McMAN’S DEPRESSION AND BIPOLAR WEEKLY
Nov 21, 2002 Vol 4
No 38
Note: This
excellent newsletter is available weekly from:
http://mcmanweb.com/newsletter1.htm
WHAT MAKES THIS REPORT DIFFERENT
"The reality is that the mental health system looks more like a maze than a
coordinated system of care. When the system fails to deliver the right types and
combination of care, the results can be disastrous for our entire nation: school
failure, substance abuse, homelessness, minor crime, and incarceration. While
there are 40,000 beds in state psychiatric hospitals today there are hundreds of
thousands of people with serious mental illness in other settings not tailored
to meet their needs - in nursing homes, jails, and homeless shelters. The rates
of serious mental illness among incarcerated persons are about three to four
times those of the general US population. Something is terribly wrong, terribly
amiss, with the mental health system."
The above is from a recently-released interim report of the President's Freedom
Commission on Mental Health, which is charged with hearing testimony and
submitting a complete report in another six months. "While many providers are
very dedicated and make valuable contributions despite the disorganization of
the system," the Report goes on to say, "no one is ultimately responsible.
Tragically, consumers and families are left with the struggle to find services,
all the while coping with disorders that strike the mind and often cripple the
ability to plan, manage, and advocate for care."
The Report cites the example of someone with both mental illness and a substance
abuse disorder, who is typically treated in different settings with different
rules governing eligibility.
For children, the system borders on disaster. According to the Report, seven to
nine percent of kids have a serious emotional disturbance (SED). "That means one
or two kids with serious emotional problems in virtually every classroom." Yet
the Commission heard from families whose children could not get an accurate
diagnosis for years, and for whom the services maze is "opaque." Says the
Report: "Intervening with good services can help to prevent the worst nightmares
for families: school failure, juvenile delinquency, substance abuse, and
suicide. Yet only a fraction of children with SED has access to school-based or
school-linked mental health services."
The Report cites three model programs for kids and their families, the
Nurse-Family Partnership, begun 20 years ago in rural New York, and now used in
270 cities in 23 states that sends nurses to the homes of high risk women during
their first pregnancy. For mothers, the program means in an 80 percent reduction
of child abuse, a 25 percent reduction in maternal substance abuse, and an 83
percent increase in employment, and for the kids 15 years later a 54-69 percent
reduction in arrests and convictions.
In Dallas, an integrated mental health-school system has resulted in
improvements in attendance, discipline, teacher evaluation, and standardized
test scores, serving mostly poor, Hispanic, and African American children and
their families.
Wraparound Milwaukee offers individualized care to SED children at less cost
than traditional services. In the words of the Commission: "The results of
Wraparound Milwaukee are eye-opening: after enrollment in the program, the rates
of felonies and misdemeanors have been cut by about half. Imagine the nationwide
impact on our juvenile justice system if this program were implemented in every
community."
The Report also cites a number of innovative and cost-effective programs for
adults, from AB-34 in California that sees to the homeless to the Texas
Medication Algorithm Project, which is about the smart use of psychiatric meds
in the public sector.
What is different about this Report is its aura of possibility, of implementing
proven programs on a wider scale at great savings to the taxpayer. Here,
fortunately, the major problem is not money, which politicians would turn a deaf
ear to, but pulling together fragmented services into a reasonably coherent
whole, which is half-way doable. The Commission's final report, one hopes, will
drive home that theme.
http://www.mentalhealthcommission.gov./reports/Interim_Report.htm
click here
THE COST OF MENTAL ILLNESS
The Commission cites a 2001 WHO study that found that mental illness accounts
for 25 percent of all disability across major industrialized countries, and a
1999 US Department of Health and Human Services study that the US economy's loss
of productivity from mental illness amounts to $63 billion annually.
CONTACT
Now that we know the Commission is for real, this is the time to let them know
what works and what doesn't. Nothing is too small or inconsequential. Think of
what has been a lifesaver to you - such as your support group or the internet -
and tell them all about it. Also let them know of any funding or eligibility
hassles. You can address your comments by mail, in person, or through the
Commission's website at:
http://www.mentalhealthcommission.gov/comments.html
click here
A MODEL CURRICULUM
In the spirit of the Freedom Commission, here is an item on the Austin Harvard
School, which bills itself as America's first school for bipolar and ADHD
students, more fully reported in the second edition of The Bipolar Child
(Broadway Books) by Demitri Papolos MD and Janice Papolos:
Austin Harvard was founded four years ago by Glad and Richard Curlee, who have
two children with bipolar. The core of the curriculum focuses on a CD-ROM
program called Switched-On Schoolhouse that allows each child to progress at his
or her own speed at separate computer workstations. Dress code is simple, a
school shirt with jeans, shorts, pants, or skirts, socks optional except for
gym. The day begins with a half-hour devotional discussion, then students split
off into two classrooms, one for five to 11-year-olds, the other for 12 to
15-year olds under the supervision of two teachers.
