The clinical history and costs associated with delayed diagnosis of bipolar disorder

The purpose of this reported study was to determine healthcare utilization and costs associated with delayed diagnosis of bipolar disorder. With use of automated data from a large integrated health system in the Midwest, all patients with newly diagnosed bipolar disorder recorded in any inpatient or outpatient encounter from January 1, 2000 to August 31, 2002 were identified. The date of initial diagnosis was the index date. For each patient in the bipolar cohort, 5 comparison patients were randomly selected from the general population of health system members and matched with the bipolar patients by sex, race, and age (-/+ 5 years). Data on healthcare utilization (inpatient, outpatient, emergency department, pharmacy) were collected with a focus on mental health, from January 1, 1990, through 1 year after the index date. The cohort is 62% female and 64% White. Median time between initial mental health diagnosis and bipolar diagnosis was 21 months, with 33% of subjects receiving a bipolar diagnosis within 6 months of their initial mental health diagnosis; however, for 31% of the remaining bipolar subjects, the time of their initial mental health presentation to bipolar diagnosis was 4 years or more. The number and duration of treatment with antidepressants increased as time to bipolar diagnosis increased. Patients with bipolar disorder had at least twice the number of interactions with the healthcare system before the index date than the non-bipolar comparison group. Mean monthly costs before and after bipolar diagnosis were not strikingly different for patients with bipolar disorder, but costs after bipolar diagnosis increased with increasing time to bipolar diagnosis. Bipolar disorder is a costly illness for which the impact on the healthcare system may vary depending on how quickly it is diagnosed. Delays in diagnosis appear related to additional costs after diagnosis.     

Why are programmes for offenders with personality disorder not informed by the relevant scientific findings?

This paper examines the evidence to justify intervening in those with personality disorder, specifically antisocial personality disorder (ASPD) as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, American Psychiatric Association 1994). The evidence from randomized controlled trials in the mental health literature is reviewed and found to be deficient with only five trials satisfying Cochrane criteria, all of which had a reduction in substance misuse as their primary outcome, rather than a change in the personality disorder per se.Next, I consider the contribution of Thomas Kuhn to explain why it is difficult to develop a scientific basis in forensic mental health. I argue that, because forensic mental health is inclusive in its purpose (interacting with the law, social services and the penal system, all of which have different rules and agendas), it is difficult to develop a consensus on fundamentals, this consensus being a hallmark of a science.Finally, I argue that despite the absence of evidence from mental health, providers for ASPD are in a fortunate position in being able to draw upon the correctional literature. This is relevant, provided that we agree that a reduction in offending is the primary outcome. While mental health can learn much from correctional practice, it can also enhance the efficacy of the latter by, for instance, drawing attention to the specific vulnerabilities of the personality structure that might impede programme delivery in correctional settings. Means of achieving a conjunction of mental health and correctional practice are urgently required as this would be beneficial to both.     

Medical Humanitarianism Under Atmospheric Violence: Health Professionals in the 2013 Gezi Protests in Turkey

During the 2013 Gezi protests in Turkey, volunteering health professionals provided on-site medical assistance to protesters faced with police violence characterized by the extensive use of riot control agents. This led to a government crackdown on the medical community and the criminalization of “unauthorized” first aid amidst international criticisms over violations of medical neutrality. Drawing from ethnographic observations, in-depth interviews with health care professionals, and archival research, this article ethnographically analyzes the polarized encounter between the Turkish government and medical professionals aligned with social protest. I demonstrate how the context of “atmospheric violence”—the extensive use of riot control agents like tear gas—brings about new politico-ethical spaces and dilemmas for healthcare professionals. I then analyze how Turkish health professionals framed their provision of health services to protestors in the language of medical humanitarianism, and how the state dismissed their claims to humanitarian neutrality by criminalizing emergency care. Exploring the vexed role that health workers and medical organizations played in the Gezi protests and the consequent political contestations over doctors’ ethical, professional, and political responsibilities, this article examines challenges to medical humanitarianism and neutrality at times of social protest in and beyond the Middle East.     

