And the Solution is Simple;

It’s not the Cost,

It’s the Productivity Lost!

Direct healthcare costs for physicians, hospitals and pharmacy are merely the tip of the healthcare inflation iceberg. Lurking just beneath the surface is a much more ominous and immediate threat to the health and well-being of the American Healthcare System and to American Employers and Workers, as well;

Indirect Healthcare Costs :

  • Presenteeism– A loss of workplace productivity resulting from employee health problems and/or personal issues.
  • Absenteeism– The habitual non-presence of an employee at his or her job. Possible causes of absenteeism include job dissatisfaction, ongoing personal issues and chronic medical problems.
  • Disability limitation in the ability to pursue an occupation because of a physical or mental impairment; also : a program providing financial support to one affected by disability.
  • Employee Turnover  the ratio of the number of workers that had to be replaced in a given time period to the average number of workers. The cost of replacing an employee is a minimum of 150% of the employees annual compensation figure. The cost will be much higher (200% to 250% of annual compensation) for managerial and sales positions.

All tallied, indirect costs far exceed the direct costs for healthcare; and employee mental health problems, even in their mildest forms, are the single largest contributor to employers indirect healthcare costs. Absence, lost productivity and disability related to mental illness cost employers more than four times the total cost of employee medical treatment!* In addition to an impaired work performance and reduced productivity, employees with mental health problems, even at a sub-threshold level, make more Emergency Room visits, Primary Care Physician visits and have more non-psychiatric hospital admissions than their mentally well counterparts.* If employers were to even partly invest in recognizing employee mental health issues, the returns would be staggering, yet the answer is right in front of their eyes; employee performance.

End of part 1

Not to worry, the answer is coming in the following posts.

Mitchell R. Weisberg, MD

Founder, CEO and Personal Physician

Optimal Performance MD

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A primer for anyone seeking to better understand mental illness

and achieve Mental Wellness 

INTRODUCTION

Medicalizing Mental Health is a concept that has evolved in my mind for over two decades. The result is a reliable method for diagnosing and treating mental illness based on the same clinical perspective from which we physicians diagnose and treat all human maladies. As both an internist and a pscychopharmacologist, I view mental health no differently nor as separate form the other facets of my patients’ health and wellbeing; in fact, I would find that to be impossible. I am well aware that my perspective is one that is far from being universally shared. In fact, most people, including many of my colleagues, seem to prefer keeping mental illness in a black box, as if it is entirely separate from all other facets of the human condition. I contend that this pervasive and arbitrary distinction between mental health and physical health is the primary obstacle keeping our society and our health care system from making significant progress in the recognition and treatment of mental illness. Medicalizing Mental Health is my humble effort at eliminating this obstacle.

According to the World Health Organization, Mental Illness accounts for one-third of all disabled persons worldwide; and the United States and the other developed nations are not immune to this trend.(1) Mental illness significantly impairs the functioning of one in four American adults, half of whom began experiencing mental health symptoms by fourteen years of age and the majority of whom are currently members of the workforce.(2) Americans who have one or more chronic medical conditions, have an even higher prevalence of mental illness. While Major Depressive Illness affects 10% of the American population annually,  the incidence is nearly three times higher (27%) in Americans with Type 2 Diabetes. In those with both disorders, recognizing and treating their Depression improves their Diabetes so they require less medication for glycemic control and they will suffer fewer diabetic vascular complications, such as heart attack, stroke, limb amputation, kidney and eye disease. (3) Nothing more eloquently confirms the inseparable nature of physical and mental health, nor underscores the urgency we face as a society and healthcare system to medicalize mental health. In spite of this, and in spite of their much higher rates of consumption of healthcare services, such as emergency room visits, primary care physician visits and non-psychiatric hospitalizations, only one in three Americans with a mental illness are ever accurately diagnosed, much less do they receive adequate treatment. Finally, mental illness is highly treatable with between 70 and 90 percent of people having significant reduction of symptoms, improvement in their quality of life as well as in their functional status with a combination of medication, talk therapy and other supports. *

What follows is the result of my relentless effort over a period spanning more than two decades to help my patients achieve their optimal level of health and wellbeing; most of what I learned in the process that, to achieve this endpoint with my patients required that I know more about the field of neuroscience than any other component of the whole human condition. I distilled everything that I have learned and experienced on this incredible journey into an organized formula for what may otherwise seem like a scrambled alphabet soup of mental illness. My mission is to demystify mental illness and give my readers a rational, medical perspective from which they can begin to make sense of the single most important facet of human health and well-being. My ultimate mission in writing Medicalizing Mental Health is to make what is currently invisible readily apparent. 

