Medical/mental help for a family member with mental health issues

[jeromedawg]

Hey all,

So my dad has been going through some major anxiety and depression lately (we think it might be generalized anxiety disorder but I'm sort of wondering if there's something bigger at play like an early onset of dementia or Alzheimer's). Usually his symptoms are worse early in the morning and then get somewhat better as the day progresses. Generally it's between 6-10pm or so where he's most lucid. In his 'altered' state he becomes fixated and worried about all sorts of things, making unsubstantiated claims about those things assuming and believing them to be truth. One example is that he believes that because he didn't do a good job with "paper trails" on his taxes properties, and also because his income is increasing, that he's going to get audited and that the govt is going to come in and take all his assets and properties away. It's pretty sensational and even though we calm him (we just had a meeting with his CPA where his CPA basically reassured him none of that was going to happen), he tends to gravitate back towards fixating on those things pretty much dismissing what anyone (including professionals) are telling him. A similar thing happened when he had their water heater replaced last week - the professional came over and my dad started touching some of the plumbing and the water heater guy told him not to and that it was a bad idea because he was touching the hot water line etc. He had to ask him several times not to and yet my dad still was hovering and fiddling. So his sense of rationalization seems to be impaired.

As far as his day-to-day operational/functional tasks, he's perfectly capable - I think he's be fine knowing how to get to places, the names of his kids and grandkids, and just in general having that knowledge of the 'present' but he just fixates on things and it sort of spirals out of control from there. Last night, he knocked on our bedroom door (they've been visiting and staying with us for several days) at midnight, waking us up, and expressed his concerns about his properties and taxes.
The other thing about all this is that if you tell him other people are in much worse positions, he disagrees and shakes his head, claiming this is the worst possible scenario he could have put us through (he claims it's not about him and that it's about his family but really it is about him and his legacy, which makes sense).

All that said, his PCP just prescribed him Lexapro recently but he only started on it last week. I understand it can take weeks to months to fully go into effect, so I guess we'll have to wait. Other than that, he was told just to do therapy/counseling, which we may pursue. However, there was no full psychiatric exam/assessment administered to him (their PCP does not specialize in that area) so we are seriously considering that for him. The problem is that he has to consent to it, which it seems he at least initially doesn't want to do (understandably, as there is a major stigma towards it particularly with older Asian males). Not sure if anyone has had to deal with anything like this but I'm wondering *how* it's possible to get that appt setup otherwise. Is it just a matter of convincing him to do it? Broaching the subject is pretty difficult with him. Even at that, he is hesitant to talk to anyone about his issues. I think there's an element of trust, which makes sense, but he also has to believe that he needs and wants help too right? Is there ever a state that he would get to though where he just can't make those decisions for himself and we are able to just make the decision for him? And what is entailed with either getting to that point or moving forward so we can get him the help he really needs?

[SimpleCycle]

Hey @jeromedawg, I'm sorry your father is going through this.  It does sound like some sort of mental health issue, but I also would want a more thorough assessment.  Paranoia that starts when someone is older is often linked to depression, so it seems like treating the depression and anxiety is a good idea.  But I agree that a psychiatric assessment is probably in order.

We are also dealing with some aging parent stuff, and I have found the website Better Health While Aging to be really helpful.  They actually have an article on this specific topic: https://betterhealthwhileaging.net/6-causes-paranoia-in-aging/

It can be very hard to convince a mentally competent adult that they need a mental health evaluation, and in all states you need that person's consent except under very specific circumstances.  Because you asked, there are circumstances where you can get someone evaluated involuntarily, but they tend to be pretty grave circumstances.  The standard in California is that the person is either a threat to themselves or or others or they are gravely disabled.  And this kind of involuntary evaluation always occurs in an inpatient psychiatric setting.  So yes, it could get to that point, but I really hope he is able to seek some help voluntarily.

Good luck, and I hope you are able to get him some help.

[andreamac]

My dad is having similar problems but was more paranoid about his health and dying. Having panic attacks in the middle of the night and going to emergency. He has ever test run in the book and was deemed very fit for his age. They eventually gave his anti anxiety meds and sleeping pills and seem to be helping. He is no longer leaving on his own though since he was not feeding himself well. Hopefully the meds work as well as they did with my dad. Overall he is doing much better!

[Villanelle]

I am somewhat surprised that his PCP prescribed mental health meds without an evaluation from a psychiatrist.  Lost opportunity.

I wonder if there is a way you could call his PCP and explain the situation.  While the docotr can't give you any medical details about your dad, you might see if he would be willing and able to tell your dad that he needs an appointment with a psychiatrist (or at least that the PCP srongly recommends such an appointment)  to evaluate the dosage of the Lexapro to see if it is working, or some similar situation.  I have no idea if they'd be willing to do that, but it's probably worth a try.  The other issued would be that your dad is likely not going to mention this stuff to the doctor if he does make the appointment, so trying to get him to let you join would be good.  I have a relative who is very, very clearly dealing with dementia or Alzheimers or something similar.  My sister (the niece) recently visited and the woman said it was nice to meet her, and made comments that seemed like she was trying to set my sister up with her married son (my sister's cousin).  IOW, she is very unwell.  But her husband is in strong denial and at a doctor's appointment, she presents just fine.  She can carry on a conversation and because she isn't aware of this strange interactions' strangeness, she reports everything as being fine.  Someone needs to go to the doctor with her and explain.  So you might face something similar to this even if you get your dad to make the appointment.

That's why it would be very good for you to try to get him to agree to let you attend an appointment with him, or give your doctor permission to discuss his medical situation with you.  Personally, I wouldn't be uncomfortable using some subterfuge for that given that it is for the greater good.  Telling him that if something happens to him you want to be able to get info from his doctor might get him to sign a HIPPA waiver. 

I'm sorry you and your family are walking this path.  Dealing with aging parents is so difficult and confusing.  Hopefully the Lexapro stabilizes things after a month or so. 

[Zamboni]

Oh, man, you so have my sympathy. My elderly Mom has started in the past year having similar doomsday scenarios. She expressed extreme and dare I say demanding levels of concern about earthquakes (she doesn't live in an area likely to get a major quake), wolves, etc. Worse, she is accusing people of doing things that are just 180 degrees from the truth.

In my opinion, it is a symptom of her generalized mental decline due to aging, but, like your dad, she is extremely resistant to getting help. She won't even go see a primary care doctor. She lives by herself, still drives, and we are very worried about her. My brother and I are at a loss. I wish I had more advice for you . . . following mostly to see what others suggest.

[lutorm]

I'm very sorry to hear about this. My grandmother, who passed away last year at age 96, started going down a similar path about a decade ago. She was always very suspicious about keeping track of finances, and her work was in bookkeeping. As she started losing it after grandpa died this turned into full-on paranoia, accusing her daughter of taking money from her bank accounts, my brother for paying bills for his "other home" (that doesn't exist) out of her account, etc. She kept digging through her belongings looking for various papers that she said proved that things were awry. It was extremely stressful for everyone around (including her) and it just went downhill from there.

[merince]

Apart from the Lexapro, has anyone reviewed the medications your dad is taking either at night or in the morning. The anxiety could be a side effect of something he's taking in the evening or could be relieved by something he is taking in the morning. If he is on any meds that he takes once a day, you might want to try splitting them up into 2 doses, one in the morning and one at night. Obviously talk to his doctor about this.

[jeromedawg]

Apart from the Lexapro, has anyone reviewed the medications your dad is taking either at night or in the morning. The anxiety could be a side effect of something he's taking in the evening or could be relieved by something he is taking in the morning. If he is on any meds that he takes once a day, you might want to try splitting them up into 2 doses, one in the morning and one at night. Obviously talk to his doctor about this.

