A BRIEF HISTORY
Historically, mental illness has been
feared and misunderstood, and those suffering from it have been
stigmatized. In colonial America, people with mental illness were
called "lunaticks" and were usually cared for at home by their
families. Often, this meant consigning the suffering individual to
a basement or attic for long periods of time. Treatment consisted
of humane custodial care at best, quackery or cruelty at worst.
By
the 19th century, asylums were built so that people with mental
illness could be cared for away from their home community. The
various treatments that were provided were largely ineffective. In
some cases, they were administered by well-meaning staff who at
least treated their patients with dignity; too often, however, they
were dispensed by inappropriate staff who cruelly mistreated their
patients.
In
the early 20th century, asylums became "mental hospitals," and the
numbers of Americans committed within their walls grew
substantially, reaching a high of nearly 560,000 in 1955. This rise
was driven, in part, by the large number of World War I and World
War II veterans whose combat experiences triggered chronic mental
illness. Approximately 90 percent of those hospitalized suffered
from a psychotic disorder; they had lost touch with reality and, in
many cases, experienced delusions and/or hallucinations.
In
the mid-1950s, the discovery of antipsychotic medications such as
chlorpromazine sparked a revolution in mental hospitals. These new
medications controlled psychotic symptoms, and for the first time,
people with schizophrenia and other psychotic disorders could be
discharged and returned to their home communities. The census of
mental hospitals began a dramatic drop in their rolls, which now
stand at just over 55,000.
This
movement away from hospital care became known as
"deinstitutionalization," as hundreds of thousands of people who
would otherwise have lived much of their lives in institutions were
able to go home. The initial hope was that antipsychotic medication
would do for mental illness what penicillin did for
infections--provide a cure for most cases. Instead, the process of
drug treatment and deinstitutionalization brought about new
problems. The medications themselves turned out to be problematic
because they sometimes triggered severe side effects, and
deinstitutionalization gave rise to a critical need for treatment
and support services in the home community.
In
response to this dilemma, a complementary revolution in mental
health care soon developed--the community mental health movement.
The goal was to provide outpatient services so that people with
mental illness could receive needed care in their home communities.
Community mental health centers (CMHCs) were launched with federal
funding in the 1960s, and there are many dedicated and talented
providers offering excellent care in today's CMHCs. Unfortunately,
however, the CMHC system is now functioning largely without
evidence of treatment effectiveness--and often without the full
range of community supports and services necessary to provide
effective care. Consequently, it is not unusual for a person with
mental illness to end up back on the street, receiving inadequate
treatment in the community, after being discharged from a
psychiatric hospital.
This
situation contributes to a rising population of the "homeless
mentally ill," and seems to provide evidence for the claim that
deinstitutionalization has failed. In fact, both
deinstitutionalization and community mental health care constitute
good public policy if they are correctly implemented. What is
lacking in the vast mental health service delivery system that has
grown up over the past 40 years is competitive, results-oriented
accountability.
Overview
This year, over $69
billion will be spent on direct treatment for mental illness, yet
many afflicted individuals will receive ineffective care--or no
care.
Consequently, there is a growing mental health care crisis in
America today, and constituents are turning to policymakers for
solutions. What is mental illness, and how can it best be treated?
What are the most serious forms of mental illness? Can insurance
parity, new Medicaid programs, or increased funding improve
ineffective services? This paper is written to provide a starting
point for policymakers facing these and related questions by
offering the following:
- A definition of mental illness, serious
mental illness, and mental health problems;
- A review of community resources that
prevent mental illness;
- An introduction to the major categories of
serious mental illness;
- An introduction to treatment for serious
mental illness;
- A recommendation for improving
effectiveness of mental health services; and
- A review of some current policy
issues.
WHAT IS MENTAL ILLNESS?
