Tuesday, December 21, 2010

Similarities Among the Differences: Genetic Research, Autism and Schizophrenia

By Brendan McLean, NAMI Communications Intern

Brendan McLean, NAMI communications intern
It may not be one of the conditions you expect to hear about from NAMI, but autism has many concerns that overlap with some of the illnesses we discuss more frequently, especially schizophrenia. They are sometimes treated with the same or similar antipsychotic drugs. They may even share a genetic marker. Taking a look at the state of autism research can shed some light on the genetic issues that affect the mental health community overall.

Mitochondria: Differences on a Cellular Level

Many mental illnesses have had their magic cure or culprit, with autism being no exception—childhood vaccines have gotten a great deal of publicity as a possible cause of the disorder.With the connection between vaccinations and autism discredited, or shown to be extremely isolated, it was necessary for researchers to begin searching in another direction for the cause of autism. This past month a new study released in the Journal of the American Medical Association by Dr. Cecilia Giulivi from the University of California, Davis, showed promise in helping identify at least one cause of autism: differences in mitochondria.

Mitochondria, the cell’s powerpacks, disassemble sugar molecules and turn the newly released energy into a form that the body can use. Defects in the mitochondria may explain the onset and severity of autism in some children. Mitochondrial dysfunction has already been shown to play a role in the development of other neurological conditions, such as Parkinson’s, Alzheimer’s diseases, schizophrenia and bipolar disorder. Dr. Giulivi found that the mitochondria in children with severe autism, compared to a control group of children than did not have autism, consumed far less oxygen , a sign of lower cell activity and leaked damaging oxygen-rich chemicals such as hydrogen peroxide, which exists at levels twice the norm because is not cleaned up by enzymes as it would in normal cells.

Genetic Similarities and Beyond
The sample size for this study was extremely small— only 10 children with severe autism. It is also not certain precisely when or why the mitochondria dysfunction starts, whether in the womb or later on in infancy, or related to genetic factors or environmental factors. These questions have also dogged mental illness research, with scientists now theorizing that schizophrenia is the result of the interaction between several possible genetic and environmental factors.

A recent comparison of the genetics behind autism and schizophrenia found that while some of the genetic differences for the two conditions might occur in the same sites, in one disorder certain proteins are overproduced while in the other the opposite is true. The more we learn about conditions like autism, schizophrenia and other mental illnesses like bipolar disorder, the more we realize that the distinctions between them are not always clear.

Autism has recently been re-categorized as a spectrum disorder, giving rise to the idea of multiple autisms rather than one. Similarly, there is currently a movement within the research community to reclassify schizophrenia as a syndrome in order to allow for a greater variation among people living with the condition, some of whom might share characteristics with other conditions like depression or bipolar disorder.

It is important to note that similarities do not only exist between people living with autism, schizophrenia or any mental illness—on a genetic level we are all more alike than different, with 99.9 percent of DNA the same in every person. As our understanding of the genetic basis of conditions like autism expands, we may find that the one-tenth of a percent that is genetically different in all of us has some unsuspected similarities, allowing us to discover knowledge that helps develop treatments for other mental illnesses.

Friday, December 17, 2010

Depression: Different in Teens

by Michael J. Fitzpatrick, Executive Director
What Families Need to Know About Adolescent Depression
When it comes to health care, one size does not fit all.

Adolescents are thought to differ from adults living with depression because they more often experience symptoms of irritability, anger and self-criticism rather than feelings of sadness and a loss of energy commonly seen in adults.

NAMI has published What Families Need to Know about Adolescent Depression, a new edition of a guide for families seeking accurate diagnosis and wanting to know effective treatment options for teenagers experiencing depression.

The 35-page Family Guide summarizes symptoms of depression and treatment options, along with providing information about suicide prevention, healthcare and therapy.

The most common forms of therapy for adolescent depression are talk therapy, including Cognitive Behavioral Therapy (CBT), medication or a combination of both.

It is important that parents and children engage in dialogue to create an open and honest environment where mental health issues are discussed and treated just like any other health risk. Communication is imperative. The family guide can help the discussion.
Teen depression

"Untreated, depression can lead to devastating consequences for adolescents, including ongoing problems in school, at home and with friends, the loss of critical developmental years and increased risk for substance abuse, involvement with the juvenile justice system and suicide."

--What Families Need to Know about Adolescent Depression

Since 2009, physicians have been encouraged to perform general depression screenings for children aged 12 to 18. Screenings and discussions with adolescents are vital in preventing them from reaching decisions where they resort to self-harm or suicide to achieve relief from distress that can be effectively treated.

A  PDF copy of the booklet can be downloaded from the NAMI website. Single and multiple copies can also be ordered through the NAMI store.

NAMI also has a Child & Adolescent Action Center that provides additional information and updates related to young people and mental illness.