I am somewhat surprised that his PCP prescribed mental health meds without an evaluation from a psychiatrist.  Lost opportunity.

I wonder if there is a way you could call his PCP and explain the situation.  While the docotr can't give you any medical details about your dad, you might see if he would be willing and able to tell your dad that he needs an appointment with a psychiatrist (or at least that the PCP srongly recommends such an appointment)  to evaluate the dosage of the Lexapro to see if it is working, or some similar situation.  I have no idea if they'd be willing to do that, but it's probably worth a try.  The other issued would be that your dad is likely not going to mention this stuff to the doctor if he does make the appointment, so trying to get him to let you join would be good.  I have a relative who is very, very clearly dealing with dementia or Alzheimers or something similar.  My sister (the niece) recently visited and the woman said it was nice to meet her, and made comments that seemed like she was trying to set my sister up with her married son (my sister's cousin).  IOW, she is very unwell.  But her husband is in strong denial and at a doctor's appointment, she presents just fine.  She can carry on a conversation and because she isn't aware of this strange interactions' strangeness, she reports everything as being fine.  Someone needs to go to the doctor with her and explain.  So you might face something similar to this even if you get your dad to make the appointment.

That's why it would be very good for you to try to get him to agree to let you attend an appointment with him, or give your doctor permission to discuss his medical situation with you.  Personally, I wouldn't be uncomfortable using some subterfuge for that given that it is for the greater good.  Telling him that if something happens to him you want to be able to get info from his doctor might get him to sign a HIPPA waiver. 

I'm sorry you and your family are walking this path.  Dealing with aging parents is so difficult and confusing.  Hopefully the Lexapro stabilizes things after a month or so. 

That's the thing - his PCP basically told them, when they asked about a psychiatrist, that he doesn't really prefer that other doctors get involved and that HE can prescribe meds. Basically, it sounds like the doc wants control playing it as "too many chefs in the kitchen." Anyway, since they're on a PPO plan, we went ahead and scheduled him to get a psychiatric evaluation in March (this is the next closest/available appt from the closest in-network group that doesn't have awful reviews). At first, as mentioned, my dad was resistant but ultimately he conceded with my mom's urges. Up until that point we just have to hope the meds start kicking in, and we will probably try to have him start talking to a therapist/counselor as well. Anyway, the psychiatric group is a medication mgmt only group, which is what we'd prefer - just have them do the proper evaluation/screening, review the Lexapro and dosage, and go from there. It could be that the PCP was correct the whole time, but I'd rather have the opinion of a psychiatrist who knows specializes in this area.
Yesterday was better as we scheduled a call with his CPA in the late AM and the CPA was *very* good about calming any of his concerns - he basically just reassured my dad that everything is fine and the CPA is handling all the nitty gritty stuff that my dad should have zero concern over. So that was good but of course I could tell my dad was looking for other things to start fixating on.

RE my dad 'presenting' himself as normal, which I'm pretty sure he does when he wants, will that really be a concern to consider for the psychiatric exam? I figure the psychiatrists are trained to ask questions that are intended to really weed out what's going on despite whether my dad is putting up a front or not, no?

[SunnyDays]

Retired psychologist here.  What you describe is definitely anxiety and also obsessive thoughts, both of which the Lexapro will address.  It does take 2-4 weeks for it to take effect, assuming it does, because not everyone responds to every medication, and some trials of other meds may be needed, so don't be discouraged if that happens.

Along with anxiety comes depression, and your mention of symptoms being worse in the morning with improvement throughout the day is typical of depression.  However, as someone suggested, do look at any other meds he may be taking, especially statins for cholesterol, which are known for causing psychiatric issues in some people, sometimes outright psychosis.

While you're waiting for the meds to kick in, make sure his basic diet is good - no/low caffeine, good protein and vegetables - and as much exercise as he can handle.  Also, anything he finds relaxing may help, like music, warm baths, massages,etc.

Anxiety and depression are very common, so I wouldn't worry unduly about dementia if he seems okay otherwise.  But I'd be curious about whether his doctor did a thorough physical before prescribing psychoactive meds?  Liver issues can present with initial psychiatric symptoms, and a good work-up should always be the first course of action in situations like this.

Hopefully there's nothing else going on and the Lexapro is effective.  Best of luck.

[hops]

That's the thing - his PCP basically told them, when they asked about a psychiatrist, that he doesn't really prefer that other doctors get involved and that HE can prescribe meds.

We're friends with a few psychiatrists who say that much of their work, especially with patients who are very young or elderly, consists of revising the diagnoses made by -- and meds prescribed by -- PCPs, pediatricians and NPs. The situation with your dad could indeed be something the PCP can ultimately handle solo, but arranging a more thorough exam is prudent given the concerns you outline.

[jeromedawg]

Retired psychologist here.  What you describe is definitely anxiety and also obsessive thoughts, both of which the Lexapro will address.  It does take 2-4 weeks for it to take effect, assuming it does, because not everyone responds to every medication, and some trials of other meds may be needed, so don't be discouraged if that happens.

Along with anxiety comes depression, and your mention of symptoms being worse in the morning with improvement throughout the day is typical of depression.  However, as someone suggested, do look at any other meds he may be taking, especially statins for cholesterol, which are known for causing psychiatric issues in some people, sometimes outright psychosis.

While you're waiting for the meds to kick in, make sure his basic diet is good - no/low caffeine, good protein and vegetables - and as much exercise as he can handle.  Also, anything he finds relaxing may help, like music, warm baths, massages,etc.

Anxiety and depression are very common, so I wouldn't worry unduly about dementia if he seems okay otherwise.  But I'd be curious about whether his doctor did a thorough physical before prescribing psychoactive meds?  Liver issues can present with initial psychiatric symptoms, and a good work-up should always be the first course of action in situations like this.

Hopefully there's nothing else going on and the Lexapro is effective.  Best of luck.

Thanks, so regarding his diet he actually is very cautious (I'd say overly cautious to the point of obsessing over it as well) over what he eats. Due to the recent scare with Diabetes Type 2 and Kidney Disease he's, I believe, overcompensating and going crazy on restricting himself as to what he can eat - no salt on anything and nutrition fact counting EVERYTHING that he consumes. The bad part is that he doesn't quantitatively measure out what his calorie intake is and guesses. He has lost 15+ lbs in the past two months and will also get fixated on that. They are planning to see a nutritionist to help in this area though.

Good point on the other meds - he is definitely taking multiple meds for his blood pressure, heart, and cholesterol (he had bypass surgery 9 years ago). I'm assuming his PCP reviewed all that but hopefully the psychiatrist will have more insight. The other thing about the psychiatric appt is that we 'tentatively' scheduled it and my mom was telling him that she can cancel it if he improves (which makes sense). Ultimately, we still may just want to follow-through with it for good measure though.

When you say "thorough physical" what does that entail? He's gone in for a number of appts (because he's so paranoid) to see multiple doctors outside of the initial visits where he disclosed Diabetes, Kidney Disease and Aortic Aneurysm. For every little thing that pops up (moles on his body, spots on his hands, sores in his throat, pain in his rear, etc) he thinks something is majorly wrong with him and needs to see the doc. He's basically fixating on the thought of death, thinking he has a terminal disease that the docs haven't found yet.
If you calm one anxiety, the anxiety just moves to another area where he will spin.

[Sibley]

Re: calming one anxiety and another pops up...

That's how anxiety works. It's not actually rational. If it were, it wouldn't cause problems. When you calm an anxiety, you're not addressing the actual root cause, you're just giving the anxiety what it wants and it'll move on to the next thing. Ultimately, this can make it harder to treat anxiety because there's such a pattern of appeasement.

Medication can be helpful, and for some people it's enough. But I've been told that often to really get a handle on the anxiety, you need to address the mental patterns through therapy. So do consider that angle.

