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Apparently My Mental Health Isn't Worth Very Much

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shop-worthless.JPGA chilling article published March 6 in The New York Times, documents the unhappy reality for me and most other mental health care consumers--we just aren't worth as much as we used to be.

At one time health insurance companies offered a psychiatrist several sessions to reach an appropriate diagnosis for a patient, and paid the doctor about the same whether they dispensed medication or talk therapy. Then, the fees for talk therapy dropped, so most psychiatrists switched to meds management. Now fees for medication management have dropped too, so that what used to be a 45 minute session 20 years ago, or a 25 minute session five years ago, is now frequently 15 minutes or less.

Is it really possible to diagnose and effectively manage a person with a serious mental illness in 15 minute increments? I don't think so, and many doctors don't either, but what made The Times article so disturbing to me was the story of a doctor who admits that he has knowingly put profits before patient well being, but doesn't see another way.

Here's how The Times outlined how things have changed for that psychiatrist, Donald Levin, MD, from Doylestown, Pennsylvania:

Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients' inner lives better than he knew his wife's; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

While the article was ostensibly about how psychiatrists can't afford to do talk therapy anymore, and how that has changed the profession and its practitioners, it also--perhaps unwittingly--shined a spotlight on how people with mental illnesses are being treated these days.

"I miss the mystery and intrigue of psychotherapy," Levin said. "Now I feel like a good Volkswagen mechanic."

No offense to auto mechanics, but I think I'd prefer something more than that from the person who must not only balance my illness and its idiosyncrasies with the limitations of the current medications, but also factor in all of the other life issues that impact on my mental health: including my job, my sleep, my diet...the list goes on.

Though The Times article does quote a few patients who say they feel grateful for the 15 minutes of face-time that Levin provides them, even he knows better.

"The sad thing is that I'm very important to them, but I barely know them," he said. "I feel shame about that, but that's probably because I was trained in a different era."

Levin's youngest son is staying at the University of California in Irvine to become a psychiatrist himself, one specializing in children and adolescents. The Times piece ends on a quote from the son, Matthew Levin. I'll let you decide whether what he says sounds more like determination or denial:

"I'm concerned that I may be put in a position where I'd be forced to sacrifice patient care to make a living, and I'm hoping to avoid that."
BP-oil-spill-logo.jpegCan gulf coasters ever catch a break? Ever since the BP drilling platform exploded and began gushing oil into the gulf in April, it seems like the residents of coastal communities in Louisianna, Mississippi, Alabama and Florida have had to endure one insult after another. The latest "dis" came from BP oil spill fund administrator, Kenneth Feinberg, who told legislators at a recent congressional hearing that the $20 billion fund is not likely to pay damages for mental illness and distress caused by the spill unless a "physical injury" is also present.

Those were fighting words for country's largest mental health advocacy organization, the National Alliance on Mental Illness (NAMI). Their executive director, Michael J. Fitzpatrick, expressed the group's outrage in terse terms, saying that Feinberg's statement was, "incompatible with modern scientific knowledge of mental illness and the impact of traumatic events."

"Denial of a class of individuals with medical disorders affecting the brain from compensation that is available to those with medical disorders affecting other organs of the body would be neither fair nor equitable," Fitzpatrick continued.

A severe trauma, regardless of its source, can negatively impact individuals and their families for years afterward. People who endured the ravages of Katrina only five summers ago, were starting to rebuild their lives and livelihoods, but that progress was precarious. For many, the "great recession" was a severe, but survivable, injury to an already weakened system. The BP disaster could be the death blow for some.

With gulf states slashing their mental health budgets, failure on the part of the fund to cover mental health claims could take away a vital safety net that has the potential to help people bounce back from this tragedy. Without it, the devastation will likely resound for years to come. 
adcouncil_mentalhealth_300x250.jpgThe Substance Abuse and Mental Health Services Administration (SAMHSA), in partnership with the Ad Council, has launched a new public service campaign to raise awareness among Hipsanics/Latinos about mental illness, combat stereotypes and stigma and increase support for people suffering from psychological disorders.

