July Newsletter

July 2020

Newsletter Editor: Denise Nelson

namitularecounty.org

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Support Groups

Family Support Group will not be held until further notice.

If you have a family member or friend with a mental illness, and you would like someone to talk to, you may call the following numbers:

Visalia Contact: Ralph (559) 627-1306

Porterville Contact: Donna (559) 280-5258

NAMI Connection Recovery Support Group will not be held until further notice.

Porterville and Visalia Wellness Centers have reopened. You can contact their offices for more information about their modified services:

Porterville Wellness Center: (559) 759-3388
Visalia Wellness Center: (559) 931-1001

(See calendar of events for Visalia included in this newsletter)

NEW WEBSITE, NEW LOOK!

We are excited to introduce our new website! It has a whole new look, making it easy to navigate and find the information you're looking for. If you have questions about our support groups and/or education programs, you will be able to find the most up-to-date information there.

We invite you to take a look.

UPDATE ON NAMI CONFERENCES

NOTE: If you made hotel reservations prior to the change, your reservations will be transferred to the new date; however, you must contact the hotel.

LEARN MORE

AmazonSmile Now Available in the Amazon Shopping App!

AmazonSmile is now available in the Amazon Shopping app on iOS and Android mobile phones! Choose NAMI Tulare County as your organization, and Amazon will donate 5% of your total order to help our cause to raise mental health awareness with no added cost to you.

Learn how to join AmazonSmile and use it in the Amazon Shopping app here .

If you do not have the latest version of the Amazon Shopping app, you can update your app. Click here for instructions.

Featured Articles

No Accountability Without Data

by Elizabeth Sinclair Hancq, Director of Research at the Treatment Advocacy Center

Accountability means being responsible for one’s actions. This could mean an obligation to justify a decision or the ability to explain an action.

We hold politicians accountable for their decisions at the ballot box. Because they are elected officials, we can vote them out of office. In a democratic society, government bodies should likewise be accountable to the public for its decisions and actions.

Accountability and trust in government go hand-in-hand. Trust is vital between citizens and their government, especially when policies depend on responses by the public. Lack of trust compromises public relations and makes government problem solving societal issues almost impossible.

The Office of Research and Public Affairs has long been calling for accountability in data availability for severe mental illness. In December of 2016, we met with leaders at the Substance Abuse and Mental Health Services Administration about the significant gaps in data and research on severe mental illness.

Data is essential for this trust and accountability. Without it, there is no way to know if policies are successful or that achievement metrics are being met. Data is also vital for reforms because it can highlight inequities or problem areas that otherwise would be unknown.

Data for Civil Commitment

Dr. Nathaniel P. Morris, a psychiatrist at Stanford University, writes in a recently published article in Psychiatric Services about the need for public tracking of civil commitment in the United States. Public tracking of this data in the United States is essential for accountability and reform, he argues.

There are a host of reasons as to why there currently exists no publicly

available, national data on civil commitment in the United States. Chief among those reasons is the fragmented system of care for people with mental illness in the United States; the decentralization and variation between systems makes national data collection difficult. Also, civil commitment laws vary by state and can vary in practice from one locality to the next. Further, patient privacy laws limit access to patient records.

Morris offers several arguments for improving public tracking of civil commitment. He suggests that public tracking of civil commitment will help to increase the public’s understanding of civil commitment and the associated laws. This understanding is important not only because of a public citizen’s role in influencing policy making through voting in elections but also because they or their family members may be subjected to the laws when in need of psychiatric treatment.

“Improved public tracking of civil commitment might help individuals navigate these laws,” Dr. Morris writes. “In many places, patients and their families might ask simple, important questions about civil commitment (e.g., ‘How long does involuntary hospitalization typically last?’ or ‘How frequently are civil commitments overturned during hearings?’), to which first responders, clinicians, judges, and other authorities may not have accurate answers.”

The Treatment Advocacy Center began working 22 years ago to improve laws and procedures of civil commitment. Publicly available data of civil commitment from state and federal mental health systems are needed to ensure government entities and their contractors are providing appropriate psychiatric treatment.

Without data on trends and inequities of how mental health providers and judicial systems use or do not use civil commitment, policy makers or practitioners cannot make evidence-based decisions. States should establish systems for collecting and publishing data on civil commitment to ensure accountability and informed decision- making.

References: Morris, N. P. (2020, June). Detention without data: Public tracking of civil commitment . Psychiatric Services .

… Bipolar on Its Own, a Review

“German psychiatrist Emil Kraepelin (1856-1926) is one of the most recognized names in the history of bipolar. He is sometimes referred to as the founder of modern scientific psychiatry and psychopharmacology. He believed mental illness had a biological origin and he grouped diseases based on classification of common patterns of symptoms, rather than by simple similarity of major symptoms, as those who preceded him had done. This forward-thinking specialist postulated that a specific brain or other biological pathology was at the root of each of the major psychiatric disorders. Kraepelin felt that the classification system needed revising and so he did just that.