Friday, December 10, 2010

De-Criminalizing Mental Illness: Is Prison Downsizing a Solution?

by Ron Honberg, NAMI Director for Policy and Legal Affairs

Ron Honberg, J.D.
NAMI Director for Policy and Legal Affairs
On November 30, a subject long important to NAMI made it all the way to the U.S. Supreme Court: the treatment of people living with mental illness who are in the prison system. Specifically, the oral arguments before the Supreme Court addressed whether courts have the power to order states to reduce their prison population as a way to solve their failure to meet constitutional standards of health and mental health care treatment in these facilities. The case originated in California, a state that has implemented 30 years of “get tough on crime” policies that have resulted in extreme overcrowding in its prisons. It starkly illustrates the difficulties--indeed the futility--of providing adequate psychiatric treatment to prison inmates living with schizophrenia and other serious mental illnesses.

The case, known as Schwarzenegger versus Plata and Coleman, actually originated 20 years ago, when a lawsuit was filed on behalf of California’s inmates living with serious mental illness alleged that the state was violating their constitutional rights by not providing treatment for mental illnesses and other medical conditions. The court that heard this case ruled that the confining conditions did not meet the level of care guaranteed by the constitution–the 8th Amendment’s prohibition against “cruel and unusual punishment.”

A “Prison Overcrowding State of Emergency”

Over the course of the next 15 years, the court issued a series of decisions ordering the state to take steps to remedy these constitutional violations. However, California was never able to solve these problems to the court’s satisfaction. It became increasingly apparent that extreme overcrowding was preventing the state from remedying these constitutional violations. Indeed, in 2006 Governor Arnold Schwarzenegger declared a “prison overcrowding state or emergency” in recognition of this crisis.

In January 2010, a three-judge panel was convened to review the case under the federal Prison Litigation Reform Act (PLRA). By this time, some of California’s prisons were operating at nearly 200 percent of capacity, housing twice as many inmates as they were built to handle. Experts concluded that the chaotic conditions in these prisons were not only not conducive to solving the problems with delivering treatment, they very likely exacerbated the symptoms and distress of inmates living with serious mental illnesses.

The PLRA permits courts to issue prisoner release orders only under very narrow circumstances, specifically if previous, less severe solutions have failed within a reasonable period of time. In this case, the judges concluded that there was ample evidence that less intrusive remedies had failed to work and only the imposition of a population cap on all of California’s prisons would work. Thus, the panel ordered California to operate its prisons at no more than 137.5 percent of capacity.

The Choice Between More Prisons and Prison Downsizing
If the Supreme Court upholds the lower court’s decision, California will be faced with choosing between releasing large numbers of inmates, including inmates living with serious mental illnesses, or building more prisons and prison mental health treatment facilities. In view of the severe budget crisis the Golden State is currently enduring, it is hard to imagine that California will choose the route of building more prisons.

California’s laws on probation and parole are among the toughest in the nation. Many of this state’s inmates–including individuals living with serious mental illnesses–are incarcerated because of technical violations of their probation, not because they have committed or re-committed serious crimes. These are the individuals who are most likely to be among the first discharged from California’s prisons.

Community Care: Net Cost or Savings?

NAMI has long advocated against the unnecessary “criminalization” of youth and adults living with serious mental illnesses. We believe that little can be gained from incarcerating non-violent offenders with serious mental illnesses who need treatment, not punishment. However, the potential release of large numbers of individuals with serious mental illnesses into their home communities presents a great potential challenge for the state and its 58 counties. California has a budget deficit of approximately $20 billion and cuts in spending are impacting adversely on the availability of mental health services in the counties. Most of these counties are having difficulty serving those individuals with serious mental illnesses they are currently responsible for. Demands on some of these counties could increase as inmates are discharged and come home.

Still, as my mother has always reminded me, “where there is a will, there is a way.”  California’s Department of Corrections stands to save millions of dollars due to lower inmate populations, lower health and mental health treatment needs and the increased efficiency resulting from less overcrowding. Some of this money should go into beefing up the capacity of counties to provide mental health treatment and services to discharged inmates. Additionally, California should consider specialized medical parole programs with personnel trained to manage the needs of parolees with severe mental illness

And, there is ample evidence that the provision of quality mental health and substance abuse treatment sharply reduces criminal recidivism and thus the burdens on correctional systems. California need only look at its experience with the Assembly Bill (AB) 34/2034 program, which demonstrated a decrease in homelessness and incarcerations while reflecting an increase in the ability of consumers to live independently, for evidence.

A Golden Opportunity for the Golden State

The fact is, many Californians living with serious mental illnesses who are currently incarcerated wouldn’t be in prison at all had they received timely services and supports. Now, the Golden State has a golden opportunity to do right by these individuals and benefit the entire state in the process.  If it does so, California will set a very positive standard for the rest of the country to follow.

