to sleep and eat; and family –focused therapy which works to educate family members about the illness and how to cope with its symptoms.

Stress and Mental Illness

News & Updates From A Leading Santa Monica Psychiatrist

Chronic stress is intimately linked to mental health and the development of mental illness, although until recently the reason for the connection was not known. High levels of stress as well as chronic stress are correlated with the development of both anxiety and mood disorders, as well as with relapse in schizophrenia, bipolar disorder and substance use disorders. Chronic stress is also associated with developing physical health problems, such as diabetes, heart disease and cancer. Some stress can be beneficial, preparing you to face a difficult or threatening situation by raising your heart rate or tensing your muscles. The problem is when stress is chronic and the body doesn’t return to its pre-stress physical state.

Santa Monica Psychiatrist Katherine Watkins, M.D.

Katherine Watkins, M.D. is a Santa Monica-based psychiatrist with an office conveniently located on Overland Avenue just off the Santa Monica freeway. I welcome residents from all over West Los Angeles who are seeking diagnosis and treatment for a wide range of psychiatric disorders and emotional problems.

Treatment For A Variety Of Issues

I provide evaluation and treatment for psychiatric disorders and emotional issues, which include:

• Mood problems, including depression, dysthymia, irritability, mood instability and bipolar disorder
• Anxiety, and more specifically panic, post-traumatic stress, obsessive-compulsive disorder, and generalized anxiety
• Adult attention-deficit disorder.
• Personality disorders
• Adjustment difficulties with life transitions, bereavement and aging
• Medical illness-related mood and anxiety problems 
• Please note that I do not diagnose and treat dementia and generally do not see people with psychotic disorders 

The First Step Toward Changing Your Life

I believe people can best realize their potential to grow in the context of supportive relationships. I also believe that a good relationship with a therapist can change your life. I stay abreast of the research literature to give you state-of-the-art treatment that is scientifically supported by the most current evidence. This allows me to individualize treatment depending on your needs and preferences. As a patient, you will find that I believe in shared decision-making. I will strive to make sure that you understand the choices you have in terms of treatment options and the risks and benefits of treatment. In addition, I recognize that mental illness is a disease of the brain, and that medication, when used judiciously, can be enormously helpful in relieving suffering.

What Makes ISTDP So Effective?

Psychiatrist West Los Angeles: Dr. Katherine Watkins

One of the things that makes ISTDP so effective is its concentrated attention to the unconscious barriers that work against successful treatment. In ISTDP, these barriers are referred to as “defense mechanisms” or “defenses.” ISTDP posits that defenses prevent us from experiencing our authentic feelings, and that it is only with active and persistent attention by the therapist to exposing and confronting these defenses will patients be able to experience the full range of their emotions. In childhood, defenses can be a useful tool in emotionally overwhelming or traumatic situations. Defenses such as dissociation and repression can shield us from intense feelings that we are developmentally unprepared to experience and process. However as we grow up, this shielding cuts us off from our full range of feelings, even when we are now emotionally able to handle the feelings. When this happens, it may lead to depression, anxiety, relationship problems and self-defeating behavior, or as one of my patients said, “I’m living a two dimensional life.”

A Sense Of Freedom

In the therapy, I will work with you to help you identify the defenses that are preventing you from having direct access to the full range of your feelings and to having emotionally satisfying relationships. In this way you can make the choice to give up your defenses and to allow yourself to experience your emotions honestly and fully. As you become able to calmly face your whole range of emotions, such as anger, sadness, remorse/guilt, forgiveness, and love, you will become able to use these feelings in a productive manner to enhance closeness with people in your life. A sense of freedom and well-being comes with the capacity to face your feelings rather than the all too common situation of ignoring and avoiding feelings.

Sometimes when painful feelings emerge, anxiety can come up. The source of the anxiety is the painful feelings that are generating the internal conflict. Together, in session, we will monitor your physiological responses to the material that come up, so that you won’t be overwhelmed. You become well acquainted to listening to your body. Thus a sense of balance is felt; for example you can use both your emotions and thoughts as guides in your life.