Mental illness is surprisingly difficult
to define. Unlike physical illness, there is neither a pathogen
that can be identified and treated nor a viral or bacterial
infection that can be readily observed. The affected organ is, of
course, the brain, and many mental illnesses are associated with
changes in brain chemistry. But the etiology, or cause, of mental
illness remains largely unknown.
Behavioral scientists work with a
"biopsychosocial" model, which means that a given
mental illness (such as depression) may have a biological component
(such as a genetic neurological predisposition to depression); a
psychological component (such as negative thought processes feeding
depression); and/or a social component (such as a significant loss
that triggers depression). The biopsychosocial model of mental
illness has proven useful for research and treatment, and provides
a good starting point for the policy arena as well.
Two
Definitions of Mental Illness
The National
Alliance for the Mentally Ill (NAMI), the nation's largest mental
health advocacy organization, defines mental illness as a "disorder
of the brain" that "disrupts a person's thinking, feeling, moods,
and ability to relate to others...[and] often results in a
diminished capacity for coping with the ordinary demands of
life."
NAMI works from the premise that most people with serious mental
illness need medication and that recovery often requires counseling
and community support services as well.
NAMI
is involved in the policy arena at both the state and federal
levels and is known for its focus on "serious mental illness"
rather than milder forms. Targeting serious mental illness makes
good sense, from both a clinical and a practical point of view.
With limited resources, policymakers should address the needs of
those who are most seriously ill on a priority basis.
The
1999 Surgeon General's Report on Mental Health defines mental
illness as "diagnosable mental disorders...characterized by
alterations in thinking, mood, or behavior...associated with
distress and/or impaired functioning." In this definition,
"diagnosable" is the operative word, and it is what distinguishes
mental illness from other, less serious problems in dealing with
the typical tasks of life.
Saying that mental illness is diagnosable
means that its symptoms meet the criteria specified in the
Diagnostic and Statistical Manual of Mental Disorders--Fourth
Edition (DSM-IV). The DSM-IV, published by the American Psychiatric
Association, lists observable/reportable criteria for every
recognized classification of mental illness. For instance, to be
diagnosed as suffering depression, an individual would have
experienced for a period of time at least five of nine specific
symptoms, including sad mood, sleep disturbance, low energy,
difficulty concentrating, and thoughts of self-harm. Since public
and private health insurers typically rely on DSM-IV diagnoses when
considering coverage for mental illness, this manual has come to
play a critical role in mental health care policy.
Drawing on a combination of these
definitions, the following is a working definition of mental
illness that could be used by policymakers: "Mental illness is a
biopsychosocial brain disorder characterized by dysfunctional
thoughts, feelings, and/or behaviors that meet DSM-IV diagnostic
criteria."
WHAT IS "SERIOUS" MENTAL ILLNESS?
Although the above definition provides a
useful starting point for policymakers who are considering mental
health matters, it is too broad in that it includes some types of
mental illness that lie outside the realm of public policy and are
best addressed by an individual's family and community. The DSM-IV
definitions were not designed to identify the most critical health
needs that should be prioritized by policymakers; rather, they were
developed by mental health researchers whose goal was to provide
distinct classifications for all experiences outside the "norm."
Such deviations from the norm that are included in the DSM-IV range
from simple cases of caffeine intoxication to life-threatening
major depression.
Caffeine intoxication results from the
ingestion of excessive amounts of caffeine, which results in
symptoms such as restlessness, insomnia, and nervousness. Although
many college students have experienced the results of a caffeine
overdose while studying for exams, it is unlikely that this form of
"mental illness" is serious enough to warrant treatment covered by
public programs or private insurance.
Major depression, on the other hand, can
be debilitating in the extreme and often includes suicidal thoughts
or actions. Untreated, it can literally end in death. More often,
it leads to a life of increasing dysfunction at home, at school, or
in the work place. It is clear that this form of mental illness is
serious enough to warrant treatment and that effective treatment
should be made available either through private insurance or
through the public mental health system.