[merince]

RE: the multiple medications for blood pressure, heart, and cholesterol. Those do tend to add up as in "your numbers don't look good, so we'll put you on that". In dealings with other elderly relatives, I've had to review the mix, and usually, the anxiety/mood changes correlate with the addition of new dosages of those. Since your father has recent weight loss, he is due a review of the dosages and new bloodwork. With the change in diet, his cholesterol meds might be bringing his cholesterol numbers too low.

You also mention diabetes 2. He might have medication to control blood sugar. If he is on a restrictive diet, the medication might be getting his blood sugar numbers too low. Please, discuss all of those concerns with his doctor and take it from there.

[frugaldrummer]

There are physiological problems that can result in paranoia - the most common one in the elderly is B12 deficiency. He should have his blood level testing - FASTING, without taking any vitamins with B12 in them for 24-48 hours before testing. The lab ranges are too broad - 200 - 900 - but anything under 400 is highly suspect and should be treated. Elderly people have more B12 deficiency because they stop making stomach acid (which is required for B12 absorption) or are on stomach acid blockers like Prilosec. 

Also, it's unusual that his confusion and paranoia are worst in the morning and he clears in the evening - usually it is the other way around with elderly people. This might be a medication effect if he is on drugs that could be affecting his thinking - I'd carefully review his meds and their timing.  Does he take sleeping pills at night that might not be wearing off soon enough? Does he take something first thing in the morning that might be affecting him? Does he have sleep apnea and is not getting good quality sleep?

Blood sugar is also lowest in the AM so if he doesn't eat much in the morning or doesn't eat breakfast until late this could be the cause.  Also if he is on metformin for diabetes it can lower B12 levels.

Early stages of dementia like Alzheimers or Frontotemporal dementia can result in paranoia like this. He should see a neurologist and have a full evaluation.

Incidentally he might be worse while he's at your house - some dementia patients function ok in their familiar environment but their dementia is unmasked when they are in a foreign environment like someone else's home or a nursing home.

Also I would see if you can gain control of his finances - in this state of mind he's likely to do something catastrophic with their finances.

[jeromedawg]

There are physiological problems that can result in paranoia - the most common one in the elderly is B12 deficiency. He should have his blood level testing - FASTING, without taking any vitamins with B12 in them for 24-48 hours before testing. The lab ranges are too broad - 200 - 900 - but anything under 400 is highly suspect and should be treated. Elderly people have more B12 deficiency because they stop making stomach acid (which is required for B12 absorption) or are on stomach acid blockers like Prilosec. 

Also, it's unusual that his confusion and paranoia are worst in the morning and he clears in the evening - usually it is the other way around with elderly people. This might be a medication effect if he is on drugs that could be affecting his thinking - I'd carefully review his meds and their timing.  Does he take sleeping pills at night that might not be wearing off soon enough? Does he take something first thing in the morning that might be affecting him? Does he have sleep apnea and is not getting good quality sleep?

Blood sugar is also lowest in the AM so if he doesn't eat much in the morning or doesn't eat breakfast until late this could be the cause.  Also if he is on metformin for diabetes it can lower B12 levels.

Early stages of dementia like Alzheimers or Frontotemporal dementia can result in paranoia like this. He should see a neurologist and have a full evaluation.

Incidentally he might be worse while he's at your house - some dementia patients function ok in their familiar environment but their dementia is unmasked when they are in a foreign environment like someone else's home or a nursing home.

Also I would see if you can gain control of his finances - in this state of mind he's likely to do something catastrophic with their finances.

RE: the multiple medications for blood pressure, heart, and cholesterol. Those do tend to add up as in "your numbers don't look good, so we'll put you on that". In dealings with other elderly relatives, I've had to review the mix, and usually, the anxiety/mood changes correlate with the addition of new dosages of those. Since your father has recent weight loss, he is due a review of the dosages and new bloodwork. With the change in diet, his cholesterol meds might be bringing his cholesterol numbers too low.

You also mention diabetes 2. He might have medication to control blood sugar. If he is on a restrictive diet, the medication might be getting his blood sugar numbers too low. Please, discuss all of those concerns with his doctor and take it from there.

I did ask about B12 before but my mom never responded. Not sure if this is something any of the doctors checked but I just asked my mom again so will find out soon.

He has been taking Lexapro and melatonin at nights. As far as his other heart/bp/cholesterol/etc meds I have no idea when he's taking those. Their PCP basically told them to try Lexapro first in the AM to see if he gets sleepy vs wired. My mom just ended up giving it to him at night and it *seemed* to have helped. I'll ask her again to see if she's tried giving it to him in the AM instead. But other than that, no sleeping pills or anything. I know he snores but not sure if it's actually sleep apnea, at least I've not heard of him having issues there.

I haven't really kept track of his blood sugar but IIRC there were concerns previously that it was too high even in the AM after waking up, and they think it had to do with him eating white rice the night before or something.

Would a neurologist be better vs psychiatrist as far as a full evaluation is concerned?

As far as finances, my brothers and I have stepped in with that and have been communicating with his CPA and CFA to try to straighten things out. Right now, he's mostly just paralyzed by his fear of things so in that sense it's good he's not trying to "fix" things - his CPA reassured him that his taxes are CLEAN and he has nothing to worry about (as far as getting audited by the IRS, etc, which is one of the major themes that kept coming up over the wknd). His accounts are kind of a mess as far as the number of them he has open but it's nothing unmanageable either - he could use some optimization but it's nothing outrageously out of control. A lot of his concerns over these things are at a base good problems, not bad ones (of course, he will convince himself that they are bad problems and worse than anyone else's problems).

[Krolik]

I am very sorry you are going through this with your father.

My mother in law suffered from schizophrenia and unfortunately many of the symptoms you are describing she also experienced. Although she was in treatment for years there were times when the disease got out of control. She truly believed that other people (including her closest ones) or government institutions were out there to get her and some other crazy things. But in her world it was very real. From what I know the first glimpses of some bizarre behavior started when she was relatively young. She suffered from the disease  + other related conditions (like depression, anxiety) for over 25 years.

[former player]

Has your father recently retired?  If he has lost his long-time daily occupation I'm not particularly surprised that his thoughts might be finding rabbit-holes to go down.

It is never a bad idea if someone is not doing well mentally to have them thoroughly checked out physically.  In your father's case it sounds like medication and diet reviews would be a good idea, and if you could get him on to some form of regular daily exercise that would be great.

[hops]

Would a neurologist be better vs psychiatrist as far as a full evaluation is concerned?

It depends on what you're concerned about. If it's dementia, either is likely to outsource some diagnostic work to a PhD who administers neuropsychological testing.

In the absence of a PCP pointing you in the right direction, the psychiatrist he's seeing next month should be able to tell you what to do next. It might be that a med-management only psychiatrist isn't the best fit for him and they refer him to a neurologist or geriatric psychiatrist instead. Or maybe the psychiatrist surveys his meds, labs, and recent life changes, finds an easy fix, and he's sent back to the PCP.

Just don't put a bunch of undue stress on yourself in the meantime, let the experts have a go at it first.

[SunnyDays]

I just meant a complete physical with standard blood tests and any other particular ones his health history might indicate.
Schizophrenia would not be a concern of mine, as he’s much too old for initial onset.  I would focus right now on getting symptoms under control and looking into possible physical causes.  In the absence of contributing health issues, then meds and/or therapy, particularly CBT.

[Cassie]

People with dementia are better in the morning and worse as the day progresses. I would definitely see a specialist too see if all the prescriptions he is on are causing these issues. As you age you are more sensitive to medications.

