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2014 > USA > Mental health (I)
India, 42,
suffers from manic depression and post-traumatic
stress disorder.
She has spent almost all of her adult life
in jails and
prisons.
Photograph: John Gress
The New York Times
Inside a Mental Hospital Called Jail
NYT
8.2.2014
http://www.nytimes.com/2014/02/09/opinion/sunday/inside-a-mental-hospital-called-jail.html
A Natural Fix for A.D.H.D.
OCT. 31, 2014
The New York Times
SundayReview | Opinion
By RICHARD A. FRIEDMAN
ATTENTION deficit hyperactivity disorder is now the most
prevalent psychiatric illness of young people in America, affecting 11 percent
of them at some point between the ages of 4 and 17. The rates of both diagnosis
and treatment have increased so much in the past decade that you may wonder
whether something that affects so many people can really be a disease.
And for a good reason. Recent neuroscience research shows that people with
A.D.H.D. are actually hard-wired for novelty-seeking — a trait that had, until
relatively recently, a distinct evolutionary advantage. Compared with the rest
of us, they have sluggish and underfed brain reward circuits, so much of
everyday life feels routine and understimulating.
To compensate, they are drawn to new and exciting experiences and get famously
impatient and restless with the regimented structure that characterizes our
modern world. In short, people with A.D.H.D. may not have a disease, so much as
a set of behavioral traits that don’t match the expectations of our contemporary
culture.
From the standpoint of teachers, parents and the world at large, the problem
with people with A.D.H.D. looks like a lack of focus and attention and impulsive
behavior. But if you have the “illness,” the real problem is that, to your
brain, the world that you live in essentially feels not very interesting.
One of my patients, a young woman in her early 20s, is prototypical. “I’ve been
on Adderall for years to help me focus,” she told me at our first meeting.
Before taking Adderall, she found sitting in lectures unendurable and would lose
her concentration within minutes. Like many people with A.D.H.D., she hankered
for exciting and varied experiences and also resorted to alcohol to relieve
boredom. But when something was new and stimulating, she had laserlike focus. I
knew that she loved painting and asked her how long she could maintain her
interest in her art. “No problem. I can paint for hours at a stretch.”
Rewards like sex, money, drugs and novel situations all cause the release of
dopamine in the reward circuit of the brain, a region buried deep beneath the
cortex. Aside from generating a sense of pleasure, this dopamine signal tells
your brain something like, “Pay attention, this is an important experience that
is worth remembering.”
The more novel and unpredictable the experience, the greater the activity in
your reward center. But what is stimulating to one person may be dull — or even
unbearably exciting — to another. There is great variability in the sensitivity
of this reward circuit.
Clinicians have long known this to be the case, and everyday experience bears it
out. Think of the adrenaline junkies who bungee jump without breaking a sweat
and contrast them with the anxious spectators for whom the act evokes nothing
but terror and dread.
Dr. Nora D. Volkow, a scientist who directs the National Institute on Drug
Abuse, has studied the dopamine reward pathway in people with A.D.H.D. Using a
PET scan, she and her colleagues compared the number of dopamine receptors in
this brain region in a group of unmedicated adults with A.D.H.D. with a group of
healthy controls. What she found was striking. The adults with A.D.H.D. had
significantly fewer D2 and D3 receptors (two specific subtypes of dopamine
receptors) in their reward circuits than did healthy controls. Furthermore, the
lower the level of dopamine receptors was, the greater the subjects’ symptoms of
inattention. Studies in children showed similar changes in dopamine function as
well.
Continue reading the main story
These findings suggest that people with A.D.H.D are walking around with reward
circuits that are less sensitive at baseline than those of the rest of us.
Having a sluggish reward circuit makes normally interesting activities seem dull
and would explain, in part, why people with A.D.H.D. find repetitive and routine
tasks unrewarding and even painfully boring.
Psychostimulants like Adderall and Ritalin help by blocking the transport of
dopamine back into neurons, thus increasing its level in the brain.
Another patient of mine, a 28-year-old man, was having a lot of trouble at his
desk job in an advertising firm. Having to sit at a desk for long hours and
focus his attention on one task was nearly impossible. He would multitask,
listening to music and texting, while “working” to prevent activities from
becoming routine.
Eventually he quit his job and threw himself into a start-up company, which has
him on the road in constantly changing environments. He is much happier and —
little surprise — has lost his symptoms of A.D.H.D.
My patient “treated” his A.D.H.D simply by changing the conditions of his work
environment from one that was highly routine to one that was varied and
unpredictable. All of a sudden, his greatest liabilities — his impatience, short
attention span and restlessness — became assets. And this, I think, gets to the
heart of what is happening in A.D.H.D.
Consider that humans evolved over millions of years as nomadic hunter-gatherers.
It was not until we invented agriculture, about 10,000 years ago, that we
settled down and started living more sedentary — and boring — lives. As hunters,
we had to adapt to an ever-changing environment where the dangers were as
unpredictable as our next meal. In such a context, having a rapidly shifting but
intense attention span and a taste for novelty would have proved highly
advantageous in locating and securing rewards — like a mate and a nice chunk of
mastodon. In short, having the profile of what we now call A.D.H.D. would have
made you a Paleolithic success story.
In fact, there is modern evidence to support this hypothesis. There is a tribe
in Kenya called the Ariaal, who were traditionally nomadic animal herders. More
recently, a subgroup split off and settled in one location, where they practice
agriculture. Dan T. A. Eisenberg, an anthropologist at the University of
Washington, examined the frequency of a genetic variant of the dopamine
type-four receptor called DRD4 7R in the nomadic and settler groups of the
Ariaal. This genetic variant makes the dopamine receptor less responsive than
normal and is specifically linked with A.D.H.D. Dr. Eisenberg discovered that
the nomadic men who had the DRD4 7R variant were better nourished than the
nomadic men who lacked it. Strikingly, the reverse was true for the Ariaal who
had settled: Those with this genetic variant were significantly more underweight
than those without it.
