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Tag: Mental Health

Transforming Diagnosis

In a few weeks, the American Psychiatric Association will release its new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This volume will tweak several current diagnostic categories, from autism spectrum disorders to mood disorders. While many of these changes have been contentious, the final product involves mostly modest alterations of the previous edition, based on new insights emerging from research since 1990 when DSM-IV was published. Sometimes this research recommended new categories (e.g., mood dysregulation disorder) or that previous categories could be dropped (e.g., Asperger’s syndrome).1

The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

Patients with mental disorders deserve better. Continue reading…

What Does HIPAA Have to Do With Gun Control? Maybe More Than You Think.


There aren’t many who would quibble with an argument that those with severe mental illness—specifically, individuals “who have been involuntarily committed to a mental institution, found incompetent to stand trial or not guilty by reason of insanity. or otherwise have been [legally judged] to have a severe mental condition that results in the individuals presenting a danger to themselves or others“—should not be able to purchase firearms. Right? Right.

Making that law isn’t actually the trouble (expanding background checks is, of course, a different story). It’s already law, and has been on the books for awhile. The trouble is enforcing it.

The federal government maintains the National Instant Criminal Background Check System (NICS), a database of people who are federally prohibited from purchasing guns, including felons, people convicted of domestic violence, and individuals who meet the extreme mental illness criteria above. Except:

Federal law does not require State agencies to report to the NICS the identities of individuals who are prohibited by Federal law from purchasing firearms, and not all states report complete information to the NICS.

To recap: We have federal criteria that prohibits certain individuals from buying firearms. The feds maintain a database of known individuals for background checks (which take 30 seconds, per the regulation). But states aren’t required to offer the names of “prohibitors” to the database.

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Combat Medicine’s ‘Golden Hour’


WASHINGTON — While the news swells this week with sad and angry retrospectives on the war in Iraq, it is worth noting that the tremendous human costs of that war would have been much greater, were it not for breakthroughs in combat medicine deployed for the first time on a broad scale in Iraq.

4,486 American men and women were killed in the Iraq war. This represents approximately 14 percent of the 32,221 wounded in action — versus the 19 percent killed in Vietnam, or 27 percent killed in World War II. These statistics are cold comfort for those whose lives were derailed and families tormented in the process, and they are a clarion call to re-double all our efforts to help those who survived.

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Drugmakers May Win Big in Effort to Curb Gun Violence

Reducing gun violence by increasing access to mental health services may cost billions of taxpayer dollars and give drugmakers that help treat mental illness a revenue windfall. But will it reduce gun violence? The answer is uncertain.

In the wake of the tragic shooting at Sandy Hook Elementary School, there have been repeated calls to increase access to mental health services as a way to reduce gun violence in the U.S., even though the evidence is weak at best that those services actually reduce gun violence.

Absent from these calls to action is any sense of how much that policy would cost. Many argue that any cost is worthwhile if it prevents just one needless death due to gun violence. But we live in austere fiscal times and knowing the price tag before taking action makes sense (click on the image above to enlarge).

A just-published Bloomberg Government Study estimates that the potential impact on the federal deficit due to increased spending on mental health services could exceed $260 billion from 2014 to 2021.

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Safe Skyping: The Evolving Doctor-Patient Relationship


Skype and videoconferencing have surpassed the tipping point of consumer adoption. Grandparents Skype with grandchildren living far, far away. Soldiers converse daily with families from Afghanistan and Iraq war theatres. Workers streamline telecommuting by videoconferencing with colleagues in geographically distributed offices.

In the era of DIY’ing all aspects of life, more health citizens are taking to DIY’ing health — and, increasingly, looking beyond physical health for convenient access to mental and behavioral health services.

The Online Couch: Mental Health Care on the Web is my latest paper for the California HealthCare Foundation. Among a range of emerging tech-enabled mental health services is videoconferencing, for which there is a growing roster of choices for platforms that market a variety of features beyond pure communications.

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The Heart’s Content

The field of medicine has long focused on how negative psychological functioning is associated with disease – for example, how anxiety and depression increase the risk of heart attacks.

Health, however, is more than the mere absence of disease. In an article published this week in the Psychological Bulletin, my colleague Laura Kubzansky and I demonstrate that positive psychological well-being – which includes feeling optimistic, happy, satisfied, and purposeful – is beneficial for cardiovascular health.