"Raising awareness that effective treatments for mental illnesses are available and that people recover, can encourage those in need to seek help," said SAMHSA Administrator Pamela S. Hyde, J.D. "This outreach to the Hispanic community will help open dialogue about supporting friends or family members with mental health problems in a culturally relevant way."

The campaign will feature posters, website advertisements, billboards, radio spots and a Spanish language website structured around social media concepts. Though not the coolest or most innovative thing out there, the website is trying to harness how younger Hispanics to talk to one another and it's a great first step. Perhaps next time they can hire some clever young coder to design a Facebook or iPhone application that uses a game to explore concepts related to mental illness and stigma. Instead of a first-person shooter game, maybe a first-person hugger?

As one of the taglines used in the campaign says: Este es el primer paso. ¿Cuándo quieres que demos el segundo?

Anxiety Cure: Take Time to Smell the Flowers

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Gardenia jasminoides 'Kleim's Hardy'.jpgScientists in Germany have found that the scent of a Gardenia packs as much of an anti-anxiety punch as valium. They found that people who took a big whiff of the plant Gardenia jasminoides had the same biochemical reaction in their brains as people who took an anti-anxiety medication. The researchers have patented their findings.

Specifically, they found that two key fragrances emitted by Gardenias, Vertacetal-coeur (VC) and the chemical variation (PI24513, had an effect on the brain signaling molecule called GABA. If they can document in a clinical trial the benefits of the scents on anxiety and sleep, it could usher in a new era of treatment that doesn't have the side effects and addictive properties of barbiturates.

If you're one of those who have turned up your nose at the notion of aroma-therapy, it's time to take a second look. Researchers have previously shown that the sense of smell is one of the most potent triggers for memory and emotion. Thus, not everything dreamed up by crunchy granola-loving new-agey types is quackery. This study is the proof.
legorobot.jpgHere's a cool story with a cool little video from one of my favorite science geeky blogs, showing how hard it is to study psychology. Essentially, the scientist here--Tom Stafford, PhD--from the University of Sheffield in the United Kingdom, built a little Lego robot with the ability to learn some very simple stuff, such as how to follow a highlighted path and to turn around before bumping into objects.

Stafford, who's a professor, as well as an author and scientist, thought he'd designed the perfect experiment for his students: run the little robots through a series of simple learning experiments and chart how quickly their learning occurred. Stafford assumed that with such simple "subjects" he'd be able to plot a beautiful curve on a graph to demonstrate how you can predict the pace of learning.

Stafford had to eat some humble pie, however, which he acknowledges in good humor on his blog. It turns out that the learning of the robots was so haphazard and all over the place that the results were a messy jagged scribble on the graph and not the elegant curve that Stafford predicted. The relevance here is that if things come out in an unexpected manner with such simple robots, how much more difficult must it be to predict the behavior of humans, whose brains and behavior are infinitely more complex. Stafford concludes:

"Trying a simple experiment with the Lego robots gave me a new respect for the experimental method, and the difficulty psychologists face when trying to discover the rules underlying the wondrous variety in human behavior."

(Photo Source: the original blog host from MindHacks)

Is Your Personality Hard-Wired in Your Brain?

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brainscan.jpgAccording to a new study published this month in the journal Psychological Science, and reported by CNN, various aspects of a your personality can be mapped directly to different regions of the brain.

For instance, extroverts--people stereotypically depicted as the life of the party--appear to have more going on in a part of the brain called the medial orbitofrontal cortex, compared with introverts.

This was just one of the big five personality types that researchers attempted to link to specific brain regions. They found distinct brain activity related to four of those five personality types: introversion/extroversion, neuroticism, agreeableness, and conscientiousness. The only personality trait that couldn't be linked to specific brain activity was openness and intellect, which has been tied directly to intelligence.

It's interesting research. There are certain personality characteristics that I've had my whole life. While environment indisputably shapes our personalities, I wouldn't be surprised to learn that my brain came prepackaged with an inclination toward some of these traits, particularly my self-consciousness in social situations.