Serious
Mental Illness Defined
Mental health
researchers and policymakers have labored for some time to define
serious mental illness (SMI) in order to distinguish it from less
severe forms of dysfunction. This definition is critical to
ensuring that care is provided for the most serious and damaging
cases of mental illness. Identifying and treating SMI is every bit
as important as treating physical disabilities, such as loss of
hearing. Private insurance and public funds should prioritize the
needs of those with serious mental illness, whereas assistance from
family, friends, and the community may be sufficient to address
less severe forms of mental illness, such as bereavement or conduct
disorder.
Although policymakers do not fully agree
on which diagnostic classifications to designate as SMI, a working
model could include the following categories:
- All cases of schizophrenia (a psychotic
disorder);
- Severe cases of major depression and
bipolar disorder (mood disorders);
- Severe cases of panic disorder,
obsessive-compulsive disorder, and post-traumatic stress disorder
(anxiety disorders);
- Severe cases of attention
deficit/hyperactivity disorder (typically, a childhood disorder);
and
- Severe cases of anorexia nervosa (an
eating disorder).
Accordingly, this paper defines SMI as a
subcategory of mental illness, based on both diagnostic
classification and severity. All those who suffer from
SMI are indeed disabled and in need of effective treatment, whether
they are children, adolescents, adults, or elderly people.
Severity
Since severity is included in the definition of SMI, it is
necessary to define what is meant by severe cases. For many
diagnoses, including depression, the DSM-IV includes specifying the
severity of a disorder as being mild, moderate, or severe. The
DSM-IV defines "severe" as cases in which "many symptoms in excess
of those required to make the diagnosis or several symptoms that
are particularly severe are present, or the symptoms result in
marked impairment in social or occupational functioning" (p. 2). In
contrast, the DSM-IV defines as "mild" cases in which "few, if any,
symptoms in excess of those required to make the diagnosis are
present, and symptoms result in no more than minor impairment in
social or occupational functioning" (p. 2). Additionally, the DSM-IV
includes a "Global Assessment of Functioning Scale" for measuring
severity on a scale of 0 to 100. Scores under 50 are considered
serious.
Using this definition, a mild anxiety
disorder would be minimally disruptive and would be seen as a
mental health problem to be addressed with indigenous community
resources. On the other hand, a severe anxiety disorder would be
significantly disruptive and would constitute a serious mental
illness requiring professional treatment. This same distinction
applies throughout all SMI categories with the exception of
schizophrenia, all cases of which are considered severe.
SYMPTOMS AND TREATMENT OF SERIOUS MENTAL
ILLNESS
As
described above, SMI includes schizophrenia and severe cases of
seven other mental disorders. Unfortunately, there is much
confusion both about mental illness in general and about its
specific disorders, as is indicated by such questions as "Is mental
illness caused by poor parenting?" or "Can mental illness be
'caught' by spending time with a person suffering from SMI?"
The
answer to both questions is "no." Although poor parenting can, of
course, contribute to a child's problems, the biopsychosocial model
is based on the premise that mental illness is caused by multiple
factors. Many people from good families become mentally ill, and
many of those from dysfunctional families do not. And, of course,
since mental illness is not a type of virus or germ, it cannot be
"caught."
Anyone experiencing SMI without the
benefit of effective treatment can easily get to the point where he
or she is simply unable to function in society. The sadness,
anxiety, and uncontrollable behaviors that are part of serious
mental illness--and, in the case of schizophrenia, the delusions
and hallucinations--can become too much for a person to bear.
However, when provided with proper treatment, the vast majority of
people with serious mental illness can live normal, productive
lives in their home communities. Effective care benefits not only
the individual in need, but also the community, which otherwise
would lose a valuable member.
A
first step in providing effective care is to identify the
characteristics of a serious mental illness and the treatment that
is available. The following is a brief profile of each of the eight
mental disorders identified as SMI. These are clustered into five
categories of disorders in accord with the classifications of the
DSM-IV.
