2. Substance Abuse Prior to engaging in this discussion, review Chapters 7 and 8 in your text, read “Recovering Health Through Cultural Traditions” by Krohn (2013).

Learning Objectives

1. Understand the evolution of societal perspectives about individuals with mental health disorders

2. Identify the basic physical and environmental elements related to different mental health disorders

3. Describe how mental health disorders affect different individual, familial, and social domains

4. Explain the connections between age groups and the prevalence of different mental health disorders

5. Compare and contrast different treatment approaches and identify which best address the different mental health disorders

6. Describe how stigma and health disparities affect diagnoses and treatments of mental disorders

Mental Health Disorders 7

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CHAPTER 7Section 7.2 History

7.1 Introduction to Mental Health Disorders

What is mental health? It isn’t just the absence of mental disorders. The World Health Organization (WHO) defined mental health as follows: A state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. (WHO, 2011b. Copyright © World Health Organization [WHO]. Used by permission.)

(For a short video produced by the WHO about the global reach of mental illness, go to http:// www.youtube.com/watch?v=L8iRjEOH41c.) In the following sections, we examine the different common mental disorders in the order that they are likely to appear across the lifespan, from early childhood (neurodevelopmental disorders) to late adulthood (dementia).

7.2 History

Mental disorders have been recognized from the beginning of human society. In some periods and cultures, people with mental disorders had recognized roles, for example, a shaman or fortune-teller. In other periods and cultures, people with mental disorders were driven from society. Ideas about causation and treatment have also varied. One frequently held idea was that mental disorders were caused by evil spirits. Evidence shows that prehistoric people treated mental disorders by cutting a hole in the skull of the afflicted person, a process called trepanation, to allow evil spirits to escape (Clower & Finger, 2001).

Written accounts of mental disorders are found in Egyptian manuscripts from 1550 BCE. Egyptians recognized the brain as the site responsible for mental function and described both depression and mood changes (Nasser, 1987). Among the Greeks, Pythagoras (sixth century BCE) and Hippo- crates (fifth century BCE, from whom we get the Hippocratic Oath that physicians should “do no harm”) understood that the brain was the center of thought, intelligence, and emotions (Millon, Grossman, & Meagher, 2004). The Romans built upon Greek approaches to mental disorders, and physicians such as Claudius Galen (second century CE) supported diagnoses based on obser- vation and humane treatment of the mentally disturbed. Most Greco-Roman understanding of mental disorders had been forgotten in Europe by the early Common Era until the 17th century. Instead, European medical understanding of mental disorders was based on faith healing, magic, and superstition (Millon et al., 2004). During a long dark period in western Europe, medical under- standing of mental disorders was kept alive in the Islamic world. The first known psychiatric hospi- tal was built in Bagdad, Iraq, in 705 CE (Murad & Gordon, 2002). Also, in Byzantium, the successor to the Roman Empire, special provisions were made for handling the criminally insane differently from other offenders (Tzeferakos, Vlahou, Troianos, & Douzenis, 2011).

In Europe, people with mental disorders were generally cared for by relatives. Only those who could not be cared for by relatives might be placed in a public institution. A famous example is Bethlem Royal Hospital (universally known as “Bedlam”), which was granted by Henry VIII to the City of London in 1547 as the first asylum for people with mental disorders. Bedlam became notorious for the poor treatment of patients and the practice of allowing fee-paying spectators, which was

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discontinued in 1770 (Bedlam, 2013). Bedlam became a syn- onym for mental hospitals and generally for confusion or uproar.

Philippe Pinel (1745–1826) played a large part in reform- ing the treatment of people with severe mental disorders in France. He became head physi- cian of Bicêtre, the public asylum for men near Paris, in 1793 and presented his Memoir on Mad- ness to the Society for Natural History in 1794. In it he explained his theory of “psychologic treat- ment,” which was also called the “moral treatment.” Pinel believed it possible to cure mental illness, and that to do so, it was neces- sary to first diagnose the patient by careful observation, gain understanding of the events precipi- tating the illness, and write an accurate case history. Pinel thought it was possible to “dominate agi- tated madmen while respecting human rights” (Weiner, 1992, p. 725). His assistant, who succeeded him at Bicêtre, removed the chains from male inmates in 1797, replacing them with more humane strait jackets when needed. Pinel did the same at the public women’s asylum, Salpêtrière, in 1800.

Benjamin Rush (1745–1813) played a similar role in psychiatric reform in the United States, where he is known as the father of American psychiatry. Rush believed that mental disorders could be diagnosed, classified, and treated humanely. His Observations and Inquiries Upon the Diseases of the Mind, published in 1812, was the first psychiatric textbook printed in the United States. Rush improved patients’ living conditions and removed their cuffs and chains (Penn Medicine, n.d.-a; n.d.-b).

The Industrial Revolution changed family life and made it more difficult for families to care for those with mental disorders at home, giving rise to community asylums (Wright, 1997). For the first time, women began to work outside the home and so were unavailable to care for family members with mental disorders. At the same time, an interest in the geographic or sociologic distribution of disease, or epidemiology, became popular in the United States. As a result, the 1840 federal census was the first one to collect data on mental disorders. However, it counted only those in institutions. A major problem was the lack of a shared language of definitions for mental disorders, so it was impossible to track how many people with what kind of disorder were housed in institutions across the country. In addition, the rate of institutionalization depended heavily on the number of places available in a given community, as well as the willingness of families to allow a stigmatizing diagnosis and the community’s tolerance for deviant behavior (Horwitz & Grob, 2011). As a result, the statistics collected were neither accurate nor scientifically useful.

Psychiatrists in the 1800s believed that the rise of industrial civilization increased the prevalence of mental illness. Their conclusion was not based on statistics but rather on their moral and reli- gious beliefs. However, the increasingly sophisticated censuses of the early 1900s proved them wrong; the data collected also showed that immigrants from eastern and southern Europe were

Mary Evans Picture Library/Everett Collection

Phillipe Pinel helped reform the treatment of people with mental disorders in France. In this image he is shown ordering the manacles removed from patients at Salpêtrière.

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CHAPTER 7Section 7.2 History

not particularly prone to insanity, as was generally assumed at the time (Horwitz & Grob, 2011). For a history of the asylum and attitudes toward the mentally ill, as well as the implications for policy change, consider reading Madhouses, Mad-Doctors and Madmen: The Social History of Psy- chiatry in the Victorian Era, edited by Andrew T. Scull.

By 1917, the American Medico-Psychological Association (which became the American Psychiatric Association [APA] a short time later) called for uniform classification of mental diseases. Interest in studying exclusively those with mental illness who were confined to institutions gradually shifted, and by the late 1930s interest in the contribution of social and environmental factors to mental illness in the community was rising. One particularly influential publication was Mental Disorders in Urban Areas (Faris & Dunham, 1939), which made the connection between community condi- tions and severe mental illness. Although much of what the authors concluded was later proved wrong, the effort to connect where someone lives and mental illness was an important advance.

World Wars I and II brought more data. As Horowitz and Grob (2011) concluded, “Psychiatric casualties soared among soldiers who were seemingly normal before entering combat. The pol- icy lesson seemed clear: environmental conditions rather than individual predispositions were the primary causes of mental disorder” (p. 639). The mental disorders that appeared in normal soldiers exposed to combat convinced mental health practitioners that social and environmental factors play a large role in the development of mental disorders. During the period after WWII, the newly formed National Institute of Mental Health (NIMH) was given responsibility for funding research into the connection between social and environmental variables and mental disorders. The movement to establish a uniform classification of mental diseases resulted in the publication of the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952. The first version (DSM-I) used the term reaction to refer to diagnoses, which reflected the theoretical beliefs of Adolf Meyers that mental disorders were reactions of the personality to psychological, social, and biological factors. Later editions of the DSM dropped this terminology along with the mindset that mental disorders result from the interaction of all three spheres of life (APA, 2012).

Development of antipsychotic medications for treating severe mental disturbance played a role in this turnabout (see “Prevention and Treatment Approaches to Mental Disorders” later in this chapter). For the first time, people who previously had to be confined to an institution could be treated in a community setting. The release of people with mental disorders from institutions, known as deinstitutionalization, started in the mid-1950s and grew dramatically in the 1960s and 1970s. The idea was that people with mental disorders could be better treated and cared for in their communities. The assumption was that sufficient funding for community mental health cen- ters to deal with those who needed guidance and treatment would be available. However, fund- ing for community centers and treatment specialists has fallen short of needs ever since, leaving many vulnerable people to depend on their families or the social service system, or worse, the prison system. Concepts of causality made an about-face during the late 1960s and early 1970s, when the Nixon administration together with Congress decided NIMH should not fund research on social problems such as poverty, racism, and violence (Horwitz & Grob, 2011). Focus instead turned to how disturbance within the individual affected society.

As of 2013, the debate about how best to treat and ensure compliance by the mentally ill is as sharp as ever. A series of violent shooting rampages on innocent victims (e.g., the Newtown, Con- necticut, massacre) have brought to light the anguish of families of mentally ill and potentially violent or suicidal people. How to protect the public while ensuring the civil rights of mentally ill people is a difficult balancing act. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 made it much more difficult to institutionalize those in danger of harming themselves or others, because it requires the affected person’s permission for anyone else to talk to mental

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CHAPTER 7Section 7.3 Definitions and Familial and Biological Basis

Case Study: The Diagnostic and Statistical Manual of Mental Disorders Our understanding is constantly changing, and the DSM reflects changes in society. For instance, homo- sexuality was considered a mental disorder until 1973. Another cultural shift can be seen when the 2013 fifth edition (DSM-5) replaced the term gender identity disorder with gender dysphoria, suggest- ing that the problem is not one of gender mismatch but rather the resulting emotional distress. Exactly how disorders are defined may depend upon the particular work environment, as well as the norms and values of society, which are always changing. So treat the definitions in this chapter as a general guide, rather than a dictionary.

The DSM, published by the APA, provides criteria for mental disorders that are used by clinicians, insur- ance companies, policy makers, and researchers in the United States and around the world. The DSM-5 was approved in December 2012 and formally adopted on May 18, 2013, at the 166th annual meeting of the APA with much fanfare and controversy. The DSM-5 is the first major update since publication of DSM-IV in 1994, and much was expected of it.

(continued)

health providers about him or her. A social worker who has had to hospitalize his mother and sister a number of times remarked that someone who is paranoid is not likely to give anyone, even family, permission to talk. The pendulum of patients’ rights has indeed swung to the other side, and HIPAA has made the family’s attempt to help much more difficult. In January 2013, in response to the shootings in Newtown, Connecticut, and Aurora, Colorado, the U.S. Department of Health and Human Services (HHS) issued a letter to the nation’s health care providers, making it clear that reporting someone they believe to be a danger to either themselves or others is not a violation of HIPAA rules (Rodriguez, 2013). Unfortunately, to date, very few health care providers appear to be aware of this.

We can see how through the ages responsibility and blame for mental disorders has shifted from “evil spirits” to social conditions and experience and to the individual. Now let’s look at definitions for many of the major mental disorders.

7.3 Definitions and Familial and Biological Basis

One of the difficulties in studying mental health and treatment of mental disorders is find-ing a common language. Without a common language, it is impossible to answer ques-tions about how disorders arise, how they are related, and how they are best treated. This section discusses current definitions of some of the major mental disorders and lists short descriptions for some of the others. It also discusses the role that family environment, genetic makeup, resilience, environment, and supportive social interactions, particularly within the family, play in various mental disorders.

Only recently have researchers begun to examine what accounts for people growing up in par- ticularly difficult circumstances who nonetheless do very well in life—those who are particularly resilient. For instance, some scientists have looked at children who experienced extreme neglect or abuse and yet appeared to function well (Cicchetti, 2010). Others examined structural and func- tional brain differences between people with bipolar disorder, their relatives, and healthy controls (Frangou, 2011).

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CHAPTER 7Section 7.3 Definitions and Familial and Biological Basis

Case Study: The Diagnostic and Statistical Manual of Mental Disorders (continued) According to Dr. Thomas Insel, director of the NIMH, the problem with the DSM is that it classifies men- tal disorders by clinical symptoms, which he thinks are not sufficient for diagnosing disease:

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. The strength of each of the editions of DSM has been “reli- ability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. 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. 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. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment. (Insel, 2013)

Dr. Insel pointed out the difference between having a shared definition so that various people are talking about the same thing, which is reliability, and being logically or factually correct (evidence based), which is validity.

The NIMH is the major funding source for research in mental health and mental illness for the entire United States and much of the world. An important goal of the NIMH is to transform diagnosis of mental illness so that it is based on biology, not on symptoms or subjective criteria. This goal can be achieved by incorporating cognitive science, genetics, imaging, and other information into the Research Domain Criteria, which is envisioned as a 10-year project (Insel & Lieberman, 2013). In other words, DSM-5 may be flawed when it comes to applying it to research, but it is still the best tool available for diagnosing mental disorders.

Some changes in DSM-5 include classifying attention deficit hyperactivity disorder (ADHD) as a neu- rodevelopmental disorder instead of a disruptive disorder. Also, several criteria within posttraumatic stress disorder (PTSD), trauma, and stress-related disorders, are now more explicit about what con- stitutes a traumatic event and specifically include sexual assault and a new preschool PTSD subtype. Changing the classification of ADHD has social implications: It removes the negative implication from this disorder and places it in a more neutral, developmental context. Similarly, by recognizing that sexual assault is by definition a traumatic event, the DSM-5 validates the impact of such events on people’s lives.

Neurodevelopmental Disorders Neurodevelopmental disorders are changes in the normal growth and development of the ner- vous system, resulting in slowed maturity in behavior, communication, or ability to focus. This section concentrates on two neurodevelopmental disorders: autism spectrum disorders (ASD) and ADHD.

Autism Spectrum Disorders Children with ASD have an unusual way of communicating with people and their environment. They may have trouble with social interactions and communication and may be unusually inter- ested in a particular subject; they also may show restricted, repetitive patterns of behavior. These

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CHAPTER 7Section 7.3 Definitions and Familial and Biological Basis

problems are believed to be caused by differences in the way the brains of children with ASD pro- cess information. When symptoms begin, when they are first noticed, and how much they affect a child’s functioning vary widely. There is also wide variation in how the families and social systems surrounding these children accept them, which has profound effects on the child’s functioning.

