NEWSMENTAL ILLNESS

On Saturday, August 14th, a group of people left St. Louis, MI, and started to walk. On good days and bad, they've been marching eastward, determined to call attention to and demand adequate treatment for a disease that affects over 20 million Americans -- depression.

Covering 835 miles in 50 days, the walk will end in Washington, D.C. on October 7th, the National Depression Screening Day. Part "pep rally" and part camping trip, the Walk to Washington for Depression Awareness includes 20 stops, where volunteers talk advocacy over burgers and set up information booths outside Statehouses.

On their stop in Zanesville, OH, walk participants, who average about 20 miles a day, rested their legs and collected signatures in front of the local courthouse. Steve Curry, director of the Walk to Washington, told a reporter why he walks.

"Five years ago, I attempted to take my own life and was hospitalized three times. After that, I started an annual 5K walk in St. Louis and thought 'why not do a cross-country walk?'" Curry said.

Although the walk is marked by meetings with like-minded groups, connecting with virtual participants and steady progress toward the Capitol, the journey also highlights the everyday struggles that people with depression face.

On September 10, Curry blogs, "it is 6:30 in the morning and I am suffering terribly. Since we left St. Louis I have had a couple of rough times but the last couple of days have been horrible. I have been sleeping a great deal, crying and isolating. I pray the pain will stop, will go away so I can smile again, but it doesn't."

But on September 22, 2010, Curry is back.

"It is amazing that we have walked in seven states ... We will be crossing into Maryland this weekend. Things are much better for me. The last two weeks have been a living hell and I began to come out of  it on Monday and I am back to my old self. It is amazing to look back at how I felt and how dark my days are."

As the rest of medical science zooms by, technologically advancing itself through non-invasive laser beam surgeries and MRI-reading iPads, doctors still harness (believe it or not) the ability to perform a basic physical exam. You can see a cirrhotic liver worsening by the yellowing of someone’s eyes and feel a lung consolidation through distinct vibrations on their back. That’s why it’s hard to imagine that with so much of medicine relying on keen observation skills, problems like starvation, physical wasting and burns or cuts on the skin could be so easily missed.

This week, researchers from Stanford’s Lucile Packard Children’s Hospital have proven this inconsistency true. In a study of over 1,400 teenagers with eating disorders, researchers found that almost 40 percent of teens surveyed admitted to inflicting self harm. Even more shocking is the fact that doctors missed almost 50 percent of these double-injury cases.

"We ask 97 percent of children 12 years and up if they smoke cigarettes; we need to get that good with screening for self-injurious behavior," said the study's lead author, Dr. Rebecka Peebles in the press release.

There’s a movie in which one of the characters is a sickly little boy who doesn’t go anywhere without his inhaler. When he gets short of breath, he takes a couple of hits off his inhaler, and within a minute or two he’s breathing easily again. Later in the movie it’s revealed that what’s actually in his inhaler is nothing more than aerosolized salt water. It’s a complete sham. Yet it still brought relief to this boy and his neurotic mother.

It’s a perfect example of the placebo effect -- benefit from a false treatment or intervention. It’s seen most commonly in situations where the symptoms are more subjective, such as pain or mood. In women, it's also seen in sex drive.

A recent study in the Journal of Sexual Medicine found that one in three women with diminished sexual desire who took a sugar pill as part of a control group reported an improvement in their symptoms. The study included 200 women diagnosed with female sexual arousal disorder; 150 of them took Cialis, the male erectile dysfunction drug, and 50 were chosen at random to receive placebo. Although the women taking Cialis showed no marked improvement in sexual arousal, a third of the women popping sugar pills reported restored sexual function. It seems that nothing had physically changed for these women, but psychologically a major shift had occurred.

The importance of diagnosing and treating mental illness is clear to everyone. What gets emphasized less are the physical health challenges of people suffering from mental illness.

In fact, the cruelest thing about bipolar disorder, schizophrenia and other mental illnesses is the way they completely wreck the mind while leaving the body without a scratch. (Excepting the more than 30,000 per year who commit suicide.) That way, other people can't tell, or don't believe, that someone is sick. But physical illness is often not far behind. (A long article in the New York Times Magazine this week is called "Depression's Upside." Anyone in the throes of depression will agree that there is none.)