CHAPTER 1

THE MENTAL HEALTH SPECTRUM:

Mental Wellness to Psychosis

All aspects of human health exist on a spectrum from normal, healthy or physiological on one end to abnormal, unhealthy or pathological on the other. Take asthma For example; there are people who have a mild form who simply need a puff of an inhaler when doing vigorous activity. On the other end of the spectrum are those people with severe asthma who, in addition to multiple inhaled medications, also need supplemental oxygen just to do their daily activities. All other disease states, such as heart disease or kidney disease, also exist on a severity spectrum; so too does mental illness.

Traveling across the Spectrum

The changing faces of anxiety and depression

Albert Einstein said that if he had just one hour to save the world, he would spend 55 minutes defining the problem, and then finding the solution would only need five minutes. Medicalizing Mental Health is a method of defining, essentially labeling, mental illness. Thus it is the compulsory first step for anyone who wishes to understand mental illness or achieve mental wellness.

Imagine the spectrum of mental health as a simple line that extends from left to right across this page with the left end of the line representing mental wellness and the right end of the line representing the most severe form of mental illness, psychosis. As we travel to the right from mental wellness I will show how the most ubiquitous and universally recognized of all mental health symptoms, anxiety and depression will evolve in their severity and their associated functional (behavioral) impairments. In fact, Medicalizing Mental Health’s simplicity derives from the fact that anxiety and depression are, in fact the only symptoms that exist across the entire expanse of the mental health spectrum. By the end of this tour, a simplified and bona-fide method of conceptualizing the myriad of mental illnesses will materialize.

Before we begin our journey, there are a few fundamental and connected rules of the road that I need to explain. The first rule is, labels matter. While often perceived as negative, within the context of Medicalizing Mental Health, labels serve to define a mental illness which lead to its solution. Secondly, as far out to the right side of the mental health spectrum that a persons symptoms have traveled labels their mental illness (diagnosis); and regardless of how far to the right a persons symptoms have traveled, they will continue to experience any or all the milder symptoms to the left of that point on the spectrum. In other words, a person with severe mental illness spend much of his or her life in the mildly symptomatic and mentally healthy part of the spectrum. Finally, just like most disease processes, mental illnesses is degenerative; left untreated, mental health symptoms tend to migrate further to the right on the spectrum, becoming more severe, more treatment resistant and leading to more severe functional impairment for the individual. Thus, Medicalizing Mental Health, a method which allows for the early diagnosis of mental illness can be categorized as preventive medicine. Exactly how these rules apply will become much clearer once we are on the road, so buckle up because our journey is about to begin.

 

