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MASSACHUSETTS NAMI 2013
KEYNOTE
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
The Burden of Mental Illness
More disability than any other medical disorders:
Costs: $317.6 billion
Lethal consequences:
• Life expectancy of patients with chronic mental illness is shortened by an
average of 25 years
• Suicide: 4th leading cause of death--ahead of diabetes, stroke and chronic lung
disease
Contribution by different non-communicable diseases to
disability-adjusted life-years worldwide in 2005
•Prince et al, Lancet, 2007
http://www.who.int/msa/mnh/ems/dalys/table.htm
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
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
•
Burden Vs Budget
WHO, ATLAS 2001
14
13%
12
10
8
6
4
2.0%
2
0
Burden of
neuropsychiatric disorders
out of all disorders
7
Median mental health
budget out of total health
budget
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 cooccurring 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
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Former congressman Patrick Kennedy
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Parity for treatment of mental illness and substance abuse is a human- and civilrights issue
instrumental in helping to pass the landmark 2008 parity bill
He recounted his mother’s struggle with alcoholism and his problems with
addiction, as well as his Aunt Rosemary’s 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 psychiatrist’s 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 now—with a “final rule” from the government that will
provide a regulatory framework for implementing the 2008 law expected very
soon—is 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.”
Stigma and Shame
50% of All Individuals with
psychiatric illness never seek
treatment
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
Most Medical Schools leave Clinicians
untrained for tx’ing psychiatric Illness
4 weeks
104 Weeks Clinical Training
If patients do seek treatment it is
mostly from Clinicians not trained
in mental health
57%
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 patient’s
patterns and behaviors do not necessarily match the
clinician’s expectations.
Cultural Identity
• The individual’s 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 patient’s 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.
DSM-IV
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.
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
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.
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
Delays in Help-seeking in Psychotic Patients
Universality
and
Ethnic
Contrasts
1600
1400
1200
1000
800
Contact Delay
Treatment Delay
600
400
200
0
Caucasians
African
Americans
Asians
Skeate A, et al, Br J Psychiatry Suppl 2002; 43:s73-7.
Explanatory Model
• Cultural explanations of the individual’s 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.
DSM-IV
Where hyenas are used to treat
mental illness
Monrovia, Liberia
Causes of mental illness
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Stress
Drugs
Trauma
Open mole
Loss of property, family and jobs
Witchcraft
Aluminum
Spirits
Demons
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.”
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.
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.”
Service Problems of Minority Groups
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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
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
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Estelle Richman
• Successful recovery from serious mental illness in the community requires
more than just clinical care—it 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 housing—moving from institution to group
homes to independent living with supports is critical—as 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.”
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)
Recovery
Holistic
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/. 33
Accessed February 7, 2007.
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
neighborhood’s 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
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.
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
Thank You!
“You must be the change you
want to see in the world.”
Mahatma Gandhi