When I was active in athletics injuries were common… the coach called and school officials contacted the parents and a trip to the emergency room ensued. If the injury was serious, overnight stays or longer resulted. When my neighbor’s wife called 911 because her husband was sweating and clammy and he described a feeling like a weight on his chest, short time later, the ambulance rushed him to the hospital. There he was treated for a heart attack. He spent a week in the hospital; after this, he was sent home. He spent months recovering. When my cousin had an asthma attack and his rescue inhaler did not work, my aunt rushed him to the hospital. The emergency room doctor ordered a nebulizer, and when his breathing did not improve, he decided to admit my young cousin for an overnight observation.
All of the above have one thing in common they all involve some type of injury to one’s physical health. Health insurers consider two types of illness… physical and mental. Physical health, what does that mean? To the casual observer all injuries involve one’s physical health; we are generally not insuring people’s metaphysical health. Nevertheless, we as a society treat some ailments as physical and others as mental. Is there a real need to separate physical from mental health? Should we limit insurance coverage for those with mental health issues? We can agree that changes occur to our bodies in all types of disease. We know for instance one cause of a heart attack, a blockage of a coronary artery. However, in many cases the cause of one’s change in behavior is not as evident.
Police sometimes will mistake the symptoms of a person who is experiencing diabetic ketoacidosis (DKA) with that of an inebriated individual. Both can act sluggish, confused and exhibit aggression. Then there is the case of delirium. A rapid change in one’s behavior particularly among the elderly frequently has a physical cause underlying the behavior. Patients with influenza, pneumonia or even a urinary tract infection may show up in the emergency department with signs of confusion, which may resemble a mental illness. Elderly patients frequently do not have an elevated temperature. This means that in the case of the flu or pneumonia, or even a urinary tract infection the primary symptom may be confusion and aggression. Here again there is a physical cause to what might be perceived as a mental illness.
Neurophysiologists explain that the mind emerges as a property of the brain. The brain is a physical organ. Students in healthcare learn that changes in the functioning of the brain often leads to changes in ones mental behavior. What about mental illness? Are there changes that can be examined in the brain? For purposes of brevity and because it is the most common form a mental illness I have limited further discussion to Major Depressive Disorders. In reality with the exception of the specific symptoms, the following discussion applies to all forms of mental illness (e.g. bipolar, schizophrenia, etc). I will address more specific symptoms in upcoming posts. Positron Emission Tomography (PET SCANS) has revealed changes in the brains of patients who have been diagnosed with depression. Clearly, there exists a physical component to mental illness. Therefore, it is correct to call mental illness a physical illness.
2008: Hasler G, Fromm S, Carlson PJ, Luckenbaugh DA, Waldeck T, Geraci M, Roiser JP, Neumeister A, Meyers N, Charney DS, Drevets WC Neural response to catecholamine depletion in unmedicated subjects with major depressive disorder in remission and healthy subjects.
Archives of general psychiatry
Volume 65, 2008. Pages: 521
2004: Neumeister A, Nugent AC, Waldeck T, Geraci M, Schwarz M, Bonne O, Bain EE, Luckenbaugh DA, Herscovitch P, Charney DS, Drevets WC Neural and behavioral responses to tryptophan depletion in unmedicated patients with remitted major depressive disorder and controls.
Archives of general psychiatry
Volume 61, 2004. Pages: 765
Years of abuse, in childhood or one’s adult life, exposure to violence in general can lead to alterations in one’s mental health. Genetics has been investigated extensively. Studies of twins and of siblings some living in different environments through adoption have reveled a strong genetic component to mental health issues. While the nature versus nurture discussion has not been not settled. What is known is that there are components of genetic and environmental influences that account for the state of one’s mental health.
There is one thing that prevents people from recognizing mental illness as a physical illness and that is the culture we live. Our society is geared towards self-survival; the rugged individualist is how we view success. Weakness in the form of one’s behavior has attached stigma to mental illness that we do not attach to those who have had heart attacks, or suffered concussions, or even those who suffer from delirium. Yet they are all physical illnesses. The difference for most people occurs because of three characteristics of many humans.
First: Fear, which is the biggest cause of social stigma, is how mental illness is often reported in the media. How many times does one read or hear, or watch on TV of an “ex mental patient” who committed some major atrocity. Just as reports of airline crashes make people afraid to fly (when driving a car is much more dangerous), people associated the term mental illness with dangerousness. However, just as mathematical analysis proves that airline travel is safer than operating an automobile, the statistics indicate that the vast majority of people with mental illness are harmless.