MENTAL WELLNESS

The place to be

The starting point of our journey is at the left side of the mental health spectrum, mental wellness. The fact is, this is not the place on the spectrum at which most people are currently living, yet it is a destination that all people can get closer to than they are now. Mental wellness is the point on the spectrum where a person lives his or her life unencumbered by mental health symptoms while at the same time maintains the full repertoire of human emotional responses. Mentally well people may have good days, great days and horrible days. However, their emotional responses remain adaptive and do not impair their ability to function, behave or perform optimally. Mental wellness serves as a reminder that sadness, excitement, fear or worry are not inherently negative emotional states. Rather, these are all facets of normal, adaptive emotional responses to events (stimuli) that occur in everyday human existence. It is when these emotional responses occur unprovoked by any overt stimuli or occur in an exaggerated way that they become maladaptive and impair a person’s ability to function, behave or perform optimally. This leads us to a fundamental working definition of Medicalizing Mental Health; mental health symptom: any sensation that impairs a person’s ability to function, behave and perform optimally. This conception of mental wellness is  equal to a person’s ability to perform optimally and begs for clarification of the commonly used term, wellness and how it is fundamentally different from the term, health. While it is obvious that health and wellness overlap to some degree, having health problems does not prevent a person from being well. Similarly, the absence of health problems is not synonymous with wellness. For instance, a person may have health issues such as high blood pressure, asthma or even cancer yet it is still possible for them to be well. However, if a person does not feel well, regardless if their blood pressure is normal and they do not suffer with asthma or cancer, they are not healthy. While differentiating health from wellness may seem a matter of semantics, it is actually a matter of numbers; health can be measured while wellness cannot be measured. I am expounding upon this point due to its relevance to the hundreds of people I have had the honor and pleasure of helping get well over the past twenty-five years. Every day in my practice I have seen patients who had their health problems “successfully” treated, yet in spite of their blood pressures and blood sugars being normalized, their kidney, thyroid or liver functions being corrected and even their tumors shrunk by chemotherapy or entirely removed surgically, they simply may not feel well and therefore are not yet healthy according to my standards, leaving work to be done. Within the context of Medicalizing Mental Health, mental wellness is in fact wellness itself and is what every person should strive to achieve, regardless of their health.

DYSTHYMIA AND NEUROSIS

Pre-depression and pre-anxiety

Moving slightly to the right from mental wellness we arrive at our first destination of interest on our tour of the mental health spectrum, Dysthymia and Neurosis. Dysthymia is best described as pre-depression in which the person feels somewhat sad and has somewhat lost interest in usual activities, but not to the degree that he or she manifests overt impairment in function, behavior or performance, such as missing work, a family or social event. Similarly, Neurosis is pre-anxiety or a persistent sensation of fear and/or worry that it is out of proportion or exaggerated relative to any stimulus in the individual’s environment, but again not to the degree that they suffer any overt impairment such as missing a day of work or a family event.

We will soon discover, that as with Dysthymia and Neurosis, all the destinations we will visit along the spectrum will similarly have two headings just as a sub-way train stops at the intersection of two streets. Along the  route of the mental health spectrum, the two crossroads that intersect are always anxiety and depression, but with continuously evolving symptoms and functional impairments, analogous to there being streets, avenues and boulevards that all share the same name. Underlying this curious observation is the fact that depression and anxiety, while perceptually two distinct symptoms, their recipes share many of the same molecular ingredients. To better visualize this concept, imagine setting out to bake cookies, cupcakes and brownies. When you get to the grocery store you realize that the ingredients needed for each of these recipes are mostly the same, yet there is no mistaking a cookie for a cupcake or a brownie. This molecular ingredient principle not only explains the constant coexistence of anxiety and depression along the entire length of the spectrum but also provides the explanation for the myriad of physical symptoms such as muscle ache, abdominal pain, headache, chest pain, breathing problems and fatigue that, more often than not, also coexist with all mental illnesses. Hence, the tag line for Eli Lilly’s anti-depressant medication, Cymbalta; Depression hurts. Having common molecular ingredients underlies why some anticonvulsants (seizure; epilepsy) medications are effective for treating depression, anxiety and pain. In other words, seizures, depression, anxiety and pain, four distinct entities, like cookies; cupcakes and brownies their recipes share many of the same molecular ingredients. I have gotten a bit ahead of us here, so let us now return to our journey right.

ANXIETY AND DEPRESSION

Are these Diagnoses, Symptoms or Both?

Moving to the right the next intersection of interest is Unipolar Depression and Anxiety Disorders. In contrast to their precursors, Dysthymia and Neurosis, the symptoms of sadness, loss of interest, fear and worry reached by people with Unipolar Depression and/or Anxiety Disorders actually cross the critical threshold causing an overt impairment in an person’s function, such as missing a day of work or a family event. It should come as no surprise that Unipolar Depression and Anxiety Disorders, more often than not, occur within the same person; and a person with Unipolar Depression and/or an Anxiety Disorder will also experience any or all the milder symptoms to the left of that point on the spectrum, including dysthymia, neurosis and even mental wellness.