[MishMash]

Has he been checked for nutritional deficiency as well?  He sounds A LOT like my FIL, he was like that even on anti depressants.  We came to find out his extremely poor diet was resulting in all sorts of issues, to include brain impairment.  He's been on B12 supplements and we forced him into a group home to ensure he was eating (he lived with us for a year, it almost killed our marriage because he is a horrible human being).  These changes seem to significantly be helping his mental state.

[kite]

Has he been checked for nutritional deficiency as well?  He sounds A LOT like my FIL, he was like that even on anti depressants.  We came to find out his extremely poor diet was resulting in all sorts of issues, to include brain impairment.  He's been on B12 supplements and we forced him into a group home to ensure he was eating (he lived with us for a year, it almost killed our marriage because he is a horrible human being).  These changes seem to significantly be helping his mental state.

Nutrition is huge.  Deficiencies are common in aging populations.  And people with depression or other mental illnesses can neglect their physical health   

[jeromedawg]

Has he been checked for nutritional deficiency as well?  He sounds A LOT like my FIL, he was like that even on anti depressants.  We came to find out his extremely poor diet was resulting in all sorts of issues, to include brain impairment.  He's been on B12 supplements and we forced him into a group home to ensure he was eating (he lived with us for a year, it almost killed our marriage because he is a horrible human being).  These changes seem to significantly be helping his mental state.

Nutrition is huge.  Deficiencies are common in aging populations.  And people with depression or other mental illnesses can neglect their physical health   

Has he been checked for nutritional deficiency as well?  He sounds A LOT like my FIL, he was like that even on anti depressants.  We came to find out his extremely poor diet was resulting in all sorts of issues, to include brain impairment.  He's been on B12 supplements and we forced him into a group home to ensure he was eating (he lived with us for a year, it almost killed our marriage because he is a horrible human being).  These changes seem to significantly be helping his mental state.

He was never that great with his diet leading up to this so that's a big part. Now that he has lost 15+ pounds, he just seems less motivated to eat. Part of it is that his stomach has shrunk and he's not *as* hungry in which case the dietitian told him to eat more meals. The other part of it is he is probably angry that he can't eat the foods he used to eat. And the final part of it is that he is lazy and complacent about doing any ACTIONABLE work - it seems he and my mom know what he can and cannot eat but they are not wanting to meal plan or really get down to calorie counting and measuring out proper portions, etc (regardless of what the doctors and nutritionists are telling him). Basically just says "no" to most things you pitch him that would help with the weight gain. Extremely negative outlook at the moment, and he tries to convince himself that nothing will work. So he's paranoid about what people tell him, will complain that he's worried about himself, and yet will do nothing to try to improve or help the situation and ends up just deferring it. Lately he's been using the term "I'll try my best" with *anything* - even things that are simple and can be done without most people having to say "I'll try." But what has been magnified in this case is his procrastination and the amount of deferring he does - he was like this before too; it's just that now even he realizes he does it, feels bad about it (and that he's burdening other people with it), yet he won't do anything to help it (even if other people offer to help him). What it boils down to is he essentially needs someone to *force* him to do the things he's not wanting to do in order to get things taken care of. Right now, that's my mom but she's getting burnt out and it's driving her insane. Some have told us that he's just "grieving" right now and needs time to accept the situation he's in... could that be what's going on? Or is that not at all relevant?

[SunnyDays]

I'm trying to figure out the relationship of his weight loss to his current symptoms, if there is one.  When was he diagnosed with diabetes and kidney disease relative to his psychiatric symptoms and weight loss?  Perhaps there is a causal relationship beyond just reducing calories?

If he made a conscious effort to restrict his diet and at the same time became anxious/depressed over health issues,this may have increased his weight loss, as both anxiety and depression can lead to loss of appetite.  And depression certainly causes loss of motivation, as everything just feels like a monumental effort, so he may not be able to take control of this situation himself.  He could be saying "I'll try my best" because he just wants everyone to get off his back.  Probably the best approach is just to provide him with whatever assistance he needs, like giving him suitable meals, without requiring effort from him and staying low-key yourself.  If he doesn't have a history of being a difficult person, it's likely that for whatever reason, he just can't help himself right now.  Ultimately, you can't make him eat and you don't want to start a power struggle over this.  If there is no health concern over his current weight, then why make an issue of it?

[lhamo]

My mom lost a lot of weight in the last couple of years of her life, largely because she lost her sense of taste.  Supplementing what she could force herself to eat with a couple of bottles of high protein Ensure every day helped slow the weight loss, but didnt stop it.  Just one of those things that happens to a lot of older people, unfortunately.

[frugaldrummer]

He needs to see a neurologist who can evaluate him for dementia. Make sure he gets a B12 level checked (probably hasn’t been done, not routine). Should be done fasting and without taking any vitamins with B12 in them 24-48 hours prior. The lab range is too broad - it may say 200-900 but anything under 400 is highly suspect.

[jeromedawg]

He needs to see a neurologist who can evaluate him for dementia. Make sure he gets a B12 level checked (probably hasn’t been done, not routine). Should be done fasting and without taking any vitamins with B12 in them 24-48 hours prior. The lab range is too broad - it may say 200-900 but anything under 400 is highly suspect.

So I looked up the diffs between neurologists and psychiatrists. Neurologists appear to deal with the brain in the context on involuntary actions (like seizures, paralysis, etc) where as psychiatrists deal with the brain in the context of voluntary actions (social withdrawal, losing weight, etc) - https://www.dementia.org/diagnosing-dementia-psychiatrist-or-neurologist

In this case, it sounds like he should see the psychiatrist at the very least (which we have him scheduled for in March). As far as B12 and other stuff, I don't know that any of that was done. I've suggested it but I think my mom is overwhelmed at the moment and can't even pay attention to the micro details about anything else.

[MishMash]

Has he been checked for nutritional deficiency as well?  He sounds A LOT like my FIL, he was like that even on anti depressants.  We came to find out his extremely poor diet was resulting in all sorts of issues, to include brain impairment.  He's been on B12 supplements and we forced him into a group home to ensure he was eating (he lived with us for a year, it almost killed our marriage because he is a horrible human being).  These changes seem to significantly be helping his mental state.

Nutrition is huge.  Deficiencies are common in aging populations.  And people with depression or other mental illnesses can neglect their physical health   

Has he been checked for nutritional deficiency as well?  He sounds A LOT like my FIL, he was like that even on anti depressants.  We came to find out his extremely poor diet was resulting in all sorts of issues, to include brain impairment.  He's been on B12 supplements and we forced him into a group home to ensure he was eating (he lived with us for a year, it almost killed our marriage because he is a horrible human being).  These changes seem to significantly be helping his mental state.

He was never that great with his diet leading up to this so that's a big part. Now that he has lost 15+ pounds, he just seems less motivated to eat. Part of it is that his stomach has shrunk and he's not *as* hungry in which case the dietitian told him to eat more meals. The other part of it is he is probably angry that he can't eat the foods he used to eat. And the final part of it is that he is lazy and complacent about doing any ACTIONABLE work - it seems he and my mom know what he can and cannot eat but they are not wanting to meal plan or really get down to calorie counting and measuring out proper portions, etc (regardless of what the doctors and nutritionists are telling him). Basically just says "no" to most things you pitch him that would help with the weight gain. Extremely negative outlook at the moment, and he tries to convince himself that nothing will work. So he's paranoid about what people tell him, will complain that he's worried about himself, and yet will do nothing to try to improve or help the situation and ends up just deferring it. Lately he's been using the term "I'll try my best" with *anything* - even things that are simple and can be done without most people having to say "I'll try." But what has been magnified in this case is his procrastination and the amount of deferring he does - he was like this before too; it's just that now even he realizes he does it, feels bad about it (and that he's burdening other people with it), yet he won't do anything to help it (even if other people offer to help him). What it boils down to is he essentially needs someone to *force* him to do the things he's not wanting to do in order to get things taken care of. Right now, that's my mom but she's getting burnt out and it's driving her insane. Some have told us that he's just "grieving" right now and needs time to accept the situation he's in... could that be what's going on? Or is that not at all relevant?

