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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.

National Hazing Prevention Week, Sept. 23-27

This week is National Hazing Prevention Week, organized by HazingPrevention.org. While many might think about hazing in the context of college Greek organizations, hazing is a widespread problem in many settings, from high school sports teams to the military. In some organizations, hazing is a sanctioned rite of passage (this NFL team video goes so far as to mock anti-hazing efforts). Recent reports suggest that many incidents of hazing increasingly involve rape and other forms of sexual violence and degradation. While proponents of hazing argue that hazing is vital to the development of group cohesion, the reality is quite the opposite. Hazing is about power and control; it is a form of abuse that strips an individual of their autonomy and self-respect. History is strewn with horror stories of hazing gone wrong; the result of which is death or serious injury. Yet rarely do these reports consider the emotional and psychological injuries that occur from hazing. Hazing can be the trigger for serious mental health difficulties, such as acute stress disorder, major depression, suicidal thinking or even post-traumatic stress disorder. A well-written article by the psychologist Robert Brooks dismantles the argument for hazing. He notes that parents, educators and coaches need to help kids understand from an early age that hazing is not an acceptable practice and have mechanisms in place to support individuals who have been hazed. I encourage you to take a moment this week and consider what you can do to help prevent hazing in your community.

For more information about anti-hazing efforts, please visit:

HazingPreventon.org
University of Maine Hazing Research and Prevention
StopHazing.org
National Bullying Prevention Center

Suicide Prevention Month

September is suicide prevention month. Every year, more than 37,000 people die by suicide. NPR’s Science Friday did a wonderful piece on suicide titled “Diagnosing Destruction” which looked at the science and research behind suicide and suicide prevention. There are many excellent books to help us understand suicide and why people kill themselves; two that I have found particularly helpful are The Suicidal Mind by Edwin S. Shneidman, and Why People Die by Suicide by Thomas Joiner.

Statistically, we know that certain demographic groups are more at risk to die by suicide. These include being male, between the ages of 15-24 and over 65 and being diagnosed with a mental disorder. Despite these statistics, it is still impossible to predict if a person will make a suicide attempt. However, here are some warning signs that a person may be considering suicide.

  • Being depressed
  • Actively talking about death or desire to kill themselves
  • Researching ways to kill themselves
  • Purchasing a firearm
  • Expressing feelings of hopelessness or unbearable emotional/physical pain
  • Increased drug or alcohol use
  • Increased agitation or anxiety
  • Increased risk-taking behaviors
  • Extreme changes in mood
  • Rage or desire to seek revenge

Always take someone seriously if they say they are feeling suicidal. Even if someone has made suicidal statements in the past and never followed through, there is always the possibility that this time they will try to kill themselves.

If you or someone you know is thinking about suicide, here are some recommendations. Any person who is thinking about suicide should be evaluated by a qualified mental health or suicide prevention professional.

  • Contact your local or national crisis line or accompany the individual to your local emergency room.
  • Never leave someone alone who says they are seriously thinking about killing themselves.
  • Remove all firearms and ammunition from the home (locking them up is not considered sufficient).
  • Secure or remove any potential lethal medications or chemicals from the home.
  • Call 911 if the person is actively making an attempt to kill him or herself or is refusing to seek help.

Visit the Suicide Prevention Lifeline for more tips on how to help someone who is feeling suicidal. Military veterans also have the option of calling the Veteran’s Crisis Line.

The National Alliance on Mental Illness (NAMI) has developed a fantastic suicide prevention program called The Connect Project that aims to train community partners in how to prevent suicide and intervene when someone has died by suicide. In New Hampshire there are several grief support groups for family and friends who have lost a loved one to suicide. NAMI New Hampshire also provides resources for those who have survived a suicide attempt. Finally, NAMI New Hampshire hosts an excellent Suicide Prevention Conference each year.

Suicide is preventable. There is hope. Please make a difference by learning more about suicide prevention and educating others.

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.

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.

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.

The Cost of Mental Health

Came across a recent opinion piece by Kathleen Sebelius, Secretary of Health and Human Services. You can read the full text here. One quote which stands out and never ceases to amaze me is the cost associated with mental illness. She writes, “In total, mental health conditions place a greater burden on our economy than cancer or heart disease; and yet more than 60% of people with mental illness do not receive help.” The lack of access to care is something that is felt especially so here in the North Country. In discussions with area providers, one area of concern is the limited access to psychiatric prescribers. The burden of prescribing psychiatric medication is being placed on our primary care physicians, who do an admiral job. Yet, I think they would be the first to say that it would be their preference to leave psychiatric medication prescribing to the specialists. The use of telepsychiatry may be a solution but deployment is still limited in New Hampshire. I am hopeful that as people become more comfortable with the use of this technology, telepsychiatry will be a service that is accessible to everyone.

Mental Health in New Hampshire

As I get Ascent Counseling ready to go live, I thought I would start by publishing the blog. My goal for the blog is for it to focus on current news and information about mental health treatment. With that in mind, I got an email today from NAMI NH about the schedule for state budget meetings. You can access the dates here. If you can’t attend the meeting, make sure to voice your support for mental health funding in New Hampshire. It is critical that NH begin reinvesting in mental health care; it has been neglected for far too long, and they are not fulfilling their promises as outlined in the ten year plan.