In the early 1900s, after extremely detailed research, he formulated the separate terms “manic depression” and “dementia praecrox” the latter later named “schizophrenia” by Eugene Bleuler (a857-190). Widespread use of the term “manic depression” prevailed until the early 1930s---it was even used until the 1980s and 1990s. Also, during the early 1900s, Sigmund Freud broke new ground when he used psychoanalysis with his manic-depressive patients: biology then took a back seat. He implicated childhood trauma and unresolved developmental conflicts in bipolar disorder.

In the early 1950s, German psychiatrist Karl Leonhard and colleagues initiated the classification system that led to the term “bipolar”, differentiating between unipolar and bipolar depression. Dr. Cara Gardenswartz, PhD. She has specific expertise in bipolar and its’ history. “In the earlies days of documentation, these people were viewed as ‘crazy’ possessed by the devil or demons. Their treatment of punishment included restraint or chaining, their blood was let out, electric eels were applied to the skull—similar to the way witches have been treated in many cultures.” The ancient Greeks and Romans coined the terms “mania” and “melancholia” and used water of northern Italian spas to treat agitated or euphoric patients. They believed the lithium salts were absorbed into the body as a naturally occurring mineral. In 300—400 BC, the Greek philosopher Aristotle had thanked “melancholia” for the gifts of artists, poets, and writers, the creative minds of his time. The doctor notes that “once there was a recognized difference between bipolar and other disorders, individuals suffering from mental illnesses were better understood and in turn---along with the progress in psychopharmacology---were able to receive better treatment.”

In 1621, Robert Burton an English scholar, writer and Anglican clergyman wrote a review of 2,000 years of medical and philosophical wisdom defining depression as a mental illness in its own right

The term “bipolar” logically emphasizes “the two poles” of mood episodes, according to the prominent psychiatrist Robert L. Sitzer, MD, who was a major force in developing the modern approach to classifying and diagnosing psychiatric illnesses. People with unipolar depression experience low mood episodes only, while people with bipolar depression experience both depressed and elevated moods in a cyclical manner. (in some cases of bipolar 1 disorder, people have manic episodes only.)

Dr. Spitzer led the task force that wrote the third version –an undeniably major revision of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders (DSM). After DSM-111 was published in 1980, the reference work became so influential it is often referred to as the “bible” of American psychiatry.

Among the monumental changes in the DSM-III, the term “manic-depression” was dropped and “bipolar disorder” introduced—eliminating references to patients as “maniacs”. Further revisions of the DSM over the years have clarified inconsistencies in diagnostic criteria and incorporated updated information based on research findings, according to the American Psychiatric Association (APA). The APA issued the latest edition, DSM-5 in 2013.

Noted American neuroscientist and psychiatrist Thomas Insel, MD, former director of the National Institute of Mental Health has said that whatever the changes in the DSM over the years, the reference work ensures that clinicians use the same terms in the same way.

Each edition has also reflected changes in philosophy in psychiatric practice. For example, the U.S. Substance Abuse and Mental Health Services Administration (SAMSHA) noted that the DSM-5 takes a “lifespan” perspective that recognizes the importance of age and development on the onset, manifestation, and treatment of psychiatric disorders.

The DSM-5 includes a more flexible category for “bipolar-like phenomena”. Furthermore, the criteria for diagnosing elevated mood states now includes an emphasis on shifts in energy level and goal directed activity.

As the labels for psychiatric disorders evolved and changed, so too, did the range of treatment for those with bipolar disorder. In the 1950s, the use of sedatives and barbiturates along with patients being institutionalized to separate them from others was common. Prefrontal lobotomies and early forms of electroconvulsive shock therapy emerged as two more radical treatment options.

“Starting in the mid-1900s, with the advent of psychiatric and antipsychotic mood-stabilizing medications, patients were able to be viewed more as human beings suffering from illness that could be treated.” Dr. Gardenswartz affirms. Additionally, doctors and the public began to view various illnesses “as the separate entities that they were: schizophrenia, ongoing without breaks or relief from symptoms when untreated; or bipolar, in which people could typically function normally during periods between this cyclical illness.”

A discussion of medications to treat bipolar cannot be complete without acknowledging the work of John Cade, an Australian physician who introduced

lithium to the practice of psychiatry in 1949 quite by accident when he observed that lithium urate appeared to calm guinea pigs. Lithium has since remained one of the most effective medications for those with bipolar disorders, providing a springboard for further research and discovery of biomedical treatments. As the ancient Greeks and Romans suspected, natural lithium can indeed be found in hot springs and there is scientific justification for their historical use as a treatment for bipolar disorder.