While we are at this destination there are some important navigational tips that deserve our attention. For one, Depression and Anxiety are actually diagnoses as they are at our present place on the spectrum. However, since depression and anxiety migrate across the full length of the mental health spectrum, often they are merely symptoms of other, more severe forms of mental illnesses further to the right of Unipolar Depression and Anxiety Disorders. Also worth noting is that anxiety itself has two, individual components, worry and fear. Some people may experience just one component, while others may experience both worry and fear, especially as we travel right on the spectrum. The greatest clinical manifestation of fear is a panic attack in which the person experiences an overwhelming sense of fear or an impending doom, often resulting in him or her seeking medical attention from their Primary Care Physician or often at the nearest Emergency Department. Physiologically, a panic attack is identical to the more commonly known fight or flight response, which is a potentially life-saving reflexive response to a mortal threat such as being pursued by a saber-toothed tiger or when stalling on the tracks as a train is coming. When such a reflexive response occurs in the absence of any mortal threat, the fight or flight response transforms from an adaptive or physiological into a maladaptive or pathological response commonly known as a panic attack.

That’s fear, now let’s take a look at worry as it migrates right on the spectrum. Worry itself can best be conceptualized on a spectrum spanning from an individual being too lax or hypo-reactive on one extreme, being appropriately concerned in the middle while worry or being hyper-reactive at the pathological end of the spectrum. For example, a parent setting a curfew for their teenager is an example of an appropriate concern, neither too laxed nor pathologically worried, about the potential harm that may befall their teenager if allowed to roam the streets at all hours of the night. However, a parent that files a missing persons report with their local police because their teen is not home at curfew has an anxiety disorder, and they will predictably over react in other, similar situations; their behavioral response is mal-adaptive, dysfunctional or pathological.

Obsessive Compulsive Disorder (OCD)

When a blessing can become a curse

From here, let’s move our worried parent a little further to the right along the spectrum to this next scenario where he installs a burglar alarm in his home. In and of itself, this is a perfectly proper level of concern and an adaptive behavior in that it can prevent his home from being burglarized and it can protect himself and his family from the potential danger posed by an intruder entering his home. However, each night when setting his burglar alarm he thoroughly inspects its batteries. Being dissatisfied with their quality, he opens a new package of batteries, but none of these seem to pass his rigorous inspection either. He proceeds to put on his robe and slippers and drives to the 24-hour mini-mart down the block where the clerk knows him by his first name and informs him that there is a sale on Duracell in aisle one. Our worried parent has now graduated to acquiring televisions’ favorite anxiety disorder called OCD or Obsessive Compulsive Disorder. As you may notice, OCD is to worry, as a panic attack is to fear. An obsession is nothing more or less than a really big worry we will call an uber-worry; a worry so big that nothing short of corrective action (compulsive behavior), such as driving to the mini-mart to buy new will ease it.

Obsessive Compulsive Disorder provides profound insight into the laws governing the fundamental relationship between mental-health and behavior. For one thing, OCD beautifully illustrates a principle which applies generally to all mental illnesses; what may have started out as an adaptive character trait or blessing can go too far and become maladaptive or a curse. Being obsessive-compulsive is not by itself a disorder. To the contrary, being obsessive-compulsive is a good character trait. During my medical training obsessive-compulsive behavior was highly regarded and encouraged by my mentors. For instance, before I would add extra potassium to a patient’s IV fluids, I always double, even triple checked the results of the patient’s potassium level. Seeing that a person can perish suddenly from high potassium levels, triple checking a laboratory report is not considered pathological but rather as an adaptive behavior that was in keeping with the golden rule of the Hippocratic oath to first do no harm. OC is an excellent character trait and it did not come with the letter D attached. OCD does not occur in a vacuüm. Most people with OCD will describe themselves as being Type-A or driven from their earliest memories and that up to some point in their lives and even now, their obsessive-compulsive trait served them well.

