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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 Iceberg

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 Manual 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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