I. Schizophrenia: A Psychotic
Disorder
Schizophrenia is perhaps both the most
debilitating and most misunderstood of the serious mental
illnesses. The misuse of the term "schizophrenic" to apply to a
Jekyll-and-Hyde syndrome adds to the confusion. Schizophrenia does
not mean "split personality" or "multiple personality," although
the term, coined by Swiss psychiatrist Eugene Bleuler in 1911,
means "split mind." The "split" referenced by Bleuler is a division
between experiences and feelings, or between thoughts and reality.
People with schizophrenia may react in a bizarre manner to a normal
social situation because their thoughts or feelings are not
corresponding to what is actually happening around them.
Individuals with schizophrenia are considered psychotic, meaning
that they have lost touch with reality. They may see and hear
things that are not there, or they may have bizarre delusions that
seem absolutely real to them.
Schizophrenia strikes seemingly out of the
blue, typically in late adolescence or early adulthood. It can
afflict the best and brightest, and often lasts a lifetime. The
tragedy of schizophrenia was well portrayed in A Beautiful Mind, a
movie about the life of Nobel Prize winner John Nash, Jr. As
demonstrated in Nash's case, some people are born with a genetic
vulnerability to this disorder. (Nash's son also has
schizophrenia.) Approximately 1 percent of the population (over 2
million) develops schizophrenia in their lifetime.
There are five types of this disorder, but
the most frequent and best-known is paranoid schizophrenia. This
often involves unrelenting and extreme delusions of persecution or
threat and the belief that others are "out to get you." A person
who is actively experiencing paranoid schizophrenia is at risk of
hurting himself or others if he does not receive treatment.
It
is not possible to describe schizophrenia adequately without
recognizing the heartbreak that this disorder entails. No amount of
love or attention can reach individuals who are psychotic and bring
them back to reality. They cannot be healed by the efforts of
family members or friends, who often feel as though they have lost
their loved one and are faced instead with a stranger who is
undergoing terrible experiences.
The
symptoms of schizophrenia vary greatly but can involve visual
and/or auditory hallucinations that are often threatening and
frightening in nature, such as hearing voices or even seeing
demons. Bizarre delusions and peculiar behavior are common
experiences of persons with schizophrenia who may believe, for
example, that they are receiving messages from the dead.
The
emotional response of a person with schizophrenia is often
completely unrelated to their actual situation. For example, some
may laugh after the death of a loved one, while others may have no
feelings at all. Of course, these symptoms result in dramatic
dysfunction at work, home, or school. The tragedy of this disorder
is compounded by the fact that a person with schizophrenia may
experience times of normalcy interspersed with periods of delusion
or hallucination.
Treatment.
Treatment for schizophrenia relies heavily on "antipsychotic"
medication that decreases the brain neurotransmitter dopamine. It
is not clear whether a high dopamine level is causative or
secondary, but targeting it usually decreases delusions and
hallucinations to the point where a person with schizophrenia can
again function at home and at work.
Fortunately, the newer antipsychotic
medications such as Clozapine, Risperidone, and Olanzapine
accomplish this with minimal side effects. In earlier times, a
person with schizophrenia faced the difficult choice of continuing
to endure the psychosis or possibly suffering devastating side
effects from antipsychotic medications, such as tardive dyskinesia
(repetitive actions that cannot be stopped). Today, once medication
has taken effect, treatment often expands to include supportive
therapy for the individual and his or her family, as well as
vocational and psychosocial rehabilitation.
Many
of those who face a lifetime struggle with schizophrenia come to
the point where they no longer want to take the medication
necessary to avoid psychotic symptoms. This is understandable;
given that all medication takes its toll, it is natural for them to
hope that the medication may no longer be needed. Tragically, this
decision is usually disastrous, just as a diabetic's decision to
stop insulin treatment would be.