The Centers for Disease Control and Prevention (CDC) has sponsored the Autism and Develop- mental Disabilities Monitoring (ADDM) Network to estimate the number of U.S. children who have shown ASD symptoms any time between birth and the end of the child’s eighth year: the prevalence of ASD. The most recent information, published in 2012 about the survey done in 2008, suggests that one child in every 88 in the United States has been identified with ASD. The trend appears to increase across time: The 2006 survey found one child in every 110 had an ASD, and the 2002 survey found one child in every 150 had an ASD. In all surveys approximately 5 times as many boys as girls were identified with ASD. The majority of children identified with ASD (62%) did not have an intellectual disability. According to a report on the prevalence of ASDs, children are identified at an earlier age, many by age 3 years, but most were not identified until they were at least 4 years old (ADDM Network, 2012).

Some signs that a child might have ASD:

• does not respond to his or her name by 12 months; • avoids eye contact; • is not interested in social interaction; • gets upset by minor changes in routine; • does not engage in make-believe or pretend games by 18 months; and • shows repetitive body movements (e.g., spinning, rocking, flapping hands).

Early identification is important, because evidence shows that it can improve outcomes for both children and their families. However, ASD goes undetected in many children until later because of limited social demands and inadequate support from parents and caregivers in early life. The resulting lack of early intervention can affect the child’s functioning throughout life.

Of late, ASD has undergone several “lumping and splitting” reorganizations. In DSM-IV, four sepa- rate disorders were recognized: autistic disorder, Asperger disorder (the highest functioning form of ASD), childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. The DSM-5 does away with this splitting and lumps all of the above into the ASD cate- gory. This change has been roundly criticized, because parents are concerned that some children, particularly higher functioning children who had been formerly labeled with Asperger disorder, may no longer qualify for special services to help them learn to function well. For an overview of ASD and its symptoms (using the DSM-IV criteria), watch a video from the National Center on Birth Defects and Developmental Disabilities: http://www.cdc.gov/ncbddd/video/autism/what isautism/index.html.

Attention Deficit Hyperactivity Disorder ADHD is characterized by age-inappropriate levels of inattention, hyperactivity, impulsivity, or a combination of these. These behaviors impair functioning in multiple settings and cause problems in school, in relationships with other children, and in the family. Although the disorder frequently begins in childhood, it often continues into adulthood. There is no cure for ADHD, but it can often be successfully managed.

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CHAPTER 7Section 7.3 Definitions and Familial and Biological Basis

A recent survey reported that ADHD is the most common childhood mental disorder, found in 6.8% of those aged 3 to 17 in the United States between 2005 and 2011. The survey described childhood mental disorders as “serious deviations from expected cognitive, social and emotional development” (Perou et al., 2013, p. 1). It emphasized that these disorders are “an important public health issue because of their prevalence, early onset, and impact on the child, the family, and the community, with an estimated total annual cost of $247 billion” (Perou et al., 2013, p. 1). (Onset is the first appearance, or beginning, of a trait, symptom, or other sign of a disorder.)

The prevalence of ADHD appears to have increased between 1997–1999 and 2008–2010, and it is higher among children whose household income is low. Non-Hispanic White children are most likely to be diagnosed with ADHD; Hispanic children are much less likely to be diagnosed with ADHD, and there was no effect of household income in that group (Figure 7.1). Boys are twice as likely to be diagnosed with ADHD as girls (CDC, 2013c), and the incidence of ADHD appears to increase with age through adolescence. Visit the CDC website for a personal account of one child helped through ADHD by her family: http://www.cdc.gov/ncbddd/adhd/stories.html.

Figure 7.1: Attention deficit hyperactivity disorder among children 5–17 years old in the United States, 2009–2010

Non-Hispanic White children are most likely to be diagnosed with ADHD.

Source: National Center for Health Statistics. (2012). Health, United States, 2011: With special feature on socioeconomic status and health (Library of Congress No. 76-641496). Hyattsville, MD: Author. Retrieved from www.cdc.gov/nchs/data/hus/hus11.pdf

Mood Disorders One in five adults experience a mood disorder (also termed affective disorder) sometime during his or her life. Major mood disorders include depression and bipolar disorder (also known as manic

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depression). As shown in Figure 7.2, each year 9.5% of adults experience a mood disorder, and in almost half (4.3%), the experience is termed severe (NIMH, n.d.-a). Severe mental illness is a loose definition that can vary according to the agency defining it. It often includes people who have psychosis (usually those diagnosed with bipolar disorder or schizophrenia) with a period of dys- function lasting for 12 months or longer. Generally those with schizophrenia, bipolar disorder, and major depression are included. Mental health disorders always occur within a social context, and how dysfunctional an individual is may be determined by the support received and the responses of family and friends in the environment.

Figure 7.2: Prevalence of mood disorders in the U.S. adult population

Definitions of severe mental illness vary according to the agency defining it, but each year 9.5% of adults experience a mood disorder.

Source: National Institute of Mental Health. (n.d.-a). Any mood disorder among adults. Retrieved from http://www.nimh.nih.gov/statistics/1ANYMOODDIS _ADULT.shtml

Mood disorders affect how people feel for long periods of time. Most people have days in which they feel particularly sad or happy, but mood disorders are more persistent and affect how people function in everyday life. Although we don’t yet understand why, people with mood disorders are also at increased risk for comorbidities, such as heart disease and diabetes (Wahlqvist et al., 2012). More generally, people with different mental disorders, including mood disorders, anxi- ety disorders, and PTSD, have a higher prevalence of cardiovascular disease and higher mortality compared with people without mental disorders (Fiedorowicz, He, & Merikangas, 2011; Weiner, Warren, & Fiedorowicz, 2011; Xue et al., 2012).

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Web Field Trip View the Synthesis Project’s online report, “Mental Disorders and Medical Comorbidity” (http://www .rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf69438; (Goodell, Druss, & Walker, 2011). After looking at the graphic on page 1 and reading the commentary, consider why the overlap between mental disorders and physical illnesses is so great.

Critical Thinking Questions

1. How could care be coordinated for these patients to achieve better health outcomes? 2. What are some of the pressing unmet needs in this area of public health?

Depression According to the WHO (2008), depression is the most important cause for loss of healthy life years due to disabling disease, or burden of disease, in middle- and high-income countries. In the United States during 2007–2010, depression had a nearly 8% prevalence among people 12 years and older (See Figure 7.3). Significantly more women (10%) than men (6%) reported experiencing depression (CDC, 2012d), and because it is influenced by social factors such as overcrowding, family turmoil, and violence, depression was more prevalent among people with lower income (National Center for Health Statistics, 2012).

Figure 7.3: Prevalence of current depression among persons 12 years and older

For all age groups, more women than men report depression.

Source: Centers for Disease Control and Prevention. (2012d). QuickStats: Prevalence of current depression among persons aged ≥ 12 years, by age group and sex—United States, National Health and Nutrition Examination Survey, 2007–2010. (2012). Morbidity and Mortality Weekly Report, 60(51–52), 1747. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6051a7.htm

Depression is also seen in children as young as 3 years old, although the prevalence appears to be lower (Table 7.1). In young children, there does not appear to be a difference in prevalence between girls and boys (Perou et al., 2013).

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Case Study: Suicide and Suicide Prevention Melissa was 13 when she made her first suicide attempt. She had always had trouble committing to and completing things. A major family gathering was coming up, but she had decided to skip it and go on a class trip instead. Then she changed her mind. But her parents sent her on the class trip; they felt she had to learn to deal with the consequences of her decisions. Just before going she said, “If I have to go on this trip, I’m going to kill myself!” She managed to stick it out during the trip, but when she returned, the first thing she said was, “I’m going to kill myself!” After attempting to hang herself (unsuccessfully), she was committed to a psychiatric hospital for a week, diagnosed with major depres- sive disorder, placed in individual psychotherapy, and put on an antidepressant medication. Melissa hated the hospitalization.

Melissa’s mom, Janice, recounts that her father was bipolar and acknowledges that mental disor- ders like this tend to run in families. Although her 22-year-old daughter and her 20-year-old nephew appear to be fine, her 24-year-old nephew has been diagnosed with ADHD. Melissa’s parents, Janice and Craig, found the National Alliance on Mental Illness (NAMI) particularly helpful in dealing with their depressed teenage daughter. They participated in a support group and were part of the 12-week Family-to-Family Program. Melissa participated in a peer support group for a while but, paradoxically, found it depressing.

Melissa made two more suicide attempts: four years after the first attempt, and again just recently, when she went off medication with the permission of her psychiatrist. She found that the medication interfered with her ability to think clearly, and because she was starting college, she wanted to apply herself to her courses. However, two months after stopping medication, she was no longer attending classes.

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Table 7.1: Prevalence of mental disorders in childhood (ages 3–17 years)

Mental Disorder Prevalence (%)

Attention deficit hyperactivity disorder 6.8

Behavioral or conduct problems 3.5

Anxiety 3.0

Depression 2.1

Autism spectrum disorders 1.1

Tourette syndrome 0.2 (children aged 6–17)

Source: Perou, R., et al. (2013). Mental health surveillance among children—United States, 2005-2011. Morbidity and Mortality Weekly Report. Surveillance Summaries, 62(2), 1–35. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/su6202a1.htm

When people are depressed, they have less interest in activities that they used to enjoy, have difficulty concentrating, may either lose or gain weight, and may have trouble sleeping (or sleep too much). Interpersonal relationships at home and at work are likely to suffer. In addition, people who are depressed are more likely to smoke, overuse alcohol, and neglect their health. Although people usually experience episodes of depression, if the first signs of depression are not treated, they are more likely to recur and to become chronic. Untreated depression can lead to serious problems in functioning and even suicide.

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Case Study: Suicide and Suicide Prevention (continued) After cutting her wrists, she called her friends and her sister, bypassing her parents, who were visiting just a few miles away. After Melissa’s sister called their parents, they came home immediately. Melissa was adamant about not wanting to return to the hospital, so her parents consulted a local suicide prevention center. A trained volunteer agreed that because she already had an appointment with her psychiatrist for the next day, Melissa could safely be kept at home with her parents.

Melissa’s psychiatrist changed her antidepressant. She seems to be doing well on this one and has fewer complaints about side effects. In addition to the antidepressant, Melissa takes anti-anxiety medication as needed and she receives psychotherapy. It has been three months since her last suicide attempt. Family support, psychotherapy, medication, and other tools that Melissa and her family have learned through NAMI have all contributed to Melissa’s improvement. Recently Melissa and Janice participated in a NAMI walk to raise funds and awareness of mental health. Melissa said, “Mom, I’m so glad that you’re doing this with me. Because you’re here, no one will think that it’s me who has the problem!”

For more information on suicide and suicide prevention, visit the NAMI website (http://www.nami .org/).

Melissa’s background is typical of people with depressive illness. In a large clinical trial report of those with major depression, more than half of the participants reported a family history of depression. Also, family history of depression was associated with an earlier age of onset of the disorder, more comorbid anxiety, and more suicide attempts. This same group had a somewhat faster onset of remission with medication but a greater incidence of side effects (Husain et al., 2009). These data point to a difference in biology between those with and without a family history of major depression, although they do not point to a particular mechanism or pathway. Although a family history of depression may produce an environment that contributes to the development of this disorder, it is also possible that the family is more attuned to depression and therefore quicker to recognize it and make sure the affected person gets help.

Bipolar Disorder Bipolar disorder (also known as manic-depressive illness) is characterized by dramatic shifts in mood, energy, and activity level. The last large U.S. study, published in 2005, estimated that 5.7 million adults 18 years old and older, or 2.6% of the population, were affected by bipolar disor- der each year (Kessler, Chiu, Demler, Merikangas, & Walters, 2005). Bipolar disorder is assessed along a spectrum, classified by severity of the manic component from bipolar I (most severe, with episodes of full-fledged mania), to bipolar II (episodes of mania that are not severe enough to qualify as full mania, but affect function), to subthreshold bipolar. A recent worldwide study of bipolar disorder found a 1.5% 12-month prevalence of bipolar spectrum disorder. Although both mania and depression increased from subthreshold bipolar through bipolar I, difficulties in pat- terns of behavior in social or work situations (role impairment) was similar across subtypes (Mer- ikangas et al., 2011). Bipolar disorder is associated with serious difficulties in social interaction and high economic costs. Despite its severity, bipolar disorder has received less research attention than depression or schizophrenia. Bipolar disorder that starts in childhood or early adolescence is termed early-onset bipolar disorder. It is associated with more severe disease. The prevalence of early-onset bipolar disorder has been a subject of controversy, because the definitions are not yet clear.

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CHAPTER 7Section 7.3 Definitions and Familial and Biological Basis

During a manic phase, someone might:

• be overly silly or joyful, • have a very short temper, • not sleep much but not be tired, and • engage in risky behavior.

During a depressive phase, a person with bipolar disorder might resemble someone who is depressed but also might have symptoms of mania. People with bipolar disorder are sometimes misdiagnosed as having depression, which can be a problem, because treatments for the two disorders differ.

Before sophisticated genetic analysis was available to examine disorders, it became clear from fam- ily, twin, and adoption studies that the risk of developing certain disorders had a strong genetic component—especially more so in monozygotic (or so-called identical) twins, who share genetic identity, than in dizygotic (or fraternal) twins, who are no more closely related than any two siblings. Studies of adopted monozygotic twins separated at birth have teased apart genetic and environ- mental triggers of a particular mental disorder. One review of family, twin, and adoption studies of bipolar disorder made it clear that the disorder is partly due to genetic risk factors and partly due to other risk factors (Smoller & Finn, 2003). Another study on twins estimated that heritability accounted for more than 80% of the risk of developing bipolar disorder (McGuffin et al., 2003). How- ever, inheritance accounted for only part of the risk (McGuffin et al., 2003; Smoller & Finn, 2003).

Recently, scientists have been looking for variation in genetic markers between people with a particular disorder compared with people without the disorder. These so-called genome-wide association studies are a powerful way to uncover the genetic components of disorders. Studies of White people with and without bipolar disorder uncovered several different markers of bipolar disorder located within known genes. In addition to identifying most cases of bipolar disorder as involving the interplay between several different genes and the environment, the researchers found some marker overlap in people identified as having schizophrenia; surprisingly, they found less overlap with people identified as having depression (Craddock & Sklar, 2013).