Make me a test and I will save the world: towards an anthropology of the possible in global health

What is deemed possible in the wake of failure? The global biotech industry's failure to develop affordable diagnostic devices for use in low- and middle-income countries (LMICs) has inspired a generation of humanitarian entrepreneurs to launch their own diagnostic start-up companies. This essay traces the rise and fall of one such start-up in Boston in the United States, Daktari, which developed a portable HIV testing device in the 2010s. I show how the alignment of humanitarian and economic valuations in a single diagnostic device depended on the ability of the start-up's founders and employees to synchronize the distinct tempos of financial capital, humanitarian design, and global health standards. Yet their failure to achieve this synchronization does not simply offer another story of biotech hype and speculation, the generation of promissory value at the expense of actual things. Instead, the essay examines the hopes and expectations that the firm's employees invested in the device's material qualities, manufacture, and distribution. What, I ask, is the meaning of failure, and its material remains, when it is measured against humanitarian rather than solely commercial expectations? The essay concludes with some reflections on the aftermath of failure in humanitarian entrepreneurship, examining the questions that Daktari's demise poses for understandings of what is possible and desirable in global health.     

The evidence‐based group‐level symptom‐reduction model as the organizing principle for mental health care: time for change?

The content and organization of mental health care have been heavily influenced by the view that mental difficulties come as diagnosable disorders that can be treated by specialist practitioners who apply evidence‐based practice (EBP) guidelines of symptom reduction at the group level. However, the EBP symptom‐reduction model is under pressure, as it may be disconnected from what patients need, ignores evidence of the trans‐syndromal nature of mental difficulties, overestimates the contribution of the technical aspects of treatment compared to the relational and ritual components of care, and underestimates the lack of EBP group‐to‐individual generalizability. A growing body of knowledge indicates that mental illnesses are seldom “cured” and are better framed as vulnerabilities. Important gains in well‐being can be achieved when individuals learn to live with mental vulnerabilities through a slow process of strengthening resilience in the social and existential domains. In this paper, we examine what a mental health service would look like if the above factors were taken into account. The mental health service of the 21st century may be best conceived of as a small‐scale healing community fostering connectedness and strengthening resilience in learning to live with mental vulnerability, complemented by a limited number of regional facilities. Peer support, organized at the level of a recovery college, may form the backbone of the community. Treatments should be aimed at trans‐syndromal symptom reduction, tailored to serve the higher‐order process of existential recovery and social participation, and applied by professionals who have been trained to collaborate, embrace idiography and maximize effects mediated by therapeutic relationship and the healing effects of ritualized care interactions. Finally, integration with a public mental health system of e‐communities providing information, peer and citizen support and a range of user‐rated self‐management tools may help bridge the gap between the high prevalence of common mental disorder and the relatively low capacity of any mental health service.     

Is Postconflict Affiliation in Captive Nonhuman Primates an Artifact of Captivity?

Researchers have conducted most studies on primate conflict management and resolution in captive settings. The few studies on groups of the same species in captivity and in the wild and the overall comparison across species of findings from studies in both settings have reported patterns of variation in the rates of various postconflict affinitive behaviors that may be setting related. In fact, some authors have claimed that the high rates of postconflict affiliation reported in captive studies could represent an artifact of captivity. I explored the claim and conclude that it is unjustified. I argue that the dichotomy captivity vs. wild is conceptually meaningless and scientists should abandon it as an explanatory variable, that differences across studies both in setting-related variables and in the methods used for assessing postconflict affiliation reduce the strength of comparisons within and across settings, that the empirical evidence thus far available neither allows adequate assessment nor supports any claim that links the rate of postconflict affiliation to captivity or wild conditions, and that studies conducted in both settings may be equally useful—and should be used—to test theoretically relevant hypotheses regarding the causes and predictors of variation in postconflict affiliation. Instead of asking the title question, I would ask which variables influence postconflict affiliation and then whether the variables are really associated only with one of the two settings.     

The Short-Doyle Act; California community mental health services program: background and status after one year

The Short-Doyle Act seeks to encourage the treatment of a patient suffering from a psychiatric disorder in his home community, with the assistance of local medical resources. One corollary of this program is the closer working together of the psychiatrist and the rest of the medical profession.A second goal of the act is the application of the public health principles to mental illnesses and mental retardation. Educational and consultative services provide implementation of these principles.     