A licensed practitioner comes in twice a week to teach social skills, such as
working through anger. Science labs, art, gym, and field trips round off the
curriculum. Students with co-occurring learning difficulties, such as dyslexia,
are given extra help, and special care is given to finding which learning
situations best fit individual students. The school uses a credit/debit system
for good and bad behavior, with certain amounts of points earning an extra art
class or some other incentive. A punching bag is there for kids to work off
aggression. Rarely does a child need to go home.
The school works very closely with the parents, who are encouraged to report
at-home troubles rather than hiding them. The school also prepares reports for
the doctors and therapists who work with the children. The school and the
Switched On learning program are Christian in orientation, though in small doses
with no proselytizing. One student summed up his experience this way: "I'll just
remember the two rules Mr Cutler explained to me: 'I love you and there's
nothing you can do about it.'"
Tuition is $5,500 a year, with parents expected to fund-raise $11,000 or make up
the difference. The bad news is being a model school, there are few others like
it. The good news is that Glad Curlee runs three training sessions over the
summer for those interested in starting their own school.
For more information, phone 512 459 9191, email
richard@austinharvardschool.org,
or visit:
http://www.austinharvardschool.org/
click here
THUMBS WAY UP
The second edition of The Bipolar Child has been extensively rewritten, with
more than enough new material to justify its purchase for those who have the
first edition, which I described in an earlier review as a godsend for the
desperate parent. Available at Amazon.com.
OOPS
No, it's not you. Last week you received issue 4#39 and this week you are
getting 4#38. Next week, assuming there are no more malfunctions in the
carbon-based unit attached to this computer, you will be getting 4#40.
ANTIMANIA MED APPROVED
The FDA has granted final approval for Bristol-Myers Squibb and Otsuka America
Pharmaceutical to market its atypical antipsychotic, Abilify (aripiprazole), for
the treatment schizophrenia. The drug is expected to be used off-label for
mania. The drug has been called, "the first next-generation atypical
antipsychotic," with a unique mechanism of action (a dopamine-serotonin system
stabilizer). Company-sponsored trials have found the drug has an improved side
effects profile over other atypicals such as Risperdal. With reference to EPS
effects, Abilify showed "very significant" improvement for Parkinson's-like
tremors and akathisia (motor restlessness) and "modest improvement" for tardive
dyskinesia. The drug also passed muster on weight, heart rhythm, and serum
prolactin.
A company-sponsored study of 262 patients with acute mania found a response rate
of 40 percent after three weeks for those on Abilify vs 19 percent in the
placebo group.
Abilify should be in the pharmacies in less than two weeks.
ZOLOFT WARNING
Pfizer has amended Zoloft's product information to include warnings that
concomitant use of the medication with the Tourette's drug, Orap (pimozide) be
contraindicated due to risk of QT heart rhythm irregularities.
http://www.fda.gov/medwatch/SAFETY/2002/zoloft.htm
click here
BIPOLAR GUIDELINES
The American Psychiatric Association has its revised Practice Guidelines for the
Treatment of Patients with Bipolar Disorder, issued in April, on its website.
Its key recommendations include an atypical antipsychotic-mood stabilizer
combination for acute mania (and tapering off the antipsychotic for maintenance
therapy), and Lamictal as an option for bipolar depression.
The Guidelines are intended for the APA's members, but this is as good a
patients' guide as you will find anywhere.
Caution: Please be sure to use the URL below only. A Google search or links from
other websites will take you to the 1994 Guidelines, which date from literally
the last century.
http://www.psych.org/clin_res/bipolar_revisebook_index.cfm
click here
For a summary of the Guidelines on my website, please go to:
http://www.mcmanweb.com/article-148.htm
click here
IT'S NOT JUST YOU
An article in Medscape reported on a Stanley Foundation study of 2,839 of its
bipolar patients, which found that:
* 85.1 percent had been hospitalized in the past, on average three times.
* The peak age of onset was between 15 and 19 years of age.
* The rate of suicide attempts was 50.3 percent.
* 54 percent had a family member with bipolar disorder, and 32 percent of family
members had unipolar depression.
* A third were currently married, another third single, and the rest were
separated, divorced, or widowed.
* Despite the fact that approximately 90 percent had high school diplomas and a
third had completed college, almost 65 percent were unemployed and 40 percent
were on welfare or disability.
* The rate of depressive symptoms over six months was twice the rate of manic
symptoms (63.6 percent vs 33.1 percent).
http://www.medscape.com/viewarticle/441618
click here
PARITY
Congress has extended the current mental health parity law that had been due to
expire this year. A stronger version of the legislation has been tied up in
Congress for the last two years.
http://www.reutershealth.com/archive/2002/11/19/eline/links/2002119elin045.html
click here
CIVIL WRONGS
This one doesn't look good: The US Supreme Court has agreed to hear an appeal
from the state of California involving a doctor, Michael Hason, who has been
successfully treated for depression and drug dependency but was denied a license
to practice by the state's Medical Board. At issue is whether a person can be
excluded from the benefits or services of a public entity under Title II of the
Americans with Disabilities Act. A Federal Appeals Court sided with Hason, but
last year the US Supreme Court in Board of Trustees v Garrett barred ADA claims
against states under Title I of the law. The case is likely to be heard early
next year.
http://www.usatoday.com/news/washington/2002-11-19-court-usat_x.htm
Click Here
NEW YORK STATE OF MIND
"The annual cost of each bed in a psychiatric hospital is about $120,000.