NAMI, the National Alliance on Mental Illness, just launched a wellness campaign called "Hearts & Minds" in an attempt to roll back some of the startling statistics on mortality among those with mental illness. People who are battling depression or a host of other debilitating conditions are at risk, unfortunately, for even more health challenges. Those affected will die, on average, 25 years sooner than people without mental illnesses.

A new website aims to be the diary for your mood. HealthCentral developed Mood 24/7 "based on technology licensed exclusively from Johns Hopkins University." Free while it's still in beta, Mood 24/7 is for people who'd like to keep track of how they're feeling on a daily basis. After someone signs up, the website sends her a text message once a day asking her to rate her mood at the moment. The website compiles these ratings into charts that she can print out and take to her doctor, psychologist or book club. Physicians can also sign up for their own accounts to check up on patients' ratings. The site is affiliated not with Johns Hopkins, but with one of the school's professors of psychiatry and neurology, Dr. Adam Kaplin.

HealthCentral is touting Mood 24/7's potential as a tool to identify depression and evaluate the effectiveness of treatments. My problem with using a mood chart, or a self-reported text message rating, is that it doesn't much matter whether you rate yourself a 1 (lowest) or 3 (pretty low) -- if you're not feeling good at all, you need to see a doctor. Likewise, if your medication brings you to a 5 (neutral) or a six (OK), it's time to talk to your doctor about switching up the dosage or adding an exercise plan. People know what they're feeling, and, even if the ratings fall above or below some arbitrary threshold, shouldn't be told that they're not sick even if they know they are, or that they are sick when they know they're not.

I signed up for Mood 24/7 today (which took about a minute) and programmed the text to come to me at 1 p.m. I hadn't had lunch yet and I was behind on my deadline, so my mood wasn't good. The message read: "On a scale of 1(lo) to 10(hi) what was your average mood today?" I had the choice to add a short message with my reply. So I answered: "MOOD 6 stressed." If I were suffering from clinical depression or bipolar disorder, would my hunger and external stressors have any less impact on my subjective daily mood report? I'd love to hear from doctors and patients both for and against this text message reporting. Has my criticism put anyone in a bad mood?

Photo credit: DCvision2006

The Obama administration issued rules today that require parity in the treatment of mental health and substance abuse disorders. The regulations, officially called the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, could affect the 150 million Americans in group health insurance plans generally provided through an employer. (Employers with fewer than 50 employees are exempt.) The rules take effect on July 1 of this year.

This means that patients who are covered cannot be charged more out of pocket than they would be for general medical care or see their benefits limited for mental health and substance abuse services. These services will now be grouped under one umbrella deductible with medical and surgical benefits.

The quest for parity has been winding its way through Congress since the early 1990s and through the minds and consciences of lawmakers since the '60s. These rules expand on a 1996 parity act that did not include substance abuse treatment.

The American Psychological Association calls it "a big win for anyone seeking mental health treatment," and adds, "under these regulations consumers are protected from insurance discrimination to the greatest extent possible." Megan McArdle at The Atlantic, however, is not feeling it. "We could have achieved the laudable goal of ensuring that serious mental illnesses are not left untreated ... without guaranteeing cheaper psychotherapy for America's ennui-laden affluent classes."

Photo credit: Jessia Hime

Every Sunday, I’ve taken to posting the best of the best – the three must-reads or must-watches from this weekend.  This Sunday, I’m choosing three articles to fill in a big gap in my blogging.  Aside from one post earlier in the week on the protesters arriving in town halls to shout down debate on health care reform, I scarcely have mentioned the topic.  This is deliberate.  While the news might focus disproportionately on the loud and bullying minority, there are many other issues at play, issues that – unlike exemptions for unions, or death panels, or national IDs or what have you – actually exist in the bills themselves, and are worthy of debate and discussion.

Turns out it’s a good thing I did, because I don’t think I could have written about the health care rowdies any better than these three.  When you come right down to it, progressives and the rowdies actually agree on a lot of the same principles!  Let’s focus on the common ground, shall we?

(Side note:  Why do I have a picture of a massive pro-reform rally up?  Well, I keep hearing about how progressives aren’t mobilized for reform – I figured a picture was worth a thousand words.)

1.)    Daily Kos – “All Right, Republicans.  We Give Up.”

