Research

Reforming the Mental Healthcare System

Mental health has been in the news a lot recently, mostly for the wrong reasons. What is most disturbing is how some commentators are using the recent mass shootings as evidence to further stigmatize mental illness. While they talk about reforming a broken mental health care system, what they are actually promoting is institutionalization for individuals with severe and persistent mental illness. This is unacceptable and distracts policy-makers from the fundamental issue; our current mental health care system is broken, underfunded and often criminalizes mental illness.

Why do we allow society to blame those who suffer from these devastating illnesses when they are the victims? It is no secret that even the best evidence-based treatments are still not good enough. Yet, they represent the latest research and should be widely available to patients. Sadly this is not the case. Community mental health centers are underfunded and lack the resources to offer such treatments. Training is expensive and access is limited. Insurance companies frequently balk at paying for treatment that they argue is questionable from an efficacy standpoint. The complexity of the mental health system, divergent opinions about treatment, and limited access to care often leaves family and patients confused, frustrated and marginalized. It is not exaggerating when people say the mental health system is broken and in crisis.

So what can be done? To start, our leaders need to stop using these isolated incidents of violence as evidence to support changes in the mental health system. However well meaning, it sends the wrong message and ultimately does more harm that good. Secondly, the government needs to get out of the way and let those who understand mental health care take the lead. There is far too much bureaucracy and inefficiency in the system (the current government shutdown an outstanding example). We need congress to appropriate funding at a level that meets the current needs of the system, without any stipulations or interference from special interest groups. Appoint a director to oversee a complete reformation of the system who is given the authority to implement the necessary changes (versus the usual congressional route of asking for a report that never goes anywhere). The director should bring together the National Institute of Mental Health, the Veterans Administration, the Substance Abuse and Mental Health Services Administration, the National Alliance on Mental Illness, the Center for Medicare and Medicaid Services, as well as various research and provider stakeholders to develop a comprehensive plan that aligns research, training, advocacy and treatment objectives on a national level. Simplify the process for accessing care and reduce the administrative burdens associated with providing mental health care. Stop kowtowing to special interest groups and make mental health parity a reality. Create a national standard for reducing the criminalization of mental illness through the use of mental health courts and mandated treatment for those most at risk for violence. Ensure that there is adequate access to various levels of care nation-wide. Prioritize the implementation of electronic medical records that allow for seamless communication between providers. Provide funding for training providers that includes national standards for graduate programs and licensing. Revamp psychiatric training programs to ensure that psychiatrists are thoroughly trained in psychotherapy as well as psychopharmacology. Mandate that insurance companies reimburse for psychiatrists who provide psychotherapy. Provide incentives for the development of novel treatments, including medications.

This is a daunting list and incomplete. Critics may call such a proposal idealistic, too expensive and unworkable. However, what other options do we have? The patchwork approach has not proven effective and there is little evidence that leaving the process in the hands of a partisan congress will produce acceptable results. Overhauling the mental health care system can only be effective if there is a comprehensive, long-term vision that aligns research, treatment, training and advocacy objectives. It will be difficult and expensive, but those who suffer from severe and persistent mental illness deserve our best effort.

Teaching Kids Skills to Manage Their Emotions

When I was in graduate school, I was required to read a book titled Emotional Intelligence, by Daniel Goldman. The book examined the then nascent research by two psychologists, John Mayer and Peter Salovey, who were developing their theory of emotional intelligence (EI). Drawing upon this line of research, the basic premise of Daniel Goldman’s book is that emotional intelligence, and not IQ is critical to achieving success in life. Furthermore, he argued that emotional intelligence could be taught. The book was a bestseller as the concept of emotional intelligence resonated with many people. The educational community recognized emotional intelligence as an important skill to develop within students, and programs teaching emotional intelligence soon began to appear in schools. A recent article in the New York Times Magazine examines this growing trend of schools incorporating social-emotional learning into their curriculum. It’s a balanced examination of such programs, and well worth reading.

In a similar vein, a pilot study out of Ohio State University’s College of Nursing looked at the benefits of incorporating a mental health component to a high school health education curriculum. Called COPE (Creating Opportunities for Personal Empowerment), the program focused on teaching students basic cognitive-behavioral skills. Results from the study were promising, with students showing improved scores on both physical and emotional measures. It’s an interesting study, and hopefully one that will be replicated in a larger randomized study to see if the results hold up.

