no health without mental health

Recent news from the NIMH (National Institute of Mental Health) suggests a call for more attention paid to data culled from co-morbidity and mortality studies in both the United States and Sweden (Director's Blog, 3/29/13) to address the alarming life-expectancy rates among those with severe mental illnesses. It goes without saying these two countries have vastly different reverences for and interpretation of good health however (!) these studies both showed increased co-morbidity and mortality rates among those with severe mental illness when compared with the general population. The schizophrenic patients that were the focus of the study in Sweden even saw health care providers more often than the general population, a trend in opposition with what is going on in the U.S., where access to care for those with a severe mental illness is ponderously out of reach. In Sweden, the problem was not with access to treatment but early detection; when detected too late, ischemic heart disease, pulmonary disease and cancers reduced life years in schizophrenic women by 12, men by 15 (Crump et al). Numbers in the U.S., where individuals included in studies have the societal advantage of accessing our notoriously inaccessible mental health care system, are equally macabre, with 8.2 years average years less lived by those with any severe mental illness diagnosis (Druss et al). I'm reading Bad Souls: Madness and Responsibility in Modern Greece (Duke 2012), by Elizabeth Anne Davis right now, who's discerning look at Greece's psychiatric reformation considers 'responsibilities' as they shape the clinical and broader therapeutic encounters between patients and psychiatric staff. These 'responsibilities' employ clinician expertise to diagnose (my use here) deceptive and performantive measures taken by patients that give form to the clinical encounter. Compliance with treatment programs and an interest in self-help are some of the identifiers of a 'responsible' patient and while mental illness itself can impede both of these characteristics, they nevertheless persist as cultural accessories to moral patienthood. These characteristics may also play a role in the lived years reduction among the severely mentally ill. The patients involved in the Swedish study on co-morbidity and mortality, despite the safety net that is universal healthcare, lived significantly shorter lives than the general population because of late detection of non-communicable (arguably 'life style') diseases. In Davis' modern Greece, as in the U.S., patients are held accountable for maintaining treatment, even though in these socio-political spaces health care is not as accessible as it should or could be. Responsibility is emphasized as a means to not only well-being but perhaps even greater care exercised by clinicians (who deal often with unruly patients and/or are held in positions as 'gate-keepers' to care). With Obamacare looming near, can we argue our numbers in co-mortality and co-morbidity studies relating mental health with life years will improve because of access or will early-detection plague us too as a silent precipitator of premature death? With the U.S. psychiatric reform era decades behind us, and a more universal health care system in the near future, are we in a position to learn from both Greece and Sweden in changing these numbers for the better? In what ways will patient responsibility interact with healthcare access to decrease these co-morbidity and mortality rates? In Sweden, early detection certainly remains stubbornly elusive for the mentally ill so we may remain hesitant to see greater access to health care in the US as an agent of longer lives lived. Despite the increased access to healthcare on the horizon, the Swedish study shows us access alone is not enough.



References:

Crump, C., et al.
2013     Comorbidities and Mortality in Persons with Schizophrenia: a Swedish national cohort study.        American Journal of Psychiatry 170 (3): 324-33.

Davis, E.A.    
2012     Bad Souls: Madness and Responsibility in Modern Greece. Durham: Duke.

Druss, B.G., et al.
2011     Understanding Excess Mortality in Persons with Mental Illness: 17-Year Follow up of a Nationally Representative US Survey. Medical Care 49 (6): 599-602.

Thomas Insel
2013     Director's Blog Schizophrenia as a Health Disparity, 3/29.

Images of Difference, Part 4 "Of Clouds and Concrete"

Tubs Sun Salon, nka "Tubs", is a former private spa turned three dimensional street-art canvas that has taken up residence in the U-District since 1982. As the name suggests, it was a public hot-tub spa (and I won't go any further than that) and tanning salon. It closed in 2007 and has remained since a creative space of expression, continually being re-touched with images and words that speak to the character of the city. Since my days in Seattle are numbered, I decided I'd take stock of this peculiar neighborhood icon over the next six months to chronicle its transformation. I will update these regularly and I hope to capture the rapidity of the changes that take place. Seattle rarely stands still for more than a moment so the next six months should prove to be revolutionary to this little wall.