Second: Lack of direct evidence, if it cannot be seen then, it is not real. Everyone can see the effects of a person with a heart attack, an asthma attack or, a compound fracture etc. However, how does the average person detect a physiological change to one’s brain? Hence is becomes easy to dismiss a person’s behavior.
Third: Many of us figure what is good for us must be good for everyone. Hence, “If I feel depressed and it is a transient feeling that I can overcome with my willpower, then everyone must be able to do the same”. This belief leads many people to tell family and friends to “just snap out of it” or some other phrase to that effect.
Some of these responses may be well intentioned, but the result is frustration, pain, and sometimes anger on the part of those who are suffering because they really cannot just snap out of their depression. Sometimes the result of years of depression, the associated suffering, and the social stigma, is a suicide attempt, for many it may be their last.
Some will get help. If fortunate, they will present in an emergency department of a local hospital and a qualified provider will evaluate the person to determine if help is necessary. If the person is deemed likely to hurt him or herself, they can be admitted to an inpatient facility where trained staff members are available 24/7. Many fear being treated in this manner. To insure one’s safety a secure environment is needed. Providing this type of security involves removing many freedoms that we as humans take for granted in our everyday lives.
Many but not all psychiatric units in hospitals have locked doors, items that can be used to hurt one’s self are removed and sleep hours are usually enforced. These restrictions can be very disheartening. One thing that can help the person, who has been admitted for inpatient psychiatric care, is to think of the hospitalization as a time out from life’s stressors. The inpatient setting creates an artificial environment that can be largely free from the day-to-day problems that prohibit one from overcoming their illness.
While one is hospitalized, the person receives care from many providers such as a nurse, psychiatrist, social worker, occupational therapist and others. Psychiatric facilities offer classes in coping, stress and anger management, social skills and other helpful programs. The combination of treatment in the form of medication, group therapy, life skills classes and occupational therapy has been found to be therapeutic.
Much has changed due to managed care with regard to hospitalizations for any type of care. For instance those who had a total knee replacement used to be hospitalized for a week or more, now they are usually sent home by the third day after surgery. This trend is no different for psychiatric care. The average length of stay is less then five days, where once people stayed several weeks to even months to work of their mental health issues. Today the goal of inpatient care is to get a person stable enough so that they can function safely upon discharge from the hospital usually with scheduled outpatient visits. Discharge from the hospital does not mean an absolute cure has been accomplished and frequently the person who has been discharged is not ready to resume all previous activities immediately. In any case, outpatient care either by regular visits to see the therapist and psychiatrist or in the form of a partial outpatient program may be necessary to help the person cope with their stressors.
Let us look at depression. The Diagnostic and Statistic Manual of Mental Disorders IV text revision, (DSM IV test revision) is the definitive guide to mental illness. The DSM IV TR defines a major depressive episode as:
Major Depressive Episode
- Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions orhallucinations.
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation mad by others)
- Significant weight loss when not dieting or weight gain (e.g. a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
- insomnia or hypersomnia nearly every day
- psychomotor agitation or retardation nearly every day (observable by others, no merely subjective feelings of restlessness or being slowed down)
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
- The symptoms do not meet criteria for a Mixed Episode.
- The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g. hypothyroidism)
- The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for long than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation,psychotic symptoms, or psychomotor retardation.
Note: To be considered a Major Depressive episode the person must exhibit at least five of the nine symptoms over at least a two-week period. This measure provides a rigorous examination of a person who is being evaluated for Major Depressive Disorder. Local hospitals provide screening for depression, with referral to qualified providers. Many people get help in this manner without need of hospitalization. If you or someone you know does not feel safe, if they indicate that they want to hurt or kill themselves then an evaluation at a local hospital emergency room is warranted. If they will not get help or if a family member is preventing help such as in the case of an abusive relationship then a wellness check can be arranged with a local police or sheriff’s department.
There is one caveat to all the previous discussion, and that is that mental health services are severely limited to those without health insurance, and to those who hare not actively suicidal. This dangerous shortcoming often leaves people in need of help without the resources to get help. Two pieces of advice for those in this predicament. First do not give up and try not to become discouraged, contact every agency that offers some form of help, and if possible do not take no for an answer. The National Alliance for the Mentally Ill (NAMI) has a website that is useful. http://www.nami.org/