What to do when those showing up against reform are making demands against things that aren’t actually in the bill?  Blogger Strozeck has a great idea – capitulate!  Specifically, we should agree not to include things in the bill like:

1.  We will not euthanize your grandmother. This is the big one, and I really hope you guys appreciate how much of a concession this is on behalf of the progressive movement. Since the days of the Bull Moose Party, progressives have wanted nothing more than to slaughter old people by the millions. That much is obvious. After all, if we wanted senior citizens to have long and healthy lives, why would we have created Social Security and Medicare? Think about it. Death to grannies has long been the core of progressive policy, so it's not without some consternation that we give it up. So there: no euthanizing old people. You've got it.

2. Rahm Emanuel's brother will not kill Sarah Palin's baby. While this will require us to gut HR 3200 "America's Health Choices and Murder Sarah Palin's Baby Act of 2009," we're currently working with Henry Waxman to remove the extensive Sarah Palin's baby-killing provisions from the final bill. While this will probably cost us Andrew Sullivan's support, we recognize that this is a necessary sacrifice for securing broad bipartisan support of health care reform.

Read the whole blog post here.

2.)    Mark Halperin – “Halperin’s Take:  Why Everything About the Health Care Mobs Is a National Disgrace”

Regular readers of Mark Halperin’s “The Page” know that few enjoy reporting the blow-by-blow parry and thrust of politics than the man who originated ABC’s “The Note.”

During the election, Halperin helped hype the horserace first between Obama and Clinton, and then between Obama and McCain to the point of “edge of your seat” drama.  This is a man who kept giving out “weekly reviews” that indicated McCain was winning the news cycles consistently.  So it’s surprising – in a good way – that he’s unflinchingly down on the street theater surrounding health care.

My three favorite points:

4. It is very easy to disrupt a town meeting and the (apparent) reward is getting their requisite 15 minutes of fame on television news.
…

6. Debating whether a given mobster is "real" or "astroturf" is like debating who the third-best professional wrestler of the 1980s was.
…

9. Ask Republican members of Congress who voted for President Bush's massive prescription drug entitlement law how many of them read that bill before they voted in favor of it -- or how many bills they EVER read in their entirety.

Read the whole list.

3.)    Harold Pollack, “Have You No Decency?”

Although he’s clearly on the side of reform, I’ve greatly enjoyed reading Harold’s commentary and his laidback and genuinely inquisitive style.  After all, I can’t think of many other bloggers who would write a post about his experiences talking to counter-protesters at a big pro-reform rally in Chicago to find out what’s motivating them.

But opportunistic politicians who have injected themselves into the limelight by spreading the most egregious false hoods about health care have prompted quite a different response in Harold – his ire.

First, these issues are quite separate from the main issues being debated in health reform. Under a single-payer system, a strong public plan, or under a libertarian’s privatized dream-system, we will still face fundamental dilemmas in caring for our loved ones, and ourselves. This is not merely or primarily a money issue. Like other forms of care, end-of-life care is sometimes wasteful or ineffective, but nobody is looking to skimp on or ration such care to finance health reform. Nor should they.

Second, health reform would address an equally fundamental dilemma of human dignity and human rights: millions of people’s lack of access to basic care. Many of these people are disabled or live with chronic illnesses. Over at Obsidian Wings, Publius yesterday noted the predicament of children with Down Syndrome denied health insurance because they have a preexisting condition.

Governor Palin writes: “And who will suffer the most when they ration care? The sick, the elderly, and the disabled.” It’s telling that she omitted one category: Poor people, whose care is now cruelly rationed in ways the Obama administration and congressional Democrats are trying to address in health care reform. Palin brings genuine moral passion to the issue of cognitive disability. I wish she would bring that same passion to the plight of uninsured patients forced to seek substandard, delayed care, or the millions of Americans facing the dual challenge of serious illness and large medical bills. If you live in any big city, go down to your local public hospital emergency room. You will probably find people in visible discomfort or illness languishing for hours. A society that cares about human rights and dignity would not tolerate this.

Read the whole blog post.

(Photo credit:  seiuhealthcare775nw on Flickr.)

