Depression Mental illness is a struggle with activities of daily living (ADLS) If you don't shower, eat, open mail bills life can go bad down fast. Problems pile up if you're when you're so tired getting prescription filled, infection or fall in the apartment that can be fatal.
In the film 2017 "Thank You for Your Service" Soldiers returning from IRAQ are not adjusting to civilian life well.
"I wish leg was blown or lost an arm anything but PTSD" When soldiers go to get help they see apathy from Medical Community, it is like they are the dark ages. There isn't a right way help people get better.
My own experience navigating as facilitator of care for my child who began with physical chronic pain that became both physical and mental anguish is exactly the situation described here. It took perseverance and trust between myself and my child to get to where we are today: The source of the chronic physical pain and concomitant anxiety and severe depressive disorder addressed by a team of integrated healthcare providers.
I want to see this level of integration and coordination of care mainstreamed as soon as possible. I should not have been left "out hanging" and scrambling to assemble and coordinate a team of providers. This is simple unacceptable and entirely preventable. Thank you, Dr. Khullar, for speaking up on this pervasive issue, recognizing the necessity of treating the whole person to achieve wellness.
2
“It may help to organize and pay for mental health care more like physical health care.”
It pains me to hear story after story either in the news or personally about people seeking a psychiatrist before making an appointment for psychotherapy; pediatricians and GPs routinely prescribing antidepressants rather than referring patients to psychotherapy.
Mental health isn’t a pathology. It’s an area of human health and we should be demanding "well" visits, "sick" visits, etc. for ourselves. Integration of genetic testing for metabolization of any medications should be part and parcel of the new patient visit, reducing drug trial and error and saving lives. People suffering with depression and suicidal ideation survive minute to minute. They can’t afford weeks or months trying out one med after another until something clicks. Genetic testing offers a road map, reducing trial and error time. This will decrease expenses on medication and improve patient outcomes.
When experiencing overwhelming negative thoughts, we should all be familiar with an action plan:
In acute distress, call 911 and/or suicide hotline.
When feeling out of sorts but don’t know why, call your mental health GP. A therapist, not a psychiatrist, is the appropriate medical professional to seek first. It is their job to diagnosis and prescribe a treatment plan that may or may not include a referral to a psychiatrist for evaluation and medication.
I agree with Dr. Khullar that integration is key.
1
My thanks to Dr. Khullar & the NYTimes for publishing this very accurate portrait of a SERIOUS problem in the USA. My 18 year-old daughter has suffered with severe autism since she was 2. In this time I have STRUGGLED when dealing with medical professionals to "see past the autism," look for ANY & EVERY physical ailment that might explain her behavior - before you medicate. Dr. Khullar has described exactly what I've experienced; medical doctors who just me see my daughter as "a lost cause" (or worse, an attitude that says "I didn't go to medical school to deal with this.") and skip all the important tests! I have to jump up and down and scream to get attention. How is it possible that they missed her moderate scoliosis? She was 15 when asked the pediatrician to "look at her hips, they're uneven." At the dentist it was again me who asked, "What about wisdom teeth?" And they did the X-rays. My daughter took a-typical antipsychotics for only 2 years, and 4 years later, her metabolism's still affected. I'm grateful for all the Commenters here who have pointed out the dangers of these far too widely over-prescribed drugs. Let me tell you, they push those atypical antipsychotics on children with a diagnosis of autism, even as young as 5 years old. We need REAL change here folks.
3
The authors fail to even mention what may be the primary reason for the increasing early death rate: the very treatment these people receive from the mental health system. Antipsychotic drugs in particular generally cause weight gain, metabolic problems, and significantly increase the risk of heart problems. Moreover, since antipsychotics work on decreasing dopamine and have dramatic and extremely uncomfortable side effects, users frequently smoke cigarettes (which increase dopamine) as a means of ameliorating these side effects. Naturally, gaining weight discourages exercise, as do antipsychotic side effects, which for some make even walking challenging, let alone more vigorous forms of exercise.
Also note that the poor health habits of the so-called "mentally ill" have not substantially changed since the 1970s, so this can't explain the increase in the death rate. What HAS changed is that more and more people are receiving antipsychotic (and other) drugs for longer and longer time periods. The responsibility for the increasing death rate should be laid squarely at the feet of the psychiatric profession. In what other profession would it be accepted that increased levels of treatment be correlated to increased death rates?
6
@Steve McCrea Yes of course you are right. That wasn't even mentioned in the article, nor was the fact that primary care docs and psychiatrists should, but often don't, monitor things like blood sugar and triglycerides in patients on "anti psychotics" and other psychiatric meds.
The story also didn't mention agranulocytosis, another risk of certain anti-psychotics and some other psych drugs, which can cause dangerously low levels of white blood cells, possibly leading to leukemia or other illnesses.
2
It has been known for more than a decade that the average age of death for people w six of the ACE (Adverse Childhood Experiences) indicators is 60. They lose more than 15 yrs of life, on average, compared to people w none of the indicators. It doesn’t surprise me that the same trend holds true for those w diagnosable mental illnesses.
3
The real killer is the medications that I take for my bipolar disorder. They affect my cholesterol, my blood sugar levels, and cause weight gain. All risk factors for serious illnesses.
5
And then there's the fact that being bipolar, as a "disease", isn't well-defined at all, so psychiatrists basically prescribe them when you have serious mood disorders and anti-depressiva don't seem to work. If you feel a bit better with anti-bipolar drugs, they conclude that you must be bipolar.
That, together with the side effects that you're mentioning here and that are so common among people taking these kind of drugs, to me implies that we HAVE to at least add other tools, if we want to truly "treat" these "diseases".
Those tools could be called active emotion management skill training, except that "management" suggests that all you can do is learning to tell harmful moods to go away, whereas the skills we're talking about here do much more than that, they actively allow you to create new, more healthy emotions. And that's how you can then install a proper emotional (and as a consequence chemical, in your brain) balance.
I have to admit that I didn't read any scientific studies about these trainings and "bipolar disorder" yet, but if you read for instance Julie Simon's "When food is comfort", you get an idea of what they actually consist of.
The basic idea is that in order to thrive emotionally, human beings need to develop specific brain networks, and they do so only when they had at least one primary caregiver able to teach them 7 self-care skills (= attunement to your inner world, validation of your emotions etc.). If not, chemical brain imbalances arise.
3
The hardest mental illness to treat with non-pharmacutical therapy is schizophrenia. Every psychiatrist tries to treat schizophrenia with drugs, which have many serious adverse side effects, including massive weight gain.
Little research has been carried out into the benefits of physical exercise on schizophrenia. But the little that has been done is promising. See for example:
https://www.tandfonline.com/doi/abs/10.1080/01612840590959551
'Although the benefits of exercise are well documented, few published research studies have examined exercise in persons with schizophrenia. This pilot examined a 16-week walking program for outpatients diagnosed with schizophrenia (N = 10). Six-minute walking distance, body mass index, percent body fat and severity of psychiatric symptoms were measured. Experimental participants in the walking group experienced significant reductions in body fat (p = 0.03) compared to a control group not participating in the exercises during the same time period. Experimental participants also had greater aerobic fitness, lower body mass indexes, and fewer psychiatric symptoms than controls at the conclusion of the program. Research is needed to identify effective exercise interventions and feasible delivery modalities for persons with schizophrenia in community settings.'
2
All these narratives are part and parcel of healthcare in American, or to be more specific the lack of cohesive healthcare in America. Most individuals have either no or inconsistent access to healthcare and rely on Physicians who may or may not know them are even care.
Welcome to healthcare in the twenty-first century driven by greed and bottom line profit.
2
I have lived this, & it is heartbreaking. I have a significant mental health history - w/a perfect record of treatment compliance. When I reported hallucinations - a rare side effect of an even rarer condition, Serotonin Syndrome - my relationship w/my beloved Internal Medicine physician never recovered. I would appear w/symptoms of pneumonia - expected, since I also have Cystic Fibrosis - & all my doctor could ask me was, “But how are the voices?” This amazing physician was suddenly so blinded by that one symptom - a strange version of psychosis where I could always identify the hallucinations as “not real,” however terrifying they were - that he wouldn’t even bother to listen to my chest with a stethoscope. I nearly died of a missed bowel obstruction during this timeframe. Even after the Serotonin Syndrome resolved & the hallucinations were long gone, EVERY symptom I reported to that doctor was forever after refracted through the lens of my “history of insanity.” Crushed, I had to stop seeing that doctor. Electronic medical records meant that I also had to abandon that entire large practice - b/c new drs see “psychosis” & stop wondering. I now find myself in the uncomfortable position of openly lying about my psychiatric medical history - to my own doctors, & to my children’s providers & their schools. (That is tragic, because two of my children have psychiatric conditions that NEED accurate familial data). I simply cannot risk having every other concern I voice dismissed.
10
Anonymous in Austin, I definitely hear you. Interactions with medical professionals are forever problematic for anyone with a psychiatric history. I have a significant psychiatric history including psychosis and hospitalization, but I've had no psych symptoms or treatment for more than 10 years. This is part of why I don't have a primary care doctor. It's easy to lie or avoid mentioning my history when dealing with, say, an urgent care provider who sees me once. With a "regular" doctor, it might eventually come up. And if I were to mention my history, game over. Any current medical issue would be assumed to be related to a recurrence of mental illness. I'd get interrogated about all the ugly details from my past. And because the accepted dogma is that you can never stop treatment for mental illness, I'd be pressured to see a psychiatrist and go back on medication despite having no recent symptoms. Sorry, not dealing with that.
7
I feel like this metric intersects heavily with the ACE score, the inventory of Adverse Childhood Events (things like domestic violence, substance abuse in the home, physical neglect, etc.) More kids with high ACE scores end up with mental illness as adults, but they also end up with more chronic diseases like heart disease, diabetes, and cancer. They die younger from all causes. (see work of Dr. Nadine Burke Harris and her excellent book The Deepest Well)
Addressing these issues will also mean addressing and preventing root causes in childhood, supporting parents and families at risk, and breaking the cycle of trauma.
6
Poor medication choices dictated by Medicaid and big pharma, poor housing and inadequate governance of code violations by landlords, little to no competent psychosocial intervention and support, underpaid staff, very, very low income (usually less than 1000 monthly), and usually a severe lack of community support for family or for a job that is suitable--this is what our mentally ill people face every day. Many lack housing and almost all receive terrible or no dental and medical care at all. Does anybody with power care?
8
The weight gain can be very hard on people. Our society makes the worst assumptions about overweight people. I'm on the generic equivalent of Zoloft and it can leave me feeling hungry even when I've just eaten a full meal. It's hard to ignore hunger signals. This medication, for me at least, also increases my sweet tooth. To counteract it I keep lots of fruit around all year long. But you have to be aware of it and doctors do not tell patients what can happen or how to deal with it.
I know from reading posts on other articles that some of the medications leave people feeling like they are living in a cocoon or that their mental facilities are being blunted. If there was as much research devoted to medications that had fewer side effects as there is to drugs like Sialis or medication to treat "weak" bladders (mostly due to an absence of sufficient public bathrooms in America) perhaps people requiring the drugs to function wouldn't stop as often.
3
One of my closest friends had a schizophrenic brother. He was brilliant - he had earned a PhD from Harvard by age 23. He came from a very wealthy family and had all the resources possible at his disposal. His first major psychotic break came when he was in his mid-20's and teaching at a major university.
He died in his 60's. I don't think they really knew what killed him - he had been dead in an unairconditioned apt for about 10 days in hot weather. But he had heart disease and Type 2 diabetes, most likely caused by his medications. His family history was one of VERY great longevity and few health problems.
He refused to take his meds, his eating habits were horrible, he would not allow anyone in his apartment to fix his plumbing or his AC, or to clean it (you cannot imagine how awful it was!). He did see his psychiatrist weekly and had seen him for over 25 years. But there was little true "therapy" as he refused to talk most of the time.
After both his parents had died,his sister tried to get more help for him and get him into a facility where he would be kept clean, safe and medicated. Unfortunately, our laws prevent such - there is simply no way to do this.