I have observed that leaders have a generous dose of the obsessive-compulsive trait, which manifests as their being motivated, driven or caring about things to the degree that they take appropriate action. If we were to make a simple graph, with Obsessive Compulsive (OC) on the X-axis and Performance on the Y-axis we would get a classic bell-shaped curve. On our graph, let’s use delivering a persuasive speech as an example of performance. A person who is on the left of the center on the X-axis has too low a level of obsessive-compulsive trait performs poorly because they don’t care enough to effectively motivate their audience to take action. A person that is equally far to the right of center on the X axis has too high a level of obsessive-compulsive trait and also performs poorly but for exactly the opposite reason. In this case the person cares passionately about the subject, has rehearsed his speech many times weeks in advance, but the morning he is to give the speech he feels that it does not adequately express his passion and concern for his subject, so he re-writes his speech several more times. When the time comes to actually deliver his persuasive speech, he flops; OC gets a after it, causing him to sweat the small stuff impairing his ability to persuade his audience to do anything other than to awkwardly avert their gaze from the speaker. This poor fellow flopped, not because he does not care enough but because he actually cares too much. The goal of treating OCD (curse) is not to rid the person of his obsessive-compulsive (OC) trait (blessing) but to curtail it just enough to allow him not to sweat the small stuff and move to the top of the performance curve.

NEUROPLASTICITY

The Molecular Structure of Human Performance

By reducing obsessive thinking to an uber-worry and compulsive behavior to the natural result or byproduct of this uber-worry we are now ready to explore in detail the fundamental relationship between mental health, behavior and performance. We are about to navigate the most demanding terrain on our journey across the spectrum, so please watch your step carefully as we go ahead.

We will begin this part of the journey by defining Human Performance as the part of human function in which a person performs purposeful tasks according to measurable degrees of efficiency, accuracy and timeliness. Being that any entity possessing function must have a corresponding structure and being that human performance is a part of human function, leads to the question, what is the structure of human performance? If we peel back human performance the first layer we will see is a collection of well coordinated behaviors. These behaviors are carried out exclusively by the human body; the skeleton, muscles, joints and connective tissues. Before the body can carry out a behavior, an impulse or multiple impulses within the brain needs to occur first.  All human behaviors, and thus all human performance, are nothing more or less than a functional byproduct or downstream effect of the continuously changing neuroplastic molecular structure that is the human brain.

To understand the concept of neuroplasticity, imagine a soldier on the battlefield that suffers a shrapnel injury to his shoulder. The first thing a medic will do when attending to this soldier writhing in pain is inject as many ampules of morphine as it takes to get the soldier to remain still while he examines the soldier’s wounded shoulder. If the medic injected this same dosage of morphine just seconds before his injury, the soldier would have died instantly; this is neuroplasticity. Each of the 100 billion cells (neurons) that form the human brain interconnects and communicates with thousands of other neurons via chemical messengers called neurotransmitters. The final destination of these trillions of chemical messages from the brain is the neuromuscular junction, which as it name implies, is the point where the brains’ chemical messages become direct orders for the body to execute. In reality, the brain behaves like a liquid soup and not a solid organ; and its composition changes as quickly as when adding salt to a bowl of soup or sugar to a cup of coffee. In the case of our injured soldier, the very instant that he got wounded the composition of his brain changed to such a degree that the dose of Morphine that would have killed him before he was injured helped save his life after he was injured.

Now, within this context of neuroplasticity, we see how an obsessive thought (cause) translates into a compulsive behavior (effect). Furthermore, what we refer to as our sense of well-being, or our mental health is merely a perceptual reflection of the molecular structure of our brains at that point in time. Whether we perceive extreme pain as our wounded soldier, anxiety, exhaustion, exhilaration or any combination of these sensations, there is always a structural template in our brain that corresponds to our perception. Thus, the genesis of all human performance, everything that we do and how well or how poorly we do it, depends on our brains’ continuously changing molecular structure. Taking neuroplasticity to it’s logical conclusion, any process that improves or impairs a persons performance, does so by changing the molecular recipe of their brain. Whether a painful ingrown toenail, a shrapnel injury, pneumonia, a manic episode or sweating the small stuff from OCD, the structure of human performance is neuroplasticity.