People have been emailing me a piece by Shawn Tully, the Editor-in-Chief of Fortune Magazine, entitled “5 Freedoms You’ll Lose Under Health Care Reform,” which was featured on the Drudge Report last week.  In sending, they've asked for me to respond. I struggled most of the weekend with a response, not because I agree with Mr. Tully – I don’t – but because the world Mr. Tully describes is not one that’s accessible to most Americans, and certainly not accessible to me.  Although he’s been able to tap into the scary narrative of “health reform will cause you to give something away,” he’s particularly focused on what the rich will have to give away, and doesn’t seem to have a real sense of the hazards of the current abusive insurance marketplace.  Every single one of the freedoms he defends either will continue to exist under health reform or, most often, currently only exists to the tiniest percentage of hardworking Americans.

Shoring up the foundation is apparently not a good idea if it rattles the penthouse.  Any student of history should immediately recognize the dynamic – it is the sense of entitlement and privilege standing in the way of progress, yet again.

Now I don’t for a second think that the supporters of Mr. Tully’s work will be won over by my arguments.  After all, Mr. Tully wrote a piece in March of 2008 entitled, “Why McCain Has the Best Health-Care Plan.”  Indeed just about every position Mr. Tully takes in his new editorial reflects something cherished about John McCain’s plan or, in the case of Health Savings Accounts, George Bush before him.  If Mr. Tully had been John McCain’s speechwriter, perhaps the plan would have been better received.  Or perhaps, as always, it’s easier to trigger the public's fear of loss than it is to trigger their hope for a better future, particularly on a topic as complicated as health care.

In the end, I can’t help but look at what he calls “freedoms” and think “Who, exactly, has these now?”

His first is “Freedom to choose what’s in your plan.”  But 160 million Americans don’t have that – their benefits are offered through their employer and determined by their employer.  Millions more have some government program – Medicare, Medicaid and SCHIP, or perhaps the VA or the Department of Defense – whose benefits are determined by law.  The remaining people are either uninsured and have no choice on what’s in their absence-of-a-plan, or are in the individual insurance market.  The individual insurance market is one that Mr. Tully championed explicitly in his support for John McCain’s plan.  However, the experience of those purchasing from this free market ideal on Earth tell a different tale.  A large portion of them do not get to choose what’s in the plan either.  A recent report by the Commonwealth Fund found:

Seventy-three percent of people who tried to buy insurance on their own in the last three years did not purchase a policy, primarily because premiums were too high. In addition, among adults with individual coverage or who tried to buy coverage in the past three years, 57 percent said it was very difficult or impossible to find coverage they could afford, 47 percent said it was very difficult or impossible to find a plan with the coverage they needed, and 36 percent were denied coverage or charged more because of a pre-existing condition, or had the condition excluded from their coverage.

So I’m afraid if you’re not a CEO or in human resources, you’re not enjoying this “freedom,” unless you happen to be the lucky fraction of a percentage who makes a deal with an insurance company for the coverage you want.  The irony with Mr. Tully’s argument is that it ignores that in both the Senate Health, Education, Labor and Pensions bill as well as HR 3200, individuals and employees at small businesses will in fact be able to determine whether they want the standard level of coverage or some additional items at higher cost (the "premium" level benefit options).  Apparently he only counts it freedom if you can remove some of your coverage, not gain more coverage that is currently unaffordable to you.

In this, Mr. Tully’s spirit of self-determinism truly takes an odd shape.  He decries the fact that a minimum standard of benefits will be set by the government.  “The Senate bill would require coverage for prescription drugs, mental-health benefits, and substance-abuse services,” he says – perhaps unaware of the fact that mental-health benefits and substance-abuse services are already a federal mandate.  Freedom to choose your plan, in his mind, means the ability to chuck coverage to save money.  To be sure, both the insurance industry and business have spent several years trying to do just that.  American citizens, on the whole, have not.  It is extraordinarily difficult to go onto the blogosphere, attend a town hall, or find a feature story in the mainstream media whose thesis is, “Woe is me.  I have too much coverage for health care.”

Every Sunday, I’ve taken to posting the best of the best – the three must-reads or must-watches that will really help you parse what’s going on.  During the presidential campaign, we took to calling the period where the importance of what was covered was in inverse proportion to the frequency with which it was covered “silly season.”  This week, the focus seemed to be on – well – beers at the White House.  ‘Nuff said.