This idea that the mentally ill have the "right" to live in squalor and in deplorable conditions is totally inhumane, but the ACLU and others lobbied heavily for this nonsense. He would not have died if he'd been properly incarcerated and cared for, but that is against the law.
3
I hear you India. A schoolmate of mine had her first psychotic break when she was 16. Because of our inadequate treatment set up this woman, who had had a promising future wound up homeless, unmedicated, knowing the location of every food pantry in the area, and often without anyone to care for her when she needed it most. I would see her in the village and she was unapproachable. It broke my heart.
What she needed was a highly structured living situation that would have enabled her to work when she could, followed her on her meds, and helped her when her demons were taking over her life. Her family could not do this. The task is beyond the means, physical and mental, of most families. Our country has money to burn when it comes to giving rich corporations and families tax breaks, going to war, and incarcerating people for petty crimes (some of which can be blamed on the effects of mental illness) but none to spare when it comes to people who can benefit from a structured caring living situation that will keep them out of prison and off the streets and out of poverty.
It still breaks my heart when I see her. I try to say hello when she is approachable and a prayer when she isn't.
12
My father was a paranoid schizophrenic. He'd started in his teens and it progressed in his 20s. He was only 17 years older than me. When he went off the deep end he'd be packed up to Kings County Hospital and eventually Pilgrim State Hospital on Long Island. He'd had every therapy out there in the 1950s. Insulin, Electro and Ice Baths.
He seemed to be better in his 30s. He took medications but he would still say strange things at times. We worked together on out of town trips and sometimes he'd start thinking people were talking about him and laughing. I'd have to talk him out of the delusion and he'd be alright for a while.
He died at 70. He'd had a bypass in his 40s but his heart didn't kill him. It was liver cancer.
His paternal great grandmother lived until 106, his grandmother until 82 and his father until 84. Ovarian cancer got the women and his father from colon cancer. He'd had prostate cancer about 25 years earlier.
Dad wasn't around long after the diagnosis. I wonder if perhaps he'd been ignored because of the things in his head? Had complaints been pushed aside?
2
So grateful for the article and discussion. The issues are complex, sad and frustrating beyond words as evidenced by the experiences here. We can and must do better at providing the support and resources that are essential for the quality of life for all members of society who need help as virtually every member of society is impacted sooner or later. My family member was fortunate to go to CooperRiis, a healing community that offers an individualized wellness approach that instills a healthy lifestyle and purpose. Teaching and supporting wellness and personal growth is not what health insurance is all about but clearly in taking care of those with mental struggles, it should.
4
The moral seems to be: don't let mental illness appear in any medical records, particularly electronic medical records that are more likely to have an eternal life. HIPAA is a flimsy barrier, and America is unlikely to adopt something like GDPR for medical records-- one stroke of a keyboard and you are branded for life.
3
My question concerns the increase in the mortality ratio. Could this have anything to do with the increase in use of drugs used to treat mental health. After all, for so many of these drugs, not only do we not REALLY know how they work, we do not know effects of LONG TERM usage. Could we be seeing shortened longevity as a long term effect?
8
RH, you raise a critical question and something I have often thought about. I actually wanted to go for a test to see how my kidneys are processing the drugs I am on. One drug, Zyprexa, made me pre-diabetic and I gained about 30 lbs. By the time my doctor took blood work, he had to put me on another drug, Metformin, to counter the effects of Zyprexa. I am no very conscious of the side effects of drugs. I don't like to nit pick over every detail, but I like to be informed. But, yes, I am on some heavy duty drugs and I wonder how they are effecting my kidneys, liver, etc..... as well as my brain. It's a tough road and not something I would wish on anybody, especially as there are so many unknowns. Psychiatrists even fumble their way through finding a cocktail of drugs that "work."
The answer is YES. Antipsychotic drugs, in particular, are known for inducing weight gain, diabetes, and heart disease. We are, in fact, killing off patients with our 'treatment' regimens. But to admit this will hurt some bottom lines, so we blame it on the victims' "livestyle" or their "disorder."
2
cook county jail is the largest mental health facility in the state of illinois
5
Well, it's that and so much more: a university for crime; a trade school; a maximum stressor; a punishment for the guilty; an outrage for the innocent; and it keeps the career criminals at least temporarily from exhibiting their skills: raping, killing, robbing, selling narcotics, driving while drunk, etc. In this world, they are a necessary evil: Some people are hardcore outlaws.
1
I would have liked to see a comparative component to this article. What are the mental health outcomes for life expectancy and well-being in other developed nations.
My mother died at 61. She was bipolar. Her care in the American mental health system was abysmal. I walked her through a lot of. Clinicians were at best overworked, burned-out but well-intentioned. At worst they were cynical professionals who checked in with patients and dispatched them to the pharmacy in the basement for their pills. The bottles and bottles and bottles of pills.
What she needed was connection. We gave her what we could in my family. But we were working adults and round the clock care was out of the question, financially.
She got care with so many holes; whole person care sounds like a dream. I need to go read up on some context to see if it really works in places where their governments care.
11
Unfortunately, you write a vital statement: "But we were working adults and round the clock care was out of the question, financially." Yes, she needed care and as a family, somehow you couldn't put the resources together to provide that and that is a shame. It really is. Bipolar is a horrible disease that sends people into the darkest of places and then, at times, provides a gasp of air. She needed you and your family, but your families and jobs obviously took priority over her, as it would in so many American families. What would have happened if she had moved in with one of you? She would have shared a daily dinner and sat on a couch (maybe) as you watched TV. So many people leave their mentally ill family members to fend for themselves when they cannot. And, yes, care is full of holes and people who are not consistent and meds work and then they don't. She didn't wish to bear you any burden, but she got sick and if you were sick as a child, she would've taken care of you.
1
Lexi, the relationships within families are incredibly complex. The stressors and dynamics are different in each situation. Many people, even if sacrificing everything they can, could not provide the care a family member needs, particularly in a society that has less free time and less financial security than past generations.
It takes a village.
"Americans with depression, bipolar disorder or other serious mental illnesses die 15 to 30 years younger than those without mental illness — a disparity larger than for race, ethnicity, geography or socioeconomic status." The point is worth repeating. Race/ethnicity/geography do not hinder an individual's capacity as a functional individual, but mental illness does to various degrees. The silver lining is the number of mentally ill people is a lot smaller than racial, ethnic, geographical, socioeconomic groups. Focus the resources on the real problem.
1
Silver lining? The number of Americans who suffer from a mental illness is enormous. According to the National Institute of Mental Health, "In 2016, there were an estimated 44.7 million adults aged 18 or older in the United States with AMI. This number represented 18.3% of all U.S. adults." Other equally legitimate sources render this statistic as "1 in 5" of your fellow countrymen. And that's just adults. Compare that number with the total population of, say, New England. That's an awful lot of anguish.
1
Most of these patients have serious diagnosis like hypercholesterolemia, hypertension, diabetes, and similar ones often due to side effects of the antipsychotic medications prescribed to deal with their symptoms and the unhealthy diet they follow due to their poverty. Also they may have substance dependency which complicates their health. Yet, our society keeps cutting budgets for their care, which includes residential and day programs and support for community health clinics which tend to take care of them.
No blame should be assigned to any particular group of providers. The problem is systemic and reflects the general tendency of society to make this care dependent on profits ( see the mediation of health care insurance companies). Time to nationalize the health care practice and stop the industrial practices that enslave it.
9
Enri,
Not all mentally ill people come from poor families, far from it. I do not have any of those conditions you listed above, although a medication I took once made me pre-diabetic. My diet is balanced and healthy. But, yes, I need care. These days my symptoms have gone off the chart and I navigate through days of hell. Hell. Yes, I have a good psychiatrist and he is working to balance me. I think there is a systematic problem with the way people with a mental condition are treated. I wrote about it in another post. National Health care doesn't necessarily work much. I know this as most of my family is from England. You have to wait long periods of time for tests and to see doctors, even if you have brain cancer (as we experienced with my Uncle). The poor definitely don't have their needs met, but I can attest to the fact that people with means also struggle to create a balance. Hell, I lost my job (and a six figure salary) with the most recent onset of my illness.
Agree, Lexi. Mental illness strikes every social group. In this society those who suffer become impoverished as a consequence. I know individuals of all social groups suffering the ravaged of schizophrenia. We need to support them but now the trend is to retire financial support from them. Which is related to general increase of inequality
1
Non-compliance. Mentally ill adults are legally competent to direct their own medical care, or lack thereof, until a court decides they are not. So regardless of how many programs and systems and safety nets are in place, the mentally ill can walk right by them and by virtue of their impaired judgment, hasten their own deaths. I have seen this first hand and learned it is impossible for families, friends, caseworkers or anyone to force people needing care to accept it, even when it is brought to them. Our laws protect vulnerable victims from everyone but themselves. Until this changes, the blame game will keep being played, heads will be shaken, and hands capable of helping the mentally ill will be tied.
7
Sorry, but this is a gross oversimplification. The very treatment promoted by the mental health system creates massive health problems, including heart disease, diabetes, and extreme weight gain. Additionally, changes in commitment laws were made because of GROSS violations of human rights in mental health facilities back in the 60s and 70s and long before. Being committed and forced into "treatment" will not be a good solution, because the "treatment" doesn't respect the individual's rights and can, in fact, kill off the recipient. Taking away one's right to decide about medical treatment should be reserved for only the most severe cases, especially when the treatment offered has a very poor track record of success (most clients stop taking their drugs within a year or so) and is actually shortening the average lifespan of those it purports to help.
2
Let’s not just blame the doctors (they don’t care or have time), the treatments (psych meds hasten mortality) or patients (they are non-compliant). There are many known pleiotropic genes that contribute to BOTH developing schizophrenia AND cardiac disease. So there’s also a biological basis for this disparity. https://www.sciencedirect.com/science/article/pii/S000292971300030X
3
Really? There is no genetic test to diagnosis schizophrenia or bipolar disease.
The contribution of the shared pleiotropic genes, doesn't explain the more than doubling of the mortality ratio of people with schizophrenia vs. the general public since 1970.
6
But the massive increase in the use of atypical antipsychotic drugs very well might.
Working in a public hospital I can attest that the author is universally correct. As an internist it is incredibly difficult to treat mentally ill patients. Many smoke and use drugs, are homeless, frequently miss appointments and don’t take their medications. Paranoia and anxiety make it extremely difficult to separate “real” symptoms from imagined ones, and often lead the patients to refuse tests or treatment that could diagnose underlying problems. Doctors not trained in psychiatry have difficulty dealing with them on a personal level, as they can become irrational and confrontational. Dealing with all of this takes a tremendous amount of time we simply don’t have. We can’t force them to comply and sadly often basically give up.
The answer lies in more resources and additional mental health professionals to stabilize these patients. However, in our resource-limited public hospital system I don’t see this happening anytime soon.
12
There is no real commitment in America to caring for patients period. And caring for illnesses as nebulous as mental illnesses is hard because insurers and laypeople and even professionals regard many of the problems as the patient's fault. It's our job to get well. It's our job to overcome our fears and act normal and deal with the stresses that disturb or undo even normal people. It's our job to advocate for ourselves when we're too depressed to care.
Where are we supposed to turn when we're in the midst of a serious depression or having a psychotic break? There aren't enough hospital beds. Health insurance doesn't really cover mental illness. If we lose our jobs or can't find jobs we have a hard time paying for medications and therapy. And yes, symptoms of other illnesses are often ignored or lumped in as mental problems.
Mental illness is more than just in our heads. It's real and treating us like we're malingering won't help. Nor does jailing people for being mentally ill, expecting them to act super normal, or treating them like pariahs help. Maybe if we were treated like legitimately ill people in need of assistance instead of nuisances we'd do better. It's not as if we asked to be depressed, bipolar, or psychotic anymore than a diabetic asks to be diabetic or a heart patient asks to have arteriosclerosis.
14
Its wrong to blame medications for the problems faced by the mentally ill. They are far from ideal, but they go a long way towards improving the lives of many people with serious mental illness. I'm a big believer in diet, exercise and mindfulness, but no amount of these good habits alone will relieve a person with schizophrenia or bipolar disorder of their delusions, hallucinations, suicidal thoughts or manic mood swings. These are serious conditions often made worse by substance use, homelessness and trauma. Medications are often essential.