2/24/13

All photography by the author's husband

2/28/13

3/3/13

On a dry day, chalk art can be identified.

There isn't a large amount of refuse left in this empty lot although from time to time a mattress will show up.


{edit 4.22.13-A few days after publishing this blog, a pair of dump trucks barricaded the front of this building and enclosed the whole area in chair-link fencing. Since that time, however, the trucks have not moved and no demolition has commenced. 

(re)commitments to mental health

     I've been thinking a lot about deinstitutionalization lately and what the communities that the mentally ill and intellectually challenged were released to have actually done in the aftermath. Access to care is a complication of our community mental health system today; cost, stigma and lack of providers are all major contributing factors here. My online discussion forum research on psychiatric patients has shown that this lack of care has driven some to seek admittance in institutions rather than have an aversion toward them and with the significant amount of foresight needed to accord with insurance guidelines. This is of course a dynamic phenomenon among this patient group and fear of hospitalization is still very salient in the discussions. 

    Almost 50 years ago, JFK addressed Congress in a message on mental illness and mental retardation (intellectually challenged). He stressed prevention and alleviation and was eager to propose 'cure' as an expected outcome of better mental health care, a view that would be considered rather chimerical today. In the contemporary, 'cure' is a much more precarious concept in the discourse on mental illness and neurodiversity at large. Positing institutional care as 'cold' and the community model as 'warm', JFK was right to see that a radical change of attitude, as well as policy, was in order but without the insight that 50 years of semi-effective initiatives on mental health have brought us, he lacked the sobriety toward therapeutic efficacy we now have. 

     At the time, this "problem unpleasant to mention, easy to postpone, and despairing of solution" was well due for national action but with a clear objective. Today, we know cure doesn't hold as an end goal and ideals are truly individualized. The hopes for today's mentally ill and intellectually challenged are the best possible alleviation of symptoms and a life with the least amount of disruptions and the most fulfilling. These are graduated rather than polarizing; successes include better employment prospects, a drug with less side effects and an overall better understanding of the brain to lessen stigma. These are goals I see as reasonable and better adapted to increase social integration rather than the elimination of these afflictions. Curative philosophies seem to miss what is so important in our approach to any measure of diversity; acceptance of difference to better face the challenges of today rather than trying to avoid difference altogether. The neurodiverse movement would abhor this exclusionary attitude and argue this is part of why stigma is so persistent. Some would argue that mental diversity is a gift and one should appreciate coming into contact with it (this is a more radical stance). What JFK said, however, was brave. He was brave to make it a priority within that sociopolitical moment and brave to point out the failings of the system as it stood.

     Last August, Barack Obama signed an executive order that outlined a strategy to alleviate mental health issues among military service members. His order addresses mental illness in a comprehensive manner and acknowledges, in many ways, the unique social circumstances PTSD and TBI (traumatic brain injury) patients face. Military service is truly a self-sacrifice that couples with an emotional burden civilians sometimes escape. Obama too has been brave for his actions in this sociopolitical climate. In the aftermath of the major shootings under his administration he has called for an attention to mental health access at a time when the link between mental illness and violence is contested at best and national anxiety clouds around the more tangible harm done by guns and physical violence rather than the internal harm these shooters have undoubtedly endured.  It requires a certain boldness to address such a disruption to our evolutionarily adaptive bulwark of emotional defense. It is, perhaps, an acknowledgment of a failing of society, the recognition of which can be dangerous. For now, the danger remains unseen, hidden in the cortical layers and incredibly versatile nuclei of the human brain. Now is the time to unearth that danger and confront the crisis with collaboration from the mentally ill and policy makers alike. Mental illness is a complicated experience, one that remains vague in its causation and obscure in its phenotype so let us proceed with the caution and sensitivity required to face such uncertainty.

References:

Barack H. Obama
      2012    Executive Order: Improving Access to Mental Health Services for Veterans, Service             Members and Military Families, August 31.