That's pretty much the same cycle my FIL followed, being to lazy to eat, deflecting, not wanting to take accountability, realizing it's a detriment to his health (after an ER trip for passing out from dehydration, and another one for malnutrition) he tried to placate everyone with what they wanted to hear and never did anything about.  I was your mom in this situation, forcing him to eat, forcing him to drink, and I met the same resistance she is (he even called me a cunt).  We heard the grieving thing too since his wife divorced him 5 years earlier.  It wasn't grieving at that stage it was laziness and confusion. 

[LaineyAZ]

One other thought:  I've read that urinary tract infections can have a connection with confusion/dementia.  As part of this next checkup I wonder if they can check for that?

[wenchsenior]

One other thought:  I've read that urinary tract infections can have a connection with confusion/dementia.  As part of this next checkup I wonder if they can check for that?

Yes, they definitely can.  My grandmother suffered from this.

[iris lily]

Urinary track problem causing confusion  is very common in senior citizens.

[jeromedawg]

Has he been checked for nutritional deficiency as well?  He sounds A LOT like my FIL, he was like that even on anti depressants.  We came to find out his extremely poor diet was resulting in all sorts of issues, to include brain impairment.  He's been on B12 supplements and we forced him into a group home to ensure he was eating (he lived with us for a year, it almost killed our marriage because he is a horrible human being).  These changes seem to significantly be helping his mental state.

Nutrition is huge.  Deficiencies are common in aging populations.  And people with depression or other mental illnesses can neglect their physical health   

Has he been checked for nutritional deficiency as well?  He sounds A LOT like my FIL, he was like that even on anti depressants.  We came to find out his extremely poor diet was resulting in all sorts of issues, to include brain impairment.  He's been on B12 supplements and we forced him into a group home to ensure he was eating (he lived with us for a year, it almost killed our marriage because he is a horrible human being).  These changes seem to significantly be helping his mental state.

He was never that great with his diet leading up to this so that's a big part. Now that he has lost 15+ pounds, he just seems less motivated to eat. Part of it is that his stomach has shrunk and he's not *as* hungry in which case the dietitian told him to eat more meals. The other part of it is he is probably angry that he can't eat the foods he used to eat. And the final part of it is that he is lazy and complacent about doing any ACTIONABLE work - it seems he and my mom know what he can and cannot eat but they are not wanting to meal plan or really get down to calorie counting and measuring out proper portions, etc (regardless of what the doctors and nutritionists are telling him). Basically just says "no" to most things you pitch him that would help with the weight gain. Extremely negative outlook at the moment, and he tries to convince himself that nothing will work. So he's paranoid about what people tell him, will complain that he's worried about himself, and yet will do nothing to try to improve or help the situation and ends up just deferring it. Lately he's been using the term "I'll try my best" with *anything* - even things that are simple and can be done without most people having to say "I'll try." But what has been magnified in this case is his procrastination and the amount of deferring he does - he was like this before too; it's just that now even he realizes he does it, feels bad about it (and that he's burdening other people with it), yet he won't do anything to help it (even if other people offer to help him). What it boils down to is he essentially needs someone to *force* him to do the things he's not wanting to do in order to get things taken care of. Right now, that's my mom but she's getting burnt out and it's driving her insane. Some have told us that he's just "grieving" right now and needs time to accept the situation he's in... could that be what's going on? Or is that not at all relevant?

That's pretty much the same cycle my FIL followed, being to lazy to eat, deflecting, not wanting to take accountability, realizing it's a detriment to his health (after an ER trip for passing out from dehydration, and another one for malnutrition) he tried to placate everyone with what they wanted to hear and never did anything about.  I was your mom in this situation, forcing him to eat, forcing him to drink, and I met the same resistance she is (he even called me a cunt).  We heard the grieving thing too since his wife divorced him 5 years earlier.  It wasn't grieving at that stage it was laziness and confusion.

Pretty awful - not sure what we're going to do with him if it gets worse.

BTW: we are looking at a psychologist who is out of network where they live but he told me he prorates his rates to come down to the 'estimated' Medicare reimbursement amounts. This *should* mean that all they will pay is a $10 copay plus the difference between the Medicare reimbursed amount and his rates, which hopefully would be $0 or close to it.
Anyone know how it works in terms of Medicare and reimbursement limits or max # of therapy sessions? I found this old article that touches upon it but it's pretty dated (from 2009!)
https://www.aarp.org/health/medicare-insurance/info-02-2009/ask_ms__medicare_17.html

[SimpleCycle]

@jeromedawg, do you know if your dad has Traditional Medicare or Medicare Advantage?  They cover outpatient mental health differently.  Based on you using the term "out of network" I suspect he has Medicare Advantage, and the rules governing fees for out-of-network providers are complicated.  I would call his health insurer.

[MishMash]

But for sure, get the nutritional aspect checked out.  When he's on his anti depressants and B12 he does good, sounds upbeat, showers on his own, has a more positive life outlook, doesn't dwell on things he did wrong 35 years ago.  He's too lazy to take them consistently though so he's a rollercoaster

[jeromedawg]

@jeromedawg, do you know if your dad has Traditional Medicare or Medicare Advantage?  They cover outpatient mental health differently.  Based on you using the term "out of network" I suspect he has Medicare Advantage, and the rules governing fees for out-of-network providers are complicated.  I would call his health insurer.

I think he's Medicare Advantage because they're on a plan through United Healthcare - https://www.uhcretiree.com/calpers/home.html

When I called UHC they referred me to this site for estimate costs for out of network providers based on CPT/HCPCS codes that the provider is supposed to notate in the superbill: https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

The way it works, from what I was told, is that you pay the out of network provider directly and they give you the superbill/invoice which you then submit with the Medicare claim. It sounds like the Medicare claim, in this case, is submitted through United Healthcare and once approved and processed they send you a check back for the reimbursement minus the copay. I guess the out of network "copay" is there to cover the work UHC has to do in submitting the Medicare claim on your behalf? That part seems weird to me but it is what it is I guess...

But for sure, get the nutritional aspect checked out.  When he's on his anti depressants and B12 he does good, sounds upbeat, showers on his own, has a more positive life outlook, doesn't dwell on things he did wrong 35 years ago.  He's too lazy to take them consistently though so he's a rollercoaster

Not sure if the psychiatrist or psychologist will bring that up. It has already been touched upon with his PCP in addition to a couple of nutritionists - it sounds like they know what he should or shouldn't eat but the part that's lacking is him actually following through (and my mom keeping him accountable to it). I asked my mom about the B12 but she never got back to me about it. When I asked about the meds dosages he's taking in relationship to his weight loss, she sort of freaked out and got stressed that I was asking her, so she's just been frazzled right now. She's basically having to micromanage aspects of his life when she hates micromanagement, so I think it's taking a toll on her.

[Another Reader]

If he is on a Medicare Advantage plan, he is no longer on Medicare.  The insurance company is his only insurer.  Medicare pays a set amount to the insurance company for each individual the insurance company insures.  There is no further responsibility from Medicare.

[jeromedawg]

If he is on a Medicare Advantage plan, he is no longer on Medicare.  The insurance company is his only insurer.  Medicare pays a set amount to the insurance company for each individual the insurance company insures.  There is no further responsibility from Medicare.

I confirmed that he is on Medicare Advantage. Looks like for out-of-network providers you have to submit a reimbursement claim form through UHC to get money back. They could not give me the actual amount of reimbursement however, as I'm assuming this varies based on locality and CPT/HCPCS code...