Psychiatrists are medically trained and can do some diagnostic medical evaluation. A good one will spot the difference between a psychiatric problem and a serious medical illness, while also determining which medication, if any should be used in the safest way. As a psychiatrist myself, I have diagnosed a number of cancers, neurological disorders, heart conditions and endocrine problems. Since I have more time to talk than some of my medicine colleagues, I often find them first. Good access to mental health care is good access to medical care.
17
I recommend you look at the research about the LONG-TERM results of these meds. Don't worry, since most drug research is performed by the pharmaceutical industry, there is not a lot a research on long-term results. Typically, clinical trials last 6-12 weeks. Patients are medicated for a lifetime.
You could start with this article: Recovery in Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose Reduction/Discontinuation or Maintenance Treatment Strategy. The free full text:
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1707650
2
Good for you! In my experience most psychiatrists do not deal with physical issues despite prescribing drugs that have many side effects. Other than an occasional thyroid test or lithium level, I have never received any "medical' advice from either of my psychiatrists. I was concerned about involuntary movement in my hands and feet. The prescribing psychiatrist sent me to my primary doctor. The nurse practitioner had never heard of tardive dyskinesia and probably chalked my complaints up to my mental illness. It was a humiliating and discouraging experience. I finally got a referral but had to find my own neurologist. After an extensive search I found a wonderful young Dr. who included TD as one of her clinical interests. She diagnosed me with TD and to her credit, my current psychiatrist has helped me slowly stop taking the Seroquel, which was originally prescribed to help me sleep while taking two activating antidepressants. Psychiatrists need to step up and use their medical training. At the very least they are responsible for the side effects of the drugs they prescribe. At least have a team of specialists to which to refer patients, making sure each specialist is able to treat the patient without prejudice about mental illness.
The Wunderlink and Harrow studies also show similar results. Additionally, the disability rate due to mental illnesses has DRAMATICALLY increased since the start of the drug-treatment era in mental health, and there are well-understood physiological mechanisms explaining why this is a predictable result.
Read "Anatomy of an Epidemic" by Robert Whitaker for a thorough treatment of the long-term outcomes for those receiving mental health treatment.
2
One factor is that many psychiatric medications cause weight gain and the resultant obesity and diabetes increases risk of death.
25
This happened to me last summer. I was suffering chronic dizziness, fatigue and severe abdominal cramping. I went to an internist, who after reviewing my drugs, recommended I see a new psychiatrist at the local hospital. My diagnosis from this doctor was anxiety. A few weeks later I presented in the ER with the same symptoms, but I also felt like I was going to black out. Initially they took my vitals, but then they sent a psych resident in to see me. I didn't know how a psych resident was going to handle my abdominal cramping or other symptoms. I then had a extreme wave of abdominal pain. It was excruciating and when I experience pain like this I often have a panic attack which I did. They gave me something in the IV for pain and something to calm down. So, now I had had a severe episode of one of my symptoms, but they still wanted to evaluate my depression and suicidality. They discharged me without any follow-up appointments, such as to the GI or GYN. I made my own appointments and so the journey of exploration began and these doctors didn't treat me like a psych patient. Eventually it was found, upon a pelvic ultrasound, that I had thickened endometrial lining and a dangling fibroid. I finally started to bleed after seven months of no period, but due to my age and ovaries not sending the correct hormonal signals, I couldn't stop. Alas, in the hands of very competent GYN, a D & C, and the excruciating abdominal pain stops.
20
Excellent article. Parity for mental illness for all those seeking help or referral given by family physician for consultation would be a good place to start. I was still working in a county mental health department when the affordable care was just beginning.
I believed that things would change because this was the parity finally there for folks to get help with mental illness. Think about sending your patient for a consultation with a psychiatrist or psychologist being the same as sending to a dermatologist. We certainly were not at that place yet as there was so much education needed about the stigma of mental illness. Also mental health treatment/parity could change prisons to treatment for people "ill" and thoughts that I would not have a house or job if I discussed my problems. Much education needed for this. When folks got rid of ACA, nothing I have seen gives parity to mental ilines, nor monies.
7
Dear Dr. Khullar, we only care about fetuses in this country, Once you are born you are on your own, disposable. As to the mentally ill we only care when they have shot someone in a mass shooting and then our reaction "You are in our prayers".
35
This is silly, trendy nonsense.
My father's siblings had bipolar disorder. Several were alcoholics. I have first cousins on my father's side who have committed suicide. I have bipolar disorder. I have tried to commit suicide and have been in psychiatric hospitals twice. I have had two rounds, six months each, of electroshock. Yet, I have been very lucky. All my physicians (I unfortunately have a few medical conditions to deal with) have been very sensitive to the psychiatric problems. I have been able to have a career, by sheer force of will I think. But I can understand that if your insurance is not good, and if the psychiatrists in your area focus on 10 minute medication management sessions, things can fall through the cracks. My experience has been, when I am in my right mind, that you must advocate unceasingly for yourself. Or a family member must do so. Otherwise the problems described in this article will surely happen. It becomes even more difficult if you live in an area that is underserved by psychiatrists, and, in some way, that includes New York City.
13
I am sorry to read about the depth of mental illness in your family and the suicides. You are fighting a hard battle, as am I. I succumbed a few years ago after having many successful years earning degrees and having a profession. Now I battle the demons daily. I have lost hope in medications and I have been hospitalized numerous times. I only hope that one day the sun shines through before it is too late. I wish you continued strength in your battle.
What is missing here is the acknowledgement of the role of trauma.
That as well as the voice of psych survivors such as Will Hall and David Oaks and the late Judi Chamberlin. This article is only the tip of a very well and purposely hidden iceberg.
17
I don't believe it's hidden at all. I think it's one or a combination of two things. 1. People don't know, or 2. People don't care.
4
My sister was diagnosed with bipolar disorder when she was in her early 20s. She died of undiagnosed uterine cancer when she was 39. She saw doctors on and off for obvious symptoms (weight loss, anemia, swelled abdomen, enlarged uterus) for six months before she was finally admitted to the emergency room with a large and aggressive tumor and died six weeks later. It was obviously her mental illness that got in the way of earlier diagnosis. I am heartened to hear that this is a problem that is getting some attention now in the medical world.
18
I am deeply sorry about your loss. I recently went through a similar situation where my medical needs were being overlooked as I was being viewed as a psych patient. I suffered from intense abdominal pains for months and I went to the internist and ER - nothing. I pain escalated. Pain on top of mental challenges = no good! Eventually I took things in my own hands and many appointments with a GI and GYN. Through a pelvic ultrasound they found I had a thickened endometrial lining and a fibroid. A thickened endometrial lining can lead to uterine cancer. It is unbelievable to me that my internist (who is no longer my internist) and the hospital pushed aside my medical symptoms while all along something serious was brewing.
1
Thank you for this article.
My career was teaching in a Clinical Psychology program and working in community mental health as a Clinical Psychologist.
What this article leaves unanswered is the graph.
Although we have negative views of mental hospitals from films such as One Flew Over the Cuckoo's Nest and The Snake Pit, we need to ask whether the closing of these hospitals has actually been a good thing for the seriously mentally ill.
These data (correlational as they are) suggest the answer may be no.
19
Closing of those hospitals is part of the pattern of attitudes toward mental illness in America; simply not taking it seriously. While pernicious American social Darwinism can grudgingly accept cancer, some heart disease, or being hit my a meteor as having external causes and therefore worthy of treatment, mental illness is chalked up to individual failing.
"Cheer up", "take a walk", "smile", "get over yourself", "pull yourself up by your bootstraps", and other oh-so-helpful advice sees mental illness as a option that people choose, and can as easily discard at will. The lucky people who have never peered out from that hole have *no idea* what it's like in there.
Current attitudes may be changing but they are still rooted in the bedrock of those prejudices and have a long way to go before articles like this one are no longer needed.
2
Many of the hospitals were closed because of under-utilization.
Back in the 1970s the ACLU won a case before the Supreme Court with the claim that many of the residents were capable of taking care of themselves but were being "warehoused". Thousands of them were put into half way houses where they could sleep, get their medications and an allowance from their disability checks.
It didn't work for the most part. Many of them didn't like any regimentation. Many wouldn't take their medications slid further down in their delusions. You saw them everywhere dragging big black plastic bags or pushing a cart containing all their possessions. You had to step over them in the morning on the subway. Some slept on the subway ventilation grates and made a living feeding parking meters. They were frequently robbed and many spent their nights at The Tombs.
The hospital buildings were empty, old and expensive to maintain so they were torn down. Now that they are needed there's no money to build again. Some of the land they were on has been sold. The only place left for them is jails and prisons which are not equipped to deal with them.
Maybe they can get the ACLU to sue because these people are endangered without a "warehouse" to live in.
Why has the greater risk of dying at any give age for people with the diagnosis of schizophrenia - more than DOUBLED since 1970?? Overuse of neuroleptics.
9
I’m glad to see that your credible, civil, and relevant comment, coming directly from one who has a severe MI, was accepted and posted by the NYT monitor.
I wasn’t so fortunate — ironic, since my post focused on physicians (and monitors?) disbelieving one’s own devastating MI history — so I will take solace in knowing that you were able to express your own experience and contribute an important consideration to the conversation, namely that "the medicines many of us have to take, however life-saving [emphasis mine], may also shorten the course of our lives."
Yours is the first comment I’ve come across that acknowledges the benefits as well as the costs of long-term use of psychotropic medications.
If not for my maximum-permitted dose of bupropion for severe major situational depression, I would have long since taken my life — which I’m sure many people would understand if they knew (and believed) my history: being hit by a car at age 8; having my now-obvious PTSD misdiagnosed as "schizophrenia" at age 11; enduring 26 hospitalizations, 118 shock treatments (ECTs & ICT’s), 1 rape by an orderly, and 7 years of phenothiazines by age 18; ceding the next 31 years of my life to a charlatan who claimed she was curing my "schizophrenia" while isolating me and withholding the truth; leaving her and finding out that life had long since left me behind at age 49; and finally being correctly diagnosed at age 51.
Hey, at least I can write. I only hope this reply will be posted.
15
I'm sorry to hear about what you've gone through and hope that you're doing much better today.
11
n.b. — The above comment was meant to be my reply to Jake Kosinski's post (see below for context). My bad.
1
Thank you, Maccles.
Being disbelieved is the most painful part of my life. (I stopped trying to get a physical after 4 different MDs wasted my 4 fasting appts with question after question about my history, and then each one of them turned unpleasant and authoritarian, as if I were lying and they needed to assume control.)
But what really shocks me is knowing that many, many multitudes of people all over the Earth experience far more misfortune every single day than I will in my entire lifetime.
On the positive side, writing comments and social commentaries ("from a perspective not often encountered outside the psychiatric profession") and composing jazz/classical(?) music are the most joyful parts of my life. I rarely leave my apartment, so writings and music are how I try to contribute to society. And I have a great friend who visits and helps me with the hard parts of life. I try to dwell on these good things.
And it's a precious gift just to be believed. Thanks again!
2
Sometimes physical illnesses actually cause psychiatric symptoms. I suffered years of depression and anxiety, and was often dismissed as a hypochondriac, until an endocrinologist diagnosed me with a pituitary tumor. It appears that Robin William's suicide was associated with Lewy Body disease. The brain is part of the body.
25
Medications can also cause mental issues.
Gabapentin and its improved form Lyrica can cause depression and suicidal ideation in some people. Both are given for orthopedic problems and neuropathy.
Chantix is a popular drug for people who want to quit smoking and can cause some people to become depressed and suicidal.
It's a good idea to go online and see what people are saying about a drug before you start taking it.
1
Of course they do, they take drugs (both legal and illegal), they probably don't get decent health care on a regular basis. What to do about it is a great question.
1
There do are already some answers though:
1. Support Obamacare, as it has been shown to cut the number of mentally ill Americans without any health insurance at all by 50%.
2. Support the Medicaid expansion that Obamacare allows every state to sign into law, in your own state, as that's one of the main ways how the ACA is increasing health insurance.
