Posts Tagged ‘mental health’
By: Fatima Chowdhry, MD
In the last 50 years, the U.S. has seen a migration in which individuals diagnosed with a mental illness, defined by the Diagnostic and Statistical Manual of Mental Disorders as “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior”, are treated not in a mental health institution but rather in prisons, nursing homes, and outpatient facilities. To understand the implications of this trend, it’s important to frame this issue as a cascade of events. For example, we can start with a member of law enforcement, not adequately trained to recognize someone in the throes of a manic phase or a schizophrenic not on their medication, arresting an individual with a mental illness. We then find that this individual, upon release, did not receive treatment and now has trouble reintegrating into their community and is unable to find gainful employment. The combination of a lack of treatment, stable community, and employment leads them to continuous run-ins with the law, restarting a vicious cycle that had led us to a prison population in which the majority has a mental illness.
The move to deinstitutionalize people with mental illness from mental institutions began in the 1960’s and accelerated with the passage of the Community Mental Health Act of 1963. This bill was an important step forward to improve the delivery of mental health care because it provided grants to states to set up community health centers. In 1981, President Ronald Reagan signed the Omnibus Budget Reconciliation Act, which sent block grants to states in order for them to provide mental health services. Aside from these two bills, and the Mental Health Parity Act of 1996, which ensured insurance coverage parity of mental health care with other types of health care, there has been little in the way of significant mental health legislation. Mental health was put on the backburner and the result is a mental health infrastructure in tatters.
During the Great Recession, states cut billions in funding dedicated to mental health. A vivid example of how decreased state funding affects mental health services can be seen in the state of Iowa. The current Governor has been put in the difficult position of balancing fiscal responsibility with maintaining access to mental health care. At one point, there were four state mental health hospitals that provided care to each corner of the state. The Governor closed down two of the facilities to save the state money. While they were old facilities built in the 19th century and cost millions to maintain, many people in Iowa felt that he moved too quickly before alternative services were in place. In addition to closing these mental health facilities, the governor obtained a waiver from the federal government to modernize the state’s Medicaid program and move from fee-for-service to managed care. Under fee-for-service, health care providers are paid for each service provided to a Medicaid enrollee. Under managed care, Medicaid enrollees get their services through a vendor under contract with the state. Since the 1990s, the share of Medicaid enrollees covered by managed care has increased, with about 72% of Medicaid enrollees covered by managed care as of July 1, 2013. The move can be difficult because hospital networks and providers have to contract with a vendor and Medicaid beneficiaries may have to switch providers. Needless to say, it can be an administrative nightmare. The transition in Iowa, to say the least, has been rocky with the vendors threatening to pull out because of tens of millions of dollars in losses. The vendors and the providers might not get paid as much as they want but the people getting the short end of the stick are people on Medicaid, which includes individuals with mental health illnesses.
Given the patchwork of mental health care across the country and the lack of funding, what can be done? According to NAMI, 43.8 million Americans experience a mental illness in a year. Many don’t receive the treatment they need. It’s a multi-faceted problem facing families, employers, health care providers and community leaders. At the federal level, lawmakers have introduced several bills to address mental health. In the United States Senate, a bipartisan group of four Senators introduced S. 2680, the Mental Health Reform Act of 2016. This bill encouraged evidence-based programs for the treatment of mental illness, provided federal dollars to states to deliver mental health services for adults and children, and created programs to develop a mental health workforce.
It was encouraging to see that many components of S.2680 were included in H.R 34, the 21st Century Cures Act, which was signed into law on December 13th, 2016. H.R 34 faces some headwinds because some of the funding portions are subject to Congressional appropriations, and if Congress is feeling austere, they can tighten the purse strings. Moving forward, a major issue of concern for mental health is the future of the Affordable Care Act. Under the Affordable Care Act, states were initially mandated to expand their Medicaid rolls. A Supreme Court decision, however, made the decision to expand optional. So far 32 states, including Washington D.C., have expanded. Some red states, like Iowa, Arkansas and Indiana have utilized the waiver process of the ACA to expand their program. If the ACA is repealed, policymakers will have to contend with the effects on the private insurance market as well as Medicaid.
Right now, the crystal ball is murky. Only time will tell.