Does anyone know what each of these fields *mean* ? This is from the cms.gov site

MAC LOCALITY
NON-FACILITY PRICE
FACILITY PRICE
NON-FACILITY LIMITING CHARGE
FACILITY LIMITING CHARGE

[SimpleCycle]

If he is on a Medicare Advantage plan, he is no longer on Medicare.  The insurance company is his only insurer.  Medicare pays a set amount to the insurance company for each individual the insurance company insures.  There is no further responsibility from Medicare.

I confirmed that he is on Medicare Advantage. Looks like for out-of-network providers you have to submit a reimbursement claim form through UHC to get money back. They could not give me the actual amount of reimbursement however, as I'm assuming this varies based on locality and CPT/HCPCS code...

Does anyone know what each of these fields *mean* ? This is from the cms.gov site

MAC LOCALITY
NON-FACILITY PRICE
FACILITY PRICE
NON-FACILITY LIMITING CHARGE
FACILITY LIMITING CHARGE

So I suspect you have the broad strokes of how this works correct, but you should verify your out of network benefits with United Healthcare directly.

MAC Locality is the locality of the Medicare Administrative Contractor.  The MAC is the TPA for traditional Medicare.
Non-facility price is the reimbursement for care provided outside a hospital facility.  This includes most freestanding doctors offices.
Facility price is the reimbursement for care provided in an outpatient hospital setting.
Non-facility limiting charge is the most a non-participating provider can charge.
Facility limiting charge is the same, but for an outpatient hospital setting.

Assuming the therapist will bill 90837, Medicare will pay right around $150 in LA County.  I believe Medicare Advantage must pay at least this much for out of network services, but again, confirm with United.

Good luck - understanding Medicare is confusing, but it's wonderful you are helping your parents with this.

[jeromedawg]

If he is on a Medicare Advantage plan, he is no longer on Medicare.  The insurance company is his only insurer.  Medicare pays a set amount to the insurance company for each individual the insurance company insures.  There is no further responsibility from Medicare.

I confirmed that he is on Medicare Advantage. Looks like for out-of-network providers you have to submit a reimbursement claim form through UHC to get money back. They could not give me the actual amount of reimbursement however, as I'm assuming this varies based on locality and CPT/HCPCS code...

Does anyone know what each of these fields *mean* ? This is from the cms.gov site

MAC LOCALITY
NON-FACILITY PRICE
FACILITY PRICE
NON-FACILITY LIMITING CHARGE
FACILITY LIMITING CHARGE

So I suspect you have the broad strokes of how this works correct, but you should verify your out of network benefits with United Healthcare directly.

MAC Locality is the locality of the Medicare Administrative Contractor.  The MAC is the TPA for traditional Medicare.
Non-facility price is the reimbursement for care provided outside a hospital facility.  This includes most freestanding doctors offices.
Facility price is the reimbursement for care provided in an outpatient hospital setting.
Non-facility limiting charge is the most a non-participating provider can charge.
Facility limiting charge is the same, but for an outpatient hospital setting.

Assuming the therapist will bill 90837, Medicare will pay right around $150 in LA County.  I believe Medicare Advantage must pay at least this much for out of network services, but again, confirm with United.

Good luck - understanding Medicare is confusing, but it's wonderful you are helping your parents with this.

Thanks! I just called UHC to confirm again - they have a reimbursement claim form PDF that you can print out and it looks like there's also an online form. They basically reimburse you the Medicare-allowed amount minus the copay.

So I found that for where the psychologist is located it is MAC Locality *should* be 0111207. He is not part of a hospital so would be Non-Facility.
Under this MAC Locality and for 90837, which is one of the codes he may in fact use, the rates are:
NON-FACILITY PRICE    $157.04
NON-FACILITY LIMITING CHARGE $171.56

A couple weeks ago when I spoke with the psychologist, he gave me a list of CPT codes and the pro-rated charges he would use.
90791 - $150
90837 - $130
90834 - $119 **NF Price is $104.80 and NF Limiting Charge is $114.49
90832 - $100 **NF Price is $78.84 and NF Limiting Charge is $86.13

After cross-checking against the CMS.gov site for all those CPT codes, I found that 90791 and 90837 will be fully reimbursed minus copay.
However, it doesn't seem that way for 90834 or 90832 and it also looks like this psychologist is setting his pricing to be higher than the non-facility limiting charge - are providers allowed to do this or are they not supposed to and can be held 'accountable' if they don't conform to the Limiting Charges?

EDIT: I tried contacting UHC again to ask them to explain to me what the "Limiting Charge" is and the person didn't really know how to explain. I also asked in a different way: "Is there some sort of maximum allowable amount a provider is allowed to charge" and the response was that the provider can charge whatever they want to but the reimbursement will be whatever the maximum allowable reimbursement is from Medicare. So I guess what I'm confused about at this point is what role that NF Limiting Charge actually plays in all of this.

[jeromedawg]

Update:

Wow, I can't believe it's already past the 'half-year' mark since posting this originally. From a distance and being further away from everything, objectively it feels like not much has really changed or improved. My mom has been breaking down and crying nearly as much as she did before, and I get almost daily calls from my brother who lives behind them with rants about the next thing my dad has latched onto.

He has been on Lexapro and over the past several months has had his dosage increased from 10mg to 20mg. Yes, the symptoms are subdued where he may seem a bit calmer and restrained (demeanor wise) but he still has very little self-control in terms of expressing his anxiety and controlling his thoughts. Symptoms are no different from before in that he is worse in the morning and 'better' towards the mid-late afternoon and evening.

My mom finally conceded to having him see the psychiatrist about a month ago - the psychiatrist sounded hopeful in that he just needs to maybe increase his dosage and he'll turn a corner in June/July? He diagnosed him with moderate anxiety and depression. So far, no corner has been turned from what I can tell. I have a friend who went through depression and told me he had to 'experiment' through a round of different anti-depression drugs before he found a combination that worked for him, so he was warning of a long path ahead.

Just this AM, my brother texted my other brother and I, saying we're going to have to consider a "living rotation" with my parents or hiring care for my dad. Apparently my mom called him and broke down (this has happened more than once btw). My dad had woken up at midnight, complaining about hearing scratching sounds outside then started spiraling into how they have to worry about selling a rental property they own and how, because of the "poor condition" it's in, it'll make my mom look bad because she's a "public servant" who works at the school district. Whaaaaaat??? But yep, this is just an example of the things my mom and brother are currently putting up with. My mom remains hopeful but it's hard to see any progress. My brother is getting more and more stressed out dealing with him and then dealing with being the point person for selling their rental property so it's taking a toll.

Oh, the other thing that I think is really messing him up still is his diet - in fact, they just saw the endocrinologist (I think) and he was told that it's OK for him to have cheat days to eat steak, pizza, whatever he wants, etc and that he *needs* to so he can gain some weight back. He's not having it though - he thinks the doctors are wrong and that what he Googles is correct :T So he's in a pretty messed up state of mind. He has lost at least 20lbs or so and started slowly gaining some of it back but it seems like he's more so just maintaining the weight.