In addition to genetic components, changes in brain pathways and circuits are likely implicated in bipolar disorder. For example, researchers have identified structural and functional differences in specific neural networks involving the emotional and motivation portions of the brain in people with bipolar disorder compared with unaffected controls (Wessa, Kanske, & Linke, 2013). These differences (observed though imaging studies), combined with genetic studies and measurements of blood levels of several components, might be useful for identifying people at risk. Eventually, this combination of factors may prove to be a good biomarker, denoting the risk of developing the disorder.

What sorts of environmental and social triggers may be involved in risk for bipolar and other disorders? A recent study has identified at least one environmental trigger: the mother’s expo- sure to the flu during pregnancy. Children whose mothers had had the flu during their pregnancy developed bipolar disorder at 4 times the rate of those whose mothers had not had the flu (NIMH, 2013a). Exposure to flu during pregnancy is also associated with increased risk of schizophrenia, and a viral disease or immune response to the flu during pregnancy is associated with an increased risk of autism in mouse offspring (Malkova, Yu, Hsiao, Moore, & Patterson, 2012), suggesting that these different mental disorders may be connected. Note, however, that these environmental triggers are still highly speculative.

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CHAPTER 7Section 7.3 Definitions and Familial and Biological Basis

Case Study: Bipolar II Disorder When Abby was growing up, her parents considered her an emotional child, but because they attributed her character to an artistic temperament (she was interested in the theater and the arts), her personality type made sense to them. During her college and graduate education, she was sub- ject to bouts of depression and phases when she felt she could do anything. While in law school, she became dependent on alcohol and went to see a counselor, who treated her for depression. After she graduated from law school, Abby moved to another city and went into a severe depression, barely leav- ing her apartment for a year except for grocery shopping and other essential errands. During her next job, as a stockbroker, Abby went into a manic state that affected all her activities except for cold-calling clients, which she hated. She quit that job after about a year, went into mild depression, decided she wanted to be an architect, and spent three really happy years, pretty much on a continuous high, in architecture school.

Only when she turned 35 did she hit bottom and move back in with her parents. Her parents said that she could stay with them but that she had to see a psychiatrist. Finally, Abby was diagnosed with bipo- lar II disorder. The psychiatrist diagnosed her in about two minutes and put her on medication. Abby was able to work in a bookstore for about eight months while her dosage was adjusted, and it was through that job that she met her present supervisor. Abby now works 30 flexible hours a week. Even with medication, some days she can’t get herself moving until 10:00 a.m., and other days she is happy to start her commute at 6:30 a.m. Abby confesses, “It would be almost impossible for me to succeed at a job requiring a 9-to-5 schedule.”

Abby’s supervisor knew about her diagnosis and yet was sure that she would be a good fit for the needs of the U.S. government agency position he hired her for. About two years ago Abby had to undergo an additional security clearance, which required an interview with a government psychiatrist. Although she was somewhat apprehensive about it, the interview went fine and Abby gained her additional clearance. Last year Abby earned agency-wide recognition for her ability to translate convoluted gov- ernment regulations into an easily understandable format.

Although Abby sometimes missed the highs of her manic phases, whenever she went off medication she found herself deeply depressed and went back on it immediately. She has been at her present job for more than 10 years now and is doing very well. She needs to be monitored at regular intervals to ensure that her medication does not cause any side effects and is at a safe and effective level.

Anxiety Disorders Anxiety disorders comprise panic disorder, obsessive-compulsive disorder (OCD), PTSD, phobias, generalized anxiety disorder (GAD), and social anxiety disorder (or social phobia). Although PTSD is often classified as an anxiety disorder, we look at it separately here, because it shares a com- mon causal agent (etiology) with other trauma- and stress-related disorders. Anxiety disorders are the most common mental disorders in the U.S. population, with a 12-month prevalence of 18% (Kessler, Chiu et al., 2005). However, compared with mood disorders, a smaller percentage of anx- iety disorders are considered “serious mental illness.” There appear to be some sex differences, with more women than men experiencing anxiety and women finding it more disabling than men (McLean, Asnaani, Litz, & Hofmann, 2011).

Anxiety disorders cause people to “feel excessively frightened, distressed, or uneasy during sit- uations in which most other people would not experience these same feelings” (NAMI, 2012a).

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CHAPTER 7Section 7.3 Definitions and Familial and Biological Basis

People with anxiety disorders are likely to use alcohol, tobacco, and other drugs in an attempt to relieve their symptoms. This self-medication can be self-defeating or even dangerous, because when the effect of the drug wears off, the person is likely to feel even more anxious. Furthermore, self-medicating interferes with learning how to cope with anxiety-producing situations. Despite the prevalence of anxiety disorders, much less attention has been paid to them, even though anxiety can result in as much impairment as, and is often found together (is comorbid) with, depression (CDC, 2011c).

Panic Disorder People with panic disorder experience sudden attacks of terror, usually with physical symptoms such as a pounding heart, sweatiness, and weakness or dizziness. Panic attacks can happen repeatedly and without warning, often producing a sense of unreality and a fear of dying. Twice as many women as men experience panic disorder, which can become very disabling, because people might avoid leaving their home (and develop agoraphobia) for fear they will have a panic attack (NIMH, 2009a).

Obsessive-Compulsive Disorders People experiencing OCD have persistent, upsetting, and unwanted thoughts (obsessions) and react with a set of repetitive activities or rituals (compulsions) to control the anxiety produced by these thoughts. For example, those with OCD might have to check that the stove is turned off several times before leaving the house or wash their hands 25 times each day to make sure they are “free from germs.” Although checking that the stove is turned off is a normal routine, for peo- ple with OCD, the obsessions and compulsions interfere with their normal activities and start to control their lives. Research suggests that approximately one third of adults with OCD experienced symptoms as children and that the disorder may run in families (NIMH, 2009a). Children whose parents have OCD face challenges and burdens in dealing with the parent’s mental health prob- lems (Griffiths, Norris, Stallard, & Matthews, 2012). Family reactions and responses to children with OCD do not make the rituals go away, but can actually strengthen them (Bond & Guastello, 2013). In contrast, an accepting and autonomy-granting parental style protects children with OCD from comorbid anxiety and depression (Cohen, Sade, Benarroch, Pollak, & Gross-Tsur, 2008).

Phobias Phobias are intense, irrational fears of something that actually poses little or no threat. Common phobias are the fear of heights, spiders, public speaking, highway driving, and tunnels (as in claus- trophobia, fear of enclosed spaces). People with phobias often acknowledge that their fear is irrational, but it doesn’t stop the fear from causing terror or panic. Phobias are twice as common in women as in men and often begin in childhood or adolescence (NIMH, 2009a).

Generalized Anxiety Disorder GAD is characterized by worrying excessively about everyday problems and events. Symptoms last for at least six months and make it difficult to concentrate and carry out everyday activities. Like people with phobias, people with GAD are often aware that their concerns are excessive, but that “head knowledge” does not stop them from experiencing disturbing thoughts and reacting to them. GAD is often accompanied by other anxiety disorders, depression, or substance abuse (NIMH, 2009a).

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CHAPTER 7Section 7.3 Definitions and Familial and Biological Basis

Social Anxiety Disorder People with social anxiety disorder or social phobia are excessively anxious and self-conscious in everyday social situations, leading to difficulties in work and personal relationships (NAMI, 2012a). Social anxiety usually begins in childhood or early adolescence and unlike many other anxiety disorders is found at the same rate in women and men (NIMH, 2009a).

Trauma- and Stress-Related Disorders When people are exposed to traumatic or stressful events, many respond with an acute stress reaction. Some, but not all, who experience an acute stress reaction may go on to develop a more chronic reaction, such as PTSD. Approximately 18% to 36% of those experiencing trauma develop PTSD (Heinzelmann & Gill, 2013).

Posttraumatic Stress Disorder Trauma consists of different things for different people. Initiating events for PTSD can be abuse or assault, combat experience, natural disasters, serious accidents, sudden and major emotional losses, or terrorist attacks (NIMH, 2010). A child experiencing neglect or abuse, a woman who has been raped, and a veteran who has been injured in combat are all likely candidates for PTSD. The severity of the traumatic event and length of exposure are critical risk factors for developing PTSD but don’t tell the whole story. Depending on their genetic makeup and early experiences, people can be more or less resilient—able to bounce back from traumatic events (Heinzelmann & Gill, 2013).

PTSD is associated with changes in parts of the brain involved with fear and stress. Symptoms include strong memories of the event, nightmares and difficulty sleeping, emotional numbness, edginess or hyperarousal (or hypervigilance) during ordinary events, and an aversion to thoughts and situations that might remind the person of the event. Approximately 7.7 million people in the United States age 18 or older, or 3.5%, experience PTSD in a 12-month period (Kessler, Chiu et al., 2005).

Web Field Trip Visit the National Center for PTSD’s website AboutFace, and view video excerpts of veterans who have suffered from PTSD after serving in the military (http://www.ptsd.va.gov/apps/AboutFace/).

Critical Thinking Questions

1. How were the veterans helped by medication and other forms of therapy? 2. In what ways to you see therapy being tailored to individual cases?

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CHAPTER 7Section 7.3 Definitions and Familial and Biological Basis

We are beginning to understand some of the biology of PTSD. Studies of military personnel both before and after deployment have yielded clues to what makes one person more vulnerable to PTSD than another. Long-term studies of people following natural disasters have been able to look at those who do and do not develop PTSD. In addition, there is a large body of literature on the short- and long-term effects of stress on animals. Stress and trauma may have direct effects on brain structures, including those involved in fear, emotional reactivity, and cognition (Sherin & Nemeroff, 2011). Children may be particularly vulnerable to these effects. One study compared 62 children who had witnessed a violent act committed on someone they knew; 27 developed PTSD, and 35 did not (Samuelson, Krueger, Burnett, & Wilson, 2009). Children who developed PTSD showed slower and less effective learning, although both groups were below average in executive function, attention, and intellectual ability.

PTSD appears to affect the neuroendocrine, the autonomic nervous (which controls automatic functions such as the heart and digestion), and the immune systems, producing changes that have both short- and long-term effects (Sherin & Nemeroff, 2011; Tucker, Tiller, & Dalthorp, 2013). One particularly sensitive component appears to be the glucocorticoid system, which is responsible for the immediate response to stress. A prospective study of 448 male soldiers looked at several measures of the glucocorticoid pathway in white blood cells before and after deployment to a military zone (van Zuiden, Kavelaars, Geuze, Olff, & Heijnen, 2013). Soldiers rated themselves for PTSD symptoms after deployment. Several predeployment characteristics, including glucocorti- coid receptor number and target gene activity, were independently associated with high risk for PTSD. Experiencing childhood trauma was also an independent risk factor for developing PTSD.

Survivors of Hurricane Katrina who relocated to Oklahoma had higher rates of PTSD and depres- sion than controls from the same Oklahoma community (Tucker, Jeon-Slaughter, Pfefferbaum, Khan, & Davis, 2010). They also exhibited greater heart rate and blood pressure responses to an interview about the trauma and had higher levels of inflammatory cytokines, all of which put them at greater risk for cardiovascular events. Previous data suggested that people with PTSD have a higher risk of comorbid heart disease, most likely resulting from biological changes induced by PTSD (Kubzansky & Koenen, 2009).

Traumatic Brain Injury Traumatic brain injury (TBI) is caused by a blow or bump to the head or penetrating head injury that disrupts normal brain function. TBI can be mild, for instance a brief change in consciousness, to severe, for instance an extended period of unconsciousness or memory loss (amnesia). Most TBIs are concussions or other mild forms, but each year, some TBIs result in severe injury and death (CDC, 2010b). Athletes who play contact sports, such as boxing and football, are prone to these injuries, as are military personnel deployed in combat situations. See Figure 7.4 for a graph showing the prevalence of TBI among military personnel.

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CHAPTER 7Section 7.3 Definitions and Familial and Biological Basis

Figure 7.4: Total worldwide traumatic brain injury diagnosis among service personnel by year

Traumatic brain injuries disrupt normal brain function. Military personnel, especially those in combat situations, are prone to such injuries.

Source: DoD Worldwide Numbers for TBI. Retrieved from http://www.dvbic.org/dod-worldwide-numbers-tbi.

Schizophrenia Schizophrenia is a serious and complex chronic mental disorder that “interferes with a person’s ability to think clearly, manage emotions, make decisions and relate to others” (NAMI, 2012b). An estimated 1.1% of the U.S. population 18 and older is diagnosed with schizophrenia in a 12-month period (NIMH, n.d.-b). Although some studies have found that men and women are equally affected by schizophrenia (NIMH, n.d.), others have found more men than women affected, with a 1.4:1 ratio (McGrath, Saha, Chant, & Welham, 2008).

Symptoms The diagnosis of schizophrenia is currently based on clinical criteria that include positive (psychotic) symptoms, negative symptoms (reductions in normal emotions and behaviors), and cognitive (thought-related) symptoms (NAMI, 2012b; NIMH, 2009b). See Table 7.2 for a breakdown.

2000 20022001

25,000

35,000

N u

m b

e r

o f

c a

s e

s

10,000

15,000

20,000

30,000

5,000

Calendar year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

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CHAPTER 7Section 7.3 Definitions and Familial and Biological Basis

Table 7.2: Variety of symptoms in schizophrenia

Positive Symptoms Negative Symptoms Cognitive Symptoms

Delusions (belief in things that are not real, or outside the person’s culture)

Flat affect (lack of facial or vocal expressiveness)

Poor executive function (inability to organize and prioritize tasks or information)

Hallucinations (hearing, seeing, smelling, or feeling things others cannot sense)

Anhedonia (lack of pleasure or interest in everyday life)

Trouble focusing and paying attention

Disorganized thought; incoherent speech (not making sense when talking)

Inability to start or follow through on activities

Problems with working memory (inability to use information immediately after learning it)

Agitated or repetitive body movements, movement disorders

Withdrawal (speaking little, even when forced to interact)

Sources: National Alliance on Mental Illness. (2012b). Schizophrenia fact sheet. Retrieved from http://www.nami.org/factsheets /schizophrenia_factsheet.pdf. National Institute of Mental Health. (2009b). Schizophrenia (NIH Publication No. 09-3517). Bethesda, MD: Author. Retrieved from http://www.nimh.nih.gov/health/publications/schizophrenia/schizophrenia-booket-2009.pdf

Schizophrenia is considered a chronic disease, but symptoms may cycle through the negative and positive phases, becoming more or less severe with time. People with schizophrenia often have difficulty taking care of themselves and so must rely on family or institutions for help. However, as they age, many people with schizophrenia manage their lives better, particularly if they have access to social support systems, and a surprising number are able to hold jobs and have regular family contact.