For
this reason, there is ongoing discussion as to whether or not there
should be some way to ensure that those needing antipsychotic
medication remain in treatment. One proposal to this end is for
"outpatient commitment," whereby a person would be released from
inpatient care contingent on his agreement to remain in treatment
(for example, on medication) in his home community. Such an
alternative would require significant reviews and safeguards to
ensure that it is not misused. Although some may view such
monitoring as intrusive, it may be the best way to avoid the
devastating consequences that could occur if a person with
schizophrenia were to cease treatment and perhaps end up hurting
himself or a loved one.
II.
Severe Major Depression and Severe Bipolar Disorder: Mood
Disorders
"Mood disorder" is
the term used in the DSM-IV for mental disorders characterized by
either depression or mania. Major depression and bipolar
(manic-depressive) disorder involve much more than simple mood
swings from sadness to elation, which are considered normal.
Severe
Major Depression
Major depression is
one of the most common mental health diagnoses and ranks among the
top 10 causes of worldwide disability. Severe major depression
affects approximately 1.1 percent of adults (2.2 million) and
approximately 1.2 percent of children and adolescents (432,000).
A
person with depression experiences, for a sustained period,
symptoms such as sad mood/crying, sleep disturbance, loss of energy
and interest, loss of appetite, difficulty concentrating, and
thoughts of self-harm. Depression can be triggered by a
"psychosocial stressor" such as a loss (for example, the end of a
relationship or loss of a job), which constitutes the social
component in the biopsychosocial model. In addition, depression
often involves changes in brain chemistry (a biological component)
and negative thought patterns (a psychological component).
The
difference between diagnosable depression and "feeling down" is a
matter of severity, duration, and impairment. Anyone can feel down
for a day or so, but depression can last weeks or months, can
immobilize a person, and can lead to suicide. Tragically, from 10
percent to 15 percent of those hospitalized for depression
subsequently commit suicide.
Treatment.
Depression can be effectively treated with psychotherapy,
antidepressants, or a combination of both. There are four major
classes of antidepressants, but the most frequently used are known
as the SSRI antidepressants, which include Prozac and Zoloft. The
primary function of these medications is to increase the active
amount of a brain neurotransmitter, serotonin, which in turn
elevates an individual's mood. With fewer side effects and greater
effectiveness than the older antidepressants, these medications
have become common and are currently taken by tens of millions of
Americans. Interestingly, most of the prescriptions for
antidepressants are written by general practitioners rather than by
psychiatrists.
Several mainstream psychotherapies have
also been shown to be effective in treating depression. Of these,
cognitive-behavioral psychotherapy (which deals with negative
thought patterns) and interpersonal psychotherapy (which focuses on
relationships) have been shown to be particularly effective. In
many cases, a combination of psychotherapy and medication
constitutes the most effective treatment approach.
Severe
Bipolar Disorder
Bipolar disorder,
formerly called manic-depressive disorder, involves experiencing a
manic episode--an abnormally elevated, expansive, or irritable
mood. This manic mood is accompanied by symptoms that could include
grandiosity, decreased need for sleep, flight of ideas, pressured
speech, and, in some cases, self-destructive activities such as
sexual indiscretion or buying sprees. Extreme cases can include
psychosis--that is, auditory and visual hallucinations, or
delusions.
As
with depression, a manic episode can be triggered by a psychosocial
stressor. The mania can last for a period of a few weeks to several
months and often either follows or precedes a depressive episode.
The cycle from depression to mania and back can occur annually or
more frequently.
Approximately 1 percent of adults (2
million) and 1.2 percent of children and adolescents (432,000)
suffer from severe bipolar disorder. Untreated, this disorder
can quickly ruin lives as a person experiencing mania proceeds to
devastate his family, property, employment, and ultimately himself
through surprisingly self-destructive behaviors, including
suicide.
Treatment.
Treatment for bipolar disorder usually requires medication
to stabilize the manic mood swings. Throughout the years, lithium
has been the most frequently prescribed and most effective
medication for this disorder, with few side effects. Recently, new
medications that were originally developed as
anticonvulsants--Tegretol and Depakote--have been found to be
particularly effective in treating bipolar disorder, especially for
those who do not respond to lithium.