So if you are nomadic, having a gene that promotes A.D.H.D.-like behavior is
clearly advantageous (you are better nourished), but the same trait is a
disadvantage if you live in a settled context. It’s not hard to see why. Nomadic
Ariaal, with short attention spans and novelty-seeking tendencies, are probably
going to have an easier time making the most of a dynamic environment, including
getting more to eat. But this same brief attention span would not be very useful
among the settled, who have to focus on activities that call for sustained
focus, like going to school, growing crops and selling goods.
Continue reading the main story
You may wonder what accounts for the recent explosive increase in the rates of
A.D.H.D. diagnosis and its treatment through medication. The lifetime prevalence
in children has increased to 11 percent in 2011 from 7.8 percent in 2003 — a
whopping 41 percent increase — according to the Centers for Disease Control and
Prevention. And 6.1 percent of young people were taking some A.D.H.D. medication
in 2011, a 28 percent increase since 2007. Most alarmingly, more than 10,000
toddlers at ages 2 and 3 were found to be taking these drugs, far outside any
established pediatric guidelines.
Some of the rising prevalence of A.D.H.D. is doubtless driven by the
pharmaceutical industry, whose profitable drugs are the mainstay of treatment.
Others blame burdensome levels of homework, but the data show otherwise. Studies
consistently show that the number of hours of homework for high school students
has remained steady for the past 30 years.
I think another social factor that, in part, may be driving the “epidemic” of
A.D.H.D. has gone unnoticed: the increasingly stark contrast between the
regimented and demanding school environment and the highly stimulating digital
world, where young people spend their time outside school. Digital life, with
its vivid gaming and exciting social media, is a world of immediate
gratification where practically any desire or fantasy can be realized in the
blink of an eye. By comparison, school would seem even duller to a
novelty-seeking kid living in the early 21st century than in previous decades,
and the comparatively boring school environment might accentuate students’
inattentive behavior, making their teachers more likely to see it and driving up
the number of diagnoses.
Not all the news is so bad. Curiously, the prevalence of adult A.D.H.D. is only
3 to 5 percent, a fraction of what it is in young people. This suggests that a
substantial number of people simply “grow out” of it. How does that happen?
Perhaps one explanation is that adults have far more freedom to choose the
environment in which they live and the kind of work they do so that it better
matches their cognitive style and reward preferences. If you were a restless kid
who couldn’t sit still in school, you might choose to be an entrepreneur or
carpenter, but you would be unlikely to become an accountant. But what is
happening at the level of the brain that may explain this spontaneous
“recovery”?
To try to answer that question, Aaron T. Mattfeld, a neuroscientist at the
Massachusetts Institute of Technology, now at Florida International University
in Miami, compared the brain function with resting-state M.R.I.s of three groups
of adults: those whose childhood A.D.H.D persisted into adulthood; those whose
had remitted; and a control group who never had a diagnosis of it. Normally,
when someone is unfocused and at rest, there is synchrony of activity in brain
regions known as the default mode network, which is typically more active during
rest than during performance of a task. (In contrast, these brain regions in
people with A.D.H.D. appear functionally disconnected from each other.) Dr.
Mattfeld found that adults who had had A.D.H.D as children but no longer had it
as adults had a restoration of the normal synchrony pattern, so their brains
looked just like those of people who had never had it.
WE don’t yet know whether these brain changes preceded or followed the
behavioral improvement, so the exact mechanism of adult recovery is unclear.
But in another measure of brain synchrony, the adults who had recovered looked
more like adults with A.D.H.D.
In people without it, when the default mode network is active, another network,
called the task-positive network, is inhibited. When the brain is focusing, the
task-positive network takes over and quiets the default mode network. This
reciprocal relationship is necessary in order to focus.
Both groups of adult A.D.H.D. patients, including those who had recovered,
displayed simultaneous activation of both networks, as if the two regions were
out of step, working at cross-purposes. Thus, adults who lost most of their
symptoms did not have entirely normal brain activity.
What are the implications of this new research for how we think about and treat
kids with A.D.H.D.? Of course, I am not suggesting that we take our kids out of
school and head for the savanna. Nor am I saying we that should not use
stimulant medications like Adderall and Ritalin, which are safe and effective
and very helpful to many kids with A.D.H.D.
But perhaps we can leverage the experience of adults who grew out of their
symptoms to help these kids. First, we should do everything we can to help young
people with A.D.H.D. select situations — whether schools now or professions
later on — that are a better fit for their novelty-seeking behavior, just the
way adults seem to self-select jobs in which they are more likely to succeed.
In school, these curious, experience-seeking kids would most likely do better in
small classes that emphasize hands-on-learning, self-paced computer assignments
and tasks that build specific skills.
This will not eliminate the need for many kids with A.D.H.D. to take
psychostimulants. But let’s not rush to medicalize their curiosity, energy and
novelty-seeking; in the right environment, these traits are not a disability,
and can be a real asset.
Richard A. Friedman is a professor of clinical psychiatry and the director of
the psychopharmacology clinic at the Weill Cornell Medical College.
A version of this op-ed appears in print on November 2, 2014, on page SR1 of the
New York edition with the headline: A Natural Fix for A.D.H.D..
A Natural Fix for A.D.H.D., NYT, 31.10.2014,
http://www.nytimes.com/2014/11/02/opinion/sunday/a-natural-fix-for-adhd.html
Expansion of Mental Health Care
Hits Obstacles
AUG. 28, 2014
The New York Times
By ABBY GOODNOUGH
LOUISVILLE, Ky. — Terri Hall’s anxiety was back, making her hands
shake as she tried to light a cigarette on the stoop of her faded apartment
building. She had no appetite, and her mind galloped as she grasped for an
answer to her latest setback.