John F. Kennedy
     1963     Special Message to the Congress on Mental Illness and Mental Retardation., February 5.

AboutFace photo courtesy of National Center for PTSD

The Great Gun Debate

     My heart broke when I heard of the Newtown, CT shooting back in December. As an anthropologist, one of the things I try to understand are the reasons for killing or otherwise harming other humans. Killing children, especially 6 and 7 year olds, is a little harder for me to wrap my head around, although it certainly serves its cultural purposes, but a masacre at an elementary school proved challenging to the point of heartbreak. What most bothers me about this incident are the future lives of the surviving children, their siblings and all other children who were profoundly altered by this event face. I lament over the psychological trauma these children faced so needlessly. Six years old is a very young age to be confronted with such bare truths of humanity as delusions, matricide, murder and suicide. Learning to cope with this incident may be one of the bravest things these children ever do. I have been writing my graduate school application essays and so I've spent some time over the last few months interrogating my own childhood memories to find what experiences may have precipitated my interest in medical anthropology. I asked myself why I was interested in illness and health in the way that I am and why I choose a non-clinical career path.  Illness touched my family when I was very young and persisted throughout my entire upbringing but it wasn't something always talked about. Perhaps I search for a deeper understanding of illness through medical anthropology to counteract the lack of understanding I felt growing up. The doctors showed their concern for my mother and treated her aggressively but with care. The 'care' she received at her general hospital was exemplary, I make no mistake, but even though we traveled the 100 miles or so to get great advanced care, I always felt a little bereft of support on the car ride home.  We still drove home with the illness (it was chronic but sustainable with frequent treatments) and brought it back to our home. It never left us and all that time in between trips to the hospital it was seldom attended to, checked up on or inquired about. That was all dealt with in the personal while the illness was addressed in the clinical and never the two should meet. This consistent lack of understanding, on all sides, left me wanting to know more about illness and not just in the clinical sense but in the meaning sense. The greater meaning behind things eluded me growing up as what information is provided to children can be abridged to fit curriculum or doctrine. Hepatitis was always learned about in association with drug abuse and carried a moral weight. My mother contracted it through a blood transfusion however and this reasoning was never morally mediated. Junkies got Hep C, not mommies.
     I wonder now about the Newtown children and how they now face the monumental task of making sense of and giving meaning to a mass-shooting at their elementary school. Will they be supported in their quest for information? I want to distinguish here between explanation and comprehension and the greater organizational feats our minds accomplish when we find meaning in  traumatic events. That Adam Lanza took his own life, and therefore his voice and story, I regret because much is lost here in way of understanding, which is immensely valuable in therapeutic contexts. How do you begin to explain to a traumatized 8 year old that abnormalities in Lanza's brain contributed to his attack? How do you explain brain abnormalities in general? Show them diagnostic images?  Detail how neurons can communicate in different ways in different brains? Would this help them understand Lanza's actions without instilling a lasting doubt of the mentally ill in their minds? How would one venture to explain that the very video games they (or more likely their older siblings) play contributed to Lanza's violence? These questions are delicate and have no absolute answers whatsoever, making this job of helping children understand such events precarious, to say the least. The clinicians and therapists that have been working with, and will work with, these children are a courageous group indeed to take on such an assignment.
     Obviously, a more engaged conversation about guns can serve to both prevent future shootings, or so suggested, and to lessen the trauma associated with gun killings. Gun violence, if 'solved', cannot provide the answer as killing is much more complex than method and motive alone.  At the very least, I hope the great debate that remains will give rise to a new application of philosophy and a better national understanding of ethics. Whatever we point our finger to or place blame upon, change is expected and needed but any change will fail if understanding isn't broadened. It will, I hope, influence the lives of those surviving children in ways that are healing and restorative. Perhaps the shooting in Newtown will give rise to a new generation of anthropologists that study links between mental illness and violence or gun culture. Without a doubt, this experience will change their world perspectives and I argue we should begin a national conversation about how these perspectives can be seen for the good rather than for the bad. My hopes for these children are that they are brought to a more dynamic understanding of human nature, in all its disturbing truth, and gain a new understanding of the world like I did. Such an understanding can become an advantage later in life and I truly hope it will be for the Newtown children and all those who were traumatized by this incident.