It
is not unusual for a person with severe bipolar disorder to be
taking a number of medications--for example, one for mania, another
for depression, and perhaps a third to control side effects from
the first two. Supportive, practical psychotherapy can also help a
person suffering from this disorder to cope and to learn skills for
managing bipolar experiences.
III. Severe Panic Attacks, Severe
Obsessive-Compulsive Disorder, and Severe Post-Traumatic Stress
Disorder: Anxiety Disorders
Anxiety disorders involve extreme or
pathological anxiety that can debilitate an individual. These
disorders are very different from experiencing fear in the face of
some danger, worrying about life's concerns, or feeling stress
under pressure--all of which are normal. A severe anxiety disorder
can lead to wild panic, bizarre obsessive-compulsive behaviors (for
example, washing one's hands every hour or constantly checking
locked doors), or terrifying re-experiences of a trauma such as
rape.
Severe
Panic Attacks
Panic attacks
usually involve a gut-wrenching, overwhelming sense of fear, often
including the belief that one is "going crazy" or about to die.
Accompanying this fear are symptoms that may include a racing heart
rate, sweating and trembling, shortness of breath, or hot flashes.
The attack usually comes on suddenly and builds to a crescendo
within 10 to 15 minutes. By then, it is not unusual for the person
who is having the attack to lose control (for example, to run out
of a building, scream, or cry hysterically).
Panic attacks are associated with other
anxiety disorders such as phobias (an inordinate fear of an object
or situation) and agoraphobia (fear of being trapped somewhere
while experiencing a panic attack). Needless to say, these attacks
and the behaviors they elicit can be highly disruptive at home, at
school, or on the job. Currently, approximately 0.4 percent of
adults (800,000) and 0.3 percent of children and adolescents
(108,000) experience severe panic attacks and their associated
disorders.
Severe
Obsessive-Compulsive Disorder
Obsessive-compulsive
disorder (OCD) consists of two components: obsessive thoughts and
compulsive behaviors. An obsessive thought is an abhorrent thought,
image, or impulse that invades a person's consciousness and cannot
be "turned off." A compulsive behavior is a repetitive, unwanted
action that cannot be resisted. The two usually go hand in hand.
For instance, Howard Hughes, who suffered from obsessive-compulsive
disorder during the last half of his life, was irrationally
concerned about germs. He could not stop thinking about infection,
so he developed elaborate and bizarre routines--such as opening
doors with feet--to avoid germs.
Severe OCD, untreated, can be completely
debilitating as an individual spends all his time in compulsive,
bizarre behavior. Currently, approximately 0.6 percent of adults
(1.2 million) and 0.6 percent of children and adolescents (216,000)
experience severe OCD.
Severe
Post-Traumatic Stress Disorder
Post-traumatic
stress disorder (PTSD) was officially recognized as a disorder in
1980, largely in response to Vietnam War veterans who were
experiencing troubling symptoms. Formerly, similar symptoms that
afflicted World War II veterans were diagnosed as "combat fatigue"
and, earlier, were known as "shell shock" with regard to World War
I veterans. But PTSD is not limited to war trauma. It can be caused
by exposure to any horrifying, traumatic stressor, including
combat, violent assault (including rape), kidnapping, torture, a
severe auto accident, or a severe natural disaster. Symptoms
include re-experiencing the trauma (sometimes many years after its
original occurrence) in nightmares or flashbacks.
Because these experiences are often
triggered by something reminiscent of the initial event, people
with PTSD may go to great lengths to avoid places or reminders of
their trauma. If, despite their best efforts, the trauma is
invoked, they may suddenly and unexpectedly re-experience the full
anxiety and horror of the original event with a flashback. Such
experiences can be truly debilitating and unnerving.