Dr. Morgen Schou, Md (1918-2005), continued groundbreaking research in lithium. Dr. Schou emeritus professor at the psychiatric Hospital in Risskov, Denmark, and was named honorary president of the International Society for Bipolar Disorders. Dr. Schou labeled manic depression “the national illness” of his country and in the 1960s, Dr. Schou used lithium on an experimental basis with a group of his patients who experienced mania. Schou’s work proved that when used properly with monitoring, lithium could be very effective in treating bipolar mood episodes. Influenced by his work the U.S. Food and Drug Administration (FDA) finally approved lithium as a treatment for mania in 1970 and in 1974 as a preventive treatment for manic depressive illness.

Treatment Triad

It is 2020, and treatment for bipolar disorder has evolved to recognize the importance of “three pillars” for wellness; medication supported by psychotherapy and self-care.

Current pharmacotherapy for bipolar disorder has expanded to include mood stabilizers (a category to which lithium belongs) antipsychotics (especially the newer “atypical formulations), antianxiety medications, sleep medications, and antidepressants under certain circumstances.

Which specific formulations and dosages to use vary according to individual responses. It often requires multiple trials of different medication to finally determine the right combination. This broad stroke approach, while frustrating at times, comes about because there are no reliable lab tests that can determine what medication will be effective in a particular case.

Meanwhile, research has validated two types of brain stimulation as effective for treatment-resistant bipolar depression. One is electroconvulsive therapy (ECT), which has been greatly refined since its notorious “shock therapy” days in the 1940s. In this technology, controlled electrical currents are passed through the brain while the individual is under sedation. An alternative therapy, transcranial magnetic stimulation (TMS), delivers electromagnetic pulses through the scalp.

Still at the experimental stage: vagus nerve stimulation (VSS), in which a device implanted in the chest sends electric pulses to the vagus nerve, and deep brain stimulation (DBS), which involves two electrodes placed in the brain plus a pulse generator in the chest.

Talk therapy also has evolved greatly since the 1970s, when more action-oriented, humanistic approaches became firmly established alongside traditional Freudian analysis.

There is a lot of scientific evidence suggesting psychotherapy specific to bipolar challenges, when used with medication, works better than medication alone. Much of that evidence relates to cognitive behavioral therapy, or CBT, since that is the most commonly researched form of psychotherapy. CBT helps individuals pinpoint unhelpful attitudes and behaviors and substitute more positive patterns. It has been found in research that CBT is effective in decreasing relapse rates and improving symptoms, mania severity and psychosocial functioning. Best results for depression or mania occurred with at least 90 minutes of treatment per session and people with bipolar 1 had a lower relapse rate.

A range of therapeutic approaches continues to diversify. CBTm adds a mindfulness component to the traditional approach. Dialectical behavior therapy, or DBT, incorporates cognitive-behavioral principles, mindfulness, and interpersonal skills to help people tolerate painful emotions and become more assertive in relationships. Interpersonal and social rhythm therapy (PRST), developed specifically as an intervention for bipolar, emphasizes establishing daily routines, managing stress, and tracking connections between mood and life events.

Perhaps the biggest transformation in managing bipolar disorder since the advent of lithium has been the shift to “patient-centered” or “person-centered” care reflecting a larger shift in medicine and psychiatry over the last two decades. Rather than passively following the dictates of health care professionals, the person being treated is considered a partner in setting goals, deciding on interventions, and pursuing independent strategies that contribute to wellness.

A large body of evidence shows that regular exercise, a healthy diet, methods to relieve stress, and good sleep all contribute to stability in people with bipolar disorder. Some practitioners prescribe exercise as part of treatment, and multiple studies indicate that both yoga and mindfulness practices are helpful in maintaining wellness. Mood tracking—a self-recorded diary of daily emotional fluctuations and activity patterns—helps with self-awareness, identifying mood triggers and better symptom management.

Bipolar disorder is a condition for which it’s blatantly apparent that lifestyle modifications, self-care, and self-management strategies make a real difference, says Erin Michalak, PhD. A psychiatry professor at the University of British Columbia. “It is now known that many people with bipolar disorder use lifestyle interventions to manage not just depression, but also escalation into hypomania and mania she adds.”

The rise of the Internet, social media and smartphones has made self-management easier for people with bipolar. Information on bipolar symptoms and treatments is easier to find. So is a community of peers, either forums, blogs, or self-help portals. A proliferation of apps can help with everything from mood-tracking to mindfulness exercises”.

Reference:

Bp Magazine, Winter, 2020, Stephanie Stephens, a freelance writer based in Southern California.