Through all of this he has been seeing a psychologist who I'm starting to think isn't that helpful at all. The basis of the 'therapy' is "you have to acknowledge you're having some kind of issue, then you need to face your fears" but it almost seems as though it's left at that with no practical application - it's a very generalized kind of help that isn't actually helpful to my dad because my dad just keeps saying stuff like "We have no options. I'm stuck. I acknowledge there is an issue but I don't have the answer and I don't know what to do even if you tell me what the answer supposedly is" - on top of that, he'll make claims about things that he can't substantiate: "We're not going to be able to sell the rental property - we have to get it into better condition because nobody will buy it" which isn't true because it can be sold as-is to someone looking to fix-up, or "We can't afford to buy anything - we don't have money" even though they bring in a low six-figure income from pensions, social security and my mom consulting. So apparently his anxiety and depression are causing him to believe in things that are actual realities to him but not rational or true at all. Or he'll spiral into worst case "what if" scenarios and go down those rabbit holes. He says he's "aware" of these things but can't stop himself. The most frustrating part is that you might know exactly what he should do to resolve something yet he won't believe it - so he basically thinks there are no answers to the "problems" he's having. And you kind of have to push forward in making decisions on his behalf etc. The latest example of this that I've alluded to is selling their rental property - he thinks they have no money to put into renovating it for resale, then spirals into how if they were to sell it they'd get hit with huge capital gains and the end result is that they'll have no money. A lot of his concerns revolve around not having any money left - it's odd. My brother has had to pick-up most of the responsibility for working with realtor and getting bids from contractors on the place through all this, while my dad continues to complain in the 'background'

Anyway, I can't help but think it's more than just anxiety and depression. Or if it is, it doesn't seem "moderate" to me. Then again, as I've never personally experienced this I wouldn't know. It's probably one of those things that's much more difficult to go through than it sounds, where perhaps to someone who doesn't know much about the topic it may just sound like a side comment: "oh he just has some depression that he's going through that's all" - at the very least, it's been an eye-opening experience (not in a good way). I'm just wondering if we ought to consider a second opinion or something. Already, it feels like he has seen so many doctors though... you kind of wonder how many more it will take to get a "right answer" if none of them seem to know what the issue is.

[former player]

It's good that your dad is seeing the psychiatrist and increasing his meds, as that seems the most likely route to improvement.

I think if I were you my immediate need would be to find help for your mum.  The burden on carers is difficult to understand unless you've been one, and she is obviously past the stage of being able to cope without it having serious effects on her.   Finding out the best form of help will take some thought and will need to be something she is happy with.  It might be taking other burdens away from her (cleaning? cooking?), it might be finding a regular activity for your dad (pensioners club? health club? maybe ask at his GP surgery), it might be providing someone to be a companion for your dad for a period every day.

[jeromedawg]

It's good that your dad is seeing the psychiatrist and increasing his meds, as that seems the most likely route to improvement.

I think if I were you my immediate need would be to find help for your mum.  The burden on carers is difficult to understand unless you've been one, and she is obviously past the stage of being able to cope without it having serious effects on her.   Finding out the best form of help will take some thought and will need to be something she is happy with.  It might be taking other burdens away from her (cleaning? cooking?), it might be finding a regular activity for your dad (pensioners club? health club? maybe ask at his GP surgery), it might be providing someone to be a companion for your dad for a period every day.

Thanks. I agree - it seems to be a slow road to recovery for him.

My mom is stubborn in that she'll say she doesn't need anything. Supposedly she has people she talks to but I'm not sure what those conversations look like - she often gets into her "projection" mode where when she starts sharing with us or others about my dad, she talks as if she were the psychologist, doctor, or expert on the topic. I guess she's the closest thing to it since she's with him all the time, and maybe that's an subconscious attempt for her to cope - to make herself feel like she has some sort of control because she can reiterate and 'explain' what she was told by the doctors about my dad?
My brother is pushed to his limit as far as how much he can help with as he has a full-time job. My oldest brother lives in San Jose and due to the whole COVID thing is avoiding visiting frequently. And I'm located in Southern CA (they're in the Bay Area), so it's not like I can consistently just 'stop by' and check on them. But we do call or Google Hangout with them nearly every day.
It might make sense to try to have a part-time caretaker but I think both my parents AND my brother would adamantly be against it in light of COVID. My mom may be willing if it gets to a critical juncture though. My dad has ZERO interest in things these days (part of the depression). He's ashamed/embarrassed that others will see him and notice the changes in his weight, etc). He's super paranoid. So I don't know what kind of 'regular activity' he would actually be capable of enjoying or at least being distracted by. A big part of this all is COVID - my mom is basically trapped at home with him all day and all night. Even if the COVID stuff wasn't as bad though, she feels like she can't trust the guy and can't leave him alone but at least they'd be able to find a caretaker/companion. In this case, I'm not sure how comfortable she'd feel about having a caretaker/companion come in with all the "social bubble", "social distancing", etc recommendations that are in place. It's sort of a catch-22 situation.
Anyway, she's definitely stretched thin as is my brother. She was wanting for me and my family to come up and visit for July 4th but I told her with the COVID stuff things are a mess and it'll probably be even more stressful having us there with two kids when my dad hates noise and stimulation. Normally when we visit we stay with them but I think that would be too much. If we were to go, we would have to probably stay at a hotel or something...

[SunnyDays]

I sounds like the meds are not working. The dose of 20 mg is the maximum recommended, so maybe it's not the right one for your dad.  Two months should be plenty of time for it to take full effect.  Maybe talk to the psychiatrist about trying something else.

Therapy sounds like it's not going anywhere either.  The best one for anxiety/depression is CBT (cognitive behaviour therapy), so if he's not getting that, then he's likely wasting his time and money.  This would give him daily, practical things to do that address both his spiraling, self-defeating thoughts and his negative behaviours.  The best thing about it is that it doesn't depend on the therapist to fix him.  Once he understands the process, he can do lots to help himself.  It's a skill he will have for life.  There are workbooks that he can use too.  Mind Over Mood is a good one.  But he has to actually do the work, and if he's not willing to, then no therapy will help him. 

Have you had his doctor review all his meds as discussed up thread, in case something else is contributing to this?  Always, always, always, look for physical causes first before assuming it's psychiatric.

If all else fails, then definitely focus on relieving your mother as much as possible, so she doesn't end up being depressed too.  Unless Covid rates are really high where you live, that's kind of a secondary consideration right now.  If you can get someone in to provide any kind of help, just mask up and wash hands.  You have to weigh the risks of Covid against what's currently happenng.

[Cassie]

Having worked in the field I agree with all of Sunny’s recommendations. I also wonder if he is developing dementia. Being paranoid is a major component.

[jeromedawg]

I sounds like the meds are not working. The dose of 20 mg is the maximum recommended, so maybe it's not the right one for your dad.  Two months should be plenty of time for it to take full effect.  Maybe talk to the psychiatrist about trying something else.

Therapy sounds like it's not going anywhere either.  The best one for anxiety/depression is CBT (cognitive behaviour therapy), so if he's not getting that, then he's likely wasting his time and money.  This would give him daily, practical things to do that address both his spiraling, self-defeating thoughts and his negative behaviours.  The best thing about it is that it doesn't depend on the therapist to fix him.  Once he understands the process, he can do lots to help himself.  It's a skill he will have for life.  There are workbooks that he can use too.  Mind Over Mood is a good one.  But he has to actually do the work, and if he's not willing to, then no therapy will help him. 

Have you had his doctor review all his meds as discussed up thread, in case something else is contributing to this?  Always, always, always, look for physical causes first before assuming it's psychiatric.

If all else fails, then definitely focus on relieving your mother as much as possible, so she doesn't end up being depressed too.  Unless Covid rates are really high where you live, that's kind of a secondary consideration right now.  If you can get someone in to provide any kind of help, just mask up and wash hands.  You have to weigh the risks of Covid against what's currently happenng.

Thanks - yea, they are meeting with the psychiatrist again this coming week I think. The psychiatrist is a med management only type deal, so no talk-therapy or whatever. And he actually did recommend CBT. Apparently the psychologist my dad has been seeing isn't as 'strong' in CBT, so maybe we'll have to find him another one who specializes in that. But I think part of the issue is that I'm not convinced that he's willing to actually put any work in - he was extremely lazy and checked out before all this hit. This is reflected in the way they managed their rental - the prior tenants, for years, had told him about things that weren't working right or needed to be fixed and he'd either ignore them or jerry-rig some half-a solution up that probably didn't do much. He barely ever checked-in on things. If something required too much 'work' he would simply just drop it and avoid it.

