One of the hardest things to accept about life is that some circumstances will stay unresolved – and that, in and of itself – is a resolution. So we should all do ourselves a favor and stop trying to extract fairness from a world that never claimed to be – or had a history of being fair. There’s simply no way to attain justice without outside cooperation.

We can however seek relief independently, through faith, therapy, fitness, spirituality. Or generosity and giving of ourselves.

The skilled mental health diagnostician is not seeking perfection as there is no such thing. Instead, this clinician is seeking diagnostic assuredness. It begins with a thorough assessment of the presenting client and not a memorization of the DSM. In fact, the mental health bible stays on the sidelines, serving only as confirmation and as a reference for coding purposes. Savvy practitioners rely on the “art of the question.” That’s not to say they don’t bring an excellent command of the signs and symptoms of the mental disorder spectrum to the process. They do. But the essence of their skill lies in the ability to frame a series of insightful, intuitive questions around the client’s presenting problem. Adroitly, assertively, yet tactfully, they approach assessment with tactical precision and are aware that success with any client means this: the language controls the discussion; the discussion controls the relationship; and the relationship controls the quality of the outcomes. As such, the highest premium is placed on rapport building.

Observation is also important. The nuances of client head movements, facial expressions and overall body language are every bit as important as the changes in their vocal delivery. What these clinicians see in a client is every bit as important to them as what they hear.

The inability to confirm a diagnosis by way of objective findings notwithstanding, mental health work has another strike against it – the intimacy of the practice setting. When a patient visits his or her primary care physician, there are often layers of staff – receptionists, lab technicians, nurses, and physician’s assistants – to sift through before seeing the doctor. Mental health settings tend to be more one-on-one, so it’s natural for someone to guard their information at first. The experienced mental health clinician tackles this head on by first putting the client at ease before getting down to work.

Systematically then, the clinician shapes the client’s responses and non-verbal behavior – gathered though their questioning and aided by insight and intuition – into a diagnosis. Then and only then does the hard work of helping the client reach their expectations for treatment begin.

A final point. Those professionals who are undeniably accomplished and highly sought after understand that while diagnoses have utility, there will probably never be clear, undeniable “markers” as found in general medicine and that the notion of chemical imbalances and neurotransmitter difficulties is highly speculative. So they don’t go there; they deal instead with what and how the patient presents.

For some time now, I’ve been taking improvisation classes and have become part of an improv group. I began taking the classes to help me with spontaneity and to think quickly when on the spot. In the very first class – all newcomers – we were welcomed and then immediately brought on stage. There was no theorizing about improv’s place in history as a viable art form. As ill-prepared as I was with the techniques at first, my journey had begun.

You can read all the books you want about improv, skydiving or poker playing, but it’s all theoretical until you step up on the first stage, jump out of the first plane or deal your first hand. I’d much rather work with someone who helps me to actually do something than someone who talks incessantly about the theory of doing it.

Antidepressants: There do not appear to be any significant gender issues in response to antidepressants.

Antipsychotics: Women respond better to antipsychotics during their first episode of illness. They require half as much medication for maintenance than men. Because women have higher body fat content, long acting injections can be given less frequently.

Anticonvulsants: Polycystic ovary syndrome (PCOS) is a metabolic condition that occurs in 7-15% of reproductive-aged women. These women have elevated testosterone, chronic anovulation, insulin resistance, elevated LDL’s with low HDL’s, and a 3x risk of endometrial cancer. (They do not necessarily have polycystic ovaries.) Women with epilepsy and women with bipolar disorder have a high risk of anovulatory disorders and PCOS.

Pregnancy: There is no such thing as a drug that is “no risk” to the fetus. All psychoactive drugs pass through the placenta. All drugs are secreted in breast milk. The more a drug is studied, the more risky it is found to be. Anticonvulsants are especially problematic. Depakote is suspected of causing developmental delays in children without birth defects. Lamictal is now linked to a small incidence of cleft lip and cleft palate (GlaxoSmithKline).

Side effects: Acute dystonia occurs more frequently in women. Tardive dyskinesia is more common in elderly men than elderly women. Men are more disturbed by side effects that detract from their performance. Women are disturbed by side effects that affect their appearance. Women are more likely to gain weight from psychotropics.

Anxiolytics: Though the benzodiazepines carry an attendant risk of tolerance development and dependence, as a class, they are generally safe unless combined with alcohol. Deaths in this instance are due to respiratory depression. These medications however, may be life saving in an acute suicidal episode when anxiety is prominent.

Lithium: Lithium has strong anti-suicidal properties. The risk of suicide in bipolar clients treated with lithium falls 10-fold. When lithium is discontinued, suicidal behavior increases 20-fold within the next 6-12 months. The anti-suicidal properties of lithium are not present with the anticonvulsant mood stabilizers such as Tegretol, Depakote.