In January, almost immediately after she got Medicaid coverage through the
Affordable Care Act, she had called a community mental health agency seeking
help for the depression and anxiety that had so often consumed her.
Now she was getting therapy for the first time, and it was helping, no question.
She just wished she could go more often. The agency, Seven Counties Services,
has been deluged with new Medicaid recipients, and Ms. Hall has had to wait up
to seven weeks between appointments with her therapist, Erin Riedel, whose
caseload has more than doubled.
“She’s just awesome,” Ms. Hall said. “But she’s busy, very busy.”
The Affordable Care Act has paved the way for a vast expansion of mental health
coverage in America, providing access for millions of people who were previously
uninsured or whose policies did not include such coverage before. Under the law,
mental health treatment is an “essential” benefit that must be covered by
Medicaid and every private plan sold through the new online insurance
marketplaces.
The need is widely viewed as great: Nearly one in five Americans has a
diagnosable mental illness, according to the Department of Health and Human
Services, but most get no treatment. If the law’s goal is met, advocates say, it
will reduce not only personal suffering but also exorbitant economic costs, like
the higher rate of general health problems among those with mental illnesses,
and their lost productivity.
Kentucky has been trying to overhaul its mental health system, partly by
allowing private psychologists and social workers to accept Medicaid patients
for the first time. The change is crucial, state officials say, because 85
percent of the 521,000 Kentuckians who got coverage through the state’s new
insurance exchange this year were poor enough to enroll in Medicaid. Previously,
only psychologists and social workers at community health centers like Seven
Counties, which are quasi-governmental agencies, could provide outpatient
therapy to Medicaid recipients here. Now, more than 1,000 private mental health
providers statewide have signed up to treat Medicaid enrollees, according to the
state.
But shortfalls in care persist. In Louisville, a city of 600,000 where The New
York Times is looking periodically at the law’s impact, most new Medicaid
enrollees are flowing to four adult mental health clinics run by Seven Counties.
Calls to the agency’s access line, the starting point for new clients, are up by
more than 40 percent this year, said Kelley Gannon, its chief operating officer.
Seven Counties declared bankruptcy last year in the face of spiraling pension
costs, and a federal judge ruled that the agency could leave the state pension
system. Ms. Gannon says the services it provides are not in jeopardy.
Continue reading the main story
The last time Ms. Hall had seen Ms. Riedel, in late June, they had talked about
her plans to return to school with a Pell Grant and work toward an associate
degree. But the next day, an eviction notice arrived in Ms. Hall’s mailbox. She
had fallen behind on her rent and was being ordered to court. The coping
techniques she learned in therapy — taking long walks and deep, slow breaths,
for example — were not helping. Nor were the antidepressants and mood stabilizer
that a Seven Counties psychiatrist prescribed. And her next therapy appointment
was still more than four weeks away.
Ms. Hall is 52, with spiky, short blond hair and a deeply lined face that
attests to a life roiled by stress. Addictions to alcohol and the anti-anxiety
drug Xanax ended her marriage and gravely damaged her relationship with her son,
who is now 27. She faced losing her small downtown apartment, and with no income
at the moment other than a $600 monthly alimony check, her forward momentum was
under threat.
“I haven’t felt this way since I got my divorce,” she said as she stamped out
her cigarette, speaking fast and sweating in the damp morning heat. “Then, I
went back to Xanax, and I don’t want to do that this time. I want to be able to
handle this somehow.”
Treating the Community
Tana Jo Wright is doing her part to treat new Medicaid recipients with mental
health problems. It is just not as easy as she would like.
A licensed clinical social worker, Ms. Wright opened her own practice last fall
after working at a busy community clinic in the blighted West End of Louisville.
In a tiny rented office with a vase of peacock feathers on her desk, she is
seeing 15 clients, several of them new Medicaid recipients.
Like their physician counterparts, many private therapists refuse to accept
Medicaid, which pays on average about 66 percent of what Medicare does. In
addition, some therapists say, the paperwork takes too much time and the poor —
who often experience more violence and trauma than those who are better off —
are too challenging to treat. But Ms. Wright, 47, has a different outlook. She
grew up in rural Lebanon, Ky., had a tumultuous relationship with her adoptive
parents and was battered by a boyfriend at 16.
“Those experiences told me that people really need someone who will listen to
them,” she said. “And I thought: ‘You can do that. You would be a good therapist
because you know what people go through.’ ”
She has worked with drug addicts at a methadone clinic, with abused children and
teenagers at Seven Counties, and with low-income adults at Family Health
Centers, the clinic in the West End. Now that she is building her own practice,
she sees more clients with Medicare and private insurance. But she said she
remained committed to treating people on Medicaid, motivated by the therapists
who agreed to see her when she was struggling.
“I believe in treating the whole community,” Ms. Wright said, “including people
who can’t afford to pay.”
The new law is a big opportunity for mental health providers to reach more
people of all income levels. But in Kentucky and the 25 other states that chose
to expand Medicaid, the biggest expansion of mental health care has been for
poor people who may have never had such treatment before.
Still, private providers face considerable headaches in taking on Medicaid
patients, beyond the long-term deterrent of low reimbursement. Ms. Wright, for
instance, is still waiting to be approved by some of the managed care companies
that provide benefits to Medicaid recipients. Eager to build her client base,
Ms. Wright has taken on a handful of new Medicaid enrollees for free while she
waits for those companies to approve her paperwork.
“It’s been months and months,” she said. “It’s always there in my mind: Am I
going to make it?”
Her clients, and the progress she sees in them, are her sustenance. There is a
young man scarred by gang violence; an older woman whose daughter was murdered
years ago; a veteran with post-traumatic stress disorder. And there is Sarah
Davis, a Louisville native struggling to get past the bullying she experienced
as a child and her negative feelings about her hometown.