In an investigation of more than 200 studies, we found that these psychological assets are associated with a reduced risk of cardiovascular disease, the leading cause of death in the United States. This relationship was present regardless of a person’s age, socioeconomic status, smoking status, or body mass index.

Moreover, positive psychological well-being seems to be connected to better cardiovascular outcomes because people with greater well-being tend to engage in healthier behaviors like exercising and have healthier biological function like low cholesterol. These findings align with the American Heart Association’s recent emphasis on ideal cardiovascular health, which it defines as more than the absence of risk factors.

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Does Anybody Want to Pay for Depression Treatment?

Imagine for a moment you are suffering from an illness that makes you feel like your soul has been run over by an angry defensive lineman, a disease that interferes with your desire to sleep, eat and make love. Oh, and this illness will continue to make you feel this way for the rest of your life. How much would you be willing to pay for a treatment makes you feel normal again?

My colleagues and I posed that question to a nationally representative sample of more than 700 Americans  and we discovered something troubling—people’s willingness to pay for medical interventions depends in large part on whether the illness in question is “physical” or “mental.”  People are much less willing to part with money to treat mental illnesses, even after accounting for the perceived severity of those same illnesses. Our article—“What’s It Worth?”—is available online at the Journal of Psychiatric Services.

Let me tell you a bit more about our study. We described a handful of illnesses to people and asked them to tell us, in effect, how bad each one would be to experience. For instance, we describe type 2 diabetes to people, and told them that it was uncomplicated by any other medical problems. People thought that would be pretty hard on their quality of life. We also described below-the-knee amputation, and they thought that would be even worse than diabetes. We described severe blindness, which only leaves one able to distinguish shadows.  People thought that one was worse than either of the first two problems.

We also described a case of moderately severe depression to people, a level bad enough to cause the victims to “feel sad and downhearted a lot of the time.” The description went on to explain that it would make people “feel like a failure” and lose interest in food and sex. Trust me, it was a thorough and devastating picture of how depression can affect people’s lives.  Indeed, people thought it was horrendous, at least as bad as any of the physical illnesses we described.

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Using Laws to Help Solve the Public Health Crisis of Mental Illness

May is Mental Health Month, a good time to remember the ten million adult Americans who suffer from a serious mental illness such as depression, bipolar disorder, or schizophrenia.  Without proper treatment, psychiatric disorders put an enormous strain on affected individuals, family members and on society at large.

In the mid-1950s, state mental hospitals housed about a half a million people with mental illness. Many held patients against their will for decades in understaffed and deteriorating wards.

Today, most of those hospitals have been shuttered; the ones remaining hold fewer than 50,000 patients.

Taking people out of psychiatric institutions would have marked an extraordinary leap in social progress, if only it had been accompanied by a proportionate and continuing public investment in community-based mental health care. Instead, we now have a public system of mental health care that is fragmented and grossly underfunded.Continue reading…

American Healthcare X

“A decent provision for the poor is the true test of civilization.”
~Samuel Johnson

“Joe” has been on the streets now for two months. He’s 35, unmarried, and diagnosed with chronic schizophrenia since age 19. His illness is difficult to manage, even with regular medication, and Joe is subject to hallucinations telling him to “fight off the evil ones”. Like most people with psychiatric disorders, Joe has never been violent—but when his illness is not well-controlled, he can become loud and belligerent.

Despite his many tries at holding down a job, the economic downturn and his worsening psychosis have left Joe jobless and homeless.  Joe’s family thinks he is “faking” his symptoms and they are “fed up” with him. They have refused to take him in or help him with his medical care. Joe has no friends willing to help him and survives on the streets by panhandling and dropping in at soup kitchens. The local shelters won’t accept Joe, because he is “too agitated.” Joe sleeps in alleyways, or, when lucky, in ATM stations. In the past month, he’s been beaten up twice by members of youth gangs.  Recently,  Joe was diagnosed with type 2 diabetes, requiring daily medication and monitoring. Joe says he doesn’t want “charity”, and would like to work again, but doesn’t see how he can.

“Joe” represents many patients I’ve cared for during nearly 30 years of medical practice, and typifies thousands of Americans with severe mental illness.   In my previous blog entitled, “The Libertarian Mind”, I posed this question: what is the moral responsibility of federal and state government to help care for people like Joe? I argued that the Libertarian Party platform—calling for the abolition of “the entire social welfare system”, including food stamps—is neither humane nor compassionate.

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