In memoriam: Sandy Hook Elementary School, Newtown, CT. 12/14/12

all about access

December 6, 2012 is a day Seattle will always remember. On that day, the streets of Capitol Hill were awash with revelry as Washington officially deemed pot socially acceptable. Or did it? The social approval of using Tetrahydrocannabinol containing plants in their various states and forms has long been around. As any piece of visual media does, Reefer Madness (1936) spoke to a certain public concern; one generative of paranoid anxieties and yet one worthy of dramatic consideration. Legislation has finally caught up with culture. Or has it? Spirits are good and smoke hangs high but this new era in Washington (and Colorado) has its ambivalences. Employment discrimination is upheld (although cigarette smoking can be discriminated against as well). You cannot legal buy or sell it anywhere but you can possess it or grow it if you are a medicinal patient.  And it is still being used in courts as derogatory claims. It is going to be regarded like alcohol is, which has long enjoyed a contradictory place in American lives, being legal but with any consumption putting one at risk for a number of alcohol related crimes. Weed is going to hold a similar place in Washington law and while I agree we are not yet ready for a full scale decriminalization, it is putting us in a tricky situation until retail markets open up. Forward moving, I think it is going to be a process for using to become fully legal in a social way. It is still a highly stigmatized drug although the negative connotations applied are less injurious than other drugs. It is, some would say, the everyman's drug. A comic drug; one that brings like minds together and disparate minds closer. It is a also poised at the interested intersection of medicine and recreation. As a healing compound, it is controlled and access points are well, not all access. As a recreational substance, however, it will eventually become easier to come by than the medicine and this delegitimizes its use for medicinal purposes. As it is, no planned changes to the medical marijuana law are up on the table. This undermining of its medicinal properties is not entirely without merit. The medical marijuana clinic system in Washington is known, by the public and medical practitioners alike, as a joke. One can walk in to a clinic and get an authorization with no medical records that prove any of the 'qualifying conditions' and no referral. They can then walk right in to a dispensary, within the same hour, and purchase 'medicine'. With this 'medicine' now being set to reach the open market, I wonder about the dynamic now between the recreational user and the medicinal user. Some would say quality may be different (better?) at the clinics but the horticultural standards are essentially nonexistent and this market, as it stands, is highly unregulated. Sold to an open public, however, there will definitely be standards in place. In fact, Washington's notoriously stringent Liquor Control Board will take over its regulation. Could medicinal users be at a disadvantage here? Could their safety be overlooked while recreational users, in the year or so it will take to open up the market, are met with product that is more regulated? Does this seem like a logical organization? What still needs to be hashed out to mediate the Federal rulings and the State's law? There is a rupture here, between a human's right of access to healing medicines and the 'access stigma' the state still fosters. This stigma makes how you procure your medicine flexible in its morality and legality. Many questions will need to be answered over the next year or so in Washington and Colorado as the public market is established and the culture becomes more acquainted with the idea of decriminalization. For now, a social arbitration exists during every purchase, sale, growth or use of marijuana in all its forms and states. Judgment is withheld, or so the law suggests, at the state level but not Federally. This is a major source of contention among users and though this has always plagued medicinal users since 1998, I can foresee major disconnects between all users and all institutions.
My hopes for this process are better and more consistent access for medicinal patients and lessened stigma against this set of users. I want to address this and bring this to conversation in a way respectful of medicinal users. It is crucial to our continued understanding of this patient group that we keep this discussion on the table despite the new laws that have passed in Washington and Colorado. As it stands, Seattle maintains several medicinal marijuana access points but many (so many) are positioned near areas of notorious criminal activity or inconveniently away from major transportation routes. I have honestly been disappointed at how Washington has handled their medicinal marijuana  system and hold legitimate concern for the new open market we are about to come upon. 

Reefer Madness: Tell Your Children

1938 Louis J. Gasnier, dir. 66 min. 

George A. Hirliman Productions. Hollywood.