Placing a patient in a home setting in the community costs less, but if done
right it still requires an investment in housing and social services to support
some 15,000 former patients. Unfortunately, the state chose to do it on the
cheap. The safety net has gaping holes. The number of hospital beds has been
reduced by more than half since 1995, well beyond what existing services can
handle."
From an editorial in the NY Times. The NY Times also reported that the state has
been shipping many of its most troubled patients to New Jersey.
SUICIDE
An East Ham Memorial Hospital (London) study published in the BMJ that tracked
140 suicide attempters from 1977 to 1980 found the overall probable suicide rate
over 22 years at 4.3 per thousand per year, which did not decline with time.
According to the authors of the study: "Previous deliberate self harm remains a
potent risk factor for subsequent suicide, even if it occurred many years ago."
http://bmj.com/cgi/content/full/325/7373/1155
click here
MORE
In an accompanying editorial to the suicide study, the BMJ reports that one
meta-analysis found attempted suicide increased the risk of suicide to 40 times
that of the general population, that the risk is greatest in the first months
following psychiatric care, and the risk of another attempt is believed to be
highest one to two years following, though the risk persists for a long time. A
study of young adult suicide victims found previous attempts in 60 percent of
men and 80 percent of women.
http://bmj.com/cgi/content/full/325/7373/1125/a
click here
KIDS ON MEDS
I pass on Church of Scientology reports very advisedly, but this one deserves to
be heard: Through its affiliate, the Citizens Commission on Human Rights, the
Church testified before the President's Freedom Commission on Mental Health,
warning of the dangers of kids over-dosing on psychiatric meds. Vicky Dunkle's
10-year-old daughter, Shaina, suffered a seizure and died in her mother's arms
following the toxic effects of an adult dose. Sixteen-year-old Cecil Reed
suffered a heart attack while on four psychiatric meds, and 14-year-old Matthew
Smith' heart gave out while on stimulants. Also, despite laws against
restraints, at least nine youths since 1999 have died from suffocation or
cardiac arrest while pinned down by psychiatric staff.
http://story.news.yahoo.com/news?tmpl=story&u=/021113/180/2odgs.html
click here
DILANTIN FOR BIPOLAR
An article on Medscape reports on an Israeli study of the anticonvulsant of
Dilantin (phenytoin), which found the drug effective for acute mania as an
add-on to Haldol, and over the longer term benefited those who had inadequately
responded to other treatments.
http://www.medscape.com/viewarticle/443972
click here
PIPELINES DRYING UP
The Financial Times reports that although the drug industry is investing three
times as much in research as it did a decade ago, the number of applications for
new drugs is down significantly, from a peak of 120 in 1996 and 1997 to 46 for
this year through September. In innovative "newer molecular entities," the
decline was even steeper, from 53 in 1996 to 11 approvals through September this
year. Priority applications have dipped from 32 in 1997 to five so far this
year. According to Henry McKinnell, CEO of Pfizer, to the Financial Times,
"Industry was trying to hit home runs, and it struck out a lot."
BRAIN SCIENCE 101
Lisa Monteggia PhD of the University of Texas Southwestern Medical Center at
Dallas has developed a lab mouse lacking the gene for brain-derived neurotrophin
factor (BDNF). Studies at Yale have found an infusion of BDNF results in an
antidepressant effect in rats. BDNF-free animals may help researchers identify a
possible depression gene.
http://pn.psychiatryonline.org/cgi/content/full/37/22/18-a
click here
SWEET SILENCE
In England they apparently listen to mental health advocates. It also helps
having an influential newspaper on board, such as the Independent on Sunday,
which has railed against the Mental Health Bill and its "draconian" provisions
for locking up those who have a mental illness. In the Queen's Speech to
Parliament outlining the legislative agenda for the year, Her Majesty failed to
mention the bill.
ESSENTIAL PHARMACOLOGY
Two books well worth purchasing, both by Stephen Stahl of the University of
California at San Diego, Essential Pharmacology of Depression and Bipolar
Disorder, and Essential Pharmacology of Antipsychotics and Mood Stabilizers
(Cambridge University Press). Both books, which have been lifted from a much
larger work, Essential Pharmacology, combine uncompromising technical
information with dummies' guide clarity. Excellent illustrations and captions
help flatten the steep learning curves posed by the fine points of medications.
Only the first book is available on Amazon.com, but both books can be purchased
at Barnes and Noble.com
MCMAN'S WEB
Check out more than 190 articles on all aspects of depression and bipolar, plus
a bookstore, readers' forum, message boards, and other features at:
http://www.mcmanweb.com/
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John McManamy
"Knowledge is necessity."
