JAMA Theme Issue Dedicated to Mental Health
Caroline Cassels
May 19, 2010 — A special theme issue of the Journal of the American Medical Association solely dedicated to mental health highlights the need to shift the focus from the problem of mental illness to mental health solutions.
The highlights of the May 19 issue include 6 major studies, 4 commentaries, a cover story describing the circumstances surrounding Vincent Van Gogh's hospitalizations, and a personal essay by Clinton B. McCracken, an addiction researcher who discusses his own struggle with drug abuse.
"In the call for papers for this JAMA theme issue on mental health, I noted the irony that in an issue devoted to mental health most of the articles would undoubtedly be about mental disorders, with the simple explanation that mental disorders are the problem and mental health is the goal; and that the goal for the JAMA theme issue on mental health was to 'be of assistance to clinicians and policy makers in helping patients, families, and communities move in that positive direction,'" writes Richard M. Glass, MD, a psychiatrist at the University of Chicago, deputy editor of JAMA, and editor of the mental health theme issue.
In his opening editorial, Dr. Glass points out that one of the major issues affecting patients with mental health disorders is that the need for treatment far outstrips the healthcare system's capacity to provide it.
One potential solution to this problem, says Dr. Glass, is "'collaborative care,' in which appropriately trained clinicians collaborate with primary care physicians to evaluate and treat primary care patients, with mental health specialty consultation as needed."
Speaking at a press briefing, where results of several of the studies included in the special theme issue were presented, Thomas Insel, MD, director of the National Institute of Mental Health, who also has a commentary included in the issue, said this issue of JAMA is "unprecedented" in terms of its broad focus on mental health.
The current status of mental illness in the United States, said Dr. Insel, "is not good." Broadly defined, he said, mental illness is the number 1 source of disability from all medical causes, including cancer, heart disease, and diabetes in individuals between the ages of 15 and 45 years.
He noted that at any single point in time about 7% of the population will be disabled by a serious mental illness, which includes conditions such as schizophrenia, major depression, and bipolar disorder, as well as a whole range of other illnesses, which increasingly includes autism.
In addition to significant morbidity, mental illness carries a significant mortality burden. Dr. Insel noted that there are 33,000 suicides every year in the United States.
"There are about twice as many suicides as homicides at this point in the United States, and that is an often overlooked factoid. To put it into context, [annually] there are about 20,000 deaths from AIDS, 16,000 to 18,000 homicides, and most forms of cancer cause less than 30,000 deaths annually [with the exception of lung, breast, and colon cancer]," said Dr. Insel.
In addition, he noted that suicide is the second most common cause of death among high school and college students.
Premature Death
Dr. Insel added that suicide is not the only contributor to premature death among the mentally ill. Several comorbid conditions, such as pulmonary disease, due to heavy cigarette smoking are also major contributors.
Last year, he said, "44% of all of the cigarettes smoked were smoked by people with serious mental illnesses, especially schizophrenia, which represents a huge, huge amount of medical disability that goes along with having this severe mental illness."
The average life expectancy for individuals with serious mental illness is about 56 years, which is on par with the current life expectancy in Bangladesh, he added.
Most costs associated with mental illness are not reflected in the healthcare system but in the prison system. "There are 3 times more patients with serious mental illness in jails and prisons than in hospitals," he said.
In large part this is due to the deinstitutionalization of patients with mental illness. During the past 30 years, said Dr. Insel, there has been a 90% reduction in the number of hospital beds for mental illness patients, so that "increasingly jails and prisons have become the de facto treatment resource for people with these disorders."
Urgent Need for Solutions
The problem of mental illness is "not just a tremendous healthcare problem but a massive social problem," and the United States must find better ways to deal with it, said Dr. Insel.
"I would propose solutions will require a refocusing of the way we think about these illnesses not in terms of the psychosocial conflicts that may underlie many of these illnesses but in understanding them as brain disorders and medical problems and as illnesses that we can begin to rethink through the biology as well as the psychology," he said.
In his commentary, Dr. Insel and coauthor Philip S. Wang write that it is time to reassess mental disorders and recognize that they are disorders of brain circuits likely caused by developmental processes.
"Reconceptualizing disorders of the mind as disorders of the brain has important implications for how and when to intervene. Although mental illnesses are more likely neurodevelopmental rather than neurodegenerative disorders, the behavioral and cognitive manifestations that signify these as 'mental' illnesses may be late stages of processes that start early in development," they write.
"If genetics and neuroscience could provide rigorous, specific, early detection years before psychosis or depression, these illnesses might be redefined in terms of a trajectory. As a result, interventions, rather than being ameliorative or rehabilitative, could become preemptive or even preventive," they add.
Dr. Glass, Dr. Insel, and Dr. Wang have disclosed no relevant financial relationships.
JAMA. 2010;303:1978-1979, 1970-1971.
Caroline Cassels
Caroline Cassels is the news editor for Medscape Psychiatry. A medical and health journalist for 20 years, Caroline has written extensively for both physician and consumer audiences. She helped launch and was the editor of Health Digest, an award-winning Canadian consumer health publication. She was also national editor of the Heart & Stroke Foundation of Canada's Web site before joining Medscape Neurology & Neurosurgery in 2005. She is the recipient of the 2008 American Academy of Neurology Journalism Fellowship Award.
-From http://www.medscape.com/viewarticle/722045 retrieved 5/24/10.
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