The real question, I suppose, is how plastic the brain may be. In other words, can we change our personalities, and if so, how much? Anyone who can definitely prove that they have the answer to that question will get a best-selling book, an appearance on Oprah, and several million dollars.
father-and-son-walk-into-fall-roland-in-vancouver3.jpgAside from being a bit sillier, and more of a joker, than my friends' fathers, my dad has always fit the stereotype of a "dude." He grew up blue collar, and though he was one of those lucky baby boomers who made it into management without a college degree, he has pretty much remained a blue-collar guy to this day. He has a temper, and can speak sharply, but he's never been mean. In fact, he's one of the most gentle and tender guys I've ever known when it comes to animals and small children.

That said, my dad is not a crier, nor is he particularly good at talking about his feelings. He grew up with the expectation that men are strong, they take care of their wives and children, and they don't complain when something goes wrong. As I learned more about my own mental health, and about psychology, I came to view this as an unhealthy way to live. The prevailing attitude over the last few decades is that the more a man can get in touch with his feelings, the healthier he'll be. The fact that men commit suicide at three times the rate of women, despite being half as likely to be diagnosed with depression, has always been thrown up as a stark example of what bottling up your feelings can lead to.

New research, however, suggests that the desire to stay strong can actually have a protective effect on men. Researchers at the University of British Columbia (UBC) conducted in-depth interviews with 38 men between the ages of 20 and 50. The UBC team found that the men's desire to stay strong and protect their families, actually helped keep them from attempting suicide--provided that the men did seek at least some kind of emotional support from a friend, family member or church counselor.

My dad and I don't have deep talks. Again, that's just not something that men in my family do, at least with other guys, but I've seen the role that my grandmother, my mom and my aunts have played in their lives. I remember when my aunt Tina died suddenly when I was a boy. My uncle Frank didn't shed a tear at her funeral, but afterward, at my grandparent's house, my mom led him out into the backyard for a private moment. I peaked out the window to see what was going on, and saw him break down as my mother placed her hand on his shoulder.

That mix of strength and fortitude in public and then momentary private weakness appears to be what helped the men in the study. "Here, men's strong sense of masculine roles and responsibility as a provider and protector enables men to hold on while seeking support to regain some self-control," says John Oliffe, PhD, one of the study's authors.

I quickly scrambled, as usual, to the gift store and the post office yesterday to send my dad a father's day card. I've learned over the years that little things like that actually do make a difference. Now that I'm in my 40s and my dad's in his 70s, the dynamic has changed somewhat. I know that the time when I'll be in a care taking roll is drawing nearer. Because he and I don't have deep talks, the cards each year and the weekly phone calls are my way of telling him that I have enormous respect for his strength and the way he always took care of us, and that he'll always be my dad--but that I'll be there if he ever needs it.
transparency20of20medical20prices.jpgThe 1990s and early 2000s were very kind to psychiatric researchers. It seemed like every other year a new blockbuster antidepressant or antipsychotic drug came to market. By 2009, antipsychotics were the top selling class of drugs in the United States, and antidepressants were in the top five. All of those profits led to a smorgasbord of earning potential for mental health researchers. Aside from running clinical trials, these experts served on advisory boards, spoke at continuing medical education programs and lent their names to journal articles ghost-written by pharmaceutical companies.

That euphoric bubble has recently begun to burst, however. The pharmaceutical industry has abandoned two new classes of promising antidepressants as failures, several market leaders have terminated their neuropsychological medication programs, and at least two large government-sponsored metaanalyses failed to find a significant difference in efficacy between antidepressants and a placebo for people with mild-to-moderate depression.

For top psychiatric researchers, however, having the scientific bottom fall out isn't the only problem. As the influx of industry money for research quickly outpaced government research grants, scientific standards fell, say critics. The congressional committees investigating potential conflicts of interest charge that the pharmaceutical industry was allowed to cherry pick what data to share, and disguise results that reflected negatively on their products, and many of the nation's top researchers went along for the ride. These alleged ethical lapses are certainly contributing to, or will contribute to, a lapse in public trust in psychological care and treatment.