POST TRAUMATIC STRESS DISORDER (PTSD)

Where Nature and Nurture Converge

It is important while we are it this point on the spectrum that we stop to visit Post Traumatic Stress Disorder or PTSD. As its name implies, PTSD can occur when a person experiences or witnesses a life-threatening trauma. The primary symptoms resulting from exposure to such trauma are a persistent re-experiencing of the traumatic event while awake and as night terrors when sleeping; avoidance of stimuli associated with the trauma and persistent symptoms of increased arousal (fear and worry). PTSD is as an Anxiety Disorder and shares the symptoms of excessive worry and fear that is common to all the other disorders in this class. Individuals with PTSD typically do not seek medical attention as a direct result of their traumatic experience but rather for the anxiety symptoms and functional impairments that are often a latent manifestation that may occur years after the traumatic experience. It is imperative to ask about any past traumatic experiences in all people who are suffering with anxiety symptoms. People whose anxiety disorders develop as a result of a traumatic experience need much more medical attention, specifically with regards to Cognitive Behavioral Therapy (CBT), than those with non-trauma associated anxiety disorders. It should come as no surprise that it is quite common that people with PTSD may also have panic attacks as well as OCD.

THE BIPOLAR SPECTRUM

Crossing the Great Divide

Up until this point on the journey across the mental health spectrum anxiety, as it progressed to Panic Disorder and OCD, commanded most of our attention while depression has remained mostly in the background. As we continue to travel right we are about to cross a border, more aptly a great divide, into Bipolar territory. As we enter, we will shift our attention towards depression, for while Unipolar Depression and Bipolar Depression have more similarities with one another than differences, recognizing the subtle differences between these two, biologically distinct disorders is the single most important part of the entire journey. On the right side of this great divide, it seems that there are new molecular ingredients contributing to the recipes of Bipolar Disorder. It is at this very point on the mental health spectrum that most explorers that came before us have gotten lost; and with devastating consequences. Please stay very close to me as we continue right.

As we set off, the most important landmark to look for is maniaits presence indicates that we are definitely in Bipolar Territory. Mania is seven or more days of a high-energy state during which a person needs little or no sleep, has racing thoughts, talks excessively, is relentlessly hyperactive, agitated and irritable. While an extremely reliable landmark when it is present, mania is  a relatively rare manifestation, typically occurring late in the course of Bipolar Disorder. Therefore, the absence of mania by no means excludes the possibility that someone is in Bipolar territory. Bipolar Disorder is primarily a depressive illness; manic symptoms may not manifest for years, even decades after the first depressive symptoms. This explains why Bipolar Disorder takes an average of 10 years and three or more physicians to diagnose and is most often mis-diagnosed as Unipolar Depression. Adding further to this diagnostic challenge, when it does occur, mania is typically perceived by the person with Bipolar Disorder as feeling good or normal and provides no impetus for the person to seek professional attention.

Healthcare providers failure to recognize Bipolar Disorder or mis-diagnosing it as Unipolar Depression are common mistakes made in the course of treating people with mental illness and here is why this is extremely dangerous. The most commonly prescribed medicines used to treat Unipolar Depression are the antidepressants. There are several classes of antidepressants with the most common and most popular being the Selective Serotonin Reuptake Inhibitors or SSRIs with Prozac (Fluoxetine), introduced to the market by Eli Lilly and Company in 1987 being the first in this class. Many others have followed since including Zoloft (Sertraline), Paxil (Paroxetine), Fluvox (Fluvoxamine), Celexa (Citalopram), Lexapro (Escitalopram) and drugs from a very similar class called Serotonin Norepinephrine Reuptake Inhibitors or SNRIs including Effexor (Venlafaxine), Cymbalta (Duloxetine) and Pristiq (Desvenlafaxine). There are many other classes of antidepressants that are older than the SSRIs that are still commonly prescribed, with Elavil (amitriptyline) being the most popular. Regardless of the class, if a doctor prescribes an antidepressant (by itself, in the absence of a mood stabilizing medicine; to be discussed elsewhere) for a person with Bipolar Disorder, it will have one of two outcomes; no effect at all or it will make the person’s mood worse with the worst case scenario being suicide.