This
disorder is somewhat unique in that its cause is known. What is not
known is why some individuals develop PTSD while others who
experienced similar (or the same) trauma do not. One study found
that 36 percent of Vietnam War veterans exposed to high war-zone
stressors suffered from PTSD. Another study found that both rape
and molestation are associated with high probabilities of PTSD.
Treatment.
Treatment for anxiety disorders often involves both
medication and psychotherapy. The SSRI antidepressants have proved
to be helpful for both OCD and panic attacks. Panic attacks are
also treated with antianxiety medication known as benzodiazepines
(for example, Klonopin and Valium), though these can become
addictive. Recently, a newer medication, Buspar, has become
available as a non-addictive alternative for reducing general
anxiety.
Many
people who are dealing with a severe anxiety disorder benefit not
only from medication, but also from psychotherapy. Psychotherapy
may be supportive and practical, focusing on strategies for
managing anxiety such as relaxation techniques; it may be
cognitive-behavioral, focusing on anxious thought patterns; or it
may be insight-oriented, helping an individual to work through his
feelings and defuse the impact of the initial trauma. Although
these disorders rarely remit altogether, with effective treatment,
those suffering from severe anxiety disorders can usually minimize
symptoms and return to a fully functioning lifestyle.
IV. Severe Attention Deficit/Hyperactivity
Disorder: Typically, a Childhood Disorder
Attention Deficit/Hyperactivity Disorder
(ADHD) is the most commonly diagnosed behavioral disorder of
childhood, although it can also be found among adults. Statistics
from clinics indicate that it is nine times more common among boys
than among girls, and it has generated a great deal of
controversy--especially among parents who feel that the diagnosis
and medication are too readily given to disruptive children.
There is, in fact, enough evidence to
warrant more research on whether the diagnosis is indeed given too
often to children who meet only some of the actual criteria for
ADHD in an effort, perhaps, to control poor behavior. Mild ADHD
symptoms may often be dealt with best through parental/teacher
attention and special tutoring or mentoring rather than with
medication.
Severe ADHD, however, involves measurable
dysfunction in the brain's ability to process information. Some
children are prone to disruptive behavior or inattention. Children
suffering from severe ADHD are simply unable to perform at home or
at school and are very much in need of effective treatment.
According to the nation's largest ADHD organization, ADHD affects 3
percent to 5 percent of children and adolescents and 2 percent to 4
percent of adults (although this estimate is
for all cases of ADHD, not just "severe" cases).
While children tend to be the subject of
most of the discussion about ADHD, it is important to recognize
that the malady also affects many adults, who often suffer more
damaging effects than children do. Adults with ADHD, for instance,
may have great trouble holding down a job or managing their
finances. Forming and maintaining relationships can also be much
more difficult, leading to increased stress in their lives.
Adolescents and adults with ADHD that is not adequately treated are
also at an increased risk of substance abuse and impulsivity, which
have often resulted in the tragedies of automobile accidents and
acts of violence.
ADHD
is characterized by two sets of symptoms: inattention and
hyperactivity. Although any child can, of course, be inattentive
and hyperactive at times--especially when upset--the cluster of
symptoms for ADHD go far beyond the normal range of behavior. For
example, a child with severe ADHD will typically:
- Make careless mistakes at school and at
home despite good effort;
- Be unable to sustain attention in
activities even when trying to focus;
- Not follow through on instructions or
schoolwork even when intending to do so;
- Have great difficulty organizing tasks and
activities;
- Often lose things, especially those
necessary for task completion, despite best efforts;
- Be easily distracted;
- Be forgetful in daily activities;
- Fidget and squirm when seated;
- Be always on the go, as if driven by a
motor; and
- Talk excessively.
Whereas a few of these behaviors are to be
expected from any child now and again, it is the sum of all these
behaviors exhibited most of the time that marks severe ADHD.
Treatment.
