David C. Henderson, M.D. Director, Schizophrenia Clinical and
Research Program Director, Chester M. Pierce, MD Division of Global
Psychiatry Massachusetts General Hospital Associate Professor of
Psychiatry Harvard Medical School MASSACHUSETTS NAMI 2013
KEYNOTE
Slide 2
The Burden of Mental Illness Costs: $317.6 billion Lethal
consequences: Life expectancy of patients with chronic mental
illness is shortened by an average of 25 years Suicide: 4 th
leading cause of death--ahead of diabetes, stroke and chronic lung
disease More disability than any other medical disorders:
Slide 3
Prince et al, Lancet, 2007 Contribution by different
non-communicable diseases to disability-adjusted life-years
worldwide in 2005
Slide 4
http://www.who.int/msa/mnh/ems/dalys/table.htm
Slide 5
Mental health has become a major international public health
concern "We believe that mental health is just as important as
physical health, maybe even more so. Donna Shalala, former
Secretary of the Department of Health and Human Services "The
challenge to humanity is to adopt new ways of thinking, new ways of
acting, new ways of organizing itself in society in short, new ways
of living. Our Creative Diversity, UNESCO
Slide 6
Inter relationship between mental and physical health Mental
health is a key factor in the adoption and maintenance of unhealthy
lifestyles Mental health problems increase the risk of premature
mortality from diseases such as cardiovascular disease Physical
health problems can affect mental health
Slide 7
7 Burden Vs Budget WHO, ATLAS 2001
Slide 8
No Family Goes Untouched 1 in 4 individuals suffer psychiatric
illness each year 1 in 16 will suffer a severe disorder The
remaining 3 will have a friend, family member or colleague who will
suffer About 20% of people with a psychiatric disorder have a co-
occurring substance use problem Schizophrenia affects 1%, major
depression 8%, bipolar disorder 2%, and anxiety disorders 12% 70%
of psychiatric disorders have their onset during childhood or
adolescence and are relapsing or chronic Barriers to care exist:
Only one-third of those who need treatment actually receive any
8
Slide 9
Former congressman Patrick Kennedy Parity for treatment of
mental illness and substance abuse is a human- and civil- rights
issue instrumental in helping to pass the landmark 2008 parity bill
He recounted his mothers struggle with alcoholism and his problems
with addiction, as well as his Aunt Rosemarys intellectual
disability, within his own family mental illness and substance
abuse were the elephant in the living room that no one talked
about. And he recalled how during his political career he parked
his car three blocks away from his psychiatrists office to avoid
being recognized. And yet, ironically, he found himself, along with
his late father, Sen. Edward Kennedy, being a champion of the 2008
federal parity law. Kennedy emphasized that nowwith a final rule
from the government that will provide a regulatory framework for
implementing the 2008 law expected very soonis a decisive moment.
He said transparency in the way insurance companies make
medical-necessity decisions will be crucial to ensuring the full
implementation of parity. The exciting thing for all of you is that
with health care reform, we are rewriting the rules, Kennedy
emphasized. Organizations like APA need to be even more aggressive
than ever before, because we are at a formative point.This is the
moment in history when we really have the opportunity to change the
landscape.
Slide 10
50% of All Individuals with psychiatric illness never seek
treatment Stigma and Shame
Slide 11
The Double Bind People suffering from a mental illness have to
deal both with the consequences of the illness and the STIGMA The
number one predictor of STIGMA is having the LABEL of mental
illness, causing people to avoid treatment (and the label) as well
as maintain secrecy in order to pass Rusch 2005; Link 1987
Slide 12
Most Medical Schools leave Clinicians untrained for txing
psychiatric Illness 104 Weeks Clinical Training 4 weeks
Slide 13
Slide 14
If patients do seek treatment it is mostly from Clinicians not
trained in mental health 57%
Slide 15
Slide 16
Culture Treating a patient from a different culture Care must
be taken when making observations, interpretations or stereotypes.
Clinicians must be aware at all times of their own feelings,
biases, and stereotypes. Significant inter-individual variability
individual may not fit into the expectations of their culture.