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By: Brian Russ, PhD
Scientific funding can be a very tricky proposition. Unfortunately, there is a finite amount of money that is put towards science each funding cycle. This means that at any given time funding agencies need to decide where they believe their funds will be best spent. Every funding cycle, one can find different groups lamenting that their favorite topic is “being underfunded” while some other group is getting “too big a piece of the pie”. There is often no right answer to the question of how much is the right amount of funding to provide different topics, and the likelihood is that at the end of the day every group will feel that they are not getting the right amount of respect and funding.
This debate has come to the forefront recently in the fields of psychiatry and neuroscience with a change in the leadership at the National Institute of Mental Health (NIMH). In September, Dr. Joshua Gordon became the new director of the NIMH. Dr. Gordon’s directorship of the NIMH comes after a 13-year period of leadership by Dr. Tom Insel. During the previous administration, there had been an increasing focus on funding neuroscience related work, often at the expense of purely behavioral work, such as cognitive behavioral therapies for psychiatry patients. It is important to point out that the NIMH’s definition of neuroscience research includes basic, translational, and clinical neuroscience research. This direction led to a new research framework for studying mental health disorders termed the Research Domain Criteria (RDoC), which has a very strong neuroscience component. The goal of RDoC is to provide a new framework in which researchers and clinicians can study and treat mental health disorders. The RDoC framework involves neuroscience components of brain circuits and physiology, and cognitive components of behavior and self-reports. The end goal is to provide a more comprehensive description of mental health disorders with the intention of developing cures and treatments. This push toward RDoC, and more neuroscience in general, has led to both praise and criticism of where the NIMH is directing its funding opportunities.
Recently, an opinion piece was published in the New York Times stating that the NIMH needs to reverse their push towards more neuroscience. Specifically, Dr. Markowitz, a research psychiatrist from Columbia University, believes that the NIMH has been funding neuroscience at the expense of clinical psychological research, in the absence of a brain oriented component. His argument is that in the current funding environment only 10% of the NIMH’s research budget is going towards clinical research. From the content of his article the research he is speaking of involves behavioral studies and interventions that contain no neuroscience component. Dr. Markowitz brings up many important points, and his main thesis that we cannot forget about behavioral interventions while pursuing the biological bases of clinical disorders is critical. For example, he makes the strong point that neuroscience research is unlikely to help solve the problem of suicide. And his final argument is for a “more balanced approach to funding clinical and neuroscience research.”
However, one can argue what that balance should actually look like. Is ten percent of the budget actually a small amount? And does that number include the multitude of basic neuroscience studies that are investigating the neural underpinning of a given disease? For example, based on the NIH reporter, schizophrenia research has been funded for approximately 250 million dollars for each of the last three years. A quick look at the total budget (32.3 billion in 2016, with ~25 billion going to research grants) suggests that that would be on the order of about 1% of the total NIH research budget. This is only one disease, and is being calculated from the whole NIH budget, not just from the NIMH budget. Only a portion of that funding is going towards clinical research, as Dr. Markowitz would define it, however the rest of that funding is going to research that will in all likelihood provide clinical benefits to patients down the road, in the form of new physiological targets or potentially new drugs.
So how can one make a determination about the correct of amount of funding that should go towards different mental health fields? Should 25% or 50% of the budget go towards clinical research? It seems that comparing the percent of money going to clinical research versus neuroscience is simply a bad comparison. Neuroscience is not one homogenous topic; it includes tens of, if not over a hundred, different fields. The various mental health fields fighting each other over funding doesn’t help anyone. Both neuroscience and clinical research need to be funded. It seems that the best way to divide the funding from NIMH would not be to specify what field gets priority but instead to fund the best grants regardless of whether there is a specific component involved. This would open the door to more clinical research while not requiring a shift in the priorities of the NIMH, whose mission is to understand and treat mental illnesses though both basic and clinical research. For instance, RDoC already contains both behavioral and self-report components. These components should be given as much priority as the other neuroscience components. If 10% of the budget is given to behavioral work, in this way, that would seem reasonable, possibly even greater than other areas might be getting.
