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The Early Warning Signs of Mental Illness

December 19, 2012

Three Questions with Dr. Ray Kotwicki, Skyland Trail Chief Medical Officer

1. Why do we see mental illness emerge in young adults in their 20s?

We’re identifying mental illnesses a lot earlier than we used to. Traditionally, young adults in their late teens and early 20s were considered most at risk. Current research indicates that symptoms may be visible in children and adolescents as young as 9 or 10. Researchers have confirmed that the emergence of pre-symptomatic “prodrome” signs may start well before development of DSM criteria for mental illnesses. The good news is that the earlier risk for development of mental illnesses is identified, the more can be done to help.

However, those symptoms may be masked until young adults move out on their own, away from their parents and the support systems they relied on in middle and high school. They experience more stress in a world with more consequences and they can potentially crash and burn without support and prevention.

Psychiatric Treatment for Young Adults



2. What early warning signs should parents and teachers look for?

Many young people at risk for developing a mental illness later in life exhibit early warning signs.

For example, in a study led by Elaine Walker at Emory University, clinicians were able to identify children who later developed schizophrenia based on the behavior documented by home videos of childhood birthday parties.

The warning sign that stands out most in research is social problems. Social isolation is what we think of the most. Being a “loner.” For adolescents, being part of a social group – even if it’s just one or two friends – is the most important thing in their world. Young people who deliberately choose not to be a part of a social group or who are actively repulsed by them may need further assessment and attention.

Another important warning sign is thoughts or actions focused on violence. Expressing violent fantasies or engaging in acts of aggression toward animals may indicate a problem.

Finally, a significant change in mood or behavior should be considered. If, no matter what you do, you can’t get a kid out of bed to go to school in the morning, if he stops making good grades, or if she starts disappearing from school at lunch time – these types of changes should prompt follow-up and attention to make sure the kid is not in danger, and is receiving approprite follow up to ensure that the community supports him or her as development continues.

3. If you suspect a young person may be struggling with a mental illness, what should you do?

I think the biggest thing is to let someone know: a doctor, a guidance counselor, or someone who can do a more formal assessment. Parents need to be involved, but you need to have an assessment from someone outside of the family dynamic with a more unbiased perspective. An outside professional can look at the young person through the lens of what one would expect for kids of that age.

Parents, and even we as the larger “grown up” community, tend to write off warning signs as the “bad teen years.” That is dangerous. We need to be more aware of these warning signs and help connect young people and their families to the help they need to prevent the development of full blown mental illness.

And the data about treatment is compelling when you can identify individuals early. We’re not necessarily talking about treatment with medications. But extra support, training in coping skills and stress management, and help interacting with peers in more appropriate ways can be extremely beneficial.

Counseling about the use of drugs and alcohol is also important. Use of hallucinogens such as marijuana can make symptoms a lot worse. On the other hand, preventive strategies such as prevention of abuse and neglect, bolstering resiliency tactics, and even dietary supplements (omega-3 fatty acids) may be helpful.

There are many things we can do to help young people at risk of developing a mental illness avoid becoming fully symptomatic, prevent harm to themselves and others, and live full and productive lives.

Dr. Ray Kotwicki is the Chief Medical Officer for Skyland Trail. He completed his residency and postdoctoral fellowship at Emory University School of Medicine following postgraduate training at Harvard Medical School and Boston University School of Medicine. Dr. Kotwicki graduated from the University of Wisconsin Medical School after completing a combined baccalaureate – medical scholars program. Dr. Kotwicki serves as Associate Professor of Psychiatry and Behavioral Sciences at the Emory University School of Medicine as well as Assistant Professor of Health Policy and Management at the Rollins School of Public Health. He is co-director of the Emory University Fellowship in Community Psychiatry and Public Health, and leads medical student teaching as the Director of Medical Student Education in Emory University’s Department of Psychiatry. Dr. Kotwicki also is a member of Emory’s Department of Psychiatry and Behavioral Science’s Executive Committee. He has been named to the Board of Directors for the Georgia Psychiatric Physicians Association in 2010 and was awarded NAMI Georgia’s ‘Exemplary Psychiatrist’ Award in 2007. His special interests include the integration of physical and mental health care, anti-stigma initiatives, health policy, and matters of social justice. Dr. Kotwicki has been at Skyland Trail since January, 2007.

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