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The DSM: A “Dictionary,” Not a “Bible”

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(May 7, 2013) NIMH Director Thomas Insel set the mental health world abuzz last week when he blogged that the National Institute of Mental Health will be “re-orienting its research away from DSM categories.” A new edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) is due to be released later this month. 

dsm“While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each (psychopathology),” said Insel in “Transforming diagnosis” (Director’s Blog, April 29). He said that people “with mental disorders deserve better” than a menu of diagnoses that ensures clinicians use the same terms in the same ways but lacks scientific basis.

“(Y)ou know what?” he told the New York Times. “Biology never read that book” (“Psychiatry’s guide is out of touch with science,” May 6).

Insel said psychiatric diseases need to be defined by their biology, genetics and neuroscience – their causes – not by their symptoms.

“Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure,” he blogged. “In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever.”

Insel said an 18-month-old NIMH project is underway “to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system.“

As supporters and partners in scientific study of severe mental illness, the Treatment Advocacy Center applauds the NIMH’s direction. As long as psychiatric disease is described in behavioral terms, it will be treated as a behavior, not a disease.

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RESEARCH: Timely Treatment = Better Prognosis

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(May 3, 2013) A new study of first-episode psychosis has found that the longer patients are untreated following an initial episode, the longer it takes them to respond to treatment once it begins.

brainA team of researchers from the University of Cantabria in Spain followed 153 patients who underwent treatment following a first psychotic break (“Delayed psychosis treatment harms chance of success,” a research summary from News.Medical.net, April 29; not yet available online). Patients who achieved remission within a year of starting treatment had an average duration of untreated psychosis of 8.8 months. Patients who did not experience remission within a year were, on average, psychotic for 15.6 months before treatment began.

The researchers found that three factors predicted remission:

  • Duration of the untreated psychosis;
  • Severity of negative symptoms;
  • No education beyond primary school.

"Early intervention clinical programs should aim to reduce the length of DUP [duration of untreated psychosis] in order to provide a better outcome for patients," according to author Benedicto Crespo-Facorro. The authors also identified the lack of effective medications for negative symptoms as “a major unmet need in schizophrenia treatment.”

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"Why Didn't They Do Something to Prevent That Tragedy?" - guest commentary

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(May 3, 2013) After each such tragedy – whether it be the elementary school in Newtown…the Aurora shooting at the movie theatre, the shooting at the shopping center in Tucson…the Virginia Tech massacre, I hear people say – “now those parents knew their sons were ill…why didn’t they do something to prevent that tragedy?” You’d be surprised how many people don’t realize that once your child reaches age 18, parents can’t force them to take their meds or be treated.

dottie_pacharisAccording to the National Institute of Mental Health, there are in this country an estimated 7.7 million people who suffer from the most severe mental illnesses – schizoaffective disorder, bipolar disorder and schizophrenia. Among them, only a small fraction ever become violent, and then, usually when they fail to get treatment. Catching the problem early is crucial. Yet parents seeking help are often turned away, or lose control when their children turn 18.

State laws vary, but all states set strict controls regarding involuntary hospitalization, limiting it to circumstances when a person is an imminent danger to self or others, or likely to become so. These laws give people with severe mental illness the right to decide when, where, how, or even if they will receive care. Yet some serious mental illnesses make it difficult for those affected to assess their need for treatment. When patient rights exceed necessary protections, individuals with a severe untreated mental illness can die because we’ve protected their civil liberties to remain mentally ill and refuse treatment. Many do die. And, sometimes they harm others along the way. The general public also has rights…the right to be protected from the consequences of non-treatment.

I’m the mother of a son who suffered from severe and persistent bipolar disorder. Despite the extraordinary and loving efforts of his family, my son’s bipolar ruined his life; his downward course was aided by a completely ineffective legal system that continually protected his civil right to remain severely mentally ill.