Biological Basis Schizophrenia, like so many disorders, is thought to result from a combination of genetic and environmental influences. Many theories and much evidence have been presented about the bio- logical basis of schizophrenia, but as yet there is little consensus as to the mechanisms involved. Because schizophrenia onset is usually seen between late adolescence and early adulthood, which coincides with a major brain rearrangement, one suggestion posits that something about this pro- cess goes amiss in people with schizophrenia. The density of nerve cell connections, or synapses (the space in which the nervous impulse passes between neurons), in the cerebral cortex reaches a maximum when children are between 2 and 4 years old and then declines to adult levels during adolescence. The process of eliminating excess connections is termed synaptic pruning. Though the data suggest that problems in synaptic pruning are a possible trigger of schizophrenia, how- ever, the process is far from proven responsible (Boksa, 2012).

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CHAPTER 7Section 7.3 Definitions and Familial and Biological Basis

Another long-held hypothesis about schizophrenia is that disruptions during early brain develop- ment increase risk for the disorder. Again, some data have correlated maternal infection, nutri- tional stresses, and obstetric complications with heightened risk for schizophrenia, but the find- ings are not definitive.

As in other mental disorders, schizophrenia is more common in some families, which suggests that risk for schizophrenia is at least partly genetic, likely involving contributions from a large number of genes involved in the nerve signaling pathways. One gene linked to schizophrenia risk was discov- ered in a large Scottish family with a number of members diagnosed with schizophrenia and major depressive disorder. Affected family members carried a chromosomal rearrangement that was later linked to a specific gene termed Disrupted in Schizophrenia 1 (DISC1; Thomson et al., 2013). DISC1 appears to play an important role in the formation of neurons during development and the production of neurons in the adult brain. In addition, DISC1 appears to be involved in neuronal signaling, and its activity is modulated by environmental stress, suggesting direct mechanisms for gene–environment interactions (Thomson et al., 2013). However, how much influence DISC1 exerts in risk for schizophrenia or other mental disorders in the wider population is unknown.

Comorbidities More than one disease or disorder occurring together in one person or population is termed comorbidity. Comorbidity can make it more difficult to determine which disease or disorder is responsible for a particular sign or symptom. Using Swedish national health care records, a recent study examined what might have caused the increase in cardiovascular mortality among peo- ple with schizophrenia (Crump, Winkleby, Sundquist, & Sundquist, 2013). Sweden has universal health care and collects extensive data on diseases and treatments. Crump et al. followed a cohort of more than six million adults from 2003 to 2009 to detect mortality and illness. Among the 8,277 people with schizophrenia, men died 15 years earlier and women died 12 years earlier than the rest of the population. Contrary to expectations, these deaths were not from suicide but mostly from cardiovascular disease and cancer, which were underdiagnosed in this population despite their having twice as many contacts with the health system as people without schizo- phrenia. Lack of antipsychotic treatment was associated with an increased mortality risk. These findings underscore the importance of integrating medical care with mental health care tailored to the needs of people with mental disorders.

Dementia Dementia is not a specific disease; rather, it is a cluster of symptoms affecting thinking and social interactions that are severe enough to interfere with social or occupational functioning (Table 7.3 compares the different forms). Dementia is usually caused by a number of different brain disorders, including Alzheimer’s disease, Lewy body dementia, vascular dementia, fronto- temporal dementia, and Huntington’s disease. Dementia is more prevalent among people older than 60 years, although there are some young-onset forms (e.g., frontotemporal, Parkinson’s disease related).

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CHAPTER 7Section 7.3 Definitions and Familial and Biological Basis

Table 7.3 Forms and Symptoms of Cognitive Impairment

Mild Cognitive Impairment

Alzheimer’s Disease

Lewy Body Dementia

Vascular Dementia

Frontotemporal Dementia

Other Forms

Symptoms Slowed thinking and mild memory problems

Apathy, memory loss, depression, poor judgment, and confusion

Fluctuations in alertness and attention

Depression and apathy

Decline in cognition

Frequent visual hallucinations

Parkinsonian motor symptoms, e.g., rigidity and shuffling gait

Depression and anxiety more severe than in Alzheimer’s

Late stage: personality changes, emotional dysregulation

Difficulties with language and changes in personality and behavior

Memory is preserved compared with Alzheimer’s disease

---

Etiology Age-related Neuro - degenerative disease (neurofibrillary tangles form in the brain)

Buildup of Lewy bodies (bits of alpha-synuclein protein) inside neurons in brain areas that control memory and movement

Brain damage following a stroke or other obstruction to brain’s blood supply

The common form, multi- infarct dementia, results from many small strokes (transient ischemic attacks)

This less common form of dementia results from degeneration of nerve cells in the frontal and temporal lobes of the brain

Mixed, e.g., Alzheimer’s disease and Lewy body disease or Alzheimer’s disease and vascular dementia

Parkinson’s or Huntington’s disease

Clinical course

Does not always lead to dementia

Mid-to-late stage: emotional outbursts, behavioral changes

Late stage: trouble walking, speaking, and swallowing; severe memory loss

Progressive; course is variable

--- Onset is early, 50s and 60s

Patients may lose language early in the disease

---

Risk factors

--- Genetic/familial component (APOE4 gene implicated)

Advanced age, cardiovascular risk factors, and head injury

--- High blood pressure, diabetes, previous stroke or heart attack, late-life depression

--- ---

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CHAPTER 7Section 7.3 Definitions and Familial and Biological Basis

As people age, they may experience slightly slowed thinking and mild memory problems; this mild cognitive impairment is part of the normal aging process and does not always lead to demen- tia. Dementia goes beyond the consequences of aging and usually results from brain nerve cells (neurons) stopping their function, losing connections to other cells, or dying. Although it may be possible to slow the rate of decline, the progress of these diseases cannot be halted or reversed. However, other types of dementia, caused by metabolic problems, brain tumors, or reactions to medications, may be reversible with appropriate treatment (National Institute of Neurological Disorders and Stroke [NINDS], 2013a).

Possible symptoms of dementia include memory problems, difficulty communicating, difficulty problem solving, difficulty planning and organizing, and difficulty with orientation in space (get- ting lost). They also include difficulty controlling emotions, agitation, the belief that people are threatening (or paranoia), and hallucinations.

Alzheimer’s Disease The most common form of dementia is Alzheimer’s disease, which is also considered a neurode- generative disease (in which neurofibrillary tangles form in the brain). The Alzheimer’s Associa- tion (2012) estimated that in 2012, 5.4 million people in the United States had Alzheimer’s dis- ease, including 200,000 who were less than 65 years old. The burden of disease in U.S. society is expected to grow rapidly, as the aging of the baby boomer population (those born between 1946 and 1964) is projected to increase the prevalence of Alzheimer’s disease to between 11 and 16 million by 2050. Alzheimer’s disease places a tremendous financial and emotional burden on the family and society because of the increased need for care between diagnosis and death, a period that is usually four to eight years but may be as long as 20 years (Alzheimer’s Association, 2012). Not surprisingly, more than 50% of caregivers of patients with Alzheimer’s disease had high anxi- ety and depression scores that increased along with the duration and severity of dementia in the people they cared for (Garcia-Alberca, Lara, & Berthier, 2011).

Alzheimer’s disease has a subtle onset. It may begin with trouble remembering names and recent events (short-term memory). People also may become apathetic or depressed and lose interest in their normal activities. As the disease progresses, problems with judgment and confusion may become apparent. A person with Alzheimer’s has trouble remembering and asks the same ques- tion or repeats the same story over and over, much to the dismay of family members and friends. Emotional outbursts and other behavioral changes may become a problem as the disease pro- gresses. The person with Alzheimer’s may need assistance with activities of daily living, including eating, personal hygiene, and toileting. In the late stage, people with Alzheimer’s disease have trouble walking, speaking, and swallowing. They often no longer recognize family members, which can be very upsetting to those closest to them. Unfortunately, during the disease course, it is com- mon for people to spend the most time in the late stages, when they are most impaired and need the most assistance (Alzheimer’s Association, 2012). However, the particular course of disease and rate of decline vary greatly from person to person.

As in Huntington’s disease (see Chapter 3), some forms of early Alzheimer’s occur in those who carry a single gene that ensures that person will develop dementia. Early-onset Alzheimer’s dis- ease appears in the 30s, 40s, or 50s and is caused by a mutation in one of three different genes (Alzheimer’s Association, 2012). Fortunately, less than 1% of people who develop Alzheimer’s dis- ease carry one of these mutations. For older-onset Alzheimer’s disease (≥ 65 years), the greatest risk factor is advancing age itself. More women than men have Alzheimer’s disease, but this is a

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CHAPTER 7Section 7.3 Definitions and Familial and Biological Basis

result of women living longer than men; at any given age, women are no more likely than men to develop the disease (Alzheimer’s Association, 2012). People who have a first-degree relative (a parent or sibling) with Alzheimer’s are at somewhat increased risk for developing the disease. Some data suggest that people who have cardiovascular risk factors (smoking, obesity, diabetes, physical inactivity) or who have had head trauma are at increased risk of developing Alzheimer’s disease (Alzheimer’s Association, 2012).

Those carrying a common variant of the apolipoprotein E gene (APOE4) are at a higher risk of devel- oping it and at a somewhat younger age than usual, but it is only an increased risk, not a guarantee of disease. APOE4 is involved in cholesterol metabolism, but how it is implicated in Alzheimer’s disease remains a mystery. Most genetic studies have been carried out in White people. A recent study of Black people in the United States found two gene variants associated with increased risk for late-onset Alzheimer’s disease: APOE4 and ABCA7 (Reitz et al., 2013). The risk for Alzheimer’s with APOE4 was similar to that seen in Whites, but the risk conferred by ABCA7 was much higher in Blacks compared with Whites. Like APOE4, ABCA7 is involved in lipid metabolism. Studies such as this one are useful because they may uncover new biological targets for treatment.

Lewy Body Dementia Lewy body dementia (also known as dementia with Lewy bodies) is a prevalent, progressive form of dementia. Lewy bodies (found in the brains of people with Lewy body dementia and several less common dementias) are clumps of misfolded alpha-synuclein protein. Their accumulation appears to be toxic to nerve cells. Researchers are attempting to prevent these proteins from mis- folding or to increase removal of misfolded proteins before they destroy the cells.

Lewy body dementia is characterized by a decline in the ability to think (cognition) combined with the following symptoms: noticeable fluctuations in alertness and attention (drowsiness, lethargy, long periods of time spent staring into space, disorganized speech); frequent visual hallucinations; and parkinsonian motor symptoms, such as rigidity and shuffling gait. Symptoms appear to be caused by the buildup of Lewy bodies inside neurons in brain areas that control memory and movement (NINDS, 2013b).

Lewy body dementia shares many features with Parkinson’s disease dementia (see Chapter 3), and many people believe that the two are part of the same disease spectrum. To distinguish between them, clinicians have decided that if signs of dementia are apparent before or within a year after the appearance of motor symptoms, then the formal diagnosis is Lewy body dementia; if the signs of dementia appear more than a year after motor symptoms, the diagnosis is Parkinson’s disease dementia (Dodel et al., 2008). Survival rates are similar to those seen in Alzheimer’s disease, aver- aging eight years after diagnosis. During this time, patients become more disabled and eventually need care for all activities of daily living.

Vascular Dementia Vascular dementia is another common form of dementia, resulting from brain damage following a stroke or other blockage of the brain’s blood supply. A common form of vascular dementia is multi-infarct dementia, the result of many small strokes. Symptoms vary depending on which brain structures are involved, but, unlike Alzheimer’s disease, personality and regulation of emo- tional states are usually not affected until later stages of the disease (NINDS, 2013a). Symptoms usually start suddenly, and the disorder is more common in people with high blood pressure and those who have had strokes or heart attacks.

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CHAPTER 7Section 7.4 Using Bronfenbrenner’s Model to Better Understand Mental Health

Case Study: ASD Diagnosis Many parents assume they will have an essentially problem-free child, and it comes as a shock to the entire family system when they realize that isn’t true for them. Steve had special needs from birth. He had an underactive suck reflex and a gag reflex, so he couldn’t feed properly; he didn’t sleep more than four hours a night; and he needed to be engaged constantly, which was hard on his mother Andrea. Steve’s pediatrician suggested using educational videos, which mesmerized him and allowed Andrea to take a break once in a while. As Steve approached his first birthday, Andrea was concerned that he was not doing what other babies his age were doing, but Steve’s father Will had been a late talker and Steve’s pediatrician reassured Andrea that Steve was fine.

(continued)

Frontotemporal Dementia Frontotemporal dementia, a less common form of dementia, results from the degeneration of nerve cells in the front and sides (or frontal and temporal) lobes of the brain. Typical symptoms include difficulties with language and changes in personality and behavior that begin when a per- son is 50 or 60 years old, rarely later in life (Alzheimer’s Association, 2012).

Mixed Forms Often, someone with dementia has symptoms that suggest more than one type of dementia. Although in the past clinicians attempted to diagnose a single type of dementia, now they are more willing to acknowledge that the hallmarks of several different dementias can coexist—this is called mixed dementia. An autopsy may reveal the presence of both neurofibrillary tangles and Lewy bodies, suggesting that the patient had a mixture of Alzheimer’s and Lewy body dementias.

7.4 Using Bronfenbrenner’s Model to Better Understand Mental Health and Mental Disorders

Bronfenbrenner’s bioecological model places the individual within several concentric circles of the larger environment: the micro perspective of the family; the meso perspective of the immediate community (including school or work); and the macro perspective of the larger world, including race, ethnicity, socioeconomic status, national origin, and political systems.