3. Systematically vote for politicians who support Obamacare and who want to increase mental HC funding.
4. Systematically vote for politicians who want to increase funding for comprehensive mental HC centers such as the one in San Antonio mentioned in this op-ed.
5. Ask your representatives to add a new mandate to Obamacare, which now also requires large employer plans to include mental HC.
5
My brother, who was brain injured, just died in the hospital because they were treating him with constant heavy doses of psychotropic drugs, which caused a heart attack, additional brain injury, and a coma.
There are many alternative treatments to the damaging pharmaceuticals. Try Craniosacral therapy. I found it to have amazingly positive results. And if it doesnt work, at least it won't destroy your liver like drugs do.
The pharmaceutical companies have a stronghold on our health care system, which can have very negative returns.
11
Exactly.
An 8-week program of mindfulness based anti-depression training has been scientifically proven to be at least as effective in dealing with depression as anti-depressants, and without any of their horrible side effects.
Bonus: it teaches you what many "normal" people were actually never taught at all, namely how to create a deep connection with yourself, your emotions, your body, and how to use that non-judgmental, loving connection to build more satisfying and deeper relationships with other people. Or call it "the art of happiness" ... as opposed to the all too common idea that happiness is a mere "emotion", something that all of a sudden happens without doing anything, or something that can be bought, or something that should arise spontaneously when you manage to achieve one of your goals in life..
We here in the West utterly lack basic self-care skills training, and it has been proven this may change our brain chemistry and reduces crucial brain networks responsible for self-regulation (= managing our emotions, thoughts and behaviors).
And then there's the fact that 17% of people in the world are having hallucinations, but only a small percentage of those people are actually suffering from those hallucinations (= hallucinations that become extremely negative and terrifying, rather than being neutral or even positive), and that people can be taught to learn to deal with those hallucinations (see "Hearing Voices movement") - without needing drugs anymore ...
17
I have taken several such classes with no benefit whatsoever. My depression is associated with brain damage resulting from an endocrine disorder, and anti-depressant medication has been very effective for me. Please don't generalize about the evils of "the West". Not every case is the same.
3
@ Ellen
I'm not contesting the fact that anti-depressants can offer relief, even in people who don't have any endocrine disorder (but then the question becomes: what caused that disorder?).
The problem is that:
1. a "mental illness" is today defined by a subjective feeling of relief when taking this or that class of prescription drugs, not by an understanding of what is actually happening in the brain or causing this absence of well-being in the first place. That's totally different from other "diseases", which are defined by what physical mechanism is disturbed and what caused it. It's also why there's no real reason to believe that the "diagnosis" of a MI is actually meaningful.
2. The "evils" of Western psychopharmacology have to do with the fact that on the one hand, many psychotropes have very damaging long-term side effects, whereas on the other hand, currently available self-care skills aren't taught nor trained, even though scientific studies have shown that those techniques directly change brain chemistry ... and overall well-being.
I have a sister who had severe hallucinations, and only haldol allowed her to get out of the hospital and start working again. So I'm certainly not against psychotropes in no matter what circumstances. All that I'm saying is that alternative methods aren't being promoted at all, in the West, although they have already been scientifically proven to be at least as effective as psychotropes, and without any horrible side effects.
2
My sister was never quite right. Brilliant, capable and insightful and caring, she was also erratic, hostile, unpredictable. Prone to a kind of paranoia, she would often isolate herself from friends and family for days at a time. We would shy away from trying to draw her out. Who knew if she would bother to respond, much less what reaction we might provoke. So when she died at age 48 of bacterial meningitis, caused by a cold that took advantage of her weakened immune system, her body lay undiscovered for five days. My parents never recovered from this devastating loss. Her psychiatrist later speculated that had she received intervention mental health treatment earlier in life, perhaps, maybe, possibly she would have reached out for help. Maybe she would not have driven herself to unnecessary exhaustion fighting her demons, making room for the bacteria to destroy her.
We can not talk enough about the fact, the near normalcy of mental illness. It's scary, it's uncomfortable. It's family.
21
I have lived all my life with immediate family (a sibling), and relations by marriage (an aunt), with severe mental illnesses. Not to mention that no one in a family with a mentally ill member is actually 'normal' - it is emotionally, physically, fiscally, and socially draining. While 1500 characters does not suffice for a full discussion, I share one important point: the hardest part, if not impossible, is to get the mentally ill person to comply with and follow a prescribed course of treatment. Heck, I couldn't even get my sister to finish all 10 days of her antibiotic last time she had a URI. No one could get my aunt to cash the generous checks from her late husband's estate 'written on the wrong paper' or to come out of the welfare motel room she'd locked herself in, smoking four packs a day. (We had to leave bags of groceries at the door, then retreat, like naturalists trying to coax a nocturnal animal from its lair long enough for a glimpse. She'd snatch the bag and slam the door again.) The doctor shouldn't feel he failed his patient; even if he'd caught the problem, the patient probably wouldn't have cooperated. There is a limit to what you can do to save people from themselves.
18
What's very interesting is that the medical community can be loathe to let patients discontinue their drugs. Sometimes not using meds can cause psychotic episodes (been there, seen that) but not always (been there, done that).
The support system created in San Antonio to help people post hospitalization sounds excellent... and it might also help people void hospitalization if it could be broadly applied.
Most people need community.
6
I am a person with severe mental illness and I really appreciate the thoroughness of this article. I would also like to add that the medicines many of us have to take, however life-saving, may also shorten the course of our lives. Medication for Bipolar disorder can be hard on the liver, kidneys, and stomach. The antipsychotics that are the mainstay of treatment for schizophrenia are heavily associated with weight gain, diabetes, Parkinson’s disease, and a host of other chronic diseases that decrease both the length and quality of life. Especially as we approach old age, many of us end up burdened by the side effects of multiple medications no matter how healthy we are in our daily habits. Increased federal funding for research into medication with fewer side effects might help this program but instead under the Trump administration we are going in the opposite direction.
40
Jake, I just posted a reply to your most eloquent and welcome comment, but I think I mistakenly submitted it as a separate comment. Hopefully it will appear not too far above your own.
Mental health is, in and by itself, a difficult subject to consider, let alone understand and do justice. While we get lost in more mundane issues, concurrent and many times contributory to illness and premature death, we may not feel equipped to offer the attention it requires. Without mental awareness as to how to care for ourselves, and others, we fall prey to the illusion that, if ignored long enough, it will stop being relevant, and contributory to our downfall from the brittle grace of health (necessary for some joy in this by force too short a life on Earth) into a hell of despair and suffering. Can we, or should we, separate mental health from our overall physical well-being? Ought we not look at a patient as a unique individual, similar to our own nature, and not just as an 'appendix' or a 'crazy mind'? The fact that we still must ask that question is disturbing. Let's try to not dehumanize ourselves in the process of belittling whoever is seeking our expertise. Our mental health depends on it, as it does theirs. Who knows, with humility and prudence we may even contribute in sparing a life... going to waste otherwise.
5
And let's not forget the role of police shootings in the death rate of mentally ill people. It is estimated that up to one half of police shootings involve mentally ill victims.
21
It is a national disgrace.... the number of mentally ill who are not only shot by police, but languishing in our PRISONS.
10
I am extremely sympathetic on the issue of MI. But some people with MI endanger others. And cops are the ones who have to deal with that.
1
This issue is not news, but is a focus for those involved in the public mental health "system", albeit chronically underfunded and varying widely among states. There are many dedicated people who have been working on this for years. Hopefully general attention will result in more support for their initiatives.
The medical directors for state mental health authorities released this paper in 2006: https://www.nasmhpd.org/content/morbidity-and-mortality-people-serious-m...
Assuring that people with mental illness have access to general healthcare has been developing over the last 16 years, with major support from the federal government. There are pilot projects around the country testing various models of improving the integration of physical and mental health services.
This SAMHSA supported paper articulated an approach for implementing integrated care in multiple settings:
https://www.integration.samhsa.gov/BehavioralHealthandPrimaryCareIntegra...
I retired shortly after writing this last paper, but the efforts of the National Council, SAMHSA, state and local governments has continued to grow. Support this work at every level of government!
6
In other words, massively vote out Republicans, as those are the only politicians systematically trying to turn the clock backwards and destroy healthcare and mental healthcare ... !
11
Everyone suffers from mental illness. The mentally ill suffer the most. But their families suffer also. And their victims if they act out.
Our whole nation suffers from the problems and burdens of mental illness. A mentally ill parent often traumatizes the children.
Families are under tremendous psychological and economic stress. An unplanned or unwanted baby sends many couples and families in chaos and functional overload. The baby suffers too.
I know of two preventable causes of mental illness: traumatic brain injury and early neglect and abuse.
We should definitely do everything possible to prevent TBI: that's a given. Concussions and repeated sports head trauma can cause serious mental dysfunction. We need to rethink sports to protect our brains.
BUT the big biggg BIGGG intervention would be to provide easily accessible and affordable family planning and birth control for every woman in the U.S. who wants it. Unplanned, unwanted children are at much much MUCH great risk of neglect and abuse.
"An ounce of prevention is worth a pound of cure." (B. Franklin)
We would save so much much MUCH money if all babies were planned.
13
This already exists, birth control pills are cheap, perhaps they should be available over the counter.
1
I am happily married, highly educated, have four grown children, keenly aware of health maintenance but for the past four months have been unable to stand or to take a step without human assistance. Why? Medical prejudice against mental illness plays a major role, When I started falling down, I asked my doctor to send me to a geriatrician. Instead, because I have bipolar II I was sent to a psychiatrist who insisted I take Seroquel, which had never been tested on older people. I was in my mid sixties at the time.
Sixty falls later my doctor recommended six hours of physical therapy. The falls continued. I have now have had over one hundred. My condition has now been correctly diagnosed as an uncommon autoimmune disorder completely beyond the ken of modern conventional medicine. Fortunately alternative medicine has made enough progress that my condition is now treatable.
And the American Geriatric Society recommends against meds like Seroquel and for immediate physical therapy after the first or second fall.
And the psychiatrist who insisted I continue taking Seroquel despite the continuing falls? He has left the field to join a company exploring an alternative treatment for depression and bipolar II.
13
So, those unfortunate enough to have developed schizophrenia have a higher mortality rate? That's not news to this retired psychiatrist. However, in retirement, I have researched and written a book on stress, which brought me to a literature on stressed mothers being more likely to have babies with a variety of mental health problems, including autism and schizophrenia. The references are in my book, "Stress R Us", now available as a free PDF on the MAHB website (just re-enter the title in their"library"), or in PB/Kindle on Amazon print on demand for 1/2 the cost of my local printer. When a mammal species is overpopulated, as has been shown in animal crowding studies since the 1920's, numerous health problems develop, mostly due to over-active adrenal glands and high cortisol levels, which includes heart disease. Finally, these crowded populations cease to exist due to family structure disruption and offspring death, and/or infertility. I believe this to be exactly what's happening to us! Our sparsely populated hunter-gatherer contemporaries living in their native lands, in their migratory clan social groups, have NONE of our "diseases of civilization"! NONE! Mother Nature is attempting to reduce our over-crowded numbers and schizophrenia is just one result. Stress R Us
3
Animal studies about increased stress levels and aggression/violence in populations that become "overpopulated" actually show what "overpopulation" means: it means that the available vital resources (mainly food, in animal groups) in a certain territory become too reduced to still be able to feed the entire group.
The only solution, in that case, is to kill certain individuals, or to chase them away (which often comes down to the exact same result, for those individuals).
Western societies indeed produce more stress too, but it's obvious that that kind of stress doesn't have anything to do with lower access to food compared to third world countries, as quite the opposite is true: we have an abundance of food at our disposal, and that goes even for the poorest among us.
Second important fact: third world countries are NOT less "civilized" than we are. They simply cultivate different types of civilizations. So it's as absurd to attribute schizophrenia to a supposed overpopulation in the West, as it is to attribute it to "civilization".