So here are the three weekend articles you won’t want to miss to remove some of the silliness from your coverage.  As we move into August, the misinformation begins to fly.  Most of it will be reported as “he says/she says” by the news – two sides of an argument that deserve equal weight.  But as these writers show, there’s a big difference.  One side is looking to address the problems of our broken health care system, and the other is trying to make it seem as confusing and hopeless as possible.

If there’s a silver lining, it’s that so many great writers are determined not to let the agents of the status quo have the last word.

1.)    Paul Krugman – “Health Reform Made Simple”

I’ve lost track of the number of people who have asked why there can’t be a simple 2 page description of what’s going on in health care reform and then, when I start to explain it in as simple terms as I know how, stop me with questions that get both deep and technical.  Of course, the deep, technical questions are how it’s supposed to be – participatory democracy should involve meat and not just baby food.   But it does point out an interesting fact – it’s easy enough to debate health care reform in a couple of hours or in a 100-page document.  It’s tough to debate it in a few minutes and 500 words.

But just as I comforted myself with that notion, Paul Krugman delivers the best and most succinct explanation of health care reform you can imagine.  And yes, it’ll take you minutes to read:

The essence is really quite simple: regulation of insurers, so that they can’t cherry-pick only the healthy, and subsidies, so that all Americans can afford insurance.  Everything else is about making that core work…

That’s it. Any commentator who whines that he just doesn’t understand it is basically saying that he doesn’t want to understand it.

Read the whole blog post here.

2.)    Jonathan Alter, “What’s Not to Like?”

Satire is the art of turning a preposterous argument on its head to demonstrate its truly silly core.  With this Newsweek article, subtitled “Reform? Why do we need health-care reform? Everything is just fine the way it is,” Alter undresses what is beginning to become a popular argument of saying the convoluted, wasteful, prohibitively expensive and abusive American health care system doesn’t need fundamental change.  It’s an argument so at odds with the experience of most Americans when dealing with an illness or injury that it deserves what Alter gives it – sarcasm:

I had cancer a few years ago. I like the fact that if I lose my job, I won't be able to get any insurance because of my illness. It reminds me of my homeowners' insurance, which gets canceled after a break-in. I like the choice I'd face if, God forbid, the cancer recurs—sell my house to pay for the hundreds of thousands of dollars in treatment, or die. That's what you call a "post-existing condition."

I like the absence of catastrophic insurance today. It meant that my health-insurance plan (one of the better ones, by the way) only covered about 75 percent of the cost of my cutting-edge treatment. That's as it should be—face cancer and shell out huge amounts of money at the same time. Nice…

Speaking of fair, it seems fair to me that cost-cutting bureaucrats at the insurance companies—not doctors—decide what's reimbursable. After all, the insurance companies know best.

Read the whole article on Newsweek's site.

3.)    The White Coat Underground, “Health Care Reform – How to Obfuscate, Confuse and Inflame”

I wasn’t following this blog but, after this post, it’s a must have on my RSS reader.  PaulMD is an internist in the Great Lakes region, and he knows malarkey when he sees it.  The new constant refrain (the new “socialized medicine is bad,” if you will) of those who would like to continue profiting financially and/or politically from the current inefficiencies of our health care system goes something like this:  the government will overrule your doctor.  The supposed villain is comparative effectiveness research.  Well, it just so happens that PaulMD is a doctor.  His diagnosis of this fear-mongering argument?  It’s baloney:

How does [Betsy McCaughey] justify this unjustifiable conclusion? She doesn't. She simply asserts it. "Comparative effectiveness" is an au courant term used to describe research that looks at medical practices and tried to assess its effects. For example, there are two surgical ways to fix blood flow to the heart muscle: percutaneous coronary interventions (PCIs) such as angioplasty and stenting, and coronary artery bypass grafting (CABG or "heart bypass"). I'm not going to teel you which one is better, because the answer is complicated and still being investigated, but to choose the correct therapy for a patient we must answer a number of questions: which works best in which kind of patient; how long does each last; which has lower complication rates; which leads to longer survival; which leads to longer survival without additional need for a second intervention; which costs more, and over what time period; which makes people feel and function better. These questions and others need to be asked about many of the things we do, and comparative effectiveness research is a reasonable way to approach this.