Micro Perspectives In Bronfenbrenner’s model, interaction is a two-way phenomenon. For example, because a child with ASD requires so much attention as a toddler, one parent probably spends a lot of time tend- ing to and interacting with the child and is less able to hold a demanding, full-time job. In turn, the extent to which the parents understand and are willing to cope with the child’s demands plays a role in helping the child learn to interact with the environment.

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CHAPTER 7Section 7.4 Using Bronfenbrenner’s Model to Better Understand Mental Health

Case Study: ASD Diagnosis (continued) A new pediatrician, who saw Steve when he was 18 months old, said, “This kid needs to be evaluated immediately.” Although the pediatrician didn’t know much about ASD, she knew that a child should reach certain developmental milestones. For instance, by 18 months a child most often:

• is afraid of strangers; • shows affection to familiar people; • says several single words; • says and shakes his or her head “no”; • knows a number of ordinary things, for example, telephone, spoon, and brush; • points to get the attention of others; and • drinks from a cup (CDC, 2008).

Steve was sent to a specialist who diagnosed him with ASD and helped Andrea connect to public inter- vention services immediately. Steve started therapy at home twice a week with a speech therapist and twice a week with an occupational therapist. The therapists helped the family learn how to interact with Steve in a way he could respond to. Andrea was also encouraged to learn as much as possible about ASD so that she could become part of the therapeutic environment.

Andrea found the training she got when Steve received early intervention services continued to help her even when Steve was almost 10 years old. For example, Steve listens to Andrea more attentively in a busy situation when she tells him something and signs it at the same time—a technique she learned from an occupational therapist when Steve was very young.

Some parents resist having their children evaluated, even when they suspect serious develop- mental delays. They may be afraid that having their child “labeled” will be a problem in the future. But in doing so, they pass up services that can help their children develop and that are available for free in every state. They also are not learning how to interact with their child in ways that might benefit both the child and the family. Other factors that may prevent children or adults from getting services for autism or other mental health problems include language barriers, lack of trust in providers, competing family demands, problems with transportation to a service provider, lack of integrated services, and the need for the parent to earn an income.

Meso Perspectives Mental disorders affect how a person functions in school, at work, or in their immediate commu- nity. Sometimes people with mental disorders are lucky and are able to receive accommodations in their various environments. For example, Abby, the woman we met earlier who has bipolar II disorder, has been functioning well for 10 years in her position as a technical writer for a govern- ment agency. But it was mainly the understanding of her supervisor and the flexible policies of her employer that made it possible.

A mental disorder in a child, such as autism, affects how family members interact with the larger community. For example, children with autism are abnormally sensitive to sensory input and can become overwhelmed when they are in a grocery store, for example, with its array of colors, pat- terns, and smells. When overstimulated, these children are likely to exhibit what is often termed a “temper tantrum.” How well the outside community (e.g., daycare facilities, schools) understands the problems of such children and makes allowances for them determines how the meso-level environment influences that child’s development, for good or ill.

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CHAPTER 7Section 7.5 Mental Disorders Through the Life Span

Case Study: Interactions With the Community Andrea, Steve’s mother, related how difficult it can be to have normal interactions in her community. Just going to the grocery store with an autistic child can become an adventure. Andrea wishes she could tell the other shoppers who eye her with disapproval when he’s upset, “No, my child is not a spoiled brat because he’s screaming; that’s just how he communicates. His nervous system becomes overwhelmed by sensory input and goes into a meltdown.”

Macro Perspectives The macro perspective looks at how the disorder affects the person within the culture and the larger society, and conversely, how the larger society affects the person with the disorder. For example, the flexible schedule worked out by Abby’s government employer allowed her to have a fulfilling job and allowed the government agency to have the services of one of their top perform- ers. This is an example in which representatives of the larger society, U.S. government officials, were able to resist the stigma of a mental disorder and look instead at the functioning of the indi- vidual with the disorder. Possibly more significantly, as a matter of public policy, the Americans with Disabilities Act (ADA) requires such employers to make reasonable accommodations for a person’s disability, if doing so will allow them to function well in their job. (For more discussion of the ADA, see Chapter 2.)

7.5 Mental Disorders Through the Life Span

The onset of mental disorders occurs at different times in the life span and, depending upon age and stage in life, has different effects on those with the disorder and their families. Mental disorders are often first diagnosed during childhood and adolescence. Fully half of all lifetime cases of mental disorders start by age 14, and three quarters by age 24 (Kessler, Ber- glund et al., 2005). However, age at onset appears to differ among the various mental disorders.

Childhood ASDs are probably among the first mental illnesses to be diagnosed. More severe forms of the disorder are likely to be diagnosed earlier. For instance, children with autistic disorder are usu- ally diagnosed by age 4, but children with Asperger’s disorder (now part of ASD in DSM-5) are not diagnosed until an average age of 6 years, 3 months (CDC, 2012d). The CDC has an active campaign to urge early diagnosis of ASD: “Learn the Signs. Act Early” (CDC, 2008). Although age at diagnosis is getting younger, many children are missing out on early intervention programs that could address specific developmental concerns and help them catch up with their peers. These programs are effective for young children, and all school systems across the country are mandated to provide appropriate education for all children, no matter what their disability.

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CHAPTER 7Section 7.5 Mental Disorders Through the Life Span

Sometimes the symptoms exhib- ited by a child with a mental disor- der are different from those seen in an adult with the same disorder. For instance, unlike adults, children with bipolar disorder sometimes have an extremely short temper and show unusual irritability when they are in a manic state, and they complain about pain when they are in a depressed state (NIMH, 2012a).

Adolescence As in schizophrenia, the peak period of onset for bipolar disorder occurs during adolescence (Merikangas et al., 2012). One recent study looked at mania and depression in a large

community sample of 10,123 adolescents aged 13 to 18 years. To their surprise, the investigators found that 1.7% of adolescents met criteria for lifetime mania only, without depression (Merikan- gas et al., 2012). A larger group, 2.5%, met criteria for lifetime bipolar I or bipolar II disorder, and the prevalence of mania increased twofold between ages 13–14 and 17–18.

What happens to children with ASD as they get older? Once graduated from high school, those with ASD have limited opportunities. One study of 1,900 youths found that fewer people with ASD than other disabilities are either employed or undergoing further education two years after graduating from high school. It also found that youths from low-income families were much more likely to become disengaged, regardless of the severity of their disability. More impaired youths were also at greater risk of disengagement (NIMH, 2012b).

Case Study: Mainstreaming Children Diagnosed With ASD Marie has a large family, starting with a husband and five children. When the family gets together, as they like to do, there are at least 15 people and often more. One of Marie’s grandsons, Charlie, is 14 and has the physique of a grown man. He was diagnosed in childhood with ASD. Marie con- fides that it is getting more difficult to deal with Charlie at family gatherings as he gets older. Family members prefer to have Charlie’s younger sister Betsy, who is “neurotypical” (not having ASD) visit without Charlie. The children’s mother, Theresa, is offended that people don’t want to have Charlie around. Charlie is now being “mainstreamed” at his local school, which means he is part of the regu- lar classes. However, Marie thinks this is the wrong idea. She protests, “He needs to learn to eat with a fork, not learn algebra!”

Tony Gutierrez/Associated Press

Early detection of ASD allows children to be placed in programs that address their specific developmental concerns.

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CHAPTER 7Section 7.5 Mental Disorders Through the Life Span

Mainstreaming has many proponents and many detractors. Some people think that children with ASD, particularly those who are higher functioning, can learn communication skills by interacting with more typical children in a mixed classroom. Others think that children with ASD, particularly those who are not so high functioning, learn social skills best from specially trained teachers. Most parents of children with ASD think it is most important to match the individual child with the school situation that best fits his or her needs, whether a special needs school, a special needs class within a regular elementary school, some mix of special needs classes and main- streaming, or all mainstreaming. For a more extensive discussion of mainstreaming, see “School Inclusion for Children with Autism Spectrum Disorders” (http://www.aboutourkids.org/articles /school_inclusion_children_autism_spectrum_disorders).

Adulthood ADHD is thought of as a childhood disorder; it is usually diagnosed in preschool or during early elementary years (Kessler, Chiu et al., 2005). Although many people diagnosed with ADHD as chil- dren seem to grow out of it, a significant percentage continues to have symptoms as adults, and some people are not diagnosed with ADHD until they are adults. In all, prevalence of ADHD among adults aged 18 to 44 years was found to be 4.4% of the population. These adults were more likely to be unemployed and have other comorbid disorders than those without ADHD (Kessler et al., 2006). Adults with ADHD were also more likely to perform poorly in the workplace, with an excess of 35 lost work days compared with those without ADHD (Kessler, Adler et al., 2005). It is not known whether treatment improves the incidence and severity of this disorder and its effects.

A recent study compared adults (mean age, 27 years) diagnosed with ADHD as children with those from the same birth cohort who had not been diagnosed with ADHD. Researchers found that childhood ADHD persisted in 29.3% of the adults and that, tragically, those adults who had been diagnosed with ADHD as children were significantly more likely to have one or more mental disor- ders and to die from suicide (Barbaresi et al., 2013).

The Elderly The most common mental disorders seen among the elderly living in long-term care facilities are dementia, depression, and anxiety (Seitz, Purandare, & Conn, 2010). Depression is quite preva- lent among people in the United States aged 65 and older. Although many experience depres- sion for most of their lives, others experience its onset late in life—even as late as their 80s and 90s. Although elderly women are more likely to experience depression, it is a greater risk factor for suicide among elderly men (NAMI, 2009a). Social factors that may contribute to late-onset depression include loneliness, loss of a spouse, perceived lack of support, and feelings of isolation. The effects of GAD do not appear to diminish with age. Instead, compared with older adults with no mental disorders, older adults with GAD were found to be more disabled and exhibited worse health-related quality of life (Porensky et al., 2009).

Although we think of PTSD as occurring in children, young adults, and those who have served in the military, it can also be found in older adults. A meta-analysis of cognitive functioning in older adults found that those with PTSD had worse cognitive performance compared with those of the same age without PTSD (Schuitevoerder et al., 2013). In some cases, PTSD emerges late in life, years after exposure to trauma. This observation is termed late-onset stress symptomatology, and it has been observed in aging combat veterans after years of functioning well (King, King, Vickers, Davison, & Spiro, 2007).

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CHAPTER 7Section 7.6 Prevention and Treatment Approaches to Mental Disorders

Psychosis is another aspect of mental illness that affects the elderly; it may be caused by schizo- phrenia, a mood disorder, or some form of dementia (most likely Alzheimer’s disease, vascular dementia, Parkinson’s disease, or Lewy body dementia). Although their functional status is gen- erally poorer than that of people without schizophrenia, many elderly adults with early-onset schizophrenia (during adolescence or early adulthood) function surprisingly well—better than young adults with the disorder. They may live independently, drive, have been employed, and have a surprising amount of social interaction with family and friends (Iglewicz, Meeks, & Jeste, 2011). Psychosocial functioning in adults with schizophrenia appears to improve over time and features better self-management, fewer psychotic symptoms, and fewer psychiatric hospitaliza- tions (Jeste, Wolkowitz, & Palmer, 2011). For those who experience schizophrenia onset between ages 40 and 60 years, or even after age 60, the response to medication is equivalent to that of younger patients (Iglewicz et al., 2011). And, unlike dementia, late-onset schizophrenia is not associated with cognitive decline.

The greatest risk factor for dementia is age, so one might expect that almost all people who reach 100 years exhibit signs of dementia. However, it seems that dementia is not an inevitable conse- quence of aging. At least one study of 244 centenarians found that 25% showed no signs of mem- ory deficits, 25% showed signs of transient confusion, and half did show signs of classic dementia (Poon et al., 2012).

7.6 Prevention and Treatment Approaches to Mental Disorders

Three basic approaches are taken to treat the major mental disorders discussed here: med-ication; psychotherapy, cognitive or behavioral therapy, and counseling of various types (in both inpatient and outpatient settings); and a group of instrumental interventions, such as biofeedback, nerve stimulation, and electroconvulsive therapy (ECT). For most mental disorders, the combination of two or more treatment types yields the best results. Tables 7.4 and 7.5 outline the major forms and providers of therapy for mental illness.

Table 7.4: Providers of treatment for mental disorders

Provider Academic Training Function Setting

Psychiatrist MD Only one who can prescribe medication; may also provide therapy

Various (inpatient and outpatient)

Clinical psychologist PhD Provides therapy Various

Psychiatric nurse MSN, NP Provides therapy Various

Licensed clinical social worker

MS, PhD Provides therapy Various

Licensed social work associate

AA Provides counseling Various

Mental health counselor MS, PhD Provides counseling Various

Psychosocial rehabilitation counselor

AA Teaches skills to reintegrate into society

Community-based mental health programs

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CHAPTER 7Section 7.6 Prevention and Treatment Approaches to Mental Disorders

Table 7.5: Therapies for mental disorders

Treatment Modality Brief Description

Psychodynamic or insight oriented Focuses on unconscious processes that contribute to present behavior; goals are self-awareness and understanding how the past influences present behavior.

Family centered Views the individual in the context of the family and the family’s history; may involve more than one person in the room with the therapist.

Cognitive-behavioral therapy Views that feelings are based on maladaptive thinking and that changing those thought patterns can change the patient’s subjective feelings.

Behavioral therapy Theorizes that rewarding desirable behavior increases that behavior and that not rewarding unwanted behavior eliminates it; teaches parents of children with ADHD or ASD techniques to accomplish this.

Psychosocial therapy for bipolar disorder Umbrella term; may include family therapy, cognitive- behavioral therapy, and other modalities. Goal is to enhance quality of life and decrease the frequency of affective episodes by teaching techniques for medication adherence, social and family problem solving, and enhanced communication.

Psychosocial rehabilitation Goal is to help clients care for themselves by developing social, vocational, and other living skills.