Finally, mental health issues have always existed in non Western cultures too. The remarkable thing here is that it's precisely what we in the West call "psychosis" or schizophrenia/paranoia that is the most frequent mental illness in those countries, whereas in Western cultures it tends to be depression and suicide that are the number one mental illnesses.
That your book ignores these basic facts shows that psychiatry isn't a science ... .
4
"There is a principle which is a bar against all information, which is proof against all arguments and which cannot fail to keep a man in everlasting ignorance-that principle is contempt prior to investigation." Attributed to Rev. W. H. Poole, 1874.
Hate to break it to you, but schizophrenia has been around for way longer than when our population began to explode. It tends to run in families and some genetic markers have already been found. The supposed link between autism and stressed mothers has been disproven numerous times over. As a representative of your profession, you should really stay away from outdated stereotypes and stay current with the research that has been vetted and peer-reviewed. More people would take you seriously.
3
Thank you, Dr. Khullar for bravely illuminating a very dark, dark corner of medical practice in the US. I hope your recognition and acknowledgment of this complicated problem will inspire both your colleagues and your readers to examine their attitudes and behavior toward the people we call mentally ill.
The severest forms of mental illness are terrible afflictions, ghastly to behold for a moment and agonizing to witness over time, especially when (as is often the case) the sufferer was once a bright, promising, nimble youth or an insightful, clever, talented beauty. But there are countless degrees of heartbreak for those of us with parents, siblings, or children whose diagnoses are more commonplace, and among the very worst is seeing a loved one's avoidable physical pain or treatable ailment be dismissed as a symptom of their mental disease.
4
Doctors, seeing their time as a scarce resource, perform triage every day. If they see a mentally ill patient as very unlikely to have good quality of life and unlikely to be anything more than a drag on society, they conclude that a major effort on their part will not produce a good return on investment. So they prescribe psych drugs (with dangerous side effects) and cut their losses in terms of sorting treatable health issues from psych symptoms. If no one else cares, why should they?
Doing a good job of treating people with mental illnesses is challenging, time-consuming, and expensive. Along with the other major problems with this country's approaches to the mentally ill (such as making them homeless or housing them in prisons), the body politic has balked at the perceived ROI. We don't want to pay for it. Let them die.
My mother was bipolar and killed herself long ago. My sister has struggled with the disorder for decades, and has only herself to thank for her survival (late 60s). She tried prescribed drugs, but in time found ways to manage her life without drugs. One way you might call equine therapy: she spends a lot of time training and riding horses. She has deep connections with them; "horse sense" seems to rub off on her and helps keep her balanced. The exercise and careful eating habits have kept her in good physical condition.
Few with such disorders are able to do what she has done for herself. And we leave most of them on their own with little or no help.
15
A much likelier explanation that doesn’t have to account for the fact that mortality rates overall have decreased:
Rate of diagnosis of serious mental illness has increased over the past few decades, sometimes dramatically. The “rise” in mortality rates is really just a result of the development of more accurate (or, if we’re being skeptical, broader and broader) diagnostic criteria during that timeframe. In other words, mentally ill people were dying at the same rate (or even higher rates) forty years ago, but, at that time, they weren’t considered mentally ill.
2
In that case the main question is: how come that physicians stop to do their jobs properly (because that's apparently what happens, once they're confronted with a mentally ill patient)?
What psychological mechanism kicks in that makes them forget about doing the necessary and crucial cancer/heart/... test to prevent/cure diseases which they're precisely trained to prevent/cure?
Maybe, in order to find an answer to this question, we have to take a look at the fact that the category of doctors with the highest suicide rate, is that of psychiatrists.
In the West, "mental illness" (= basically mood disorders that are so intense that they start impairing the capacity to have a normal social and professional life) is still poorly understood, and few ways of approaching its treatment are truly satisfying.
That makes being a psychologist/psychiatrist a highly stressful job, as you have to constantly confront your own failures, professionally.
Add to that the fact that contrary to for instance heart attacks, there's no way to "measure" emotions in a preventive way, so when a cardiologist can meet his patients without having to worry that he'll get a heart attack too as long as his own risk factors are low, the same cannot be said about people dealing with the mentally ill.
Maybe the solution here is to finally start taking emotional management training for caregivers seriously, so that their own fears no longer make them turn away from patients when they should do the opposite?
2
There is another confounding issue. Patients have rights. I had a patient that had a large abnormal blood vessel that needed surgical intervention to prevent a fatal rupture. He was in our locked ward, and was being treated for his psychotic episode. Once he was treated and was no longer psychotic, he said he did not want surgery. After explaining the risks and benefits of treatment, he still chose not to have surgery. We went down the appropriate paths to determine his competency. He was deemed competent and his decision stood. He was given an outpatient follow up is he changed his mind, and he did not return. He had the right to make that decision, but because of it he is going to be a datum point of which you speak.
9
We have a family member with a history of mental illness. He refuses to get badly needed cataract surgery and is showing some signs of some physical disability. He's been stable for many years, but he's "doctored out." Many years in an out of mental health institutions with mixed results leads to not trusting the medical establishment. Then, who pays for all of this? Seriously mentally ill people don't have big jobs for health insurance. "Community mental health" is a joke. And how do they get to the specialists and hospitals? Our family member can't drive, uses a mediocre public transit system. As our family says, "when you're crazy, you don't know you're crazy." The patient has to be well enough to understand the severity of the illness, trust the doctors, have a way to pay for it and get physically get access to healthcare. No wonder there's a "health disparity."
16
My 40 y.o. ex-husband with schizoaffective disorder broke both of his wrists in two separate incidents on a skateboard, during an extended bout of mania. After weeks of him complaining about it and getting drunk to manage the pain, I convinced him to see a doctor.
He was x-rayed, and the ER physician consulting informed him that his wrists were indeed broken and that he should see an orthopedic specialist.
With two semesters of community college anatomy/physiology under his belt, he decided that he was more knowledgeable than the doctor and refused.
7
Look at tobacco use, it's only mentioned once at the end of the article. There was a good sized study out of Texas in 2015 that make things fairly clear.
6
This is HUGE.
People with mental illness are often heavy smokers. It has been found that cigarettes are a somewhat effective way for people with psychosis to self-medicating as the Nicotine increases their ability to shift focus away from hallucinations, and it's accessible without seeing a doctor.
5
All too often the overbearing stress of these illnesses is ignored. The grueling mental strain and exhaustion to simply keep going take a devastating toll. It's like carrying a boulder your entire life then being surprised when your back gives out.
19
A researcher from a California university (Stanford?) has compared the stress hormone levels of people living with depression to those of people living in war zones. It is an exhausting, physical strain. It disrupts sleep. Of course it wears out your heart.
1
After watching my brother suffer with schizophrenia since his late teens and early 20s, he passed away at 61. Although I agree with much of the article, I would also like to suggest that years of powerful anti psychotic medicines prescribed to treat my brother also took their toll on his body and organs. This too played a key role in his death that doesn't get talked about.
18
This really should not be a surprise, when it seems as if the psych industry devolved into the biggest drug pushing organization around. Powerful brain altering chemicals, often prescribed for years on end, and for ever younger patients, can only lead to this tragic outcome. Sadly, this applies not just to those with serious mental illness, but to anyone with innumerable minor issues that now all get lumped into the ill-defined term "mental illness" and talked about as if serious disorders are on a par with minor bumps in life and the endless list of "syndromes", some of them utterly ridiculous.
Psychiatry loves to tell us it really knows how to handles these "diseases" but unlike say a diagnosis of cancer, for instance, a lot of it is guess work and supposition. Have three psychiatrists examine a person and you might end up with three answers. Yes, they can help some seriously affected people, and that is praise worthy, but much of it is ridiculous and waste.
5
I bet the number of depressed and mentally ill people increases when Republicans are in charge. Republican economic austerity and degradation of the social safety net causes people to suffer great stress, uncertainty and insecurity. Stress can cause certain types of mental illness which may plague families for generations and affect life expectancy.
8
So-called "atypical" antipsychotics are now widely prescribed for both psychotic and non-psychotic patients. They are known to cause "metabolic syndrome" as a dangerous side effect. The syndrome includes obesity that may reach morbid levels; high blood pressure; high lipids; and diabetes. So this may be one preventable cause of decreased life-expectancy among the mentally ill.
13
"“When there’s a commitment to these patients, there’s a lot we can do,” Dr. Velligan said. “But right now, they’re not a priority. People have to want to care for them. We have to care.”
Thanks for this very interesting, informative and important op-ed.
I have a sister suffering from mental illness, and witnessed first-hand what a huge difference finding the right hospital and a comprehensive approach can make. I didn't suspect at all, though, that mentally ill people tend to die much earlier and from the same causes as we do, and that one of the main reasons is that ... doctors don't take their complaints seriously.
That means that first of all, it's DOCTORS who have to start to care about this - and then we as a society who have to urgently vote for politicians who vow to increase mental illness funding.
Obamacare is a step into the right direction. Where before the ACA a whopping 1 out of 3 mentally ill Americans didn't even have health insurance, today that's down to 1 out of 5. But that's still twice the number of people without mental illness and who don't have insurance.
https://namijc.org/heres-obamacare-mental-health/
The ACA also requires all insurance plans to cover mental health. And as mentally ill people are often chronically ill, which insurers often rejected as a pre-existing condition, the fact that the ACA mandates insurers to no longer refuse or discriminate against people with pre-existing conditions also helps.
But much more needs to be done ...
3
ACA actually does NOT require mental health coverage as part of minimum insurance plans offered by many employers -- those plans only cover preventative health care and qualify one to avoid the penalty.
That minimum plan includes once-per year doctor visit (plus 1 well woman visit if you are female). And that visit would include your doctor you asking you screening questions on mental health.
Appointments with a mental health professional (therapist, psychologist, psychiatrist, mental health counselor) are NOT included.
Including appointments with such a mental health professional, and including things like group classes on how to manage your mental health, would be items that actually constitute real medical care.
A RX alone after answering some questions is not sufficient medical treatment for anyone with a on-going mental health care need.
Coverage for appointments with a mental health professional would be for Bronze, Silver, Gold, Platinum plans, which are broader coverage than the mandated minimum of the preventative health care plan which many employers only offer. Such employers only offering these minimum plans include well-established national companies, including one raked within the Fortune 500 in 2017.
I know the above from my actual experience over the past few years, from researching on plans offered by my employers, and from speaking with the insurance company representatives.
We need a single payer all-in health care plan.
3
@ TC
I agree.
Mental healthcare is now mandated, thanks to the ACA, for small employer and individual exchange market plans, but not yet for large employer plans.
And yes, of course it should include more than what minimum plans today offer.
That being said, two remarks:
1. The ACA already makes it perfectly legal for any state to switch to single payer TODAY. Vermont has tried to do so, but then suspended its attempt because of high costs. That problem would probably disappear as soon as all blue states would switch to single payer simultaneously.
2. Thanks to the ACA, twice as many mentally ill people are now at least having health insurance whereas before they weren't insured at all, so the problem that is being discussed in this op-ed (lack of physical care for the MI) is at least partially addressed by the ACA.
Personally, I'd tend to follow Paul Krugman on this. With tremendous opposition from the pharma and health insurance industry, which completely bought the GOP and Fox News in order to maintain their power and profits, we probably won't be able to get single payer nationwide any time soon.
In that case, we need to look at what the main goal here is, and that is universal affordable coverage - including full mental HC coverage.
And as Krugman has shown, we can obtain this through small amendments to the ACA (basically subsidies for those buying on the exchanges and who don't have them yet, combined with a public option).
1
One might also say instead that that was 15 to 30 years less of suffering from the onus a punitive society has placed on them for the way they are. We're just jealous that they can get relief from it sooner.
3
Having lost a close relative recently to schizophrenia, I can attest to the devastation an undiagnosed or undisclosed mental illness wreaks on a family.
My relative never showed any signs of mental illness when we were growing up. Instead, she had late-onset symptoms, which only grew worse as time went on.
She became lost in her illness and lost to her family and even though they were heroic in their attempts to both find and rescue her, ultimately, she succumbed to the effects of her illness and to untreated cancer. She died at just 52
The sadness and devastation my family felt when she passed away was indescribable and life-changing. She is never far from my mind and heart.