Ms. Davis, 30, was teaching English in Japan when the devastating earthquake and
tsunami struck in 2011. She came home, suffering nightmares and panic attacks
and clashing with her parents as she tried to readjust. Earning less than
$15,000 a year as a home health aide, Ms. Davis qualified for Medicaid under the
new law. She heard about Ms. Wright from someone at a meditation session and has
been seeing her once a week.
“So what’s happening?” Ms. Wright asked as Ms. Davis settled into a soft chair
in her office one summer afternoon, tucking her legs underneath her.
They talked about Ms. Davis’s precarious finances and her trouble finding a job
she loved. Then they returned to a familiar theme: Ms. Davis missing her life
abroad and chafing against the realities of adulthood in Louisville, where she
felt isolated and judged.
“My life used to be so beautiful and colorful, and I want that back,” she told
Ms. Wright.
“There are some great things about this town if you open yourself up to
experiences,” Ms. Wright countered as a small fan ruffled the peacock feathers.
Ms. Davis allowed that she had gotten back in touch with an old friend the
previous week and struck up a conversation with a new neighbor. Ms. Wright, who
has an emphatic laugh and a penchant for colorful “bling rings,” leaned forward
and smiled.
“Two times you’ve told me you stepped out of your comfort zone. That is
progress!” she said. “Take that in.”
Feeling Abnormal
As a teenage loner in Elizabethtown, Ky., Ms. Hall never felt normal. “I knew
something was wrong with me,” she said, “but I didn’t know what.” She had a
chronically ill mother and a domineering father. Always anxious, swinging
between high moods and low, she started drinking heavily after she got married
at 22.
Ms. Hall temporarily stopped drinking when her son was born a few years later.
But then she became addicted to Xanax — “I was still numbing myself,” she said —
and resumed drinking once her son started kindergarten.
Her husband divorced her in 2004 and married one of their friends. She made
several suicide attempts, she said. After her father paid for her to go to
rehab, she moved to Louisville in 2011 to live in a halfway house for recovering
addicts. When she found the rental apartment last year, she sold her last asset,
a car, so that she could afford the rent of $475 a month plus utilities. She was
working at the time, running concession stands at sporting events, but making
only about $500 a month.
By the beginning of this year, loneliness and grief about her severed
relationships with her ex-husband, son and other family members threatened to
swallow her again.
Without therapy, “I would have gone back to drinking and using drugs, because I
was hurting so bad that there was nothing left for me to do,” she said. “I knew
I would not live the rest of this year.”
In an interview, Ms. Riedel, 33, said that Ms. Hall’s therapy sessions had been
successful because she had been so motivated — so desperate — to change.
“She’s still struggling with some pretty serious life issues,” she said, “but
her attitude has changed so much. She’s so much more optimistic.”
As her outlook improved in recent months, Ms. Hall busied herself with other
projects. Besides registering for community college and applying successfully
for a Pell Grant, she used her new health insurance to get treatment for spinal
stenosis, which causes pain and numbness in the legs and back, and forced her,
she said, to leave her job. She also sought assistance from an agency that helps
people with disabilities, which gave her some tuition money and is helping her
look for jobs.
Even when adversity struck, Ms. Hall stayed purposeful. Within a day of getting
the eviction notice, she gathered the names of a dozen organizations that might
provide rent assistance, dialing one after the other from her mother’s antique
rocking chair in her apartment. She did not find any organization willing to
help pay her back rent, but her relentless research did lead to another option.
For $248 a month, she could move to a privately operated “sober living” house.
She started packing her apartment, but took a break one recent morning to attend
a group-therapy session with Ms. Riedel.
“We haven’t really gotten to talk, and so much has happened,” she said. “I just
want her to be proud.”
As of that morning in mid-July, Ms. Riedel’s schedule was booked six weeks out;
her caseload had grown in the past year to 263 clients, up from 100 just a year
before. But Seven Counties was hiring new therapists, Ms. Riedel said, and she
hoped to soon return to seeing Ms. Hall once every two weeks.
Given the long waits for individual therapy sessions, Seven Counties is urging
new clients to also try group therapy, for which there is no wait. Ms. Hall has
sometimes attended Ms. Riedel’s weekly “Empowering Women” group, and at one
recent session, she sat at an oval table with Ms. Riedel and four other women,
paper and pen before her in case she gleaned something interesting. She was
quiet as several of the others discussed their own problems: an abusive
relationship; binge-eating; regret about growing old.
Finally, it was her turn. “Terri, how about you?” Ms. Riedel asked.
“Well, I got an eviction notice,” she said. “But I found a place, it’s for sober
living. The woman who runs it accepted my application, but she wants to meet
with me and talk first. I’m just praying everything goes well.”
A week later, things took another turn for the worse. Ms. Hall went home to
Elizabethtown and stayed a day longer than she had planned to attend a family
funeral. When she returned, she learned that she had lost the room in the
sober-living house because she had not arrived on the appointed date.
She moved in temporarily with a neighbor, and then a friend, leaving her few
possessions in the basement of her former building. She attended more group
therapy sessions, thought about college starting and pictured herself in her
first class: psychology. Last week, she finally returned to Ms. Riedel’s office,
her hands shaking again as she unloaded weeks’ worth of tribulations. She talked
about the pain of being judged by her family — if they knew about her eviction,
she said, “they’d be madder than heck at me.” With Ms. Riedel’s support, she
decided to stop contacting them for now.
She also discussed her fear of not finding a new home, and Ms. Riedel offered
reassurance. “You are taking steps toward a career that will give you a steady
income,” she said. “You are a very resilient person. I see this as you
bouncing.”
The 45 minutes flew and they made another appointment, only two weeks away. Ms.
Riedel said that in the meantime, she would see if Medicaid would pay for a
caseworker to help Ms. Hall with things like finding housing.
“Are you feeling O.K. right now?” Ms. Riedel asked as Ms. Hall got up to leave.
“Yes,” Ms. Hall said, tucking away her appointment card. “I’ll be fine.”