Thoughts About DSM-5

As I discussed in a previous post, there has been much controversy about the DSM-5. Now that it has been released and people have a chance to review it, I think we can all take a deep breath. I do not believe that the changes to the manual are as dramatic or controversial as I think people were expecting. There are changes that may be disliked by some (such as the consolidation of Autism, Aspergers and Pervasive Developmental Disorder NOS), but one the whole, I think the APA did their best to find a balance in the changes they made. I doubt that most clinicians (or journalists for that matter) bother to read all the fine print in the introduction, but I recommend that they do. For one, the authors readily acknowledge the limitations of the current categorical system and splitting of disorders.

“The historical aspiration of achieving diagnostic homogeneity by progressive subtyping within disorder categories no longer is sensible; like most common human ills, mental disorders are heterogeneous at many levels ranging from genetic risk factors to symptoms (APA, p. 12).”

Further on they outline some of the problems with trying to diagnose a mental disorder based upon a categorical system:

“…it is not sufficient to simply check off the symptoms in the diagnostic criteria to make a mental disorder…it is well recognized that this set of categorical diagnoses does not fully describe the full range of mental disorders that individuals experience and present to clinicians on a daily basis throughout the world (APA, p. 19).”

The inclusion of dimensional measures of symptom severity that cuts across diagnostic category is a good start. I am pleased with the inclusion of assessment tools in the manual, as well as their availability online. I hope that this pushes more clinicians to include the use of standardized assessment tools in their daily practice.

One argument about DSM-5 that I have heard is this notion that it has pathologized normal behavior by expanding what constitutes a mental disorder. There is some merit to this concern, especially if you just read the names of the disorders and their respective diagnostic criteria. However, there are very clear cautionary statements included in DSM-5 (and previously in DSM-IV) about this very issue. A core feature of what defines a mental disorder is the concept of “clinical impairment”, or how the symptoms negatively affect an individual’s functioning in daily life. This can be a challenging question to answer, especially if the symptoms and/or impairment are not recognized by the individual (such as in the case of psychosis). In DSM-IV, clinicians used the Global Assessment of Function scale (or GAF as it is commonly referred to) as a means of quantifying impairment. In truth, the GAF was a very ineffective means of quantifying impairment, as the authors of the DSM-5 readily acknowledge:

“It was recommended that the GAF be dropped from DSM-5 for several reasons, including its conceptual lack of clarity (i.e., including symptoms, suicide risk and disabilities in its descriptions) and questionable psychometrics in routine practice (APA, p. 16).”

Instead, the DSM-5 recommends using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS). While it requires a bit more effort that the GAF, I believe it does a better job of capturing and quantifying this concept of “clinical impairment.”

One of the underlying problems with DSM-5 is less to do with the manual, and more to do with how it is viewed by both clinicians and the general public. I often hear people call the DSM the “bible” of psychological disorders. This is a most unfortunate term for several reasons. First, the word bible has obvious religious and cultural connotations that suggest the book is somehow sacred and immutable. The truth is the DSM is anything but; it is a living document, based on current research and always open to having the contents challenged and modified by new discoveries.

As stated by the book itself, “Diagnostic criteria are offered as guidelines (my emphasis) for making diagnoses, and their use should be informed by clinical judgment (APA, p. 21).”

The DSM is not the last word when it comes to diagnosing mental disorders. The diagnoses are simply the best way at present of understanding a set of symptoms. I always caution clients not to focus too much on what diagnosis they are given. While it is true that a diagnosis can help inform treatment, it is far more valuable to focus on the particular set of symptoms that are present and the suffering that comes with them. Ultimately, mental health treatment is about relieving suffering and not a diagnostic name. So while the new edition of the DSM is certainly interesting and important, it is only one facet of mental health treatment, and not the most important one at that.

Bibliography

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Washington, D.C.: American Psychiatric Publishing.

