Spare me your heart: the plight of the mentally ill

In the aftermath of the Newtown shootings, a shocked nation seems finally to be taking a hard look at mental illness, although for the wrong reasons.  Gun control, with 250 to 300 million guns out there, owned by 60 million across the United States, would be a hard nut to crack even if legislation, unlikely, were to become law and remains the salient issue.  Unfortunately, indicting the mentally distressed is subterfuge for not dealing with the primary source of our national mayhem.

While I agree with those voices calling for attention to our mental illness epidemic,  I think it’s kindled by media sensationalism that would indict millions who suffer grievously as it is.  I must point out that only 4% of our annual murders are committed by someone mentally ill (Richard Friedman, NYT, December 17, 2012).  These vociferous voices simply add to the stigmatizing  of the mentally ill.  On the other hand, guns are very much the public health issue, if we define health as well-being.   In the wrong hands, they foster tragedy, and most of these guns are found in American homes as happened with the Lanzas.

I want to outline here, however, just how serious mental illness is as a pervasive and growing presence and the compassion it should elicit from us rather than lynch mob condemnation.   At the conclusion, I’ll offer some final commentary.

What is mental illness?  When we talk of someone being mentally ill we’re not necessarily dealing with hard core psychotics such as schizophrenics.  Mental illness affects  how one feels, thinks, and ultimately behaves.   While all of us occasionally experience ups and downs,  those suffering from a “mental disorder” are simply overwhelmed and unable to cope.  They may suffer, for example, from acute depression, anxiety, obsessive thoughts,  and addictions that simply won’t go away.  This frequently results in problems at work and at home and needs prompt, professional intervention.

What are its causes? Possible causes may include

Heredity: Genetics may be suspected when mental illness affects several family members within or across generations.  Certain stress situations may trigger it.

Trauma: an experience such as a death of  a loved one or break-up in a relationship, being a crime victim,  group rejection, war violence, declining health, a financial loss and a problematic childhood leading to low self-esteem and distorted thinking can be tipping points.

Chemical imbalance: Changes in brain chemistry affecting neurotransmitters and/or hormonal abnormalities may affect mood.

How common is it?  Mental illness is pervasive world-wide.  The World Health Organization (WHO) reports an incidence rate of  33% . In the United States, the figure approaches 46%.  It affects all social-economic sectors.

Key symptoms:                                                                                                                            

Inability to focus
Constant sadness
Excessive worrying
Insomnia
Difficulty managing anger and hostility
Detachment from reality: hallucination, delusional thinking, Paranoia
Obsessive-Compulsive rituals
Sudden mood fluctuations
Excessive anxiety
Suicide thoughts
Feelings of abandonment
Eating disorders: anorexia, bulimia, etc.
Substance abuse (frequently addiction is associated with mental illness).

How is it treated? Treatment includes counseling, often accompanied with medication; brain stimulation such as electroconvulsive therapy for those not responding to traditional methods; treatment in a residential community (hospital).

Prognosis:  Outcomes can be positive for milder forms of mental illness, provided the individual adheres to treatment protocol, has a network of support, and makes lifestyle changes such as reducing stress,  exercising,  making friends, finding interests, and developing a positive outlook.  There are many others, however, who can only be managed, not cured.

Cost impact: The costs of mental illness are staggering, both direct and indirect costs.  Direct costs include therapy, hospitalization and medication.  Presently, these outlays consume nearly 20% of medical expenditures annually.  Indirect costs, more difficult to measure, outweigh direct costs by a hefty margin in lost income (an estimated $192 billion in 2008), educational attainment, disability payments, homelessness (one third of our homeless population is deemed mentally ill), social violence, litigation and incarceration (22% of prison inmates have been diagnosed as mentally ill).  (Thomas Insel, “Assessing the Economic Costs of Mental Illness,” Journal of American Psychiatry, June 2008).

And then there are the suicides, those thousands who have simply surrendered to their depression.  (Suicide numbers, by the way, have been increasing, not helped by the economic recession, and currently are the 10^th leading cause of death annually.

Final Reflections:  The mentally ill, unfortunately, are frequently stigmatized as “maniacs,” “loonies,” “crazies,” “weirdoes,” “zombies,” etc.  I think we know the litany.  It’s so bad that a large number of the mentally distressed are afraid to get help.  Psychiatry itself hasn’t helped the situation.  Many psychiatrists in private practice turn down Medicare patients in favor of more lucrative insurance payouts, or cater to a more affluent clientele.  They eschew paper trails and generally require  cash payment in full for each session, though they may allow you the convenience of your credit card, but don’t bet on it.  Like all professionals, they differ in quality or competence.

Psychiatry itself, since the 90s, has primarily surrendered therapy to the psychologists and social workers, opting for chemical treatment instead and, for this, a client can expect a usual allotment of 15 minutes to periodically check on the SSRI effectiveness at $100 plus.  The truth is that much of this medication may be dubious, as new research continues to confirm that those given a placebo do virtually as well.

Health insurance, meanwhile, more often than not, discriminates against those with a “history,” that may simply be a prescription for anxiety or depression.  Formularies have a way of being akin to finger prints in tracking down the mentally distressed, even if now recovered, under the guise of pre-existent illness.  While the Health Reform Act when fully implemented in 2014 prohibits using pre-existent illness as a pretext for rejecting an applicant, it does not prohibit insurance companies from setting higher rates, which is like trusting the fox to take care of the chickens.

The one tool that has helped a good many to cope is cognitive therapy, sometimes called Rational Emotive Therapy) in which patients are taught how to think past painful emotions by substituting positive thought alternatives. We need more of it—a whole lot more.

One of the dismaying aspects of the mental illness syndrome is how neglected it has been, from the homeless right down to the incarcerated.  While you can find a plethora of resources for the mentally challenged, not so for those suffering mental distress and we, as well as they, suffer the consequences.

All of this should not be!  Consider that every year nearly 60 million Americans wrestle with mental illness.  It knows no social/economic boundary.  It could be your neighbor, your fellow worker, your spouse, your child.  It could someday be you.

Returning to Richard Friedman in his NYT article, he hits the nail on the head in summarizing the wolves howling to get at the mentally ill when he writes, “All the focus on the small number of people with mental illness who are violent serves to make us feel safer by displacing and limiting the threat of violence to a small, defined group.  But the sad and frightening truth is that the vast majority of homicides are carried out by outwardly normal people in the grip of all too ordinary human aggression to whom we provide nearly unfettered access to deadly force.”

In the 1930s there was a landmark song that defined those tough times:  “Brother, can you spare a dime?”  There’s a new song in town:  Brother, sister, can you spare your heart?”

rj

POSTSCRIPT: I came upon this just published article on the paucity of mental health resources since publishing this post two weeks ago. it reinforces what I’ve written in my post:
Families Face Mental Illness Barriers