THE SHORT-DOYLE ACT—California Community Mental Health Services Program: Background and Status After One Year

The Short-Doyle Act seeks to encourage the treatment of a patient suffering from a psychiatric disorder in his home community, with the assistance of local medical resources. One corollary of this program is the closer working together of the psychiatrist and the rest of the medical profession.A second goal of the act is the application of the public health principles to mental illnesses and mental retardation. Educational and consultative services provide implementation of these principles.     

Lowering Cardiovascular Disease Risk for People with Severe Mental Illnesses in Primary Care: A Focus Group Study

Background

People with severe mental illnesses die early from cardiovascular disease. Evidence is lacking regarding effective primary care based interventions to tackle this problem.

Aim

To identify current procedures for, barriers to, and facilitators of the delivery of primary care based interventions for lowering cardiovascular risk for people with severe mental illnesses.

Method

75 GPs, practice nurses, service users, community mental health staff and carers in UK GP practice or community mental health settings were interviewed in 14 focus groups which were audio-recorded, transcribed and analysed using Framework Analysis.

Results

Five barriers to delivering primary care based interventions for lowering cardiovascular risk in people with severe mental illnesses were identified by the groups: negative perceptions of people with severe mental illnesses amongst some health professionals, difficulties accessing GP and community-based services, difficulties in managing a healthy lifestyle, not attending appointments, and a lack of awareness of increased cardiovascular risk in people with severe mental illnesses by some health professionals. Identified facilitators included involving supportive others, improving patient engagement with services, continuity of care, providing positive feedback in consultations and goal setting.

Conclusion

We identified a range of factors which can be incorporated in to the design, delivery and evaluation of services to reduce cardiovascular risk for people with severe mental illnesses in primary care. The next step is determining the clinical and cost effectiveness of primary care based interventions for lowering cardiovascular risk in people with severe mental illnesses, and evaluating the most important components of such interventions.     

Mental health system in China: history, recent service reform and future challenges

This paper summarizes the history of the development of Chinese mental health system; the current situation in the mental health field that China has to face in its effort to reform the system, including mental health burden, workforce and resources, as well as structural issues; the process of national mental health service reform, including how it was included into the national public health program, how it began as a training program and then became a treatment and intervention program, its unique training and capacity building model, and its outcomes and impacts; the barriers and challenges of the reform process; future suggestions for policy; and Chinese experiences as response to the international advocacy for the development of mental health.     

Mental health; a discussion of various program approaches used in California and the basic assumptions involved

The nation's Number One health problem, mental illness, compels careful reevaluation of past and current methods of attack. It also invites consideration of the ways and means of integrating preventive measures that emphasize the conservation of mental health with prophylactic efforts that stress the avoidance of mental illnesses.A REVIEW OF THE DEVELOPMENT OF BOTH LOCAL AND STATEWIDE MENTAL HEALTH PROGRAMS IN CALIFORNIA REVEALS THAT THREE FUNDAMENTALLY DIFFERENT APPROACHES HAVE BEEN USED: (1) The traditional approach which confines itself to the protection of society from the "insane" by the state, and to the treatment of those who are not legally insane through "private enterprise"; (2) the public health approach which seeks to minimize the causes and/or spread of selected types of psychiatric disorder regarded as mass phenomena; and (3) the sociological approach which stresses the importance of social factors both in the causation and in the rehabilitation of those mental conditions that are considered to be symptomatic of a "sick" society. An approach that combines the theoretical and practical implications of all three viewpoints offers some new solutions to the problems of (1) fitting mental health programs to populations; (2) financing; and (3) balancing preventive and clinical services. Mental illness is not a single disease-entity but a long list of distinctly different conditions. The causes and manifestations are multiple. Biological, psychological and social components in either mental health or mental illness cannot be dissociated in any attempt to understand and deal with so wide a range of illnesses and states of comparative health. Therefore, many professions and multiple public and private agencies are involved in planning, developing and administering a mental health program.     