A version of this article appears in print on August 28, 2014,
on page A1 of the New York edition with the headline: Expansion of Mental Health
Care Hits Obstacles.
Expansion of Mental Health Care Hits
Obstacles, NYT, 28.8.2014,
http://www.nytimes.com/2014/08/28/us/
expansion-of-mental-health-care-hits-obstacles.html
The Heavy Burden
of Post-Traumatic Stress Disorder
JUNE 20, 2014
The New York Times
The Opinion Pages | Editorial
By THE EDITORIAL BOARD
Post-traumatic stress disorder has reached staggering levels
in the American military. An estimated 7 percent to 20 percent of all service
members and veterans who have served in the wars in Afghanistan and Iraq may
have the disorder, and rising percentages of veterans from earlier conflicts are
also afflicted.
The Departments of Defense and of Veterans Affairs have poured billions of
dollars into treating the debilitating condition. Yet neither department really
knows whether the treatments offered and applied are effective, according to a
report issued Friday by the Institute of Medicine, a unit of the National
Academy of Sciences, which had been asked by Congress to evaluate the programs.
The disorder is characterized by severe mental health problems — like repeatedly
reliving a battlefield trauma, hiding from anything that might trigger those
memories, and adverse swings in moods or thoughts — that persist for at least a
month and impair functioning.
Such symptoms can occur soon after a traumatic event or not until years later.
The disorder can last a lifetime, and it can impair physical and mental health,
family and social relationships and the ability to perform a job.
Since October 2001, more than 2.6 million American military personnel have been
deployed to Afghanistan and Iraq. The proportion of service members who have
PTSD increased from less than 1 percent in 2004 to more than 5 percent in 2012.
In that year, some 500,000 veterans made at least two visits to veterans’
hospitals or clinics for outpatient care of the disorder; they made up 9 percent
of all users of V.A. health services, up from 4 percent in 2002. The Defense
Department spent some $294 million and Veterans Affairs some $3 billion on care
for the disorder in 2012.
The agencies have combined to develop and disseminate clinical guidelines to
help doctors choose the best treatments, such as various psychotherapies and
pharmacotherapies that are backed by scientific evidence. Yet none of this
knowledge is applied consistently. The Institute of Medicine said it was unclear
what therapies most military members or veterans get and whether their symptoms
improve as a result.
Although the departments have substantially increased their mental health
staffing in recent years, the demand for services has increased even faster,
causing yearslong waits for what V.A. doctors consider “minimally adequate
mental health care.” Another impediment is lack of coordination between the two
huge departments.
What is needed, the institute’s report says, is a better integrated approach and
the collection of data to document which practices and treatments work best and
how patients progress over the years. Those who have suffered mental trauma on
the battlefield deserve the best care the nation can provide.
A version of this editorial appears in print on June 21, 2014,
on page A20 of the New York edition with the headline:
The Heavy Burden of Stress Disorder.
The Heavy Burden of Post-Traumatic Stress
Disorder, NYT, 20.6.2014,
http://www.nytimes.com/2014/06/21/opinion/
the-heavy-burden-of-post-traumatic-stress-disorder.html
Guns and Mental Illness
JUNE 2, 2014
The New York Times
The Opinion Pages | Op-Ed Columnist
It is difficult to read stories about Elliot Rodger, the
22-year-old man who went on a murderous spree in Isla Vista, Calif., last month,
without feeling some empathy for his parents.
We know that his mother, alarmed by some of his misogynistic YouTube videos,
made a call that resulted in the police visiting Rodger. The headline from that
meeting was that Rodger, seemingly calm and collected, easily deflected the
police’s attention. But there was surely a subtext: How worried — how desperate,
really — must a mother be to believe the police should be called on her own son?
We also learned that on the day of his murderous rampage, his mother, having
read the first few lines of his “manifesto,” had phoned his father, from whom
she was divorced. In separate cars, they raced from Los Angeles to Santa Barbara
hoping to stop what they feared was about to happen.
And then, on Monday, in a remarkably detailed article in The New York Times, we
learned the rest of it. How Rodger was clearly a troubled soul before he even
turned 8 years old. How his parents’ concern about his mental health was like a
“shadow that hung over this Los Angeles family nearly every day of Elliot’s
life.”
Constantly bullied and unable to fit in, he went through three high schools. In
college, he tried to throw a girl off a ledge at a party — and was beaten up.
(“I’m going to kill them,” he said to a neighbor afterward.) He finally
retreated to some Internet sites that “drew sexually frustrated young men,”
according to The Times.
Throughout, said one person who knew Rodger, “his mom did everything she could
to help Elliot.” But what his parents never did was the one thing that might
have prevented him from buying a gun: have him committed to a psychiatric
facility. California’s tough gun laws notwithstanding, a background check would
have caught him only if he had had in-patient mental health treatment, made a
serious threat to an identifiable victim in the presence of a therapist, or had
a criminal record. He had none of the above.
Should his parents have taken more steps to have him treated? Could they have?
It is awfully hard to say, even in retrospect. On the one hand, there were
plainly people who knew him who feared that he might someday harm others. On the
other hand, those people weren’t psychiatrists. He was a loner, a misfit, whose
parents were more fearful of how the world would treat their son than how their
son would treat the world. And his mother, after all, did reach out for help,
and the police responded and decided they had no cause to arrest him or even
search his room, where his guns were hidden.
Once again, a mass killing has triggered calls for doing something to keep guns
away from the mentally ill. And, once again, the realities of the situation
convey how difficult a task that is. There are, after all, plenty of young,
male, alienated loners — the now-standard description of mass shooters — but
very few of them become killers.