To ignore these questions because we don't like the answers is so frighteningly ignorant that it's hard to believe an intelligent person could suggest it. Knowing these answers doesn't mean it's time to start making Soylent Green. What we do with the information is where our ethics as individual and as a society are tested. If we find that kidney dialysis in eighty year olds on average does not provide much quality or quantity of life, do we decide to stop covering it? Do we create algorithms for deciding what do offer an individual? Do we make a subjective choice in each case?

Read the whole post here.

(Photo credit:  taekwonweirdo on Flickr.)

The Senate Health, Education, Labor and Pensions Committee voted along party lines to advance its bill for comprehensive health care reform to the floor of the Senate.  This makes it the first of three – although the House will be working on its bill through 3 committees, they’ll be working on the same bill.  There were lots of sage congratulatory words and even a pensive release from Sen. Ted Kennedy, who has not been able to attend any of the hearings or mark-ups in person because of his illness.  But because so much of the week has been focused on what the President had to say or about the House bill, the Senate HELP proceedings have largely flown under the radar.  So the obvious question is – how did they do?

Well, if you haven’t seen any of the mark-ups, let me show you the single best three minutes.

No, this isn’t a parody scene on The Office.  Sen. Chris Dodd and the Democrats offered to accept without revision 65 amendments authored by Republican committee members.  The Republican members didn’t want them accepted – they wanted votes.  Why?  Pretty much just to run out the clock.

And the kick in the pants is after scores of non-preposterous Republican amendments were accepted (check out some of the amusing ones here and here) were accepted, all the Republicans on the committee voted against the bill so they could loudly complain the process wasn’t “bipartisan.”  Classy.

So how much did the bill improve or decline under this marathon month of mark-up?  The short version is it’s largely the same bill, with changes so minute that I’m having trouble telling the difference.  That’s a great thing, by the way – Dodd could easily have given away the farm for a bipartisan vote that would never have been forthcoming.  The most intriguing amendment was a requirement that federal elected officials would be required to enroll in the public plan (called the “Community Health Insurance Option” in the bill) once it’s created.  Republicans thought they were being clever when they offered it, but Dodd and others called their bluff.  (For the record, I think this is a phenomenal idea -- I’d throw the whole Federal Employee Benefits Program pool in there while you’re at it!)

How different is the Senate HELP bill from what’s being worked on in the other committees?  Well, we can’t compare it yet to the Finance bill, which doesn’t yet exist.  The general structure of the House and HELP bills may not be identical twins, but clearly they’re fraternal.  A lot of people say the HELP bill is watered down – certainly, the initial principles outline released by Kennedy was bolder than the detailed bill we actually have.  The employer pay (contribute to a fund) or play (give your employees benefits) is weaker than what’s in the House:  Wall Street Journal did some estimations and found that a 50-person company with a $2.5 million payroll would pay $200,000 as part of the employer mandate in the House bill, but only $37,500 in the HELP bill.  The cost of premiums in the Gateway/Exchange for families at 400% of poverty is a little higher than the House.  The cap on how much you spend out-of-pocket is higher, too. The eligibility for people to get their insurance through the Gateway/Exchange would be more closed (the Congressional Budget Office thinks we’d be talking 20 million+ in the Gateways instead of the 30 million + for the House, with those extra millions staying in employer-provided insurance).  The “community health insurance option” would need to negotiate rates with providers from the get-go, meaning it’d take longer to set-up and would have less of an immediate effect on costs – although hey, the Senate HELP bill doesn’t suggest that it will push off creating a public plan until 2013, so it may be faster after all.

All true.  But considering that the Senate is traditionally the place where a good reform goes to get crushed or die, it’s remarkable all the same that we’re really talking about degrees rather than a fundamentally different or even a gutted plan.  The HELP bill’s new regulations on insurance is just as strong, its commitment to developing the provider workforce we need is just as strong, the ideas for improving quality for insured and uninsured alike are just as strong, and its focus on primary and prevention to transform us from a mediocre quality “disease care system” instead of a high-performing health care system is just as extensive.

The Senate HELP bill, for reasons of jurisdiction, can’t outline how it would pay for reform or modify anything relating to Medicare and Medicaid.  But presuming Senate Finance sticks to the script, the CBO estimates it will cover 97% of Americans.  You may or may not agree with the approach Congress and the President have taken, but it can’t be denied that this is a pretty significant milestone on the road to reform.

Jungle gyms and all.