Probe for cultural clues Remain flexible enough to recognize that
the patients patterns and behaviors do not necessarily match the
clinicians expectations.
Slide 17
DSM-IV Cultural Identity The individuals ethnic or cultural
references and the degree an individual is involved with their
culture of origin and host culture is important. It is important to
listen for clues and ask specific questions concerning a patients
cultural identity. Attention to language abilities and preference
must be addressed. An Asian American male who grew up in southern
United States may exhibit patterns, behaviors, and views of the
world more c/w a Caucasian southerner.
Slide 18
Differences in Presentation of Illness There are cultural
differences in the presentation of psychiatric illnesses. Cambodian
woman may present with complaints of fatigue and back pain, while
ignoring other neurovegatative sx. & unable to describe
dysphoria. This same patient may admit to hearing the voices of her
ancestors, which is culturally appropriate. In many traditional,
non-Western societies spirits of the deceased are regarded as
capable of interacting with and possessing those still alive.
Slide 19
Diagnosis Increased diagnosis of Schizophrenia in African
Americans and Hispanics Language Non-Verbal- poor eye contact- A.A,
laughter-Japanese Verbal- word finding=paucity of thought, LOA
Translators-inaccuracies, omissions, editing Written- illiteracy
rate
Slide 20
Acculturation and Immigration Recent immigrants arrive to the
United States with a host of difficulties and psychosocial
problems. A clinician must ask about and understand the
circumstances surrounding their immigration. There is significant
literature on the contribution of acculturative stresses to the
emergence of mental disorder. The impact of acculturation may also
lead to symptoms of depression, culture shock and even PTSD-like
symptoms.
Slide 21
Impact on Psychiatric Treatment Mistrust of the health care
system Legacy of of fraudulent/unethical scientific studies Seek
attention at later stage of psych./substance problem Misdiagnosis
More severe diagnosis, depression under diagnosed, substandard care
Cultural beliefs and expectations Perception of illness and its
treatment Perception of substance use
Slide 22
Delays in Help-seeking in Psychotic Patients Universality and
Ethnic Contrasts Skeate A, et al, Br J Psychiatry Suppl 2002;
43:s73-7.
Slide 23
DSM-IV Explanatory Model Cultural explanations of the
individuals illness It is important to understand how distress or
the need for support is communicated through symptoms (nerves,
possessing spirits, somatic complaints, misfortune). The meaning
and severity of the illness in relation to ones culture, family,
and community should be determined. This explanatory model may be
helpful when developing an interpretation, diagnosis, and treatment
plan.
Slide 24
Where hyenas are used to treat mental illness
Slide 25
Monrovia, Liberia
Slide 26
Causes of mental illness Stress Drugs Trauma Open mole Loss of
property, family and jobs Witchcraft Aluminum Spirits Demons
Slide 27
War and Violence All children in this age group were affected
by the war and have some memory of it. They all had to leave school
at some point during the war. Despite how common it is for students
to be years behind in school, many expressed shame about this. Some
children saw neighbors or close friends shot and killed before
their eyes and described it in vivid detail, as though they were
reliving it. Others never came that close to the fighting. They
were very young and were not allowed to go outdoors. One boy
lamented that some classmates were disruptive because they were
former child soldiers. He explained that they have brain problems
because of what they experienced during the war. When asked how it
was that he did not have brain problems from his own war
experiences, he said, Yeah, I saw those things, but it was at a
distance, not too close.
Slide 28
Family Many children were sent to live with a relative in
Monrovia in order to attend school Of the children attending
school, nearly all identified someone who looked after them. As for
the children out of school, there was a split. Some sounded very
much like the school children. They had been in school and were
focused on returning to school. They also had caretakers. There was
another subgroup of street children who were very different from
the school children. They were living on their own or in drug dens,
with dozens of people sharing a single room. They were addicted to
drugs and supporting themselves with theft or prostitution. Some
mentioned school, but their immediate goals were more focused on
getting off drugs than returning to school.