And you can’t go around committing them all because a tiny handful might turn
out to be killers. Indeed, the law is very clear on this point. In 1975, the
Supreme Court ruled that nondangerous mentally ill people can’t be confined
against their will if they can function without confinement. “In California, the
bar is very high for people like Elliot,” said Dr. E. Fuller Torrey, who founded
the Treatment Advocacy Center. In a sense, California’s commitment to freedom
for the mentally ill conflicts with its background-check law.
Torrey believes that the country should involuntarily commit
more mentally ill people, not only because they can sometimes commit acts of
violence but because there are far more people who can’t function in the world
than the mental health community likes to acknowledge.
In this, however, he is an outlier. The mainstream sentiment among mental health
professionals is that there is no going back to the bad-old days when people who
were capable of living on their own were locked up for years in mental
hospitals. The truth is, the kind of symptoms Elliot Rodger showed were unlikely
to get him confined in any case. And without a history of confinement, he had
every legal right to buy a gun.
You read the stories about Elliot Rodger and it is easy to think: If this guy,
with all his obvious problems, can slip through the cracks, then what hope is
there of ever stopping mass shootings?
But, of course, there is another way of thinking about this. Instead of focusing
on making it harder for the mentally ill to get guns, maybe we should be making
it harder to get guns, period. Something to consider before the next mass
shooting.
A version of this op-ed appears in print on June 3, 2014,
on page A23 of the New York edition with the headline:
Guns and Mental Illness.
Guns and Mental Illness, NYT, 2.6.2014,
http://www.nytimes.com/2014/06/03/opinion/nocera-guns-and-mental-illness.html
Depressed, but Not Ashamed
MAY 21, 2014
The New York Times
The Opinion Pages | Op-Ed Contributors
By MADELINE HALPERT
and EVA ROSENFELD
ANN ARBOR, Mich. — MOST of our closest friends didn’t know
that we struggled with depression. It just wasn’t something we discussed with
our high school classmates. We found that we both had taken Prozac only when one
of us caught a glimpse of a prescription bottle in a suitcase during a
journalism conference last November. For the first time, we openly discussed our
feelings and our use of antidepressants with someone who could relate. We took a
risk sharing our experiences with depression, but in our honesty, we found a
support system. We knew we had to take the idea further.
In the United States, for people between the ages of 10 and 24, suicide is the
third leading cause of death, according to the Centers for Disease Control and
Prevention. Untreated depression is one of the leading causes of suicide.
According to the National Comorbidity Survey: Adolescent Supplement, 11 percent
of adolescents have a depressive disorder by age 18.
We were not alone. We wondered why, with so many teenagers dealing with
depression, it was still addressed in such impersonal ways.
As editors at our high school newspaper, we decided to fight against the stigma
and proposed devoting a whole edition to personal stories from our peers who
were suffering from mental illness. We wanted honesty with no anonymity.
We knew that discussing mental health in this way would be edgy, even for our
progressive community in Michigan. But we were shocked when the school
administration would not allow us to publish the articles.
With the help of other journalism students, we interviewed teenagers from around
our school district who shared stories of depression, eating disorders,
homelessness, prescription abuse, insomnia and anxiety. Many discussed their
personal struggles for the first time. All agreed to attach their full name — no
anonymity or pseudonyms. Following online recommendations of the Student Press
Law Center, we asked the parents of each student to sign consent forms for the
articles.
As we were putting the stories together, the head of our school called us into
her office to tell us about a former college football player from our area who
had struggled with depression and would be willing to let us interview him. We
wondered why she was proposing this story to us since he wasn’t a current high
school student. We declined her suggestion. We didn’t want to replace these
deeply personal articles about our peers with a piece about someone removed from
the students. After we asked her why she was suggesting this, she told us that
she couldn’t support our moving forward with the articles.
From an administrative perspective, this made some sense. It is her job to
protect the students to the best of her ability. She believed that the
well-being of those who shared their experiences — and most important, their
names — would be put at risk because of potential bullying. She also mentioned
that she had consulted a mental health professional, who told her that reading
about their own depression could trigger a recurrence in some of the students
and that those who committed to telling their stories might regret it later.
Our school has a very tolerant atmosphere, and it even has a depression
awareness group, so this response seemed uncharacteristic. We were surprised
that the administration and the adults who advocated for mental health awareness
were the ones standing in the way of it. By telling us that students could not
talk openly about their struggles, they reinforced the very stigma we were
trying to eliminate.
The feeling of being alone is closely linked to depression. This can be
exacerbated if there is no one to reach out to. Though there are professionals
to talk to, we feel it doesn’t compare to sharing your experiences with a peer
who has faced similar struggles. And, most important to us, no one afflicted
with a mental illness should have to believe that it’s something he should feel
obliged to hide in the first place. If someone has an illness such as diabetes,
she is not discouraged from speaking about it. Depression does not indicate
mental weakness. It is a disorder, often a flaw of biology, not one of
character.
By interviewing these teenagers for our newspaper, we tried — and failed — to
start small in the fight against stigma. Unfortunately, we’ve learned this won’t
be easy. It seems that those who are charged with advocating for our well-being
aren’t ready yet to let us have an open and honest dialogue about depression.
Madeline Halpert, a junior,
and Eva Rosenfeld, a sophomore,
are managing editors at their high school newspaper
in Michigan.
A version of this op-ed appears in print on May 22, 2014,
on page A29 of the New York edition with the headline:
Depressed, but Not Ashamed.
Depressed, but Not Ashamed, NYT, 21.5.2014,
http://www.nytimes.com/2014/05/22/opinion/depressed-but-not-ashamed.html
Report Says Medication Use Is Rising
for Adults With Attention Disorder
MARCH 12, 2014
The New York Times
By ALAN SCHWARZ
The number of young American adults taking medications for
attention deficit hyperactivity disorder nearly doubled from 2008 to 2012,
according to a report to be released Wednesday by the nation’s largest
prescription drug manager.
The drug manager, Express Scripts, which processes prescriptions for 90 million
Americans, also found that almost one in 10 adolescent boys were taking
medications for the disorder, usually stimulants such as Adderall or Concerta.