The Institute of Medicine (IOM) published a report in 2009 suggesting it is possible to prevent mental disorders in children and youth by instituting new universal public health interventions to promote parental education, teach strategies that improve behavior in schools, and make sure that all children receive omega-3 fatty acids, which have been shown to improve behavior (O’Con- nell & Boat, 2009). Hawkins, Kosterman, Catalano, Hill, and Abbott (2008) highlighted an urban Seattle elementary school program that decreased mental health disorders (e.g., major depres- sion, GAD, PTSD, social phobia) and significantly increased educational and economic status 15 years after the intervention ended. Another group of researchers performed a meta-analysis of interventions to prevent depression. They concluded that such efforts can reduce the number of new cases of depression in adolescents and lower depressive symptomatology among children and youth (Cuijpers, van Straten, Smit, Mihalopoulos, & Beekman, 2008) Although the United States funds research into evidence-based preventive efforts, it lags most high-income countries in implementing these cost-effective measures (Embry, 2011).

Neurodevelopmental Disorders Treatment for ASD is mostly behavioral and should be instituted as early as possible—as soon as a child is diagnosed. Early intervention services help the child between birth and 3 years learn to talk, walk, and interact with others (CDC, 2012a). These services greatly improve the child’s devel- opment and help the family learn how to help their children. In rare cases, medication may be helpful if children have very high energy levels, depression, or are unable to focus. More informa- tion about different early intervention programs is available at the Autism Speaks website: http:// www.autismspeaks.org//what-autism/treatment.

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CHAPTER 7Section 7.6 Prevention and Treatment Approaches to Mental Disorders

Although children who have been diagnosed with ADHD are usually treated with medication as well as behavioral therapy, the American Academy of Pediatrics recommends that behavioral interventions be the first line of treatment for young children (4 to 6 years old; Wolraich et al., 2011). Many people think that it is best to try behavioral therapy first for all children and to pre- scribe medication only as an adjunct therapy for those who need it. Behavioral therapy gives the child self-regulatory tools that will be there when medication is stopped. In addition, definitive data on the long-term effects of these medications in children are not yet available. Recommen- dations for helpful behavioral therapy programs are available through the CDC. Learn more about evidence-based behavioral treatments for ADHD through the CDC website: http://www.cdc.gov /ncbddd/adhd/treatment.html.

For older children (aged 6 through 11 years), both medication (stimulant or nonstimulant) and behavioral therapy are useful. For adolescents (12 to 18 years old), medication can be useful if they agree to take it (Wolraich et al., 2011).

Mood Disorders Both major depressive disor- der and bipolar disorder usually respond well to a combination of medication and therapy. People with major depressive disorder are often treated with more than one modality, usually antide- pressant medication and some form of psychotherapy or a sup- port group. It often takes two to four weeks for antidepressant medication to have a full effect, so people should not expect overnight changes (NAMI, 2013).

Depression Four different classes of medication are used to treat depressive disorder: selective serotonin reuptake inhibitors (SSRIs); norepinephrine and serotonin reuptake inhibitors; and, less frequently, tricyclics and monoamine oxidase inhibitors. Selecting which medication to use is often based on the tolerability of side effects, which can differ from person to person. It may take trials of several different antidepressant medications to find the best fit.

Cognitive behavioral therapy and interpersonal therapy are types of psychotherapy often found helpful for treating depression. Until recently, little evidence supported the effectiveness of any psychotherapy. However, a randomized trial of cognitive behavioral therapy plus medication com- pared with medication alone found that twice as many participants receiving the behavioral ther- apy improved on a standard measure of depression (Wiles et al., 2013). For mild to moderate depression, psychotherapy alone may be the best choice.

Mild to moderate depression that is resistant to medication and therapy may respond to a type of brain stimulation called transcranial magnetic stimulation (TMS), which was approved by the U.S. Food and Drug Administration (FDA) in 2008 (George, Taylor, & Short, 2013). TMS is a noninvasive

iStock/Thinkstock

Mood disorders are often effectively treated with a combination of medication and therapy.

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CHAPTER 7Section 7.6 Prevention and Treatment Approaches to Mental Disorders

procedure that uses magnetic fields applied to the forehead to stimulate nerves in the region involved in mood control and depression.

For very severe depression that does not respond to medication and therapy, ECT can be highly effective. ECT involves passing an electric current through the body to cause a seizure, which rap- idly changes brain chemistry and relieves depression. ECT has been used for many years, but it was stigmatized by the way it was done in the past—using bilateral electrode placement (which is more likely to cause memory loss than right unilateral electrodes used today), longer pulses, and no anesthesia or muscle relaxants. When administered today, ECT is highly effective and much safer, although it can cause some memory problems and is generally used as a third-line therapy (NAMI, 2013).

Bipolar Disorder There is less agreement about the best treatments for bipolar disorder than for depressive dis- order, including what classes of medication are best and whether to add psychosocial therapy. Most trials have found the combination of medication and psychotherapy to be most effective, but therapy isn’t always considered. Although very few randomized controlled trials have been undertaken for behavioral approaches, almost all support groups and personal accounts empha- size their importance in controlling this difficult disorder. Treating bipolar disorder is problematic, because medication for mania may push the person into a depressive phase, and vice versa, so achieving stability is difficult. As with all medications, efficacy must be balanced with tolerability or people stop taking it (become noncompliant).

Lithium was the first effective treatment for acute mania, but many people find it difficult to tolerate and it is less effective than some of the newer agents. Acute mania is treated with sev- eral different medication classes, including mood stabilizers, antipsychotics, and anticonvulsants (developed to treat epilepsy).

There is not much evidence-based research for treating children and adolescents with bipolar disorder. To address the lack, the NIMH has sponsored an ongoing study (“Treating Early Age Mania”) of mania in children and adolescents. One trial looked at the efficacy and tolerability of three agents in medication-naive 6- to 15-year-old children undergoing manic or mixed phase episodes. They found that risperidone (an antipsychotic drug) was more effective than lithium or divalproex sodium (an antiseizure medication), albeit with some troubling metabolic effects (Geller et al., 2012). Efficacy was found to differ across study sites, and older age and less severe ADHD symptoms were correlated with better response (Vitiello et al., 2012). A recent meta-anal- ysis of medications used to treat acute mania in adults found that antipsychotics were generally more effective and tolerable than mood stabilizers or anticonvulsants. It concluded that risperi- done, olanzapine, and haloperidol are among the best options (Cipriani et al., 2011).

Less evidence is available and a good deal more controversy exists about the appropriate treat- ment for the depressive phase of bipolar disorder—the more enduring one. Recently, it has become clear that antidepressants are not useful and are possibly harmful (Warner, 2013). The antipsychotic quetiapine, which also has some antimanic and antidepressant properties, has shown some utility in both manic and depressive phases of the disorder and may be useful for long-term maintenance treatment in those who can tolerate it (Geddes & Miklowitz, 2013). The only medication that has reliable data for long-term efficacy in bipolar disorder is lithium, which

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CHAPTER 7Section 7.6 Prevention and Treatment Approaches to Mental Disorders

has also been shown to reduce suicide by more than 50% (Geddes & Miklowitz, 2013). The prob- lem has been with lithium’s tolerability, as it may cause a laundry list of side effects, including hand tremor, diarrhea, vomiting, weight gain, poor concentration, muscle weakness, and acne. Some- times these side effects disappear as the body adjusts, and sometimes tweaking the dose helps, but some people cannot tolerate lithium.

Several studies have shown that adding psychosocial therapy to medical treatment reduces relapses, including those requiring hospitalization, in people with bipolar disorder (Miklowitz & Scott, 2009). In studies that examined cost, adding this form of therapy resulted in overall sav- ings. The goals of psychosocial therapy include increasing the patient’s ability to recognize and intervene in early signs of recurrence; enhancing medication adherence; increasing the patient’s ability to cope with environmental stressors; stabilizing sleep, diet, and other daily routines; and enhancing family and social interactions.

Family-focused therapy, with or without the person with bipolar disorder, decreased relapse and hospitalization rates (Geddes & Miklowitz, 2013). Cognitive behavioral therapy has been useful in several different mental disorders, though several studies failed to find any utility in bipolar disorder. Several other modes of psychosocial therapy have been found to decrease relapses or increase psychosocial functioning with decreased costs (Geddes & Miklowitz, 2013). With a view to cost savings and efficacy, treatment guidelines are increasingly emphasizing the need to inte- grate psychosocial therapy along with medication for managing bipolar disorder.

Anxiety Disorders Both medication and psychotherapy have been shown to be effective in treating anxiety disor- ders in adults; generally, psychotherapy is considered first, and if not sufficient, then medication may be added. The most commonly used psychotherapeutic mode is cognitive behavioral therapy (NAMI, 2012a).

Cognitive behavioral therapy has been useful for children and adolescents with anxiety disorders, although a combination of therapy and medication may be needed for those with moderate to severe disorders. The one medication type that has consistently been useful for this age group is SSRIs (Connolly, Suarez, & Sylvester, 2011; Muris, 2012).

GAD is a common anxiety disorder in adults aged 55 years and older. A meta-analysis of 14 medi- cal trials and 13 psychotherapeutic trials found that both treatment modes were effective in this age group, though as of 2012, no trials have been done on combined treatment (Goncalves & Byrne, 2012).

Posttraumatic Stress Disorder People exposed to trauma often undergo an acute stress reaction, which can lead to PTSD. Acute stress disorder develops within the first 30 days after a traumatic event. In the absence of treat- ment, most people exhibiting acute stress disorder develop PTSD (Gibson, 2011). Therefore, it makes sense to treat those who exhibit an acute stress reaction in order to prevent, delay, or decrease the severity of PTSD. Cognitive behavioral therapy appears to be most effective for pre- venting acute disorder from developing into PTSD (Gibson, 2011).

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CHAPTER 7Section 7.6 Prevention and Treatment Approaches to Mental Disorders

But could intervention before an acute trauma have any effect on outcomes? This is exactly what Wolmer, Hamiel, and Laor (2011) examined with schoolchildren in Israel. All children attending the fourth and fifth grades in six schools received “stress inoculation training” from their teach- ers, while those attending fourth and fifth grades in another six schools in the same city did not (the control group). The training took place nine months before all children happened to be exposed to rocket attacks that last three weeks. The training consisted of 14 sessions (45 minutes each) focused on increasing resilience; these sessions were delivered weekly, when the children normally participated in a life-skills program. Children in the control group participated in their regular life-skills program.

The children were assessed 3 months after the rocket attacks. Those who received training exhib- ited significantly fewer symptoms after the trauma and developed PTSD at less than half the rate of the children who did not receive training (Wolmer et al., 2011). This study suggests that resil- ience is a skill that can be learned and that trained laypersons (not just therapists) can teach it effectively. Such training might benefit children who live in violent neighborhoods and soldiers who are training for combat, among others.

Several therapies have been tested for treating PTSD. To date, the data are strongest for the effec- tiveness of cognitive behavioral therapy and eye movement desensitization and reprocessing (EMDR) (EMDR; Gillies, Taylor, Gray, O’Brien, & D’Abrew, 2012; Hamblen, Schnurr, Rosenberg, & Eftekhari, 2010). EMDR therapy combines several components of cognitive behavioral ther- apy with specific eye movements that are thought to help defuse the effects of reimagining and remembering trauma (EMDR Institute/, 2011), much as rapid eye movement (commonly known as REM) sleep helps the brain to process memories and experiences through dreaming. Research into EMDR is ongoing, and the practice remains controversial, as the benefit may derive from the therapeutic interaction rather than the eye movements themselves. Psychological debriefing, a one-time, loosely structured conversation with people who have just experienced a stressful or traumatic event to talk about the event, has generally been discredited.

Cognitive behavioral therapy for PTSD may contain several different components:

• Exposure therapy (also called prolonged exposure therapy) helps people control and face their fears by having them re-experience their trauma in a safe environment.

• Cognitive restructuring or processing helps people look at the facts of what happened by challenging and modifying inaccurate beliefs about the trauma; it often includes a written component.

• Stress inoculation training teaches people to control their own anxiety (Hamblen et al., 2010; NIMH, 2008).

If medication is needed, two SSRI antidepressants have received FDA approval for use in PTSD: sertraline and paroxetine (NIMH, 2008).

Psychologists at the National Center for Telehealth and Technology (2012) and the Veterans Administration’s National Center for PTSD have been working together to develop mobile apps and other portable technology that can aid in PTSD treatment. For instance, a mobile app called PE Coach (short for Prolonged Exposure Coach), available for both Apple and Android mobile devices, was designed to help patients practice between therapy sessions. Although developed for use by military personnel, the apps are available for civilians as well.

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CHAPTER 7Section 7.6 Prevention and Treatment Approaches to Mental Disorders

Schizophrenia Schizophrenia treatment requires a combination of medication, psychotherapy, and psychoso- cial interventions, such as illness management skills and social and vocational training. Treatment for schizophrenia works best when all aspects—medical, therapeutic, and psychosocial interven- tions—are well integrated, but that is an ideal often not met in practice. The treatment combina- tion is designed to help people with schizophrenia stay on medication, stay out of the hospital, and function well in daily life. Despite the severity of the disorder, a surprisingly large proportion of people with schizophrenia manage to attain good quality of life as they get older (see “Mental Disorders Through the Life Span” in this chapter).

Antipsychotic medication is aimed at reducing the positive symptoms of hallucinations and delu- sions but is unlikely to affect the cognitive problems associated with schizophrenia. There are two major groups of antipsychotic medications, the so-called typical (conventional or first-generation) antipsychotics, which gained FDA approval before 1990 and act by almost completely blocking brain dopamine receptors, and the atypical (or second-generation) antipsychotics, which act on a subgroup of brain receptors. Typical antipsychotics are more likely to cause a severe movement disorder known as tardive dyskinesia, although this disorder can also develop among people with schizophrenia who have never been treated with antipsychotics (Tenback & van Harten, 2011). Atypical antipsychotics have other safety problems: Clozapine can cause a severe blood disorder, and others can result in significant weight gain and metabolic changes.