He was previously on numerous meds before to help with his cholesterol, blood pressure and heart (he had bypass surgery 10 years ago). Since losing all this weight, he dropped off the cholesterol and BP medication so those aren't factors. But I think the weight loss is definitely a factor (someone pointed this out prior in this thread). I think he's upset that he can't eat the things he used to (or as much) so he's gotten into this "all or none" self-destructive state where he has gone the extreme to avoiding eating the things he very much enjoys.

The COVID rates I think are not great up in the Bay Area, so they are still kind of on 'lockdown' - at least, my brother really gets on them. My dad refuses to wear a mask (he complains about it being hot) and my mom has been taking him out and around - he's definitely in a higher at-risk category so I don't think it's good that she's doing that but I think it's also helping her keep her sanity at the same time.

[jeromedawg]

Having worked in the field I agree with all of Sunny’s recommendations. I also wonder if he is developing dementia. Being paranoid is a major component.

This is what I'm wondering too - it seems like there's a component of dementia at play here but the psychiatrist didn't seem concerned about that at all. Of course, the assessment was done over Zoom which probably isn't the best thing....

In a state of depression/anxiety, and if someone is 'aware', is it common for them to manipulate their response to mask or hide the fact that something's wrong? My brother has observed that in some cases when my dad is talking to certain people, he'll act and give off the impression that he's totally fine and normal.

[lhamo]

Not sure what your family history is, but if your parents immigrated to the US after growing up in China/Taiwan some of this may be connected to traumas related to the course of history.  Even stuff that happened to their parents/grandparents could have left a mark -- for example, a family that was wealthy in mainland China in the 20s-30s may have lost everything/been forced to flee suddenly in the 40s or 50s.  Or if they made it through that period then they almost certainly lost everything in the late-50s/60s, along with probably being struggle targets.  Taiwan had to deal with Japanese colonialism and then martial law under the KMT until the early 90s.  I wonder if some of your dad's unwillingness to put money into his properties, worries about losing everything might be linked to this sense -- born out by historical reality in many families -- that a happy life can disappear in a second. Couple that with natural anxiety about aging, etc. and it is a lot to untangle.   Anyway, it is hard to know whether asking your parents directly about family history would be helpful or harmful at this point, but something to consider.

[jeromedawg]

Not sure what your family history is, but if your parents immigrated to the US after growing up in China/Taiwan some of this may be connected to traumas related to the course of history.  Even stuff that happened to their parents/grandparents could have left a mark -- for example, a family that was wealthy in mainland China in the 20s-30s may have lost everything/been forced to flee suddenly in the 40s or 50s.  Or if they made it through that period then they almost certainly lost everything in the late-50s/60s, along with probably being struggle targets.  Taiwan had to deal with Japanese colonialism and then martial law under the KMT until the early 90s.  I wonder if some of your dad's unwillingness to put money into his properties, worries about losing everything might be linked to this sense -- born out by historical reality in many families -- that a happy life can disappear in a second. Couple that with natural anxiety about aging, etc. and it is a lot to untangle.   Anyway, it is hard to know whether asking your parents directly about family history would be helpful or harmful at this point, but something to consider.

Interesting points - my grandparents on both sides have an interesting history. My dad was born in Canton in 1944 and shortly moved to the US after - I vaguely recall my grandmother recounting how they were fleeing from the Japanese but not the full details. I know the Japanese occupation of China coincides with when my dad was born and likely while they were living there for a short period. My dad doesn't know the full history of his father, other than that he was schooled here in the US and received part of his education (including college) here as far back as 1915. He was working as some sort of chemical scientist/engineer and did work for the govt, which was never fully disclosed or revealed to my dad - he was pretty secretive according to my dad but I think my dad mentioned that he thinks my grandfather was involved in potentially some sort of chemical warfare contracts which would explain why. This may have provisioned for some sort of 'safe passage' to the states by the time my father was born. My dad just recalls my grandfather having a lab with chemicals and thinks he lost his sense of smell due to that. He spent part of his life growing up in Hawaii and Chicago and never mentioned anything traumatic. But I'm sure part of my dad's childhood was bleak, so yes that could be a contributing factor in all this. My dad, afaik, was pretty successful in his career. He studied nuclear engineering at Texas A&M and worked for a nuclear power firm before moving over to the electric and gas company and retiring there. I actually don't know his full history and my oldest nephew is writing a report on my parents and grandparents, so he interviewed them recently to recount their stories. I should try to get his report when he's done. EDIT: I think there might be more complexities in the history as I'm trying recount if my grandmother was born in Hawaii or China - she may have been born in Hawaii LOL. I know she grew up there though...
I probably know more about my mom's side because I did a short report on my grandfather back in junior high IIRC. My grandfather's story was more the "Traditional Gold Mountain" story that those with Chinese American heritage may be more familiar with: immigrated over somehow (whether through Angel or Ellis Island), paper sons/daughters, serving in the military, owning some sort of small shop/business, and providing for family. My grandmother on my mom's side actually suffered from depression which may be explained from what you described regarding losing a lot. I don't know how wealthy my grandparents' families were in China but that very well could have been a factor - my grandmother was actually pregnant with my mom when my grandfather had her immigrate over via boat but I'm sure they were fleeing the country a that time (my mom was born in November 1945).

[SunnyDays]

From your description of your dad having had little motivation for years, he may have been suffering from depression for a long time.  It's not unusual to have low levels for much of one's life then escalate at some point due to other factors, such as age, life losses that come with age, or simply an accumulation of hardships over time.  Early traumas actually have an organic effect on the brain that can set someone up for mental health problems later in life.  The solutions are the same though - psychotherapy if the person will participate, CBT and meds.  Plus general lifestyle management to optimize mental health:  good sleep, diet and exercise, social connections and purposeful work of some sort (not necessarily paid).  Taking a "shotgun" approach works best, where every aspect gets some sort of address, because there is no one thing that will be the "silver bullet."  (Forgive the weapons analogies!)

And yes, it's totally normal to cover up depression in some social situations.  It could be just because he doesn't want to admit to it or he may actually feel better in the presence of some people, so he has a temporary boost in mood.

[jeromedawg]

From your description of your dad having had little motivation for years, he may have been suffering from depression for a long time.  It's not unusual to have low levels for much of one's life then escalate at some point due to other factors, such as age, life losses that come with age, or simply an accumulation of hardships over time.  Early traumas actually have an organic effect on the brain that can set someone up for mental health problems later in life.  The solutions are the same though - psychotherapy if the person will participate, CBT and meds.  Plus general lifestyle management to optimize mental health:  good sleep, diet and exercise, social connections and purposeful work of some sort (not necessarily paid).  Taking a "shotgun" approach works best, where every aspect gets some sort of address, because there is no one thing that will be the "silver bullet."  (Forgive the weapons analogies!)

And yes, it's totally normal to cover up depression in some social situations.  It could be just because he doesn't want to admit to it or he may actually feel better in the presence of some people, so he has a temporary boost in mood.

It's weird, he had been checked out of a lot of things after retiring. He was selective about things that he was interested in but in the past several years especially, he has showed little interest in things (like grand kids, etc). I never noticed him being 'depressed' per se in his actions - he was very sociable outside of the house before all this and was a docent at Angel Island and the Oakland Museum, so it's hard to see that he was depressed. At home, however, he would detach and go off and watch TV (tons of Lifetime/Hallmark which I found odd) and barely made effort to interact with the kids. If my mom hassled him about cleaning up or organizing his room(s) or garage, he'd just get pissed off and not want to do it. He had kind of a short fuse with people and it often felt like he was on edge with many things.

In any case, the diet part is tough - he basically believes he can't eat anything and restricts himself, even though all the doctors and nutritionists have been getting on him.