Some experts said the report provided the clearest evidence to date that the
disorder is being diagnosed and treated with medication in children far beyond
reasonable rates, and that steeply rising diagnoses among adults might portend
similar problems. These drugs can temper hallmark symptoms like severe
inattention and hyperactivity but also carry risks like sleep deprivation,
appetite suppression and, more rarely, addiction and hallucinations.
In examining actual prescriptions filled, the report also strongly corroborated
data from several government surveys that many prominent mental health experts
had discredited for relying on parents’ recollections of their children’s health
care.
“It’s hard to dismiss the data in this report,” said Brooke Molina, an associate
professor of psychiatry at the University of Pittsburgh School of Medicine and
one of the disorder’s leading researchers. “There are limitations with every
study, but it’s hard to do anything here but conclude that we have a continually
forward-marching increase.”
Dr. Lawrence Diller, a behavioral pediatrician in Walnut Creek, Calif., said
that he hoped the Express Scripts report would extinguish questions of how many
children are taking A.D.H.D. medications, and direct attention toward possible
solutions.
“How long will experts’ heads remain in the sand on this epidemic?” Dr. Diller
said.
Express Scripts, which is based in St. Louis, said it analyzed a nationally
representative sample of 400,000 people ages 4 to 64 who filled at least one
prescription for an A.D.H.D. medication from 2008 to 2012.
Medications included stimulants like Adderall and Concerta, as well as newer
nonstimulant formulations such as Strattera. Express Scripts reported that the
number of American adults receiving prescriptions for A.D.H.D. drugs had risen
53 percent, to an estimated 2.6 million in 2012 from 1.7 million in 2008. Use
among young adults ages 26 to 34 almost doubled, to 640,000 from 340,000, during
the four years.
Several mental health experts ascribed the steep rises among adults to better
medical and societal understanding that the disorder affects more than just
children. Some studies estimate that about 10 million adults have it, suggesting
that medication use still has plenty of room to grow.
“We still know that a majority of adults with A.D.H.D. are untreated,” said Dr.
Lenard A. Adler, director of the adult A.D.H.D. program at NYU Langone Medical
Center.
Paula Rudofsky, a 56-year-old resident of Chappaqua, N.Y., was among the adults
who received a diagnosis of the disorder and began taking Adderall in 2010. “We
always felt that it was something for children,” she said. “It’s almost a relief
to be told there’s something you can do to help.”
Express Scripts reported that use of medication among children, already much
higher than among adults, rose less — about 19 percent over the four years — but
still reached levels that many experts found troublesome.
In 2012, 5.7 percent of all children ages 4 to 18 were being prescribed A.D.H.D.
medications, 7.8 percent of boys and 3.5 percent of girls. (More boys receive
the diagnosis because they tend to appear more hyperactive.) Among adolescents
12 to 18, however, the rates reached 9.3 percent of boys and 4.4 percent of
girls.
Adjusting for age ranges and insurance coverage, these rates and others confirm
those reported last year by the federal Centers for Disease Control and
Prevention through its telephone survey of 76,000 parents nationwide. While some
onlookers said those data demonstrated overmedication of the condition in
children, most influential experts dismissed the evidence as lacking scientific
rigor.
An article published by the American Medical Association stated that such
studies “overestimate true prevalence” of A.D.H.D. diagnoses, while Dr. Sanjay
Gupta of CNN reported, “There’s not a lot of value in these studies.”
In an interview last year, Dr. Peter Jensen, then of the Mayo Clinic in
Rochester, Minn., said: “Single-question surveys based on yes-no parent report
are notoriously inaccurate. You simply can’t make scientific statements based on
them.” In a follow-up interview on Tuesday, Dr. Jensen said that the C.D.C.
survey probably was more accurate than he originally thought.
The agency had conducted similar surveys since 2003, to similar skepticism. In
reporting prescriptions actually filled, however, the Express Scripts report
strongly supported the C.D.C.’s data as accurate, Dr. Molina and Dr. Diller
said.
Susanna Visser, the C.D.C.’s lead epidemiologist for the disorder since 2006,
said that experts’ consistently discrediting the agency’s survey data over many
years had cost the public not just understanding of the issue but also the
consideration of possible solutions.
Children’s inattention can be caused by many factors beyond A.D.H.D. —
inadequate sleep, anxiety and more — that stimulants not only do not address,
but can also exacerbate. Improper prescriptions for stimulants have fueled the
sharing and selling of pills, particularly among high school and college
students who use them to improve focus and perhaps achieve better grades.
A Partnership at Drugfree.org study last year reported that almost one in 10
teenagers admitted having misused or abused stimulants, with that number
believed to be higher in high-pressure schools.
“It’s difficult to respond to the patterns that we see if the patterns in
diagnosis and medication are not taken seriously,” Dr. Visser said, adding that
she was not involved in the Express Scripts report. “We need to look at these
patterns as a whole public health need in order to appropriately respond, and
not snipe over the prevalence estimates.”
Dr. Visser pointed to increasing evidence that young adults are abusing
stimulants as well, with significant health costs. A report last year by the
federal Substance Abuse and Mental Health Administration found that emergency
room visits related to nonmedical use of stimulants among adults tripled from
2005 to 2010, to more than 22,000.
Dr. Adler said that those signs need to be heeded as increasing numbers of
adults visit their doctors for A.D.H.D. evaluations.
“As we move forward, we want to make sure that people who have the disorder get
the prescription,” he said. “And that people who don’t have the disorder don’t.”
A version of this article appears in print on March 12, 2014,
on page A16 of the New York edition with the headline:
Report Says Medication Use Is Rising for Adults
With Attention Disorder.