Few head-to-head trials have compared atypical antipsychotics with the older, typical class. Atyp- ical antipsychotics held 90% of the market share when the NIMH sponsored a large multiphase, randomized trial (Clinical Antipsychotic Trials of Intervention Effectiveness [CATIE]) comparing the effectiveness and discontinuation rates of several newer agents with the typical antipsychotic per- phenazine (Lieberman et al., 2005). The results were surprising: 74% of patients discontinued their randomly assigned medication within six months because of inefficacy or intolerable side effects, and there was little difference in efficacy between the typical and newer agents. The lead author reviewed the findings from CATIE in 2011 and concluded that despite the controversy gen- erated by the results, prescribing practices had changed very little: “Although the introduction of second-generation antipsychotic drugs brought new options for the treatment of psychosis, the major advance many had hoped for remains elusive” (Lieberman & Stroup, 2011, p. 774). The results of this study also highlighted how evidence-based practice and physician prescribing habits may not always coincide.

Clozapine is the only atypical antipsychotic that stands out in its efficacy for treatment-resistant schizophrenia—particularly its ability to reduce the risk of suicide. Even so, it is seldom prescribed, because it requires frequent blood tests to monitor effects on white blood cells (Meltzer, 2012).

Neuregulin-1 is a growth factor involved in orchestrating many different aspects of neuronal growth and connectivity, including nerve cell migration, forming connections with other nerve cells, or synaptogenesis, and transmission of nerve signals (Harrison & Law, 2006). Excess levels are associated with heightened risk for schizophrenia. Scientists bioengineered mice to produce higher than normal levels of neuregulin-1, and these mice exhibited schizophrenia-like symptoms, including less interaction with other mice and impaired cognitive ability (NIMH, 2013b). Decreas- ing levels of neuregulin-1 in adult bioengineered mice, by switching off the gene or treating with an antipsychotic medication, reversed abnormal behavior (Yin et al., 2013). These experiments may lead to novel therapies that target this growth factor.

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CHAPTER 7Section 7.6 Prevention and Treatment Approaches to Mental Disorders

Psychotherapy is an important part of the treatment plan for people with schizophrenia, once they have been stabilized on medication. Cognitive behavioral therapy can help people manage symp- toms that persist by developing proactive coping strategies and improving medication adherence. Because families are so often involved in the care of people with schizophrenia, family therapy can be useful for educating families about coping strategies and problem-solving skills (NIMH, 2009b).

Psychosocial interventions and rehabilitation are most often delivered through local community mental health centers. The aim is to teach people with schizophrenia skills of everyday living, such as managing money, using public transportation, and communicating effectively with other peo- ple. Job training and job counseling may be important components.

Dementia Some data has suggested that physical activity, intellectual activity, and social engagement may prevent or delay dementia (Savica & Petersen, 2011). Research is under way to develop biomark- ers for early-stage dementia that will allow for clinical trials of neuroprotective agents that could alter the disease process. In the meantime, current treatments include medications designed to slow the progress of the disorder (little can be done to halt or reverse the decline). Thus far, FDA-approved medications are available only for Alzheimer’s and Lewy body dementias.

Alzheimer’s Disease Two main classes of medication have been approved by the FDA to slow cognitive decline in peo- ple with Alzheimer’s disease: cholinesterase inhibitors and memantine. Both drugs target the syn- aptic environment in the brain. Cholinesterase inhibitors increase the amount of neurotransmitter acetylcholine in the synapse, and memantine blocks the activity of a neurotoxin. Other medica- tions may be used to treat symptoms of dementia (e.g., antidepressants for depression or anxiety and antipsychotics for delusions and behavioral disruption).

One cholinesterase inhibitor (rivastigmine) has been approved by the FDA to treat Parkinson’s disease dementia, and many physicians prescribe off-label all the medications approved for Alz- heimer’s disease to people with Parkinson’s disease dementia and Lewy body dementia. Other medications may be used to treat specific symptoms, such as depression or anxiety. However, behavioral disruption in people with Parkinson’s disease dementia and Lewy body dementia should never be treated with typical antipsychotics, which can have severe side effects, even lead- ing to death. If antipsychotic treatment is needed, most clinicians agree that quetiapine or clozap- ine (atypicals) should be used (Lewy Body Dementia Association, 2012).

Sometimes studying traits that decrease risk for a disease or disorder yields useful information. A variation in the gene that encodes amyloid precursor protein has been found to substantially lower the risk for Alzheimer’s (Jonsson et al., 2012). This finding increases certainty of the role that the amyloid protein plays in the disease process.

Another important aspect of treating Alzheimer’s patients is supporting their caregivers. Support organizations can provide caregivers with information about how to modify the environment and best deal with the person with dementia. In addition, they can help caregivers cope with the demands of caregiving, particularly in later stages of the disorder. The Alzheimer’s Association, Lewy Body Dementia Association, and Association for Frontotemporal Degeneration provide valu- able education, resources, and training. The Alzheimer’s Association deals with many types of

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CHAPTER 7Section 7.7 Social Issues in Mental Health and Mental Disorders

dementia and is probably the largest organization with an in-person presence and online training and support groups available in every state. Other organizations rely solely on online activities.

See the section in Chapter 3, “Preparing for Late-Stage Disease,” for a guide to living wills, advance directives, medical power of attorney (or health care proxy), skilled nursing care, and hospice. These topics are equally relevant to the late-stage dementia patient.

7.7 Social Issues in Mental Health and Mental Disorders

The social issues surrounding mental health and mental disorders have a tremendous impact on how they are researched, diagnosed, and treated. Stigma, the question of deinstitution-alization and reinstitutionalization, racial and ethnic diversity and disparities, societal costs, and treatment access are just a few related topics that pertain to mental illness. Policy issues are interwoven throughout these social issues and are especially relevant to treatment access.

Stigma According to NAMI (2009b), stigmatizing means attempting to label a particular group of people as less than worthy of respect than others; it is a mark of shame, disgrace, or disapproval that results in discrimination. The WHO (2003) has identified stigma as a major barrier to mental health care access. The history of mental health and mental disabilities leaves no doubt that people who have mental disabilities have suffered from stigma for hundreds—if not thousands—of years. As touched on in the beginning of this chapter (see “History”), “madness” was considered either punishment for sin or a sign of demonic possession. Stigma affects not only the individual with a mental disorder but the whole family. As a consequence of stigma, some people do not seek treatment, have difficulty finding or keeping employment, and receive inadequate health care.

Research presented at the 2013 APA annual meeting found that physicians and nurses were influ- enced by stigma (Mittal et al., 2013). In half of otherwise identical scenarios, a patient was iden- tified as having schizophrenia. In these hypothetical cases, providers were less likely to refer the person for weight loss treatment, assumed the person was less likely to adhere to medication, and considered the person less able to make treatment decisions. The researchers concluded that “stigma-reduction interventions that target all provider groups are needed” (Mittal et al., 2013, p. 266).

The need to campaign against stigma in the mental health field has been acknowledged since at least the 1990s (Dain, 1994). The WHO (2003) listed stigma eradication as one of the four core strategies of its Mental Health Global Action Programme, launched in 2001. Current antistigma initiatives include a program in the Substance Abuse and Mental Health Services Administration (SAMHSA; part of HHS)—its Resource Center to Promote Acceptance, Dignity and Social Inclusion Associated with Mental Health—and the White House National Conference on Mental Health. The latter was convened on June 3, 2013, and “focused on ways we can all work together to reduce stigma and help the millions of Americans struggling with mental health problems” (Comp- ton, 2013). Learn more about the National Conference on Mental Health by visiting the “White House Blog” and watching the video of President Obama’s talk: http://www.whitehouse.gov /blog/2013/06/03/national-conference-mental-health.

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CHAPTER 7Section 7.7 Social Issues in Mental Health and Mental Disorders

Deinstitutionalization and Reinstitutionalization The movement toward deinstitutionalization was a reaction to what was seen as inhumane treat- ment of psychiatric inpatients, as exemplified by Ken Kesey’s 1962 book, One Flew Over the Cuck- oo’s Nest, and Titicut Follies, a documentary film about the Bridgewater State Hospital for the criminally insane in Massachusetts. State hospitals were often poorly funded, with inadequate conditions and documented abuses of human rights. The development of antipsychotic medica- tion made deinstitutionalization possible, and the goal of more humane care in the community, closer to family and friends, seemed to make sense. The mass movement of people with mental disorders from state-run mental hospitals to community care, which took place in the late 1950s and early 1960s, was well meaning but, unfortunately, poorly carried out.

Several factors made the reality of deinstitutionalization quite different from the idealized goal and has stirred up much controversy about the practice. As pointed out, policy makers have to “plan a dynamic community-based system to match the needs of people moving from institu- tions” (Knapp, Beecham, McDaid, Matosevic, & Smith, 2011, p. 113), but often, the realization of these support systems did not happen. The proposed community-based mental health centers were never adequately funded.

In addition, a provision of the Medicaid law of 1965, known as the Institution for Mental Disease Exclusion, prevents federal Medicaid funds from being used for people between the ages of 21 and 65 years who live in institutions specializing in the treatment of mental disorders. This pro- vision has forced people with severe mental disorders into nursing homes or general hospitals in the community to ensure eligibility for Medicaid reimbursement. Nursing homes and general hospitals, however, are not prepared to handle people with severe mental disorders.

Many people released from state mental institutions have ended up homeless (a highly visible minority on city streets) or in state prisons or local jails. A disproportionally high rate of mental disorders is found among people who are homeless in the United States, and, conversely, a high rate of homelessness is found among people with mental disorders—particularly schizophrenia (Foster, Gable, & Buckley, 2012). A study of adults in a public mental health system found that 11.5% had been incarcerated during one fiscal year (Hawthorne et al., 2012), and it is unlikely they received adequate mental health treatment. Those who received outpatient or case management services after release were less likely to be reincarcerated within 90 days. The practice of moving people with mental disorders from the streets into prisons and jails is known as reinstitutionaliza- tion. According to the U.S. Department of Justice,

At midyear 2005 more than half of all prison and jail inmates had a mental health problem, including 705,600 inmates in State prisons, 78,800 in Federal prisons, and 479,900 in local jails. These estimates represented 56% of State prisoners, 45% of Federal prisoners, and 64% of jail inmates. (James & Glaze, 2006, p. 1)

Because of the budget constraints imposed on states and localities by the Great Recession (2007– 2009) and its aftermath, we may see another wave of deinstitutionalization. People with mental disorders are being released from prisons and jails back to the streets, with even less funding of community mental health centers to accommodate them.

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CHAPTER 7Section 7.7 Social Issues in Mental Health and Mental Disorders

Racial and Ethnic Diversity and Disparities Attitudes toward mental health and mental disorders differ among individuals, families, communi- ties, ethnic groups, and cultures. Carpenter-Song et al. (2010) studied the understanding of men- tal disorders and the response to mental health services in Hartford, Connecticut, among Whites, Blacks, and Hispanics diagnosed with severe mental disorders. They found differences among the three groups in perceived stigma, interpretation of symptoms and illness, and acceptance of advice given by the mental health center. Whites accepted the medical model most easily and wanted advice from mental health professionals. Although they were aware of the stigma of men- tal illness, they did not focus on it. In contrast, the stigma of mental illness was a prominent theme for Blacks and Hispanics, and they were less accepting of mental health care. This type of informa- tion is important to keep in mind when designing community mental health care programs.

A gap or state of inequality is known as a disparity. Disparities in mental disorder diagnosis and hospitalization because of race or ethnicity can be seen as early as childhood. For example, med- ical records for children and adolescents presenting to an urban hospital’s psychiatric emergency room during one year were reviewed. Black or Hispanic children and adolescents were much more likely to be diagnosed with psychotic or behavioral disorders than Whites. Blacks were less likely to be diagnosed with depression or bipolar disorder and more likely to be hospitalized than Whites. These results illustrate the pervasiveness of disparities in the accessibility and quality of health care among different racial and ethnic groups (Muroff, Edelsohn, Joe, & Ford, 2008). For more detail on this topic, refer to the IOM’s consensus report on racial and ethnic disparities in health care (http://www.iom.edu/Reports/2002/Unequal-Treatment-Confronting-Racial-and -Ethnic-Disparities-in-Health-Care.aspx).

Similar results were seen when disparities in diagnosis and treatment of childhood ADHD were examined. Black and Hispanic children were less likely to be diagnosed with ADHD, and when diagnosed, were less likely to be taking medication than White children (Morgan, Staff, Hillemeier, Farkas, & Maczuga, 2013). Morgan et al. ascribed this difference to underdiagnosis among Black and Hispanic children compared with White children. They hypothesized that clinicians are “dis- proportionately responsive to white parents who are more likely to solicit ADHD diagnosis and treatment of their children” (p. 91). Because the only treatment that appeared to be offered was medication, it is also possible that minority parents were more wary of medicating their children.

Haeri et al. (2011) found that among adults, Blacks are more likely to be diagnosed with schizo- phrenia and less likely to be diagnosed with bipolar disorder than Whites. The authors suggested that this disparity might result from how racial or cultural factors affect behaviors and symptoms and how they are interpreted during diagnosis.

Disparities in the use of mental health service by minority ethnic or racial groups also might result from attitudes (e.g., thinking that the problems will get better on their own or fear of stigma) or structural barriers (e.g., inability to get an appointment). Diala et al. (2001) and Shim, Compton, Rust, Druss, and Kaslow (2009) found that Blacks were more likely than Whites to endorse seek- ing mental health services, so structural barriers are probably more significant in the disparities. A recent study of beliefs about mental health treatment found that although some differences in attitudes among the different racial or ethnic groups existed, they were small and could not account for the observed persistent disparities in mental health care (Hunt et al., 2013).

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CHAPTER 7Section 7.7 Social Issues in Mental Health and Mental Disorders

Societal Costs A nationally representative sample of U.S. households revealed that diagnosis with a serious men- tal disorder led to an average drop in 12-month earnings of $16,000 between 2001 and 2003 (Kes- sler et al., 2008). The authors of the study emphasized that this societal-level impairment should be considered in decisions about funding for research and treatment of these disorders.

More recent studies of the direct and indirect costs of employee mental disorders have found that slightly more than half the costs are indirect—deriving from absenteeism and lost productivity (Johnston, Westerfield, Momin, Phillippi, & Naidoo, 2009). Major depressive disorder and anxiety disorders were found to have similar direct costs, and the emergence of comorbidity of the second disease within a year of diagnosis of the first led to substantially increased costs (Francois, Despie- gel, Maman, Saragoussi, & Auquier, 2010).