Slide 29
Religion Religious faith seemed to be an important source of
hope and comfort for many children. Among the street children,
church attendance was a clear marker of community involvement and a
more stable situation. Those whose narratives were more like those
of the school children nearly all attended church and spoke about
religion. Those who were using drugs said they did not attend
church because they did not have church clothes.
Slide 30
Service Problems of Minority Groups High use of hospitals and
emergency rooms Low use of community services Poor treatment
retention Misdiagnosis Missed Diagnoses Access barriers, including
lack of insurance Social stigma
Slide 31
Availability of Care Many psychosocial treatments with
established efficacy have been developed but are not readily
available or adequately reimbursed Assertive community treatment,
Cognitive Behavioral Therapy Supported employment and housing,
Psychoeducation, Social-skills training, Cognitive remediation
31
Slide 32
Estelle Richman Successful recovery from serious mental illness
in the community requires more than just clinical careit requires a
range of human and social support systems At the IPS, she expressed
optimism about the movement toward integrated care and the
expansion of care, including the coverage of mental health and
substance abuse treatment under the Affordable Care Act, Vision of
a truly successful mental health system not yet been achieved. She
emphasized the need for a range of social and supportive services
in the community for people with mental illness. For people with
mental illness to be successful in the community, community
resources need to be expanded, These resources include
housingmoving from institution to group homes to independent living
with supports is criticalas well as case management and supported
employment. Work and employment are central to the growth of the
individual people want meaningful activities of their choice.
Slide 33
The December 2004 Consensus Conference on Mental-Health
Recovery, SAMHSA Mental-health recovery is a journey of healing and
transformation for a person with a mental health disability to be
able to live a meaningful life in communities of his or her choice
while striving to achieve full human potential or personhood.
Recovery is a multi-faceted concept based on the 10 fundamental
elements and guiding principles (shown in the circle) 33 SAMHSA =
Substance Abuse and Mental Health Services Administration.
Substance Abuse and Mental Health Services Administration Center
for Mental Health Services; US Dept Health and Human Services;
December 2004. Available at:
http://mentalhealth.samhsa.gov/publications/allpubs/sma05-4129/.
Accessed February 7, 2007. Empowerment Self-direction Holistic
Strengths-based Nonlinear Respect Peer support Hope Responsibility
Individualized & person-centered Recovery
Slide 34
Comparing Neighborhoods of Adults With Serious Mental Illness
and of the General Population: Research Implications Results
Neighborhoods in which adults with serious mental illness resided
had higher levels of physical and structural inadequacy,
drug-related activity, and crime than comparison neighborhoods.
Higher levels of physical and structural inadequacy, crime,
drug-related activity, social instability, and social isolation
were associated with higher concentration of persons with serious
mental illness in the neighborhoods adult population. Conclusions
The differences in neighborhood characteristics identified in this
study point to factors that merit closer attention as potential
barriers or facilitators in the functioning, participation, and
community integration of persons with serious mental illness.
Byrneet al. Psychiatric Services 2013; doi:
10.1176/appi.ps.201200365
Slide 35
Adebimpe VR. OVerview: White norms and psychiatric diagnosis of
black patients. Am J Psychiatry 1981; 138:279-85; Mukherjee S, et
al. Misdiagnosis of schizophrenia in bipolar patients: a
multiethnic comparison. Am J Psychiatry 1983; 140:15671-4; Impact
of Ethnicity on Psychiatric Diagnosis In the U.S., race and
ethnicity have a significant impact on psychiatric diagnosis and
treatment. People of color are frequently misdiagnosed as having
schizophrenia instead of an affective disorder. African Americans
patients receive higher doses of antipsychotic agents, have higher
rates of involuntary psychiatric hospitalizations and
seclusion-restraint. Biases in treatment continue & must be
acknowledged. A number of studies have confirmed the misdiagnosis
of schizophrenia in Blacks, Hispanics, and Asians in the United
states.
Slide 36
Slide 37
Thank You! You must be the change you want to see in the world.
Mahatma Gandhi