One Flu Over The Cuckoo��s Nest: Comparing Legislated Coercive Treatment for Mental Illness with that for Other Illness

Many of the world’s mental health acts, including all Australian legislation, allow for the coercive detention and treatment of people with mental illnesses if they are deemed likely to harm themselves or others. Numerous authors have argued that legislated powers to impose coercive treatment in psychiatric illness should pivot on the presence or absence of capacity not likely harm, but no Australian act uses this criterion. In this paper, I add a novel element to these arguments by comparing the use of the harm to others justification for coercive treatment in mental illness with its use in illness due to infectious disease, and suggest a double standard applies. People with mental illness are subjected to coercive treatments at levels of risk to others far, far lower than would precipitate coercive treatment in people with influenza. In effect, this element of mental health legislation represents an example of sanism—state-sanctioned discrimination against people with mental illnesses.     

MENTAL HEALTH—A Discussion of Various Program Approaches Used in California and the Basic Assumptions Involved

The nation''s Number One health problem, mental illness, compels careful reevaluation of past and current methods of attack. It also invites consideration of the ways and means of integrating preventive measures that emphasize the conservation of mental health with prophylactic efforts that stress the avoidance of mental illnesses.A review of the development of both local and statewide mental health programs in California reveals that three fundamentally different approaches have been used: (1) The traditional approach which confines itself to the protection of society from the “insane” by the state, and to the treatment of those who are not legally insane through “private enterprise”; (2) the public health approach which seeks to minimize the causes and/or spread of selected types of psychiatric disorder regarded as mass phenomena; and (3) the sociological approach which stresses the importance of social factors both in the causation and in the rehabilitation of those mental conditions that are considered to be symptomatic of a “sick” society.An approach that combines the theoretical and practical implications of all three viewpoints offers some new solutions to the problems of (1) fitting mental health programs to populations; (2) financing; and (3) balancing preventive and clinical services.Mental illness is not a single disease-entity but a long list of distinctly different conditions. The causes and manifestations are multiple. Biological, psychological and social components in either mental health or mental illness cannot be dissociated in any attempt to understand and deal with so wide a range of illnesses and states of comparative health. Therefore, many professions and multiple public and private agencies are involved in planning, developing and administering a mental health program.     

Psychosocial interventions and the demoralization of humanitarianism

This paper critically analyses from a political sociology standpoint the international conceptualization of war-affected populations as traumatized and in need of therapeutic interventions. It argues for the importance of looking beyond the epidemiological literature to understand trauma responses globally. The paper explores how the imperative for international psychosocial programmes lies in developments within donor countries and debates in their humanitarian sectors over the efficacy of traditional aid responses. The aim of the paper is threefold. First, it discusses the emotional norms of donor states, highlighting the psychologizing of social issues and the cultural expectations of individual vulnerability. Second it examines the demoralization of humanitarianism in the 1990s and how this facilitated the rise of international psychosocial work and the psychologizing of war. Third, it draws attention to the limitations of a mental health model in Croatia, a country which has been receptive to international psychosocial programmes. Finally it concludes that the prevalent trauma approaches may inhibit recovery and argues for the need to re-moralize resilience.     

The Cultural Construction of Mental Illness in Prison: A Perfect Storm of Pathology

Large numbers of individuals in U.S. prisons meet DSM criteria for severe psychiatric disorder. These individuals also have co-occurring personality and substance abuse disorders, medical conditions, and histories of exposure to social pathologies. Based on nine months of ethnographic fieldwork in a U.S. prison, focusing on staff narratives, I utilize interpretivist and constructivist perspectives to analyze how mental health clinicians construct psychiatric disorder among inmates. Discrete categorization of disorders may be confounded by the clinical co-morbidities of inmates and the prison context. Incarcerated individuals’ responses to the institutional context substantially inform mental health staffs’ illness construction and the prison itself is identified as an etiological agent for disordered behaviors. In addition, diagnostic processes are found to be indeterminate, contested, and shaped by interactions with staff. Analysis of illness construction reveals that what is at stake for clinicians is not only provision of appropriate treatment, but also mandates for the safety and security of the institution. Enmeshed in these mandates, prison mental health becomes a particular local form of psychiatric knowledge. This paper contributes to anthropological approaches to mental disorder by demonstrating how local contexts mediate psychiatric knowledge and contribute to the limited ethnographic record of prisons.     