Bipolar disorder appears to be more costly on a per-person basis than many other mental disor- ders. The total economic costs of bipolar I and bipolar II in the United States were estimated to be $151 billion in 2009, with indirect costs almost 4 times that of direct costs (Dilsaver, 2011). Com- pared with people diagnosed with asthma, depression, diabetes, coronary artery disease, or even comorbid diabetes and coronary artery disease, people diagnosed with bipolar disorder incurred more per-person direct costs than any group, second only to comorbid diabetes and coronary artery disease. Most of the costs were for medication and both inpatient and outpatient psychiat- ric care. The authors concluded that the results “provide further evidence for employers, insurers, and providers to seek innovative models to deliver effective and efficient care to individuals with bipolar illness” (Williams, Shah, Wagie, Wood, & Frye, 2011, p. 1073).

Although those with bipolar disorder incur large costs on a per-person basis, the real “elephant in the room” in terms of cost is dementia. The aging of the population, combined with the increased risks for dementia with age, means that a larger percentage of the population will be affected by dementia. Among caregivers of people with cognitive impairment or dementia, the presence of neuropsychiatric symptoms (e.g., delusions, hallucinations, agitation, irritation) in their charges was associated with increased time needed for care—that itself is a significant societal cost (Okura & Langa, 2011). In 2011 unpaid caregivers provided an estimated 17.4 bil- lion hours to the care of people with dementia, a contribution valued at $210 billion. Compared with people 65 years old and older without dementia, those with dementia-incurred Medicare payments were 3 times, and Medicaid payments 19 times, as great. Payments for health care, long-term care, and hospice services for people aged 65 years and older with dementia were expected to reach $200 billion, not counting the services of unpaid caregivers (Alzheimer’s Association, 2012). This was higher than the combined costs of heart disease ($102 billion) and cancer care ($77) for the same year (Hurd, Martorell, Delavande, Mullen, & Langa, 2013). As the WHO (2003) concluded in its examination of mental disorders, “it is not surprising that there is an enormous emotional as well as financial burden on individuals, their families and society as a whole.”

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CHAPTER 7Section 7.7 Social Issues in Mental Health and Mental Disorders

Treatment Access and Advocacy Parity within the realm of mental health means that services and medications are funded at levels equal to other health services and medications. Although the Mental Health Parity and Addiction Equity Act of 2008 requires group health insurance plans that offer coverage for mental disorders to provide benefits that are no more restrictive than all other medical and surgical benefits, it does not go so far as to require coverage of mental disorders (SAMHSA, n.d.).

The Patient Protection and Affordable Care Act of 2010 (ACA; commonly known as Obamacare) goes a step further: It increases parity in mental health and other areas by expanding the types of regulated insurance, and it requires them to cover specific conditions (which are, however, as of the end of October 2013, not yet specified; Sarata, 2011). In addition, the ACA addresses the lack of integration in primary medical care and specialized mental health care, which is a problem in the current U.S. health care system (Barry & Huskamp, 2011). The HHS explains how the ACA will change mental health coverage in its brief: http://aspe.hhs.gov/health/reports/2013/mental /rb_mental.cfm. For more in-depth discussion of the ACA, see Chapter 10.

Although the law’s proponents look forward to expanded access to mental health services for a wider sector of U.S. society in the future, present coverage is inadequate. According to SAMSHA and NIMH, respectively, approximately 40% of adults and almost 50% of children with a diagnos- able mental disorder receive mental health services in a given year (NAMI, 2009c). Also, the NIMH estimates of a combined total of 7.7 million people with schizophrenia and bipolar disorder, 40% and 51%, respectively, go untreated each year (Treatment Advocacy Center, 2011). Of course, it is possible that these advocacy groups overstated the unmet need for mental health services. A study of children and adolescent mental health care access spanning 2011–2012 found access inadequate compared with access to primary and hospital care and was characterized as “pro- foundly lacking.” Neighborhood violence was found to be a major problem for both children and teens in the target communities. Overall, health care was perceived to be less available in areas with apparent racial or ethnic inequalities (National Voices Project, 2013).

Data from the National Comorbidity Survey Replication, a large representative survey of U.S. house- holds, found an often long delay between onset of mental disorders and when people first sought treatment (Wang et al., 2005). A more recent survey confirmed this observation and found that the unmet need for mental health services increased substantially between 1997 and 2010 (Roll, Kennedy, Tran, & Howell, 2013). People who lacked health insurance were particularly likely to be underserved. The authors emphasized the need for monitoring access as the ACA is rolled out.

The WHO (2013b) adopted a comprehensive mental health action plan for 2013–2020. Its overall goal is to promote mental well-being, prevent mental disorders, provide care, enhance recovery, and reduce mortality, morbidity, and disability among people with mental disorders. To achieve this ambitious end, the global organization is relying on several approaches: achieving universal coverage of mental health services in community-based settings; implementing strategies to pro- mote mental health; and strengthening information systems, evidence, and research for mental health. For the first time, the WHO included specific measurable targets, including a 20% increase in service coverage for severe mental disorders and a 10% decrease in the suicide rate by 2020 (Saxena, Funk, & Chisholm, 2013).

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CHAPTER 7Section 7.7 Social Issues in Mental Health and Mental Disorders

Web Field Trip Kathleen Sebelius, HHS secretary, talked about how the ACA will increase access to mental health services in her blog entry: http://www.whitehouse.gov/blog/2013/04/10/increasing-access-mental -health-services. She also discussed efforts “to increase awareness about mental health and reduce the fear, shame, and misperceptions that too often prevent people from getting the help they need” (Sebelius, 2013), which are essential for promoting mental health services uptake.

Critical Thinking Questions

1. What role does the community play in increasing awareness? 2. What sorts of activities do you think might help reduce the “fear, shame, and misperceptions

that too often prevent people from getting the help they need” (Sebelius, 2013)?

Mental health advocacy is alive and well in the United States. Several branches of the federal gov- ernment are cooperating with private nonprofit organizations to promote awareness of mental health and to increase access and uptake of mental health services. Some of the major players are listed in Table 7.6.

Table 7.6: Selected mental health advocacy organizations

Organization Website Special Focus

Depression and Bipolar Support Alliance

http://www.dbsalliance.org Support and advocacy for people with mood disorders

Mental Health America: We Advocate!

http://www. mentalhealthamerica.net

Behavioral health access for mental illness and substance use

National Alliance for the Mentally Ill

http://www.nami.org Public policy; support for families of the mentally ill

National Center for PTSD (under the U.S. Department of Veterans Affairs)

http://www.ptsd.va.gov Support and clearinghouse for the public and professionals working with PTSD

National Institute of Mental Health’s Outreach

http://www.nimh.nih.gov /outreach

Liaison between government- supported research and public policy

Substance Abuse and Mental Health Services Administration on Health Reform

http://www.samhsa.gov /healthReform

Informing the public about the ACA and other health reform efforts

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Chapter Summary CHAPTER 7

Chapter Summary

Mental health is more than the absence of mental disorders; it gives people the potential to live productive and fulfilling lives and make a positive contribution to their communities. Although mental disorders place many barriers to achieving this ideal, most mental disorders can be treated. Hope and help are available, but finding them can be a challenge and often involves the individual, the family, and the community.

In the past, mental disorders were often considered either character flaws, retribution for sins, or signs of demonic possession. The definitions are still shaped by society’s attitudes. Now the criteria for diagnosing mental disorders are often taken from the APA’s diagnostic manual, a new edition of which (DSM-5) was published in May 2013 amid much controversy.

Half of all lifetime cases of mental disorders appear by age 14. Neurodevelopmental disorders, such as ASD and ADHD result in slowed development in age-appropriate behavior, communica- tion, or ability to focus. Early intervention in ASD is critical for both the child and the family.

Mood disorders, including depression and bipolar disorder, are among the most severe mental disorders. They can be effectively treated by a combination of medication and psychotherapy or counseling, often involving the family. Anxiety disorders are the most common mental disorders, but they tend not to be severe. Psychotherapy is the first choice for treatment.

PTSD may arise after exposure to traumatic or stressful events such as abuse, assault, combat, natural disasters, or serious accidents, especially in people who are less resilient. Parts of the brain dealing with fear and stress appear to be affected and therapy focuses on calming these parts.

Schizophrenia is generally chronic and serious, although many people do manage to live produc- tive lives with this disorder, particularly as they get older. Medication, psychotherapy, and psycho- social support services are often needed for this to happen.

Dementia is usually seen in people older than 60 years, although there are some early-onset dementias. Currently medication can only slow the rate of decline or treat accompanying symp- toms, such as depression or anxiety. If possible, families should prepare for late-stage disease early on. Support organizations can be critical in helping caregivers.

The U.S. health care system for the most part does not provide adequate support for either those with mental disorders or their families. This lack is short-sighted, as the cost of adequately caring for people with mental disorders is less than the costs of dealing with the consequences of inad- equate treatment.

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Key Terms CHAPTER 7

Key Terms

agoraphobia Fear of leaving one’s home or a safe place, thereby avoiding situations that cause anxiety, such as public or open spaces.

anxiety disorders Comprise panic disorder, OCD, PTSD, phobias, GAD, and social anxiety disorder (or social phobia). These disorders are characterized by excessive feelings of fright, distress, or uneasiness in certain situations.

biomarker A biological indicator of a disease or disorder, ideally measurable before symp- toms appear. For many mental disorders, clear biomarkers have not been discovered.

comorbidity A finding of two or more dis- eases in the same person or population.

deinstitutionalization The movement in psy- chiatry that began in the 1950s and 1960s of removing people with mental disorders from institutions and asylums and (it was hoped) treating them in the community.

delusion A persistent belief in something that is untrue despite evidence to the contrary. A symptom of a psychotic mental state, for example, schizophrenia.

dementia Symptoms affecting cognitive abilities (thought processes) and social inter- actions, severe enough to interfere with social or occupational functioning. Usually caused by brain disorders, including Alzheimer’s disease, Lewy body dementia, vascular dementia, frontotemporal dementia, and Huntington’s disease.

disparity Gap or inequality in treatment or outcomes, for example, in health care. The differences often can be seen when compar- ing people of different income levels, race, or ethnicity. Disparity suggests that the difference is unjust and arises from discrimination.

eye movement desensitization and reprocess- ing (EMDR) An experimental therapeutic tech- nique that combines several components of cognitive-behavioral therapy with specific eye movements by patients, cued by the therapist. The combination of talk therapy and EMDR is thought to help defuse the effects of repeat- edly imagining a past trauma.

epidemiology Study of the geographic or sociologic distribution of disease.

executive function The ability to organize and prioritize tasks and information; associated with the frontal cortex of the brain.

generalized anxiety disorder (GAD) A state of mind characterized by worrying excessively about everyday problems and events that lasts for at least six months and makes it difficult to concentrate and carry out everyday activities.

hallucination Seeing, hearing, or sensing something that is not there.

Mental Health Parity and Addiction Equity Act of 2008 A federal law that requires any group health plan (covering more than 50 employ- ees) that offers mental health or substance use disorder coverage to provide it on par with medical and surgical benefits, that is, with no greater financial requirements or treatment limitations. Does not mandate that plans cover mental health or substance abuse treatment.

mild cognitive impairment Problems with thinking and memory that are more severe than normal aging but less severe than dementia.

mixed dementia Cognitive decline that shows signs of more than one type, for instance, both Alzheimer’s disease and vascular dementia, or both Alzheimer’s and Lewy body dementia.

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Key Terms CHAPTER 7

obsessive-compulsive disorder (OCD) A syndrome that involves persistent, upsetting, and unwanted thoughts (obsessions). These, in turn, trigger a set of activities or rituals (com- pulsions) to control the anxiety produced by these thoughts (e.g., needing to check repeat- edly that the stove is turned off before leaving the house).

panic disorder A mental illness characterized by sudden attacks of terror and physical symp- toms such as a pounding heart, sweatiness, and weakness or dizziness. Panic attacks can happen repeatedly and without warning, often producing a sense of unreality and a fear of dying. More common in women.

paranoia Mistaken belief in a person that he or she is being threatened; irrational distrust of others.

parity In relation to mental health, the term means that services and medications are funded at levels equal to other health services and medications.

phobia Irrational fear (e.g., of high places, speaking in public) that can impair a person’s ability to function in certain situations or overall.

posttraumatic stress disorder (PTSD) A type of anxiety disorder whose symptoms include strong memories of a traumatic event, bad dreams, emotional numbness, edginess or hyperarousal (or hypervigilance) during ordinary events, and avoiding thoughts and situations that might recall the event. Initiat- ing events include physical, sexual, or mental abuse; assault; combat experience; natural disasters; serious accidents; sudden and major emotional losses; and terrorist attacks.

psychosis Personality derangement and loss of contact with reality, causing negative changes in social interaction; usually accompa- nied by delusions or hallucinations.

reliability Yielding the same results from dif- ferent people or trials (repeatability); used to measure the value of a scientific trial or study.

resilient Able to recover from a stressful situation or traumatic event without having an acute stress reaction or other mental problem.

schizophrenia A serious chronic mental dis- order that interferes with a person’s ability to think clearly, manage emotions, make deci- sions, and relate to others. At different phases, includes positive (e.g., psychosis), negative (e.g., flat affect), and cognitive (e.g., thought disorder) symptoms.

social anxiety disorder Also known as social phobia, this disorder involves excessive ner- vousness and self-consciousness in everyday social situations, leading to impairment in work and personal relationships.

synapse The space in which the nervous impulse passes between nerve cells (neurons)

traumatic brain injury (TBI) Caused by a blow or bump to the head or penetrating head injury that disrupts normal brain function. TBI can be mild (e.g., a brief change in conscious- ness) to severe (e.g., an extended period of unconsciousness or memory loss [amnesia]).

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Critical Thinking and Discussion Questions CHAPTER 7

Critical Thinking and Discussion Questions

1. Many mental disorders are found to be more common in particular families. How might genetics contribute to this finding? What other explanations might be offered for this observation?

2. What is dementia? Why do we expect the prevalence of dementia to increase over the next several decades?

3. What is the difference between a hallucination and a delusion? Which do you think might be more difficult for family members to handle?

4. Give an example of the stigma of mental disorders. How might stigma affect the life of a person diagnosed with a mental disorder?

5. What is exposure therapy? Do you think it is an effective method of treating PTSD?

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