Medication compliance is the key to living with bipolar disorder or any mental illness. My son was not medication compliant. I don’t know why he would stop taking his meds…he just did. I’m not even sure he knew why. He, at times, lacked insight and used poor judgment. When this happened, the map for his recovery was full of dead ends, and both he and his family suffered the consequences. Click here to continue reading this poignant commentary by -

Dottie Pacharis
Author of Mind on the Run: A Bipolar Chronicle

 
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"When Tragedies Occur, 'I Stay Glued to the TV'"

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(May 2, 2013) When tragedies like Sandy Hook occur “I stay glued to the TV because I am so afraid Edward did it ‘cause he is out there and he’s going to do this and nobody will take him off the street,” says Sylvia Benninger (“Mom fears mentally-ill stepson will act on death threats,” ABC News, April 30.)

abc_7_newsBenninger is referring to her stepson, Edward, 50, who has been diagnosed with schizoaffective disorder and deemed to be dangerous. She says “he has left hundreds of threatening phone messages against family members.” He also has a history of threatening public figures, including judges in Pittsburgh and a federal judge in Indiana.

“He has never once stayed on his treatment plan, and I know of at least a dozen institutions he has been in. And he always goes back to his psychotic state,” his stepmother Benninger told the network.

The Benninger’s believe that Edward is currently in California. They have received multiple phone calls from law enforcement and doctors warning them that their stepson with severe mental illness is intent on killing his father. Edward has an extensive psychiatric and criminal record and represents one more example why every state needs better mental health treatment laws to allow families to get help for a loved one before they are dangerous.

Laura’s Law in California is one such tool that needs to be implemented statewide to help people like Edward get and stay well.

It is because of the prospect of helping people like Edward that two recent votes on Laura’s Law by the California Senate Committee on Health give us hope.

SB 664 removes the requirement that each county board of supervisors adopt a resolution prior to implementing the assisted outpatient treatment (AOT) law. California is the only state that requires each county to opt in to AOT, creating a hurdle that is unnecessary and obstructive.

SB 585 clarifies that money from the Mental Health Services Act (MHSA) can be used to fund the program. Confusion about whether MHSA funds can be used for Laura’s Law has been a persistent barrier to its implementation by California counties. Removing this barrier will be a crucial step toward making assisted outpatient treatment more widely available to qualifying individuals with severe mental illness.

SB 585 is scheduled to be heard May 6 in the California Senate Appropriations Committee.

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It's Time to Start Brainstorming!

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(May 1, 2013) It’s May Day, the annual kickoff for Mental Health Awareness Month, an observance that’s been around since 1949 to “raise awareness of mental health conditions and mental wellness for all.”

lightbulbLast year, we promoted awareness of what’s tragically missing in many people with severe mental illness: awareness of their own mental illness. The brain condition called “anosognosia” gets in the way of improved mental health for about half the people with diagnoses of schizophrenia or bipolar disorder.

This year, we want to bring attention to an opportunity to submit your views about mental health science and policy to IMHROs Brainstorm Essay Contest, starting today and running through the month of May. Contestants may submit essays of up to 650 words in length in one or both of two areas:

  • What one discovery or technology would you most like to see emerge from neuropsychiatric science in the next five years, and why? 
  • What one update to national mental health policy would you like to see instituted in the next five years, and why?

To help writers get started, IMHRO has suggested some topics. The first one under "national mental health policy" is “Legal reform enabling court ordered outpatient treatment for persons with a history of dangerousness or re-hospitalizations due to noncompliance.”

Here’s an opportunity to put your passion for mental illness treatment law reform and your talents to work!

Our proposed nationwide assisted outpatient treatment (AOT) demonstration project is a “national mental health policy” that could profoundly change the lives of individuals who could be living and functioning successfully in their communities but are instead trapped in the revolving door of non-treatment. “Toward a National Assisted Outpatient Treatment Demonstration Project” offers a quick primer on the policy we proposed to the president’s task force on gun violence.  

Contest sponsor IMHRO – “International Mental Health Research Organization – is a nonprofit that focuses on neuropsychiatric research “to find preventions and cures for severe mental illnesses, focusing on schizophrenia, bipolar disorder, and major depressive disorder, within a generation.”

We applaud IMHRO for including public policy in its contest. Scientific research and breakthroughs in psychiatric disease are desperately needed. Until they come, public policies that make treatment possible for those too ill to seek it themselves are a crucial bridge to recovery.    

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