Caring Through Restraint: Violence,Intimacy and Identity in Mental Health Practice

In this article, I discuss the meanings of “restraints,” or physical intervention strategies that are used at a total institution for mentally ill adolescents in the United States. This paper argues that this particularly complex form of mental health treatment is simultaneously a violent and an intimate way in which men relate to one another and also takes on complex meanings about trust and identity in mental health recovery. Using data from 18 months of ethnographic fieldwork at one residential treatment center, this article examines what restraints reveal and embody about intimate interpersonal staff/client relationships, how Black men relate to one another in this setting and how staff members use physical interventions to link institutional mental health treatment with street violence in the outside world. I conclude that understanding these meanings of restraints provides a valuable way of understanding local knowledge in mental health practice, treatment and recovery.     

Mental Ill Health,Recovery and the Family Assemblage

The recovery approach is now among the most influential paradigms shaping mental health policy and practice across the English-speaking world. While recovery is normally presented as a deeply personal process, critics have challenged the individualism underpinning this view. A growing literature on “family recovery” explores the ways in which people, especially parents with mental ill health, can find it impossible to separate their own recovery experiences from the processes of family life. While sympathetic to this literature, we argue that it remains limited by its anthropocentricity, and therefore struggles to account for the varied human and nonhuman entities and forces involved in the creation and maintenance of family life. The current analysis is based on an ethnographic study conducted in Australia, which focused on families in which the father experiences mental ill health. We employ the emerging concept of the “family assemblage” to explore how the material, social, discursive and affective components of family life enabled and impeded these fathers’ recovery trajectories. Viewing families as heterogeneous assemblages allows for novel insights into some of the most basic aspects of recovery, challenging existing conceptions of the roles and significance of emotion, identity and agency in the family recovery process.     

Conflict Resolution in Chimpanzees and the Valuable-relationships Hypothesis

Reconciliation, or peaceful postconflict interaction, can restore the usual pattern of interaction between social partners after open conflict has disrupted it—i.e., it can resolve conflicts. Researchers have documented reconciliation in >20 primate species, but the tendency to reconcile typically varies among dyads and dyad classes. The valuable-relationships hypothesis proposes that differences in the value of social relationships account for much of this variation. Value depends on how likely partners are to act in ways that benefit each other, where the benefits are ultimately direct or indirect increases in fitness. Researchers have responded to studies that have tested predictions of the hypothesis with extensive, if not universal, support. For example, kin show higher conciliatory tendencies than nonkin in many species, and conciliatory tendencies between unrelated females are high in several cercopithecines in which nonkin agonistic support is important for rank acquisition and maintenance. However, most of the support is indirect, because we lack direct evidence on the link between assays of relationship value and fitness. Also, some studies have methodological weaknesses, e.g., analyses based on pooled data and insufficient sample sizes. I review evidence in favor of the hypothesis with special attention to studies that come closest to providing evidence for predicted fitness effects. I also present new data on postconflict interactions between adult male chimpanzees at Ngogo that show how often pairs of males formed coalitions and how much time they spent grooming influenced the likelihood that they would reconcile after conflicts, and that allies were particularly likely to reconcile and to do so by grooming each other. The most important future research direction is to integrate detailed data on conflict management, analyzed at the level of dyads, with long-term data on reproductive success, such as that now available from several study sites, on the same populations.     

Mental health services--the user's view.

The needs of people with serious mental illnesses have dominated much of the debate on reforming community care. In this article Peter Campbell, who has used mental health services many times in the past, explains how the reforms could affect people like him. He welcomes the thinking behind the changes, particularly the idea that people who use community care should take part in planning services, but he warns that implementing the new philosophy might prove very difficult. Mr Campbell is secretary of a voluntary organisation for users of mental health services called Survivors Speak Out. The views he expresses here are his own, and do not necessarily reflect those of Survivors Speak Out.     

Morals, Medicine and Change: Morality Brokers, Social Phobias, and French Psychiatry

This paper will examine how French neurotics are being transformed into 'social phobics' and how the appearance of this group may be tied to new personal and social ideals. There are many people and factors that contribute to this changing definition of mental illness. Amongst these, I will focus on the role of three groups who are most vocally acting as morality brokers in the creation of these new subjects: psychiatrists, patients' groups and pharmaceutical companies.