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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.

Embracing Difference

There’s a website I’d like to share today called Positive Exposure. The goal of the website is to show the unique beauty of people with various genetic conditions (albinism etc.) that are often portrayed in dehumanizing ways. It’s an amazing project, and it happened to come to my attention at the same time as I was reading two unsettling articles. The first was a report on CNN about the actress Mellissa McCarthy (of Bridesmaids among other films). Mellissa is a highly entertaining and talented actress who also happens to be plus-sized. Promotional material for her latest movie included a photograph of her that had been digitally altered to make her slimmer. While this practice is nothing new, it once again illustrates how hyper-focused our society has become on the thin ideal. While lifestyle choices are a contributing factor for obesity, there is also fact that weight and body type (ectomorph, mesomorph, endomorph) are genetically determined. What I found especially disturbing in the article was a quote from Ms. McCarthy where she stated that sometimes she wishes she would wake up and get people’s attention because she is emaciated. While disturbing, the comment does not shock or surprise me. Anyone who has worked with individuals who are obese or have an eating disorder other than anorexia has heard people refer to themselves as “failed anorexics.” Then you have Abercrombie & Fitch, a clothing company that goes out of it’s way to promote an ultra-slim body style by not making clothes in sizes that fit the average woman. Not only do their clothing sizes exclude most women, the CEO Michael Jeffries actually stated that their clothes are for “cool” kids (i.e. unnaturally thin women) and not overweight women. The venom against obese individuals even extends to college professors and Disney. I understand that the rising obesity rate in the US is concerning, and certainly a lot of it is due to lifestyle choices. But our current approach to tackling the problem is misguided. Shaming and ostracizing people because of the weight is not going to help them make lifestyle changes. Fad diets, diet pills and cosmetic surgery do not encourage people to make healthy choices. Ever-growing food portions at restaurants and the abundance of processed foods do not promote intuitive eating. Even the way exercise has become something you have to plan into your day, instead of being a natural part of one’s lifestyle (e.g. walking, hiking), is problematic. What we need is to do is rethink what it means to be healthy. The truth is that you can be healthy even if you are obese (the absurdity of the BMI is a whole subject itself). There are many people who eat healthy, exercise, and still are technically obese. Yet they are in good health. Instead of shaming them, we should be celebrating their accomplishments. Beauty is not determined by weight, and the promotion of the thin ideal in our society is backfiring. We not only have rising obesity rates, but rising rates of eating disorders, and they are occurring at younger and younger ages. Obese girls are often the subject of bullying, placing them risk for suicide and mental health problems such as depression. Being the victim of bullying and dieting are two known risk factors for developing an eating disorder. Disordered eating and body dissatisfaction are more and more common among women even if they do not have an eating disorder. It is not just women who are at risk. Males are also showing increasing rates of disordered eating and body dissatisfaction. The use of steroids, HGH and other methods of altering one’s body is becoming more common among young men in high school. When you consider all this, the reality is that we don’t have an obesity epidemic, we have a body dissatisfaction epidemic. It’s so engrained in our culture, we may not even realize we have an implicit bias against obese individuals (take the Project Implicit test for weight to see what I mean). Which brings me back to the website Positive Exposure. As a society, we like to talk about “diversity” and “acceptance”, yet often in our every-day lives we don’t live up to these aspirations. Take a moment and think about what it means to truly see beauty in every individual; to celebrate their uniqueness. Everyone is different; this is a good thing. The variety and diversity of life is what makes it so special. I challenge myself, as well as you, to be ever mindful of this truth and try and exemplify it each day.

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.

I Am One of the 26 Percent

If you read the Concord Monitor, or are involved with NAMI NH, you probably have kept up on the series of articles over the past few years about the crisis within the NH Mental Health system. A number of these articles were written by a staff writer named Annemarie Timmins. She just published an article today called “I Am One of the 26 Percent” in which she has bravely discloses her own struggles with mental illness. It is a very powerful article, and a reminder that the majority of people who struggle with mental illness do not fit the stereotype many people imagine. I am including the links to all the articles from the Concord Monitor series – they are worth the read. One more reminder that as a society, we need to rethink our approach to mental health care.

A Four-Day Focus on the State Troubled Mental Health System
Mentally Ill Patients Face Spartan Conditions – Long Delays in NH
New Hampshires Mental Health System – From Leader to Failure
Community-Level Care is Key to Help Patients Return Home
Mental Health Court Gives Offenders Treatment – Not Time
In Crisis – Future Uncertain for Mental Health Care in NH
That’s Not the Kind of State We Are – Why NH Needs to Fix Mental Health Care Now

Eating Disorder News

Just a few eating disorder-related news items to pass along in this post. The first is that a parental education law was just passed in Virginia. If you haven’t heard about the controversy regarding the new Victoria Secret “Bright Young Things” product line that targets young teens, I recommend you read this and this. While eating disorders are certainly biologically based brain disorders, there is no doubt that cultural influences that perpetuate the thin ideal contribute to these illnesses. I hope that pressure can be put on Victoria Secret to end this product line. On a more positive note, there was a nice article on CNN recently about a woman who recovered from her eating disorder. While we still have a long way to go in developing effective treatments for eating disorders, one fact that research has shown is that if you intervene when an eating disorder first presents, and are able to treat it effectively, the risk of relapse decreases significantly. That is why programs such as the one being developed in Virginia are so important. The earlier we identify and treat these illnesses, the better chance they will not become chronic conditions. I hope that we see similar legislation in New Hampshire in the near future.