Clozaril: The second-generation antipsychotic Clozaril (clozapine) also has strong anti-suicide properties. It is FDA approved as a suicide deterrent in clients with schizophrenia or schizoaffective disorder. Evidence of suicide protection is not as strong with the other antipsychotics.

This collaboration, which unites Pfizer, AstraZeneca, Eli Lilly, Roche and others, will co-mingle findings on 67 trials regarding 11 currently approved drugs. This will make up the largest database of clinical trial data in psychiatric research.

It’s about time! From a pure scientific perspective, the psychiatric community has learned much about brain science in the last 30 years, but apparently not enough. The expectation was that this knowledge would readily translate into new and exciting blockbuster medications that would break new ground in the treatment of mental health disorders. That hasn’t happened. In 2010, the FDA approved only two drugs for psychiatry – Latuda (lurasidone) for the treatment of schizophrenia, and Oleptro (trazodone extended release) for the treatment of major depressive disorder. This is a paltry track record for this year, to say the least.

The major barriers to new and novel drug development have been the fierce competition between rival companies and the limited exchange of science across the industry. This is a classic example of how huge egos impede progress for the greater good. Other barriers include antiquated clinical trial methodology, inaccurate animal models for doing experiments and a paucity of tools and tests in healthy volunteers to provide early indications of whether agents in development might work. In short, many pharmaceutical drug trials are simply a mess.

Supplanting new drug development in recent years has been the pharmaceutical industry’s propensity toward finding new markets for existing drugs – something they’ve become quite adept at doing. This keeps the cart before the horse, and it’s high time for this tactic to change. By working together, hopefully this will be one step that will help reverse the dearth of new medications in psychiatry.

Of particular importance, researchers studying this issue found that this physical activity needs to be taken in people’s leisure time if they are to reap the benefits. The study demonstrated that those who exert themselves during working hours, by doing lots of walking or lifting for example, are no less likely to be depressed than people with sedentary jobs.

The team discovered that the more people engaged in physical pursuits during their off-work time, the less likely they were to be depressed. And those who were not active in their leisure time were almost twice as likely to have symptoms of depression compared to the most active individuals. Also, the intensity of the exercise made no difference. Even people who exerted themselves minimally without breaking into a sweat or getting out of breath were less likely to manifest depressive symptoms.

The study’s conclusion: People who engage in leisure time physical activity, regardless of intensity level, are less likely to have symptoms of depression. Also, the context in which the activity occurs is paramount and the social benefits associated with the exercise, like making friends and increased social support, are more important in understanding how physical exertion may be linked to mental health benefits than biological determinants of fitness.

So get out there and exercise, low impact or high impact, it makes no difference. But remember to do it in your leisure time to feel the benefits.

What I find strikingly poignant was how painful this ordeal was for Thomas Jefferson. Jefferson’s draft of the Declaration of Independence was subjected to more than 80 changes during the period that the Continental Congress deliberated. Most of the changes were minor and served to enhance Jefferson’s work.

One section that didn’t survive the cutting room floor hurt him significantly though. Jefferson wanted to include a section that addressed the pain of parting from the British Crown. “After all, the Brits were our friends, we were leaving them, we might have been a free and great people together,” he lamented. The Congress however, was not in a conciliatory mood. The abrupt ending of old ties with England was not on their mind; their focus was on the denunciation of high-handed treatment.

We all know “the rest of the story.” We handed the Crown their heads in the Revolutionary War. They came back at us again in 1812, burning the White House and the Capitol in the process, but were eventually vanquished in New Orleans, never again to return to American soil as an army.

I believe Jefferson was troubled by the act of burning one’s bridges. I believe that in spite of the waging of two substantial wars on his watch, he perceived that the United States of America and Great Britain would eventually rekindle their relationship. How right he was, and how beneficial for us (World War II immediately comes to mind.)

Relationships that damage us, cause irreparable harm, or serve as an ongoing threat to our well-being should end, and stay that way. But these should be in the minority, because with ardent dedication to damage control and the contributions of father time, allies that became enemies can become allies again. We should all cherish the desire to grow old together in harmony.

Happy 234th Independence Day.

On a 3X5 index card, have your client write down the following five questions, and recommend that they ask these after the doctor has completed the initial assessment and has evaluated the client’s history and presenting symptoms.

1. “What do you think is wrong with me?”
2. “What might be causing this?”
3. “What else could it be?”
4. “Is there more than one treatment for my disorder?”
5. “Would you please tell me about the medication(s) you’re prescribing for me?”

Why suggest clients do this? Because these questions, simple as they may be, often go unanswered due to the flurry of activity in physician offices. So clients have to empower themselves to maximize the benefits of office visits. And an empowered client is usually a compliant client.