It's incumbent on us to face the very real ravages of mental illness and to start talking about it openly and honestly.
17
Nearly all anti-depressants have lousy sad effects for type 2 diabetics. Most will permanently transform type 2 diabetes into type 1 diabetes. The depressed person may become insulin dependent until death. Death could be sooner, not later.
I am 62, 200+ pounds overweight and have type 2 diabetes. I hardly exercise at all. My inactivity indicates mild, chronic Depression. Taking an anti depressant to reduce my level of unhappiness may not help that much, may not raise up my motivation to get up and take a walk around the block, but the side effects of the drug could make me permanently a type 1 diabetic. That's worse than feeling a little unhappy most of the time.
I do not get up and walk around for 15 minutes or so 2 or 3 times a day, even though that's a matter of life or death for me. What's changed is that I do not buy or eat sweets that much. When I look at bread, cakes and cookies, ice cream, and snack chips in the supermarket, the images that come to my mind are of diabetics in wheelchairs with limbs cut off; doctors say that's good if it keeps me from buying and eating sugar.
6
The good news is that specific meditation practices have been scientifically proven to have all the positive effects of anti-depressants (and more than that, as contrary to drugs they address your basic psychological needs in life, such as the need for love and self-love and how to see love as a verb rather than a mere emotion, a skill to develop rather than something you hope will come from the outside and knock one day at your doorstep) ... and NONE of their side-effects.
All it takes is an eight-week training (which often feels so good that it doesn't take a lot of effort but merely "discipline" (read: regular practice) to continue you to do it beyond those two months).
For more information, see for instance Mark Williams' book "The Mindful Way through Depression" (University of Oxford).
Good luck and take care.
1
By definition type 1 diabetes is what one is born with not a result of aging and diet = type 2.
You could do a lot for your type 2 by moving.
If you are not moving because of pain or vertigo.... problem here. I don't think most people in average health should have replacement surgery on knees before the late 60s--igven your life expectancy. (Hip replacement is relatively easily redone). But if you need replacement surgery have it done.
Do get up and move. It will make a difference in your numbers and your mood. Can you walk to the library? Can you walk to do your grocery shopping? banking? Create some reason to move.
Keep the images ... and put dialysis on your list.
And remember a better diet begins with the very next mouthful -- celery or popcorn -- instead of cheese or ice cream
1
As an internist treating a population with a disproportionate burden of psychiatric issues, I have also had an interest in this topic and appreciate Dr. Khullar's insights. Getting one's hands around the problem isn't easy--"mental illness" is a catch-all for wide ranging and very different problems; but certainly there are some common threads--1) Poor or no insurance coverage for mental health problems, 2) Few social supports, 3) Significant difficulties interacting with the private health care system and following through on medical instruction, 4) Great difficulties modifying life style and behavior, and, frequently, 5) poverty. These factors alone place persons under the Mental Illness catch-all at very increased risk for increased illness and premature death. Add to that the direct harms caused by common addictions like smoking and alcohol, the side effects of psychotropic medications, and (as has been mentioned) misinterpretations of symptoms and complaints by health care personnel and you do not need to look much further to explain the numbers. There are, of course, yet more explanations and certainly it is very evident that, when it happens, the combination of physical illness and mental illness is devastating. These are very difficult problems, but, if the basics were addressed, the numbers would improve. To do this, of course, we would have to live in a country that actually wants everyone to get health care.
34
You have nailed it with these two factors:
2) Few social supports, 3) Significant difficulties interacting with the private health care system and following through on medical instruction
My ex has schizoaffective disorder, and is on SSDI. For the years he was waiting for his claim to go through, he was served well on Medicaid.
Then his claim was accepted, and he received a large manila envelope full of forms and papers to apply for Medicare and no guidance. He threw it away, lost his insurance as Medicaid was automatically unenrolled and he decompensated as a result of no-one recognizing that a basic feature of the disability he is receiving benefits for, is inability to complete paperwork.
Once he was actually on Medicare, then it became a hurdle of finding a psychiatrist that took it and also served people younger than 65.
Later, when I broke it off with him, I attempted to find community supports to fill my role as de facto social worker. I went to the Area Agency on Aging and Disabilities, they only help seniors and people with physical disability.
There exists no public agency that assists non-seniors who are mentally disabled; only private charities such as NAMI or The Arc, and they don't have the resources to do much more than teach families how to help. Some families don't have the capacity to help - mental illness does run in families.
10
The alternative therapies advocated are excellent. And they need to be considered in a larger context. These therapies or their social equivalents benefit people who are not mentally ill. And people lacking these therapies or their social equivalents tend towards the same illnesses, and also tend towards diagnoses of mental health issues. A big unanswered question is the impact of the powerful psychiatric drugs on other diseases, and their impact on accelerating those diseases. While the short term effects of the drugs may be significant in a positive way, their long term effects may be more significant in an opposite way (an issue which drug makers do not want to acknowledge). The common sense conclusions are that social context matters, and no psychiatric drugs should ever be given without a plan to discontinue their use after the short term benefit is realized.
7
Our precious daughter Alyson died two weeks after her 48th birthday. Diagnosed with the catch-all of schizo-affective disorder in her early 20’s, she was faithfully compliant with her heavy schedule of medications. These enabled her to live a life of grace, friendship, and I may even say charisma. There were so many side effects of the drugs but she took them anyway. She gained weight from most of them. In the end, the autopsy was basically inconclusive. But I think her dear body just could not support the subtle ravages of the years of medications. The same ones which allowed her never to be lost to us in her mental illness. A catch-22 if there ever was one.
73
The major tranquilizers of the past, such as haldol, had cardiac side effects listed prominently. The newer generation of drugs, such as Zyprexa, caused elevated blood sugars implicated in triggering diabetes. Likewise Lithium has renal issues. Bottom line, powerful drugs are used to combat psychosis. Stress and lower social and economic status is bad for your health for everyone. But as more genetic studies continue, we may even find that there are correlative factors with mental illness and other medical issues.
4
Mentally ill people may appear to lie, cheat and steal on purpose. But, I believe they are being deceitful to cover up for deficiencies. We need to help them address their problems, like the article spells out, for stability in their lives.
2
Schizophreniacs are poor liars. Their lousy lying is a way they can be identified.
1
The diagnostic overshadowing is something I am very familiar with from first hand experience. I have problems with depression and fatigue can either be caused by the depression itself or the medication for depression. One semester I got mono and I thought it was depression the entire time, until I received a blood test for something unrelated. But by that time my grades were already submitted so I suffered academically and of course still had to deal with depression the following semester.
10
There is very little research into the long term side effects of many of the drugs used to treat mental illness. Some can precipitate cardiac problems, such as rapid heart beat, if taken incorrectly. Some area highly addictive. Some have a very short half lives, and skipping even one dose can increase the risk for problems like seizures. Some drugs affect sodium and potassium levels. It is not known if the drugs themselves increase the risk of cancer after many years of use. Is it the countless CT scans? It is easy to obtain expensive tests, but difficult to obtain weekly psychotherapy, a service which we know can help. Do physicians ever take the time to explain these important considerations?
17
After my then-19-year-old daughter's discharge from her second involuntary hospitalization and a diagnosis of schizophrenia, I tried to obtain services for her at a behavioral health agency in Augusta, Maine.
She was rejected.
Repeated phone calls and even a letter to the agency's head failed to produce a reason, indeed I did not even receive a response.
A friend suggested that the agency 's rule was to reject anyone who had "only" one hospitalization. On spec, I drove a 550-mile round trip to the out-of state medical center from which she had been discharged (with no discharge plan beyond "to home," by the way). I returned with fresh copies of both discharges, having had them mail releases to me which--thank God--she had signed.
Only then were services finally offered. My friend had been correct.
The following year I became a clinical psych practicum student at that agency, and sat in on numerous team meetings. To my horror, the team leaders encouraged a culture of deriding both their clients and young clients' parents. Their chuckles resonate in my memory. Stigmatization of families dealing with psychiatric illnesses was commonplace there.
61
Unfortunately that's an all too common story.
When I was studying Medicine, I had the exact same experience. I didn't know yet, at the time, that my own sister was mentally ill, but you don't need to have a family member suffering from mental illness to be shocked by the cruelty and lack of real compassion on the part of the medical staff (not only when it comes to mental illness, but for other patients as well). Some basic sense of our common humanity seems to be enough to reject this kind of despicable attitudes.
It's only now, years later, that I started to understand why this kind of behavior may be so widespread among physicians and psychologists.
You have to imagine to be confronted with tremendous human suffering day after day, hour after hour (and often not being able to help). How could any normal person keep his sanity, in such a circumstances? The most logical, spontaneous reaction is to gradually start protecting yourself by creating a huge gap between who you are and your patients - and irony and despising them are VERY effective tools to stop identifying with other people.
Fortunately though, today alternatives do exist. Joan Halifax for instance describes them in her two books about accompanying dying people professionally.
It turns out that you have to TRAIN yourself to be able to cope with other people's suffering without shutting down your own heart, and a very strong self-compassion practice is precisely what makes this training possible.
11
I have stopped using the term "stigma" and have replaced with with "discrimination". It is more than just a self-image problem. There is active discrimination against people who have gotten labeled as "mentally ill." Stigma is way too gentle a word for it.
1
Judging from all the dangerous side-effects caused by psychiatric drugs, it is no wonder mentally ill people die younger. The other side of the issue is non compliance with the drug regime because they don't like how they feel on the drugs or they don't remember to take them. Obesity is a side effect of many of the psychiatric drugs which leads to other health problems. Maybe the worst are the physical manifestations of tardive dyskinesia or parkinsonian symptoms. I once warned a friend to tell his doctor about these side effects and the doctor sent me a message, "Mind you own business." I thought at the time that stopping the drugs would end the side effects. That is not necessarily the case. There are a lot of areas in the care of the mentally ill that can cause early death. Iatrogenic ones are also on the list.
19
My mother was a very well-educated psychologist and severely mentally ill. No one in the family really accepted it until she was about 60, so she had never had treatment until the police picked her up. She had severe bi-polar one and maybe something else as well. But she was unable to understand that she was ill and that understanding, which some of the commenters here clearly have, is the key to negotiating mental disorder. Without it, people make bad decisions. Mom, for instance, was determined to "go out on the streets and live with the holy people". She gave all of her money and possessions away. She depended on voices telling her what to do. It was a bit of luck that she ended up in convalescent care for 14 years when, having been given the wrong drug, she became unable to walk. I hate to think how her life would have ended otherwise.
There are many types and severities of mental illness. Some people cope pretty well with it and have a disciplined approach towards treatment. But some do not. They really are a danger to themselves and others and are intransigent when offered options. The laws we have sometimes support this intransigence to the physical detriment of the ill person who is unable to make good decisions. That inability will inevitably shorten lives. Living on the streets with the other holy people is not safe.
32
I'm a psychiatric social worker with training in psych units here, Brussels and Argentina. I use Cognitive Behavioral Therapy for psychosis CBTp to help alleviate some distress of patients symptoms. I also have a brother who is 40 with Schizophrenia first break at 19.
This article is correct on the merits. Funding + well trained clinicians can help tremendously. Prop 63 in CA brought in 100s of millions for serious mental illness. Beaurocrats didn't disperse it and when they do they hire consultants. Joke! I'm quite hopeless to a certain extent given all the barriers to equal care let alone specialized.
Funds + specialized multidiciplinary clinicians + supportive family + rehab/job skills (having a job) + socialization = recovery. Less recidivism in psych units and ER units that cost taxpayers billions. It's that simple. + Pharma gave up long ago, Fed $ is needed. And having solid (well paid) clinicians can rule out other issues besides mental illness that folks brought up on this post like inflamation, etc.
Socrates called madness/schizophrenia the holy disease and people were brought to nature and waterfalls and treated well. Today a cardboard box suffices for the US. We are judged as a society how we treat the mentally ill. I love my much younger brother and he'll most likely die before me. Its crystal clear to me. We needed to have been born in Brussels where they at least try to emulate my equation.