Treatment for severe ADHD usually involves both medication and
behavioral therapy. The medications--"psychostimulants" including
Ritalin and Adderall--arouse or stimulate brain regions that are
responsible for directing attention and inhibiting impulses.
While it may seem counterintuitive that an
energizing medication would help to treat a hyperactive disorder,
the results have clearly been positive. At least 75 percent of
children with ADHD respond well to psychostimulants. The actual
mechanism of improvement is not known, but it has been hypothesized
that a stimulant may improve the ability of a child with ADHD to
focus more effectively on one thing at a time by "arousing" his
interest level.
Behavioral therapy is often required as a
complement to medication in order to help parents and teachers
establish structure in the childís life and reinforce
consequences for actions. Otherwise, dysfunctional learned
behaviors (bad habits) can deter improvement, even after successful
medication.
V. Severe Anorexia Nervosa: Eating
Disorder
Anorexia nervosa is an eating disorder
characterized by refusal to eat what is required to maintain a
minimally normal body weight. The person suffering from this
disorder is inordinately afraid of gaining weight and exhibits a
significant disturbance in perception of the shape or size of the
body. For instance, an individual may be emaciated yet see an
overweight body in the mirror.
Anorexic females, who account for more
than 90 percent of all cases, are amenorrheic. Anorexia nervosa is
a potentially life-threatening disorder, since people who
experience it are in jeopardy of literally starving themselves to
death. There is also a likelihood that they could die from suicide
or from starvation complications such as electrolyte imbalance.
Tragically, the long-term mortality among those entering university
hospitals for anorexia is over 10 percent.
Treatment for anorexia nervosa can involve
medication and/or psychotherapy. There is an indication that
antidepressants may help with this disorder--perhaps suggesting
that, in some cases, depression accompanies anorexia. It has also
been found that a person struggling with anorexia benefits from
psychotherapy, especially given the "therapeutic relationship"
wherein a caring professional helps monitor and work against
starvation. Unfortunately, this disorder has proven to be
particularly difficult to treat effectively. Many who suffer from
it go from treatment to treatment but never fully recover.
MAKING MENTAL HEALTH SERVICES MORE
EFFECTIVE
People who are struggling with serious
mental illness should be able to access effective care, through
either private insurance or public support, and many individuals
are able to do so. However, many others receive care that is far
from effective and spend their lives endlessly cycling in and out
of mental health services that miss their mark.
A
significant portion of the "homeless mentally ill" are persons who
have been hospitalized and then discharged without adequate
follow-up care. They end up back on the street until their
condition deteriorates to the level where they once again meet the
criteria for hospitalization. The fact that thousands of men and
women are trapped in this continuing cycle is one indicator of the
need for reform in the nation's mental health system. The pressing
question is where to begin.
Measure Results
Although the improvements needed in mental
health services are multiple and complex, there is one certain
simple step toward needed reforms: Focus on results. Measurement
and evaluation is a proven impetus for improved performance.
Currently, it is difficult to determine to
what extent a given treatment has been effective for a specific
person receiving care. Most mental health management information
systems in the public and private sectors simply list demographics
and services provided. Rather than documenting process, a valuable
evaluation should measure progress--the actual outcomes of care
provided. Many instruments, such as questionnaires, are already
available for such purposes, and recent developments in software
can facilitate the retrieval and interpretation of the information
that is gathered.
Outcome-based evaluation should be
conducted not to punish programs that have minimal impact, but to
identify and promote the treatments that work and improve those
that do not. It is not compassionate to fund failure, especially
when so much is at stake.
The
regular use of standardized outcome measures would help transform
mental health services into an evidence-based practice, improve the
overall quality of care, and ensure that more people with serious
mental illness are able to resume their lives in their home
communities. Some states have begun to move in this direction, but
a nationally coordinated effort could do much to establish the
standardization in measurement that is necessary to use data
effectively. Ultimately, such evaluation would require coordination
and leadership at both the state and federal levels, since it would
be implemented with regard to both state and federal mental health
agencies.