Monday, January 10, 2011

Mental Illness: the Facts

I have to admit that when I heard of the shooting of a District Judge and a Democratic Representative who had narrowly defeated a Tea Party candidate in Arizona, my first reaction was fear that it was done by a political extremist. But as the story of the shooter, Jared Lee Loughner, has come out, it looks more and more as if mental illness may be involved. Because of his behavior, the young man had been removed from his college algebra class, had several run-ins with the campus cops, and was prohibited from returning to college without a doctor's note to the effect that he was not a danger to others. One Walmart refused to sell him ammo for his 9 mm Glock because of his behavior; unfortunately, another Walmart was not so discriminating. His political videos on You Tube have been described as rambling and lacking coherence. There is a very good possibility that this man, accused of wounding more than a dozen people and killing 6, has a severe mental illness.

Now I am worried that instead of jumping to conclusions about certain people's politics, the conclusions leaped to will concern the mentally ill. My first job as a nurse was working on a psychiatric floor. Later I worked on a neurosurgery floor. I have stayed interested and informed on the growing research on the brain and so I would like to separate fact from fiction on this topic.

The mentally ill are no more likely to be violent than those who are well. Studies have shown that the rate of violence among the mentally ill is no higher than among the general population. An analysis of violent rampages, in which at least one person was killed, found that a little less than half were committed by mentally ill individuals. The other half were committed by people with no previous indication of mental illness. Only about 3% of the violence in this country is committed by the mentally ill.

Mental illnesses are brain illnesses.
Now that we have PET scans and other imagining technology, we are discovering key differences in the way the brains of mentally ill people work and sometimes in the structure of their brains. Mentally ill people are no more responsible for their sickness than someone with sickle cell anemia is. Mental illnesses have physical causes and are physical illnesses of the brain. The puzzling or disturbing behavior they cause are really the symptoms of the illnesses, just as fever is a symptom of infection.

Because of the illness that affects his or her brain, a person with a mental illness classified as a psychosis often has problems perceiving or interpreting reality. These manifest themselves in delusions or even hallucinations. A delusion is the false belief of an individual that persists despite overwhelming evidence to the contrary. The person may perceive himself to be Jesus Christ, or the President, or some other highly exalted or important person. These delusions of grandeur can lead to paranoia. If you are so obviously and superlatively special and others don't perceive or treat you that way, there must be a reason. It could be jealousy, envy, hostility or a massive conspiracy. Such feeling are intensified if the mentally ill person is also suffering from hallucinations. He or she may see or hear things that aren't there. Usually hallucinations are disturbing to the person perceiving them. They may see grotesque monsters, inexplicable or sinister objects, or ordinary things in bizarre contexts, such as babies crawling on the ceiling. They may hear voices that tell them they are special or, more often, which torment them with accusations, denunciations, or insults. The voices may frighten or depress them. And yet others do not acknowledge these voices. Either they are telling the truth and this reinforces the hallucinating person's idea that he is special. Or other people are lying about not hearing the voices and so are part of the conspiracy against them.

There are many effective treatments and medications for the mentally ill. The reason why some mentally ill people do not get treatment is because either they have no health insurance, or the health insurance doesn't provide coverage equal to that provided for "physical illnesses," or the person, because of his illness, is non-compliant with or refusing his treatment.

A high proportion of the mentally ill are unemployed and thus less likely to have health insurance. Even those with health insurance may find that their policy offers limited coverage for mental health treatment. The number of days per year they can be hospitalized for a mental illness may be inadequate. There might even be a lifetime cap. Their medications may not be on their plan's formulary or the number of refills may be limited. George Bush once announced parity in the coverage for mental and physical illnesses but it has yet to become reality in most health care plans.

Then there is the problem of non-compliance. A mentally ill person suffering paranoia is obviously going to be skeptical of drugs prescribed by those who very well could be part of the conspiracy against him or her. Or he may hate the side-effects so much that he stops taking the drugs. When I worked as a psych nurse, I often saw the same people come in again and again. We would get them on their meds, they would improve and be discharged home. But the side effects would bother them. They might feel sleepy or slowed down. And they might convince themselves that their hospitalization and first round of drugs had cured them and so they didn't need to keep taking them. Then their symptoms would return and they would have to be readmitted to the hospital to get back on their medications.

There are acute conditions that can cause mental symptoms, such as kidney or urinary tract infections, high or low blood sugar in a diabetic, exposure to toxic substances, or reaction to recreational drugs. But illnesses like schizophrenia or bipolar disorder are usually chronic and the person may need to be treated for life.

A major part of the problem is the stigma attached to mental illness. It causes people to fear and isolate the mentally ill. Let's face it: when a person you know begins acting or speaking in a bizarre fashion, it is unsettling. When it's someone you don't know, the temptation is to avoid him or her. Yet if you saw someone with a broken leg, you would probably get them help. Our fear and lack of understanding of mental illnesses clouds our compassion for those suffering.

The effect of untreated mental illness can be a descent into poverty and even homelessness. The wholesale emptying of mental institutions under Ronald Reagan also added to the number of homeless mentally ill. The stigma kept many of the community mental health treatment centers that were supposed to complement this de-institutionalization from being built. People didn't want "crazy" people coming into their neighborhoods. Yet these illnesses can strike people of any socio-economic class and any ethnicity. Add depression into the mix and it is estimated that 1 in 5 Americans will suffer from a major mental illness some time during their life.

The stigma also keeps some people from getting a diagnosis and treatment. Many still see mental illness as a failure of the will or an embarrassing weakness. A lot of that is the belief that mental illnesses are radically different from "physical" illness. But as we've seen that's a fallacy.

I hope that this horrific incident doesn't further stigmatize the mentally ill. Remember, we were perfectly willing to see this as the action of a person just swayed by extreme political rhetoric. I hope that it does alert us to the importance of recognizing and treating mental illness. And I hope more bloggers and reporters spread the facts about mental illness rather than repeat the fallacies.

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