23
1. There is no such thing as mental illness that is separate from physical pathology. Mental illness is just a dodge for physical pathologies that result in maladaptive beliefs and behaviors. As soon as the medical profession traces down the physical pathways that lead to problematic mental states, they declare the very same clinical condition to be a physical illness that was "mistaken for mental illness." See anti-NMDA receptor encephalitis for example.
2. Many of the "treatments" (i.e., psychotropic drugs) given to half of the people with bipolar and schizophrenic diagnoses are known cause organ damage (lithium in particular) or alter metabolism such that diabetes and obesity become much more likely. It is not just a lack of receptive medical care that is shortening lives, the psychiatric drugs and, in many cases, confinement directly contribute to deadly diseases. How was this not acknowledged?
3. All of the most dangerous psychiatric diagnoses are associated with neuroinflammation driven by chronic immune system activation. Elsewhere in the body, chronic immune inflammatory activity leads to cardiovascular disease and cancer. But instead of treating the overactive immune system, mental "health care" treats psychiatric symptoms with dangerous drugs.
4. My partner was diagnosed as rapid cycling bipolar with psychosis and told she needed to stay on psych meds forever. We treated her inflammation and genetically driven detox problems instead. She's fine now.
18
Mental illnesses may well be a result of very impaired metabolism. Many of those with diagnosable mental illness also have a copper toxicity. Protocols to bring metabolism back into balance, such as the one developed by Morley Robbins, owner of the Magnesium Advocacy group on Facebook, are showing reversal of numerous health issues, including mental illness. Copper toxicity, if present, is resolved as metabolism improves.
2
May I ask how you treated the inflammation? My partner suffers from bipolar as well.
1
You wrote, "All of the most dangerous psychiatric diagnoses are associated with neuroinflammation driven by chronic immune system activation".
This is a pretty dogmatic generalization-- Can you provide a single, credible literature reference? Please.
6
In my experience as a patient advocate accompanying women to the oncologist and often to other specialists as new problems arose, I often observed physician discomfort with patients who also had a mental health diagnosis. Perhaps what I saw was lack of familiarity with the underlying mental illness, but it was clear to me that the doctors seemed to be in a hurry to leave, at least early in the doctor patient relationship. I was there to make sure the doctor or nurse heard what the patient had to say and that the health concerns were addressed.
Interestingly, this seemed to be less of an issue when the patients saw a nurse practitioner.
62
Observation from 40+ years in medicine: most NPs are women and prepared by training to be the history-taker and decision-maker "with" not "for" their patients . . .unlike the older docs and men across health professions.
More work needs to be done on helping those of us with mental health issues (including autism) learn how how to self-soothe and manage our symptoms of anxiety, depression, overstimulation, despair, low self-esteem, executive function deficits and other issues using meditation, relaxation, journaling, stress reduction, meeting in sharing/caring groups and similar activities that cost little and are far less invasive than medication.
14
Anytime you have one disease, it is harder to diagnose others. I have major depression and when I got really tired and had trouble concentrating, organizing myself and so on I thought I needed a medication adjustment for my depression. I did find a medication that worked better but I was still needing to sleep sixteen hours a day and barely functioning. I was so weak from lack of exercise from sleeping all the time that I couldn't run or hop at all without falling down.
Finally I noticed that the only time I had any energy was before I ate in the morning (usually an apple, I thought I was being healthy!) and was also drinking more. I did have gestational diabetes with one child, so I knew I was at risk for diabetes, so I contacted my doctor and got a blood test. Before the blood draw appointment I went on a low carb diet and felt much better, which made me more confident that I was right about diabetes.
Turned out my fasting sugar was about 380 and my a1c was over 12. Metformin helped a lot, but I still had a long recovery because I couldn't exercise much and was still easily confused about whether I'd taken my medications or not. It was really hard to get to a place where I could really manage myself and my new disease.
So, to me, my depression masked the diabetes because the symptoms were similar. I thought the depression had simply gotten worse due to the recent death of my husband.
60
Excellent piece. Hopefully it’s not just read but acted on by people in positions capable of implementing change and improving outcomes. Our country’s inability to deal with mental illness with the same level of care and compassion shown to those with cancer or ALS is unacceptable. I truly believe we have the resources, technologies, and treatments to affect positive change. We just lack the will, courage, and determination to fight for these resources to be available to all who need them, regardless of social standing, incarceration, or ethnicity. Health care professionals must make this a priority NOW.
16
well put......but the missing piece is the will and co operation of the mentally ill patient.All too often a person who is mentally ill refuses help both for his mental illness and his physical problems, and it may take several family members to drag him in kicking and screaming to make sure he gets the care he needs.And in order to stay mentally healthy, And physically healthy he has to do all the things none of us want to do...the exercise, the meds, the doc visits, careful diet, not doing things like smoking etc.Until we have draconian laws that insist people get the help they need whether they think they need it or not youll have the same problems over and over again.Given that the present laws we have are a result of a time when people Had no rights over their minds and bodies{and as a result horrendous injustices occurred} its unlikely to happen.
9
Another reason for these early deaths is that weight gain is a side effect of many psychiatric medications. A friend and his wife were dropping their son off in Ct after a day in New York City. The son dropped dead from a heart attack on the sidewalk. He was 42 and doing well in treatment, compliant with his medication for schizophrenia.
Few health clinics have integrated psychiatric and physical health care and even fewer psychiatric clinics have nutrition programs for their patient with serious mental illness. This is true even at Ivy League and other major universities.
Yet outcomes for all patients would be better if doctors were trained to ask the hard questions.
When I worked in psychiatry some time ago, interns and residents rotated through departments. They spent one day in psychiatry; none in addiction services, a subspeciality in the hospital outpatient psychiatric program where I was director of the evening addiction treatment program.
I hope today they get better training, but I fear they don't. I still see far too many people released from inpatient psychiatric stays with no referral for outpatient psychiatric care, let alone physical health follow-up.
23
So what's the point here? That MI causes people to die young? Not because of MI itself; many correlates of MI include joblessness, homelessness and poverty which can be considered the cause of early death. We blame MI for everything. It certainly needs attention. But certainly everyone has some form of 'mental illness'. It's human. And we need to take better care of each other. Let's understand the issues clearly.
6
Note that the BIG jump in Mortality came when Reagan was elected and Millions of the mentally I'll were Dumped on the street, where they have remained ever since
76
T wasn't Reagan who started that. It was started in the 60s, by people who didn't believe in traditional standards of mental illness. Look it up and read about them. It will make you angrier than you already are.
19
Reagan did cut off major funding for mental institutions and many patients were put on the streets.
It was Reagan and his cronies on the far-right and, on the far-left, the anti-psychiatry movement. I was a student in California in 1968 and I well remember the protest signs "Mental Patience for Reagan". The far ends of left and right often support each other.
Smoking is the number one cause of death in people with mental illness- why no mention of tobacco?
27
It's astounding and irresponsible that an article about mortality rates for those with serious mental illness doesn't even mention the mental illness with THE highest mortality rate --eating disorders. It is notoriously difficult for the victims of these disorders to find effective treatment. Many MH professionals have little or no training in the area, and fewer medical practitioner are trained to diagnose or treat these disorders.
29
It's called medication side effects.
8
Vice versa,
pre-natal, peri-natal and early post-natal health care may affect the risk of actually developing schizophrenia later in life...
https://www.nature.com/articles/s41591-018-0021-y
https://www.libd.org/new-study-finds-placenta-health-affects-risk-of-sch...
5
There is no health care for most americans.
11
It would helped us readers had Dr. Khullar provided more facts about his patient: his age, whether he was afflicted with bi-polar disorder when he was in his late teens or early 20s and his general health when he first examined the patient. Did his father suffer from coronary artery disease? How old was he when he died.
The factors that promote health and well-being as we get older are: a certain amount of physical activity or exercise, a healthy diet, and a certain amount of social interaction with other people, often peers.
People with serious mental disorders often lack all three. On the other hand, their symptoms and signs tend to moderate and disappear as they age. They no longer experience the stress and anxiety of making a living and adhering to the demands and listening to the criticisms of uncaring bosses.
People with these terrible diseases often suffer from cumulative mental and physical insults as they age. They start out at a disadvantage and fall further behind. New psychopharmacologic agents and drugs, such as lithium may help to bring relief.
We don't know whether there is a genetic or biological connection between mental disorders and physical ones, such as heart disease, cancer, and diabetes.
4
You seem nice, and interested but kind of misinformed. Lithium is not at all new, for example. And it is not just lack of exercise, unhealthy diet or isolation - the drugs seem to slow the metabolism dramatically, and increase hunger. Avoiding significant weight gain is impossible on many of these drugs. But they can bring someone back to a much better level of capability for living in the world. It is an awful conundrum.
17
Thank you.
You are dumping pretty much everyone in together here -- from mild depression to severe schizophrenia. And "the stress and anxiety of making a living and adhering to the demands and criticisms of uncaring bosses" describes literally everyone on the planet from ages 16 to 65.
3
For several years I ran a large human service agency in Massachusetts which provides services to individuals with behavioral, psychiatric and developmental disabilities. We employed, proudly, many individuals with lived experience. Our employees and those we served all had horror stories of their physical complaints being disregarded, being shunted aside in emergency rooms and monitored by a sitter simply for disclosing the medications they took, being ill treated for the mental illness and\or substance abuse and\or body weight. You can’t treat people if they don’t show up in the clinic. Through a Medicare Innovation grant we found great success sending health care providers, nurses in this case, into the community and used technology which was inherently bias free to help identify issues early on. Our community outreach teams are great partners has they had meaningful and respectful relationships with the individuals we served and often had lived experience which gave them tremendous empathy and credibility.
33
Although one cannot be sure, it will be critical to explore the effect of psychotropic medications on this alarming statistic. People with serious mental illnesses, i.e., those with psychotic symptoms, tend to lose natural supports such as friends and family. Hence there is practically no political constituency for their support. Meanwhile, the usual suspects, including big pharma, have a financial interest in the status quo.
32
I have struggled with depression all my life. I have managed to have a family a relatively successful career, and in thirty years had to get a long-term sick leave due to depression and PTSD once. I take care of myself: control my weight, get regular checkups, etc..., but I've seen very often how doctors dismiss any other symptoms I may have as soon as they see depression in my chart. I have over the years found some excellent doctors, and I try to stick to them, but the condescending attitude of others is devastating when you are already feeling sick. The best one was a male psychiatrist "in training" (I don't know if it was a rotation of working on the specialty). When I explained to him how hormones affected my depression symptoms, he immediately dismissed me and, with a lot of medicalese, explained to me how it was "all in my head". As you can imagine, I never went back. What I have done is find a doctor who listens, and a good therapist, and managed to get genetic testing to find out which medications were more appropriate for me. I also found a good person to help with my hormones, and the improvement was substantive.
I cannot imagine how doctors would treat someone who is not highly educated, who doesn't have private health insurance, or who has illnesses more difficult than depression. Or even, someone who takes doctors at their word and don't do their own research or look for a second opinion.
121
Congratulations, you not only survived the system but flourished in spite of it. Depression is my all too familiar "friend" and yes many doctors are all too willing to prescribe antidepressants without looking beyond depression as a cause for other symptoms. I think one thing that compounds effective diagnosis and treatment today is the fact that we no longer have our long standing GC's who are familiar with our medical history and know us also as individuals. We live in the age of being shuffled from one "specialist" to the next, without any one have full command.
3
It's all about education, the ability to speak well and ask probing but appropriate questions. When a patient lacks that profile and has a mental disorder as well, both the level of care and compliance plummet.
Then there's the whole issue of treating individuals with intellectual disabilities, hearing loss, profound speech impairment, addiction...
1
Of course it couldn't possibly have anything to do with the side-effects of psychotropic drugs now could it? If it did the one prescribing such meds is part of the causation of the death
Schizophrenia -medications cause weight gain, diabetes and high cholesterol
Bipolar - weight gain (then comes diabetes & cardiac disease) thyroid malfunction, liver impairment
Depression - weight gain is common (then comes diabetes & cardiac disease from the weight gain)
And those who are overweight have an exponentially higher rate of cancer
Gee --- like maybe there could be a link between the psychotropic meds and a lot of physical illnesses that cause death?
