If you've seen the photos of crumbling Detroit buildings that are being circulated lately, you'd probably expect the whole city to be full of miserable, despairing people, a place where a suicide rate of zero is unthinkable. Think again! Detroit is struggling but not nearly as badly as those photos suggest, and this Crain's article on the Henry Ford Health System that serves southeast Michigan suggests that "perfect" depression care is entirely possible even in an area that's going through tough times:

"The bigger issue was this culture change that we eventually implemented which simply did not accept the notion that people would kill themselves, the idea that zero would be our goal," says Ed Coffey, a physician who is vice president at the Henry Ford system and CEO of its behavioral health services division. The division has a staff of about 500 and provides mental health and substance-abuse services through its integrated delivery system of two hospitals and 10 clinics that serves Southeast Michigan and adjacent states. "That to me was the biggest thing and the key lever that allowed us to accomplish the success we had," he said.

...The Perfect Depression Care initiative includes six major tactics: commit to "perfection" (zero suicides) as a goal; develop a clear vision of how each patient's care will change; listen to patients regarding their care redesign; conceptualize, design and test strategies for improving patient partnership, clinical practice, access to care and information systems; implement relevant measures of care quality, assess progress and adjust as needed; and communicate the results.

Within the first four years of the program, the annual rate of patient suicides in the behavioral health services department dropped 75 percent to about 22 per 100,000 -- the average rate between 2002 and 2005 -- from 89 suicides per 100,000 at the baseline in 2000, according to an April 2007 article in the Joint Commission Journal on Quality and Patient Safety. In the past two years, or the last 10 consecutive quarters, the department has not seen one patient suicide.

Clearly other mental health treatment professionals need to look into this system and consider ways to learn from its success.

As Christmas and New Year's draw closer, many of us are bracing for changes to our routines that could shake anyone's mental health. Travel and jetlag, a break from the rigid schedule of work or school, meals at unusual times, and the distractions of family can all contribute to forgetting to take medication. Many therapists and other mental health providers are out of reach while they enjoy their own celebrations (and hard-earned rest). Holiday stress may worsen mental health conditions, and while holiday joy is a wonderful thing, January can be a real let-down.

Here's how to get through these busy days and long winter nights:

• Make sure you take all your medication as prescribed.
• Be prepared for mental health emergencies and have a plan for how to handle them, especially while you're away from home or your regular treatment provider is on vacation. If you're your own primary caregiver, carry a paper copy of your emergency plan and share it with a family member or friend who will be spending time with you.
• Get your prescriptions refilled with plenty of time before you travel. You may need an extra note from your doctor if you're taking heavy-duty meds and want an early refill, so start the process now. If you think you might need to increase your dose or take extra meds to get through the holidays, now's a good time to consult with your doctor about that too.
• Use these smart tips for traveling with prescription medication. You don't want your life-saving pills lost, damaged, or confiscated!
• If travel, family, and parties are difficult or tiring--as even the most loving and wonderful family can be--get through them with some holiday stress-busting tips that will help keep you on an even keel. (Got your own tried-and-true techniques? Share them here.)

May your holidays be healthy and happy!

The American Psychiatric Association (not to be confused with the American Psychological Association) has released new treatment guidelines for depression. According to Medscape Today, the guidelines include:

• A clinician- and/or patient-administered rating scale for psychiatric symptoms to help with treatment strategies;
• A recommendation for the use of electroconvulsive therapy (ECT or "shock therapy") to treat depression if many other treatments have been tried unsuccessfully, along with monoamine oxidase inhibitors (MAOIs), transcranial magnetic stimulation, and vagus nerve stimulation as other potential options;
• Aerobic exercise or resistance training to improve mood symptoms, especially in older adults with other physical or mental illness; and
• Consideration of long-term maintenance treatment, especially for patients at risk for recurrence.

It's worth noting that Reuters reported that first suggestion as follows: "Doctors should use rating scales to assess their patients' conditions and tailor treatment according to the severity of symptoms. They can adjust various strategies such as medication, healthy behaviors, exercise and therapy." This implies that current treatment for depression takes a one-size-fits-all approach, which of course is not at all true. Doctors already tailor treatment to patients. The important part of this recommendation is the use of rating scales for various symptoms.

Going by the DSM-IV guidelines, if you meet more than a certain number of criteria you are diagnosed with depression. The new approach gets rid of the "has depression/doesn't have depression" binary and replaces it with scales that measure the severity of your symptoms. Some of the questions might look like this: How unhappy do you feel on an average day? How often do you have difficulty getting out of bed in the morning? How frequently do you think about suicide? Using rating scales like this, doctors can get a much better idea of what sort of treatment will be useful, and can also provide treatment to people who have a few signs of depression but would not be "diagnosable" under the old guidelines.

These guidelines hadn't been updated in over ten years, so I'm glad to see that the APA isn't waiting for the DSM-V to release this very important update that will hopefully improve diagnosis and treatment for many, many people who suffer from depression.

Toxoplasma gondii is a parasite that infects mice and makes them less afraid of cats. The fearless mice are more likely to be eaten by cats, and the parasite reproduces in the cats' digestive tract. Toxoplasma's ability to alter mouse behavior has led to a bit of evidence and a lot of theories about how human brains might be affected by the parasite. Since about a third of adult humans worldwide have toxoplasmosis, this is a pretty important question.

The most obvious starting point is behavior driven by fear or fearlessness. According to Stanford researcher Robert Sapolsky,  "Two different groups independently have reported that people who are Toxo-infected have three to four times the likelihood of being killed in car accidents involving reckless speeding." Patrick House of Slate observes that countries where rates of toxoplasmosis are higher have better soccer teams. Less obvious but perhaps more intriguing is a possible link between toxoplasmosis and schizophrenia. According to Physorg:

Evidence that T. gondii infections may be a cause of schizophrenia, while not yet conclusive, is growing, [Johns Hopkins researcher] Yolken said. A review of past studies, published last year by Yolken and Torrey, collected a variety of intriguing correlations. For example: People with schizophrenia have a higher prevalence of T. gondii antibodies in their blood. There are unusually low rates of schizophrenia and toxoplasmosis in countries where cats are rare, and unusually high rates in places where eating uncooked meat is customary. And some adults with toxoplasmosis show psychotic symptoms similar to schizophrenia.

Studies have linked a history of toxoplasmosis with increased rates of other mental changes, too, including bipolar disorders and depression. A 2002 study in the Czech Republic noted slowed reflexes in Toxoplasma-positive people and found links between the infection and increased rates of auto accidents.

A University of Maryland study last year found that people with mood disorders who attempt suicide had higher levels of T. gondii antibodies than those who don't try to take their own lives. Still, the links between schizophrenia and toxoplasmosis are not simple. For example, most people infected with T. gondii never become schizophrenic. And not all schizophrenics have been exposed to Toxoplasma.

Even seemingly clear-cut research results are open to interpretation: witness Sapolsky talking about recklessness while the Physorg article connects the auto accidents to slow reflexes. The practical question of whether the symptoms of schizophrenia can be effectively and efficiently reduced by treating toxoplasmosis--which is itself a difficult task due to T. gondii's talent for hiding and protecting itself--remains to be answered. Nonetheless, it's always interesting to see physical causes suggested for mental illness, even as we stay wary of anyone offering a simple cure.