For more information, see the amicus curiae (“friend of the court”) brief submitted for  this case by NAMI, NAMI California, the American Psychiatric Association, the American Psychological Association and several other organizations.

Thursday, December 2, 2010

What Does the Election of New Governors Mean for Mental Health Advocates?

By Sita Diehl, NAMI's Director of State Policy and Advocacy

Sita Diehl, Director of State Policy and Advocacy
They may have been elected in different states this November, but America’s 27 new governors—17 Republicans, nine Democrats and one Independent—will take office in January in the same daunting political environment. Most will appoint new directors for Medicaid, state mental health authorities and insurance commissions who will be in a position to dramatically influence our nation’s mental health care system, a system that the NAMI Grading the States 2009 report gave a “D” grade. These state government administrative leaders will face a steep learning curve as the economy continues to sputter and implementation of the Patient Protection and Affordable Care Act (ACA), otherwise known as the health reform bill, moves to the states.

Conserving Scarce Resources, Looking To More Prosperous Times

Despite improvements in the economy, last year was tough for state governments and next year will be even tougher for state budgets. In 2011, state budgets nationwide closed with $100 billion in shortfalls. In 2012 states are projecting a total deficit of $140 billion with enhanced federal Medicaid funds expiring June 30, 2011. Unemployment is part of the issue. For every one percent increase in the unemployment rate state revenues fall over three percent, just as more people enroll in Medicaid or join the ranks of the uninsured.

Governors will make key decisions over the next few months about how to conserve scarce resources while simultaneously preparing for the promise of more prosperous times. Some governors will examine what government should be doing versus the private sector and will be looking for ways to become more efficient so they may invest scarce dollars in direct care. Contracting with nonprofit organizations and businesses is one method for states to shift toward non-governmental jobs to deliver efficient, effective care.

Unfortunately, many mental health systems are already at the point of collapse, due in part to steep budget cuts over the past two years without a corresponding investment in community services. As mentioned earlier, on average, state mental health care systems get only a “D” grade in part because of a lack of adequate investment in community services. And this grade was in 2009—predating some of the worst fallout from the economic crisis. Reducing state government investment even further may precipitate a complete mental health care system failure.

Health Care Reform: Roots on the Democrat and Republican Sides of the Fence

Some governors will move forward to implement the ACA, planning for state insurance exchanges and expansion of Medicaid to cover uninsured residents with incomes at or below 133 percent of the poverty level. Despite widespread distrust of the law as a whole, the ACA has roots on both the Democrat and Republican sides of the fence. Republican principles of reduced government and personal responsibility are embodied in private insurance exchanges and small business coverage. Democratic values of a just and equitable society are represented in insurance industry reforms and coverage of the uninsured through Medicaid expansion. Mental health parity, incorporated throughout the law, has long standing bipartisan support.

What else can mental health advocates do to help save mental health?
  1. Familiarize yourself with talking points and personalize them to your comfort.
  2. Contact and congratulate your new Governor in a letter introducing yourself and mentioning your support of mental health.
  3. Inform him/her that mental illness is common and treatable.
  4. Urge the governor to preserve the mental health budget from further erosion.
  5. Urge Medicaid directors to apply for a Medicaid1915i option to provide mental health services such as peer support not traditionally funded by Medicaid.
  6. Monitor parity in public and private health care; contact NAMI if you or someone you care about is denied equal coverage for mental health care.
Most governors, regardless of party affiliation, will take a hard look at Medicaid as a strategy to bring the budget into line. Because the ACA prohibits states from excluding categories of Medicaid beneficiaries, state governments are considering alternative cost control measures such as managed care, service and pharmacy limits or even opting out of Medicaid altogether.

Mental Health Advocates Must Stand Firm in 2011

Mental health advocates must urge governors to preserve mental health benefits in Medicaid and encourage the development of a plan for 2014 when, as insurance exchanges begin, people with mental illness will be able to join the workforce without losing health care coverage.

In states across the country, this is a time of economic retrenchment, but it is also a time to plan for a more prosperous future. The smart choice is to invest in supporting mental health systems that deliver the right care at the right time and in the right place so children and adults living with mental illness can succeed and contribute to their family, workplace, school and community.

Sita Diehl, M.A., M.S.S.W., is NAMI's director of State Policy and Advocacy. She served as executive director of NAMI Tennessee from 2004 to 2010. She has developed a range of mental health curricula for individuals living with mental illness, families, mental health care providers and criminal justice personnel. Her research experience includes a two state comparison of the effect of public managed behavioral health care on women and children, a multi-site study of consumer-operated services and a longitudinal study of mental health services in Tennessee county jails.