Latest NIMH Research News

There are three recent and exciting research study reports from NIMH I want to share. The first discusses the potential of modifying gene expressions to treat schizophrenia. While a major limitation of the study is that it was looking at the brains of mice, it still holds much promise for understanding the mechanisms associated with schizophrenia and developing novel treatments. The second study examined the relationship between bipolar affective disorder and influenza. Researchers have long suspected that prenatal exposure to the flu virus may be a risk factor in developing bipolar disorder and schizophrenia. This current study suggests there is a fourfold increased risk. Finally, over the past several years I have been watching with interest the research on ketamine as an antidepressant agent. Research has been taking place on the use of ketamine as a rapid antidepressant. One of the challenges with ketamine is that it has many unwanted side effects and is a drug of abuse. Researchers have now developed a molecular cousin to ketamine that seems to have similar antidepressant effects without these side effects. Such a medication could revolutionize the treatment of depression like Prozac did when it first came onto the market. One of the drawbacks to current generation antidepressants is that they can takes weeks to reach full effect. Imagine the benefit of a medication that achieved the same or better results in minutes or hours? It could lead to lower rates of inpatient treatment, decrease the risk of suicide, reduce time waiting for services and service utilization. There is still a long way to go before such a medication may be available, but it gives hope to all those affected by mental illness.

ICED Conference

I recently returned from the International Conference on Eating Disorders, which was held this year in Montreal. It’s my first time attending the conference, and I’m very pleased to have had the opportunity. The ICED is the annual conference for the Academy of Eating Disorders, and is attended by some of the best researchers and clinicians in the eating disorder field. The conference took place over 3 ½ days, and included numerous presentations and educational opportunities. I learned more than I could possibly put into a blog post, so instead, I thought I would comment on the theme of the conference, “Crossing Disciplinary Boundaries in Eating Disorders”.

The conference was kicked-off with a keynote address by renowned psychologist David Barlow. Dr. Barlow is well known for his research of cognitive-behavioral treatments for anxiety disorders, and focused his discussion on the idea that it may be more effective to investigate psychiatric disorders from the perspective of what they have in common, versus what separates them. He termed this “lumping” versus “splitting” and noted that the latest version of the DSM, DSM-5 has continued the trend of “splitting”. Interestingly, DSM-5 is slated to be released this month, and the director of the NIMH has gone on record as saying NIMH is moving away from researching psychiatric disorders using the DMS-5 nosology. His comments provoked a response by the American Psychiatric Association, who basically said, “This is the best we can do until you researchers give us better evidence.” Meanwhile, the shortcomings of DSM-5 have led some to question the biomedical framework for psychiatric disorders, while others argue that it encourages mental health practitioners to pathologize normal human behavior. I think this controversy is unfortunate and only serve as fodder for the anti-psychiatry movement. The mental health field has worked extremely hard at reducing the stigma around seeking treatment for mental illnesses. It would be devastating if the current DSM-5 controversy negatively impacted this effort.

Eating disorders, in my opinion, are an excellent example of the “lumping” versus “splitting” issue. Research has shown that for many individuals with eating disorders, their diagnostic presentation changes with time. It is not unusual to have someone develop Anorexia Nervosa during adolescents, but then continue to struggle with a variety of eating disordered behaviors over the course of the lifetime, including binging and purging. In fact, most individuals with an eating disorder end up in the Not Otherwise Specified category because, while clinically impaired, they do not meet the specific criteria for either Anorexia Nervosa or Bulimia Nervosa. This would suggest that there are strong commonalities between disorders that are conceptualized as being separate. On the other hand, Binge Eating Disorder, which is being added to DSM-5, may be more distinct from AN & BN. For example, prevalence rates for men are much higher for BED than for AN or BN and there does not seem to be the diagnostic “crossover” that occurs with AN & BN. However, the inclusion of BED in DSM-5 does continue the trend of “splitting” diagnostic categories, which may or may not be helpful to our understanding of eating disorders.

One of the fascinating things about eating disorders is the interplay between biology and psychology. A classic study informally referred to as the Keys Study showed how starvation can induce behaviors that mimic Anorexia Nervosa (the ethics of the study are a different story). It was one of the first studies to clearly demonstrate the biological underpinnings of eating disorders and how starvation can negatively affect psychological functioning. Another such example is the research that suggests there are different personality traits associated with Anorexia Nervosa and Bulimia Nervosa and how they may impact the development of these illnesses. We desperately need better research into the biological basis for personality traits and how these relate to psychiatric disorders. I think a major shortfall of the DSM-IV was the artificial separation of personality disorders and mental illness. The reality is that the two are intertwined and likely share common pathophysiology in the brain. So I am firmly in the “lumping” camp at this point, and hope that the NIMH RDoC effort helps us develop better dimensional models of psychiatric disorders that delineate the underlying biological mechanisms and associated environmental factors.