53
Yes, there are risks of side effects to psychiatric medications--as there are to any medications for chronic illnesses. But to assume that such health disparities are just due to the side effects of the medications is, at the least, disingenuous.
22
Gee--like maybe my medications actually keep me alive, instead of dying at 30?
24
I also thought this was an odd omission from the article. The meds can be hugely beneficial with severe mental illness. But they cause huge weight gain. My relative managed to quit smoking and drinking years ago but cannot get the weight down. And he's disinclined to get much regular medical monitoring. In a humane world, there would be extra support for health care when people must go on these meds - and less overprescribing of them for the less severe situations.
16
How do you spell S T I G M A?
No different from any other prejudice.
43
You spell it "D-I-S-C-R-I-M-I-N-A-T-I-O-N."
Thank you for this article.
17
Good luck at getting mental illness treated like physical illness. This country has long held prejudices against mental illness, considering it a moral weakness and not a disease.
And if we really took it seriously, insurance companies would be paying similar amounts for treatment of a mental illness as it does for treatment of a physical one.
It's curious that insurance companies will pay tens of thousands of dollars for surgery so that someone can play golf but are only willing to pay a few hundred to stop someone from committing suicide.
88
Profit needs to be removed from health care.
17
I call it "passive suicide". The person is too overwhelmed by mental illness to do even simple things like taking or refilling meds, self-medicating with alcohol/drugs/food, or just plain letting physical health issues run their natural course.
37
Psychotherapists can make more money treating neurotics, so people with serious mental illness have fewer professionals who are willing to deal with them. Plus there is a shortage of public funds. There are treatments that work but a large % of the seriously ill don't receive them.
11
Most psychotherapists work for clinics. They do not choose to treat "only" neuroses, which, by the way, can be quite debilitating. These dedicated people don't choose their clients. They are assigned.
The bigger problem is the lack of public funds and insurance funds for effective psychiatric treatment.
7
Along similar lines, the medical research community is looking at ACE (adverse childhood events) and the later occurrence of major chronic health problems. What the data show, so far, is a dose-response effect in the number of ACE events and the severity of health problems (e.g. asthma, autoimmune diseases, substance abuse).
Ace events can be physical trauma, but they are equally often psychological trauma in nature.
36
Agreed, I just think that we are reaching a point at which we should realize that the neat division between the physical and the psychological is arbitrary. The brain is not a separate thing, but part of the body, with constant interactions. The brain affects the body and vice-versa.
25
I am living proof of that.
6
I wonder if ACE events before the age of memory have effects? My father died when I was a toddler and I don't know if that has affected my health or not, since I barely have any memories of him. Mom remarried to my Dad, who adopted me and has been the best father anyone could wish.
4
I suspect the problem of diagnostic foreshadowing in pyschiatric medicine is enormous. It appears the general rule of thumb among pyschiatrists is that, if a physical symptom could be attributable to a "pyschiatric problem" (generally meaning one stemming from a condition amenable to treatment with pyschotropic drugs) then the problem is, in fact, a psychiatric problem, the resolution of which via other interventions need not be investigated.
If a patient reports symptoms of depression in life circumstances that sound sorrowful to a physician, then the physician assumes the patient has depression. Insomnia, anxiety, low energy, etc., are all attributed to depression, which the physician can treat with anti-depressants. The whole thing might just as well be a function of low vitamin B12 or folate.
When the issue is something as profoundly disruptive as shizophrenia or Bi-Polar I, the problem gets even worse. The patient loses a great deal of ability to communicate with the physician. An internist whose economic viability turns on seeing a new patient every 15 minutes (or every 3 minutes) has no economic incentive to get to the bottom of things, assuming the patient even gets to see an internist. Moreover, the medications used to treat these diseases (and which are lifeblood to those who rely on them) themselves can cause a great many problems.
19
This is very sad especially right after Memorial Day. My son who had an extreme diabetic problem and also was mentally ill died when he was 48 from myocardial infarction. My other son who developed schizophrenia when he was about 19 died when he was 48 because his health care was compromised when Utah changed and streamlined the way his care was delivered. The last six months of life he lived alone in an apartment and had to go ten blocks every day for his medication. Friends helped him and his quality of life socially was better than it had been for years, but medically he lacked comprehensive health care. We feel he died because he lacked the care he had been receiving and needed to sustain his life
45
I am so sorry.
10
So sorry about the loss of your sons, Joanna.
11
I suspect there are two kinds of mental health issues:
1) clinical (i.e. PTSD, bi-polar, etc)
2) generalized anxiety/depression because one cannot live up to their perceived ideals of society/parental expectations
A lot of people seem to fall into group 2. Kid's go through school being told that they are the future leaders of the world, only to find themselves either unemployed or working a job that they hate. Then these same people spend hours on social media helplessly consuming the successes in other peoples lives.
People in group 1 definitely need the help of a physician.
People in group 2 need some type of life adjustment, and it doesn't necessarily need to be clinical. Maybe a career change, maybe a location change, maybe just doing some weekly community service or deleting twitter... or maybe a prescription of xanex.
5
Apparently, you've never met someone with clinical depression, an eating disorder or major anxiety disorder. These are clinical, just as schizophrenia, PTSD, and BPD.
Xanax is a poor treatment for a real disorder, without attendant counseling/psychotherapy. As a clinician, I know better. I wish you did.
12
Besides, Xanax is highly addictive and then you have another problem
3
The central point of this issue is: "Those with serious mental illness are more likely to struggle with homelessness, poverty and social isolation. They have higher rates of obesity, physical inactivity and tobacco use. Nearly half don’t receive treatment, and for those who do, there’s often a long delay. "
I deal with two such cases in my daily life --as friends. They also often refuse and/or to take their psych medications, engage in risky behaviors, actively avoid doctors, refuse medical treatment and have often "burnt-out" the willingness of their immediate family to repeatedly come to their assistance.
Of course this leads to early demise...
My two friends would have been in custodial care fifty years ago -- in an institution that would have looked after their mental and physical health 24/7. Today there is no place for these people to go -- they live on their own on various state welfare programs that are under-funded and over-worked.
Truthfully, it is heartbreaking to help these friends as all efforts to help them and any gains they make can be lost in the blink of an eye to yet another alcoholic binge leading to black-out and self-injury or a depression so deep that behaviors cause loss of benefits so desperately needed.
Can we do better? We must -- but the needed infrastructure and laws are not there to make much needed improvement possible.
90
You're a wonderful and perceptive friend. Bless you.
16
Many people with severe depression avoid alcohol and drugs, listen to their (albeit condescending as the article mentions) doctors advice, eat healthy diets, and do everything they can to ease their illness, yet receive no respite from what can be an utterly debilitating disease. Like myself. So my takeaway from the article is there is a lack of understanding about mental illness, even among doctors. Would your friends be better off if they did not engage in those behaviors? Most likely. But it doesn't help people like myself to stereotype depressed people as basically people with bad habits they aren't willing to break. Those false beliefs have alienated me from many of my friends and family because they just see me as lazy.
3
I wonder if countries with health care for all do a better job with the integration of mental and physical health care.
37
As the article rightly points out, lifestyle issues are at the forefront of diseases that cut short the lives of people with mental illness and substance use issues. Tobacco, particularly, is a huge killer in this population. Beliefs about smoking, mental illness symptoms, and a long history of handing our cigarettes like candy — all contribute to the staggeringly high mortality and morbidity. Thanks for this important article.
12
Some psychiatric hospitals still pass out cigarettes as "rewards" for good behavior.
1
My cousin with mental health illness died in his sleep at barely 50, of what they believe was complications of his complex medication regimen. Specialists and primary care doctors often have critical failures of communication and coordination of care.
21
My 36 year old son with a long history of bipolar d/o and schizoaffective d/o died 2 years ago. He was found dead in his own bed and the autopsy revealed no apparent cause of death. The medical examiner speculated a fatal arrhythmia. As described in the article he was overweight, smoked too much, little exercise and poor eating habits. While I encouraged him to seek help with his physical problems, he did see a psychiatrist (MD) for years who may have mentioned to him the need for medical care but families aren't allowed to know the content of discussion between a doctor and patient. It's heartbreaking to this day that more couldn't have been done for him and I definitely blame myself for not being more proactive on behalf of my son.
26
Perhaps you could have done something to help your son. But I suspect you did do a whole lot to help him, and, any parent, any ill patient, deserves to be actively partnered by the system.
8
Let's say this one more time: the U.S. needs, urgently, a comprehensive healthcare system for ALL. Anyone who says we can't afford a comprehensive healthcare system is just not paying attention to economic and social history. When workers are healthy, they are more productive. When they are sick, they are much less productive and more likely to have workplace accidents. And when workers can't work, they don't pay taxes, they lose their homes, their children suffer, our schools suffer, our infrastructure suffers, etc. Comprehensive healthcare is a no brainer, but then, doing what's best for the well-being of the citizens and the economy seems to take a back seat tax cuts that majorly benefit the very wealthy.
144
Read the story and comments. Just about every story is about someone that entered the medical system. I suspect it was because they likely all were either in Medicaid, VA or SSI system and getting treatment. The article concerned problems treatment delivered with best intentions of doctors. No sidetrack action by insurance firms occurred. While I. expect homeless are in a different status, they would not move the dial on the statistics cited that affect millions. Fly the single payer banner elsewhere today.
9
Except, Mr. Blazin, that those nations with some form of universal care, whether single payer of a combination of public/private initiatives, have MUCH better health outcomes, both physical and mental, than we do, and at much lower cost.
58
Mr, Blazin, countries with comprehensive health care have healthier and happier people. Sorry you are so angry at the prospect of everyone receiving health care including mental health care.
8
My daughter who suffered with bipolar disorder all of her adult life, died at age 43 from breast cancer. She died within 2 weeks of diagnosis. Maybe there was some relationship between her physical illness and her mental disorder. If I could turn back the clock, I don't know if anything could have been done to intervene. All I know is that the situation is very sad and I still mourn.
46
I'm sorry for your loss.
33
Thank you Kelly.
1
It may well have been that some MDs do not like to touch women with mental illness, fearing delusions, misunderstandings etc. This ends up having poor outcomes for physical disorders. Some women docs do better with female mentally ill.
1
Remember when you were little and someone on the school playground accused you of having "cooties"? Remember the surge of panic when other children--even the ones you'd just been playing with--would start to echo the charge? And remember the shame and profound misery you felt when every kid within earshot had joined in and was shrieking "Get your cooties away from me!"? Well, that's kinda how it feels when you're labeled "mentally ill." And there is no worse cooties to have in this world than mental illness, because not only will no one defend or befriend or comfort you, but--ironically--you can no longer share in the constructive social fantasy that human nature is essentially good; that encouraging prophylactic delusion is shattered forever. Instead you are obliged to see, day after day, what people are really like: supremely selfish, irrationally fearful, fundamentally tribal, and endlessly cruel. Mention that you or a relative has any type of mental illness, and otherwise-average citizens become anxious and, yes, even paranoid that they will be somehow contaminated by this dreaded affliction. They can't get out of the room fast enough. This goes for doctors as much as anyone else.
48
I seriously hope that mental illness becomes one of this country's next meaningful intiatives to tackle. I can't even imagine how painful it must be, when one's entire existence is dictated by one's mental illness, and especially when, for whatever reason, that person does not have the wherewithall to properly manage that illness. So they go about their day-to-day life like a zombie, and/or angry at the world, confused, ostracized, marginalized, and...suffering.
When folks have a physical ailment, everyone wants to help them. Everyone can empathize. But when someone has a mental illness, especially one that makes them 'scary' to others, no one cares to help such a person. We shun them. Yet, this could happen to any one of us. We simply must do better, not only for our fellow men who suffer on a daily basis, but for society as a whole. Fewer mentally ill walking our streets, is a good thing for all of us.
31
Everyone does not want to help them. Obese people are blamed for their issues for example. Drug users similar.
8
At least some of the issues regarding drug abuse and obesity have roots in mental illness or how we deal with our thoughts. I think education about our general mental health and empathy for those who struggle with it would be beneficial for everyone and hopefully would make most want to help.
1