Report Says Medication Use Is Rising
or
Adults With Attention Disorder,
NYT, 12.3.2014,
http://www.nytimes.com/2014/03/12/us/
report-says-medication-use-is-rising-for-adults-with-attention-disorder.html
Inside a Mental Hospital Called Jail
FEB. 8, 2014
The New York Times
Nicholas Kristof
CHICAGO — THE largest mental health center in America is a
huge compound here in Chicago, with thousands of people suffering from manias,
psychoses and other disorders, all surrounded by high fences and barbed wire.
Just one thing: It’s a jail. The only way to get treatment is to be arrested.
Psychiatric disorders are the only kind of sickness that we as a society
regularly respond to not with sympathy but with handcuffs and incarceration. And
as more humane and cost-effective ways of treating mental illness have been cut
back, we increasingly resort to the law-enforcement toolbox: jails and prisons.
More than half of prisoners in the United States have a mental health problem,
according to a 2006 Justice Department study. Among female inmates, almost
three-quarters have a mental disorder.
In the jail here, some prisoners sit on their beds all day long, lost in their
delusions, oblivious to their surroundings, hearing voices, sometimes talking
back to them. The first person to say that this system is barbaric is their
jailer.
“It’s criminalizing mental illness,” the Cook County sheriff, Thomas Dart, told
me as he showed me the jail, on a day when 60 percent of the jail’s intake
reported that they had been diagnosed with mental illness. Dart says the system
is abhorrent and senseless, as well as an astronomically expensive way to treat
mental illness — but that he has no choice but to accept schizophrenic, bipolar,
depressive and psychotic prisoners delivered by local police forces.
People are not officially incarcerated because of psychiatric ailments, but
that’s the unintended effect. Sheriff Dart says that although some mentally ill
people commit serious crimes, the great majority are brought in for offenses
that flow from mental illness.
One 47-year-old man I spoke to, George, (I’m not permitted to use last names for
legal reasons) is bipolar, hears voices and abuses drugs and alcohol. He said he
had been arrested five times since October for petty offenses. The current
offense is criminal trespass for refusing to leave a Laundromat.
The sheriff says such examples are common and asks: “How will we be viewed, 20,
30, 50 years from now? We’ll be looked on as the ones who locked up all the
mentally ill people.
“It really is one of those things so rich with irony: The same society that
abhorred the idea that we lock people up in mental hospitals, now we lock people
up in jails.”
A few data snapshots:
• Nationwide in America, more than three times as many mentally ill people are
housed in prisons and jails as in hospitals, according to a 2010 study by the
National Sheriffs’ Association and the Treatment Advocacy Center.
• Mentally ill inmates are often preyed upon while incarcerated, or disciplined
because of trouble following rules. They are much more likely than other
prisoners, for example, to be injured in a fight in jail, the Justice Department
says.
• Some 40 percent of people with serious mental illnesses have been arrested at
some point in their lives.
In the 1800s, Dorothea Dix led a campaign against the imprisonment of the
mentally ill, leading to far-reaching reforms and the establishment of mental
hospitals. Now we as a society have, in effect, returned to the 1800s.
Among those jailed here is Russell, 46, who is being held for burglarizing a
garage. He has been diagnosed with severe depression and said that he
self-medicates with alcohol and drugs. Most of his adult life has been spent
behind bars for one offense after another, and he said he became aware of his
mental health problems when he was being clubbed by a thug with a baseball bat
and realized that he was enjoying it.
“I just want to be normal,” he said as we spoke in a large dormitory room for
inmates with psychiatric problems. “I want to have a job. I’ve never had a job.
I want to be able to say hi to a co-worker.” He stopped, and there were tears in
his eyes.
In 1955, there was one bed in a psychiatric ward for every 300 Americans; now
there is one for every 3,000 Americans, the 2010 study said. So while more
effective pharmacological treatments are theoretically available, they are often
very difficult to access for people who are only borderline functional.
“Some people come here to get medication,” says Ardell Hall, a superintendent of
a women’s unit at the jail. “They commit a crime to get in.”
India, a 42-year-old woman, suffers from manic depression and post-traumatic
stress disorder. She said she tried at various times to get psychiatric care but
found it almost impossible, so she self-medicates when on the outside with
heroin — and has spent almost all of her adult life in jails and prisons on a
succession of nonviolent offenses relating to drugs and shoplifting.
TAXPAYERS spend as much as $300 or $400 a day supporting
patients with psychiatric disorders while they are in jail, partly because the
mentally ill require medication and extra supervision and care.
“Fiscally, this is the stupidest thing I’ve seen government do,” Dart says. It
would be far cheaper, he adds, to manage the mentally ill with a case worker on
the outside than to spend such sums incarcerating them.
Cook County has implemented an exemplary system for mental health support for
inmates. While in jail, they often stabilize. Then they are released, go off
their medications and the cycle repeats.
One woman in the jail, Kristen, said she had been diagnosed with depression and
anxiety disorders. On the outside, her prescription medication cost $100 a
month, so she skipped it.
“When I’m not on my medicine on a regular basis, I don’t make decisions well,”
she said, explaining her long arrest record for theft and narcotics offenses. I
asked her if access to medicine would keep her out of jail, and she said: “I
don’t know if that’s necessarily true, to be totally honest. But it would help.”
As Sheriff Dart puts it: “We’ve systematically shut down all the mental health
facilities, so the mentally ill have nowhere else to go. We’ve become the de
facto mental health hospital.”
Do we really want to go back two centuries? Doesn’t that seem not only inhumane
but also deluded — on our part?
I invite you to comment on this column on my blog,
On the Ground.
Please also join me on Facebook and Google+,
watch my YouTube videos and follow me on Twitter.
A version of this op-ed appears in print
on February 9, 2014,
on page SR1 of the New York edition
with the headline:
Inside a Mental Hospital Called Jail.
Inside a Mental Hospital Called Jail, NYT,
8.2.2014,
http://www.nytimes.com/2014/02/09/opinion/sunday/
inside-a-mental-hospital-called-jail.html
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