The pharmaceutical watchdog blog, Pharmalot, has posted two entries over the last couple of days detailing the efforts of two scientific leaders--the American Psychiatric Association (APA) and the National Institute of Mental Health (NIMH)--to increase transparency among psychiatric researchers, and hopefully restore that trust.

Unfortunately, as Pharmalot reports, the APA's former president and initiator of the group's new transparency policy was himself probed for transparency problems by the Senate Finance Committee, and the current director of the NIMH--a principal architect of new NIMH transparency guidelines--is being chided for his role in helping Charles Nemeroff, MD, find a new job after Emory University let him go over failure to report hundreds of thousands of dollars in pharmaceutical earnings.

It's hard to know how all of this is going to play out over time. Is the current storm of controversy going to blow over and things will largely go back to the way they were, or will there be lasting change? Will greater transparency actually change anything, or will the institutional incentives to produce a positive research result ensure that it will take a decade or more to accurate assess a new drug's worth? These are important questions, and as of yet, I haven't read anything to make me feel too confident.

Happy Days, Star Trek and Mental Illness

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BosleyNimoy.jpgWhat do Happy Days star Tom Bosley, Star Trek's Leonard Nimoy, and the National Institute of Mental Health (NIMH) have in common? They all collaborated on a new set of videos about the brain and mental illness geared toward high school students.

The two videos--the first featuring narration by Nimoy, and the second by Bosley--are aimed to 9th through 12th graders. They're supposed to help younger people understand some of the inner workings of the brain's structure, chemicals and processes: a sort of "what's under the hood" of the mind.

I encourage you to watch the videos and would love to have you comment and let me know what you think about them. On the one hand, I'm glad that the government is trying to communicate in more innovative ways, but for all the fancy animation, I think they fall short on several counts.

The first thing I thought while listening to Mr. Spock explain the wonders of synapses and neurotransmitters was, "Did they actually go over the script with any high school students or teachers when they created it? If they did, I'd be curious to know whether the students were science prodigies.

The way they referred to people with mental illness raised wasn't much better.  Maybe I'm overly sensitive, but when they talk about people with schizophrenia or depression, I get the sense that the producers think of people with psychological disorders as tragic victims, objects that must be fixed. If their aim, at least partially, was to reduce stigma toward people with mental illness, I'd give them a C at best. Watch the vids and ask yourself the following question while viewing them: if you were a high school student who'd been diagnosed with depression, anxiety or bipolar disorder, and your science teacher showed this video, how would it make you feel?

Our country has grown so skeptical of science and mental health research in particular over the last couple of decades, so I completely applaud the government doing everything it can to stimulate excitement about psych research among school kids. I hope that these videos help in that process, but I fear that they'll be more likely to turn teens off than to encourage them to "like" the videos on Facebook. If the NIHM wants to know how to do it better next time around I'd be glad to help.
Onfire.jpgI do my best to follow science and medical news and it seems like every week there's another study showing that cellular inflammation is at the root of all kinds of diseases and conditions. You may be wondering, "What the heck is inflammation?"

It turns out that's a very good question, one that scientists are still struggling to answer definitively. One way to define inflammation is to view it as our body's way of responding to injury or threat, although this is oversimplifying things tremendously. If a cell is damaged, or works too hard, or if we are infected with a critter that isn't supposed to be inside of us, then microscopic proteins and amino acids are released that alert other cells to the problem. A chronically engaged cellular alert system can cause extensive tissue damage in the brain, clog up our arteries and ultimately provide an ideal environment for cancers to develop. There are dozens--actually probably hundreds--of inflammatory proteins, and we're finding new ones every day.

