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Featured Article
The State of the Field of Mental Health
Currently in the United States, for a
child with a mood disorder approximately 10 years
pass from the time of symptom onset before the correct diagnosis and
treatment is initiated. So much wasted time during a
child's
developmental years is a real crime. For adults there are
similar
situations that we run into all the time. For example, there
are
those originally diagnosed with depression that in actuality have a
bipolar-like mood disorder, and have found that the typical
antidepressants cause them to feel horrible. This is because
depression is very tricky and frequently masquerades as something that
it really is not. A similar example involves post partum
depression, a very much genetic and inheritable condition. I
recommend the autobiographical books, Marie
Osmond's Behind the Smile
or Brooke Shields Down Came
the Rain,
for more information. Severe post partum illness can affect
women, like it did for Andrea Yates, with psychosis and subsequent
tragedy. Post partum depression is, in fact, a continuum of
bipolar illness. Remember hearing about Andrea Yates
treatment
with antidepressants such as Paxil or Prozac? It was the
wrong
medication in her case and a part of the problem, not part of the
solution. It is cases like this with the wrong diagnosis and
the
wrong treatment that are so tragic.
Treating the Tip of the Iceburg
We call this treating to the tip of the
iceberg approach.
Our field is so diagnosis driven that
it's dangerous. For
example, if a person is sad, are they depressed? If a person
cannot concentrate, do they have ADHD? The power of managed
care
to demand a diagnosis that fits the treatment is strong. It
is no
wonder that when a wrong diagnosis is made, then the wrong medication
is prescribed given that most of treatment is diagnosis
driven.
This is where Diablo Behavioral Healthcare comes in. We do not
diagnose and treat to the tip of the iceberg; instead, we actually take
the time to figure it out. Our initial evaluation is two
hours
long and this is after the patient has filled out a 38-page history
form. If the clinician doing the history feels medications
would
help balance the patient's neurochemical
state, then another two hour
visit with the psychiatrist takes place to make sure we get it
right. We have done some checking and found out that if a
patient
sees a therapist and psychiatrist within their managed care system for
two years, their total out of pocket co-pays will amount to around
$1820. Our evaluation fee is $1100 for four hours to get it
right
the first time. Subsequently, even paying out of pocket is
cheaper than two years of co-pays and not getting it right.
The Myth and Lore of Mental Illness
Not
long
ago there was the tragic killing of a woman by her son right here in
Danville. He was known to have been acting strangely for some
time and his symptoms were completely denied by his mother.
He
would have responded to the correct medications had someone done
something earlier. There is just no way this was a real
surprise
to those who really knew him well. To deteriorate to the
point of
hearing voices is a slow and insidious process, one of the reasons
theses diagnostic categories are in fact called process illnesses. We
had a case of a mother so much in denial of the psychotic thinking of
her daughter that she brought in some sort of faith healer to cleanse
the house of evil spirits that the daughter had been communicating
with. We have another case of twins that both have psychotic
episodes and use street drugs, a frequent combination. It is
a
real urban myth that street drugs cause mental illness. It is
much more common and real that those who abuse drugs and alcohol are
attempting to self medicate the associated anxiety that accompanies
emotional problems, which are in fact the result of
one's genes more
than due to whether or not someone was breast fed, bottle fed or bonded
with their binky. The longer we continue to use the term mental
illness, the longer it will take to rise out of
the mire of myth,
lore, and pure ignorance. The expanding world of medical
genetics
and stem cell research will cause the ignorant to be dragged to
enlightenment. This will happen whether or not they want to
go,
as the public will demand it. There is just no reason for
stigma
and shame to be associated with neurobiological conditions than there
ought to be for a broken arm, or a diagnosis of diabetes or
epilepsy.
The
Problem with Categorization
We still have, for instance, some
categories that are so incorrect
as to be laughable. Take
Tourette's syndrome for
example.
This condition is still in the book some refer to as the Bibleâ: the
DSM-IV-TR, which stands for the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision by the American
Psychiatric Association.
Tourette's is a neurological condition
that is not remotely connected to any form of emotional
problems.
What, then, accompanies Tourettes? Well, for example there is
the
fact that 60% of those with Tourettes have Obsessive-Compulsive
Disorder (OCD) and 50% of those have symptoms of Attention
Deficit/Hyperactivity Disorder (ADHD). Curious,
isn't it?
What is not an emotional illness has tag-a-longs that are also in the
DSM-IV-TR book. Could it be that OCD and ADHD are, in fact,
just
genetic oddities and not a real
emotional
illness? If this is
true, then what is an emotional illness?
Is Schizophrenia
an emotional
illness? It certainly causes emotional
problems
for those so afflicted, but perhaps its root cause is a genetic
variance that effects a change in the neurotransmitters that then cause
schizophrenia. Is Autism or Stuttering an
emotional
illness? I certainly don't
think so, yet there it is in the
DSM-IV-TR. Remember what that stood for? The Diagnostic and
Statistical Manuel of Mental Disorders, 4th
Edition, Text
Revision by the American Psychiatric Association. My own
brother
had a speech problem when he was younger and no one considered him to
have an emotional disorder, unless it was the embarrassment he felt not
being able to keep from stuttering.
Time for a Paradigm Shift
You
see by now that there is no order to the disorders that are
listed. The scary thing here is that far too many treat the
DSM-IV-TR as the
Bible to organize
their thinking and these are the
providers that are supposed to be treating our loved ones and making
decisions that affect their health. It is clear to me that a
real
paradigm shift is called for in this area. What is a paradigm
shift, anyway? The term
paradigm shift
was first used by Thomas
Kuhn in his 1962 book The Structure of Scientific Revolutions
to describe a change in basic assumptions within the ruling theory of
science. This is what is needed in the field commonly called Mental Health: a
real change in thinking and education that actually
keeps up with the scientific advances that are
known.
Currently in the United States, most
of the service providers are
about 10+ years behind what is known to the researchers and those that
care to keep up with the advances in clinical neuroscience.
It is
incumbent on those in the positions of responsibility to do all that is
possible to inform folks that most of the approaches we currently use
to treat our community are obsolete and no one even knows it.
Hopefully, this paper has done a little to increase the awareness that
we can and need to do a better job with the people we treat.
They, for sure, deserve it.
Author
William
Shryer, DCSW,
LCSW
Clinical
Director
Diablo Behavioral Healthcare
Danville, CA
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