On a final note, while we should always be looking internally at how we are funding different types of science, and if we, the public, are getting our money’s worth out of projects, it is also important for us to ensure that science funding as a whole is increasing. The current funding environment has been relatively static for years. We need, through advocacy and outreach, to get the public and government to provide more funding opportunities to the NIH. As the saying goes “a rising tide raises all boats”.
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By: Katherine M. Reding, Ph.D.
Major Depressive Disorder (MDD) is one of the most common mental health disorders in the United States. According to the National Institute of Mental Health, in the year 2014 alone, approximately 7% of the population, or 5.7 million adults, aged 18 or over experienced at least one major depressive episode. Of these adults, women were almost twice as likely to have experienced an MDD episode, such that 8.2% of women compared to 4.8% of men reported an episode in 2014. In general, women are two to three times more likely than men to develop stress-related psychopathology, such as MDD, across their lifetime. Importantly, MDD is also common in adolescents between ages 12 and 18. Approximately 8% of adolescents have been diagnosed with MDD, according to a recent study from the U.S. Preventive Services Task Force (USPSTF), an independent and volunteer panel of experts in disease prevention and evidence-based medicine.
Throughout young adulthood, between the ages of 19 and 31, being female is one of the largest risk factors for developing MDD. Although the USPSTF report identified the ‘female sex’ as a risk factor for developing MDD in adolescents, it lacked any discussion regarding the sex and gender differences in disease onset, screening, and treatment. In fact, sex-differences in MDD onset emerge around the time of puberty, and girls show a spike in onset at age 14, such that the two-fold increase in female prevalence of MDD seen in adulthood is apparent beginning at 15 years of age.
Exactly why sex differences in MDD emerge during adolescence is still in debate. Some researchers suggest that it is the biological process of puberty, or the maturation of the female reproductive system and the production of ovarian hormones such as estrogen and progesterone, that causes the increased susceptibility to depression in adolescent girls. Unfortunately, the correlation between female hormones and teenage mental health is not a simple one to demonstrate. The process of puberty is not isolated to reproductive biology, but is also a time of increased physical, social, and emotional changes.
Another potent predictor for the development of depression in women is a history of exposure to stressful life events. The prevalence of MDD in women may be due to a combination of exposure to stressful or traumatic events coinciding with the production of ovarian hormones leading up to menarche when girls begin menstruating. Dr. Amy Marshall, a clinical psychologist from Pennsylvania State University, suggests that traumatic events such as major disasters, witnessing family violence, physical assault, or sexual assault occurring between 6 years prior to menarche and 2 years afterwards were a significant risk factor for developing depression in young women. Peak risk resulted when traumatic events occurred 2 to 6 years prior to menarche, when ovarian hormones are in the early stages of production.
As an update to their 2009 recommendations, the USPSTF found that there is essentially “no harm” in screening for and treating MDD in adolescents age 12 to 18. Previously, the USPSTF had limited its recommendations for screening to only those adolescents with access to psychotherapy due to concerns regarding the negative side-effects and harms of pharmacotherapy in adolescents. Current recommendations suggest universal screening due to more recent findings that show no significant harm resulting from using pharmacotherapy, psychotherapy, collaborative care, psychosocial support interventions, or complementary and alternative medicine approaches. Instead, the most harm appears to come from not detecting and not treating adolescent onset MDD, as one episode of MDD in adolescence greatly increases the risk of recurrent episodes throughout adulthood.
Despite broadening their screening recommendation, the report unenthusiastically stated that “there is moderate certainty that the net benefit [of screening for MDD] is moderate to substantial,” which does not appear to be a huge vote of confidence on their own findings. This seemingly indifferent review is a direct result of the limited data available on the outcomes of adolescent screenings for MDD. In fact, the USPSTF found no studies directly assessing the benefits or harms of screening for MDD in adolescents, making it impossible to detect actual benefits derived from the screening process. It is also important to note, that the USPSTF could make no recommendations for screening or treating children younger than 11 years of age, as no studies that were found that included children of those ages.
In conclusion, healthcare providers and researchers must begin to collect data on MDD screening and treatment outcomes in teens to determine just how beneficial these screening recommendations might be. The benefits to women’s health, as well as men’s health, across the lifespan may be significant, but only time and data will tell.