This week, it looks like scientists have added further evidence to the suspicion that brain cell inflammation might be at the root of another psychological problem: bipolar disorder. According to reporting by MedWire news, researchers at the Karolinska Institute in Stockholm found that microscopic structures--which are a sign of cellular inflammation in the brain--were present in the cerebrospinal fluid (CSF) of people with bipolar disorder, but not in people who are mentally healthy. The research team, led by Lennart Wetterberg, MD, PhD, was prompted to explore these microstructures by a series of studies showing similar inflammatory proteins in the CSF of people with schizophrenia.

Wetterberg's team suspected the same might be true of people with bipolar disorder, so they tapped the spinal fluid of 31 people with bipolar I--which is associated with severe mania--25 people with bipolar II--which is associated with a milder form of mania, and 20 people with no mental illness.

Ultimately Wetterberg and his colleagues found the inflammatory microstructures in 45 of the people with bipolar disorder, and the more likely to have bipolar I and to have experienced more severe manic episodes. In other words, the more severe the psychological disease, the more likely a person was to have these proteins.

While the study of inflammation and mental illness is in its infancy, the evidence that inflammation plays a central role in psych disorders is gathering rapidly and coming in from all sides. In fact, a number of recent studies have found that the ability to reduce inflammation in the brain and encourage the formation of new healthy brain cells might have more to do with how psych meds actually work than their impact on specific neurotransmitters, such as serotonin.

We haven't yet identified what causes inflammation in the first place--inflammation is likely spurred on by substances, such tobacco smoke to sugar, as well as an excels of fat in the gut. In fact, our own stress hormones can also set of a chain reaction of inflammation that ultimately damages healthy cells. We also don't know why some people seem more vulnerable to inflammation than others, however, and it will probably take decades to really get a grasp on it.

But I'm really encouraged by these studies. For one thing, inflammation is being implicated in all kinds of things, including cancer, cardiovascular disease, and aging itself. If it turns out that inflammation really is at the root of many types of mental illnesses, and if inflammation is something that we can easily and consistently measure, it could radically transform both the diagnosis and the treatment of psychological disorders.

It's possible that I'm overstating things here. I'm not a neuroscientist, nor a physician. I'm just an average guy, living with bipolar disorder, who has learned a lot about how the body--and science--is supposed to work. I'm encouraged, however, by the chance to finally give doctors and patients better tools for diagnosing and treating psychological problems. One of the primary weaknesses of modern psychology is the lack of consistency in how we define and identify the various disorders, and the lack of hard information on the biological underpinnings of psychological problems.

It's the lack of solid and consistent information--and evasions or prevarications on the part of the pharmaceutical industry and researchers most closely tied to them--that has led a growing number of people to be rightly skeptical about what mental health professionals tell us, and to question whether psychotherapy or medication even works at all. It doesn't help that a number of scientists and pharmaceutical companies have been caught with their metaphorical pants down when more rigorous scientific methods were used to explore how and whether various kinds of therapies and medicines work.

I'm not pinning all my hopes on biological interventions. There is obviously an environmental component to most psychological disorders, and we'll probably never get to a place with most illnesses where you can simply pop a pill and you'll be "all better."

I think we'll be better off, however, if we can more clearly understand what happens in the brain before, during and after people develop problems and from that begin to develop more targeted and rational treatments--whether those treatments are as simple as meditation and exercise or as complex as gene therapy.

Kay Redfield Jamison--the noted psychiatrist, author, and person living with bipolar disorder--penned a best seller back in 1996, which suggested that some of our most brilliant thinkers and artists were possibly suffering from bipolar disorder. The book, presciently titled Touched With Fire, argued that the ravaging heat of mania might also provide the fuel for brilliance.

It's possible that neurological inflammation induces mania, which can in turn provide the energy for artistic achievement. but most of us will never be a Mozart or a Virginia Woolf. I enjoy the effervescence and ecstasy of my "up" moods, and they do--at least in the beginning--increase my creative output. The price is awfully high, however, to my emotional and financial wellbeing, and to the health of my relationships. I'm not suggesting that we put out the fire entirely--a metaphor for life and vitality in many cultures--but the flame of mania can easily become an inferno, from which no one escapes alive.


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