This information should make it painfully clear why knowing our precise location on the mental health spectrum is of vital importance. It also makes sense of the U.S. Food and Drug Administration’s (FDA) public warning in October 2004 about the increased risk of suicidal thoughts or behavior (suicidality) in children and adolescents treated with SSRI antidepressant medications and the 2006 recommendation that extended the warning to include young adults up to age 25. Most people with Bipolar Depression experience their first major bout of depression before the age of 25 years, provides us a landmark that must always be sought. Any person that has a major depressive episode before age of 25 years has Bipolar Disorder until proven otherwise!

What is clear at this point on our tour of the mental health spectrum is the diagnostic dilemma Bipolar Disorder presents. Mania, the most distinguishing characteristic of Bipolar Disorder, is a rare phenomenon which when it does occur typically does so decades after an individual experiences their first major depressive episode. Distinguishing Bipolar from Unipolar Depression is not merely an exercise in semantics. To the contrary, making or not making this distinction can be life saving or life threatening. Thus, it is imperative that we recognize when we have crossed the great divide into this region of the mental health spectrum.

Here are all the major landmarks in Bipolar Territory:

  • Age under 25 years, or a history of a previous major depressive episode before age 25 years.
  • A strong family history of Bipolar Disorder
  • A family history of suicide
  • A non-response or an adverse response to earlier treatment with antidepressant medications.
  • A current or a history of a manic or hypomanic episode
  • Cyclical nature to the depression or mood swings
  • A rapid onset of an extremely profound depression (melancholia)
  • Prior attempts or thoughts of suicide

As we continue to move further right on our journey through the mental health spectrum we will mostly be traversing the vast space represented by the Bipolar Spectrum. While there is still much to learn about this complex disorder one thing is certain; recognizing, diagnosing and initiating treatment for an individual with Bipolar Disorder as early in its course as possible is paramount! With each episode the person experiences, whether depression, mania or mixed stateBipolar Disorder is a degenerative process which actually causes brain damage in its wake while becoming more indistinguishable from Schizophrenia and Psychosis while becoming ever more treatment resistant. At this extreme right end of the mental health spectrum, anxiety manifests as paranoia in which a persons’ fear becomes so extreme and so pervasive that they have excessive and irrational suspiciousness and distrustfulness to the degree that they isolate themselves from society and all other people who were before a part of their lives. Their depression is so extreme and consuming that as many as 40% of people in this part of the spectrum attempt to end their own lives with 10% being successful.

CONCLUSION

Where we came from and where we go from here

We have come to the end of the mental health spectrum, so let’s review our journey. We now understand that an individual with Bipolar Disorder, especially early in their course, experiences some or all the milder symptoms to the left on the mental health spectrum. It is not uncommon to see an individual with Bipolar Disorder also meeting the diagnostic criteria for Obsessive Compulsive Disorder, Panic Attacks or Dysthymia. In addition, an individual with Bipolar Disorder can have many normal days, weeks months and years of their lives. Depression and Anxiety are not always a diagnosis, and to be certain that we make the correct diagnosis, we should always initially suspect of being manifestations of the more severe disorders that are further to the right on the spectrum. Our tour of the spectrum has shown us that mental illness is a medical process and like any other medical processes the sooner it can be recognized and treated the better will be the long-term outcome. Medicalizing Mental Health and viewing mental illness on a spectrum allows us to accurately define mental illnesses, and we do not need to be Einstein to understand that this is the first step towards solving the problem.

Conspicuous by its absence on our tour of the mental health spectrum is the most common mental health disorder in the US today. Attention Deficit Hyperactivity Disorder (ADHD) does not exist anywhere on the mental health spectrum. Instead, it travels on its own parallel spectrum, frequently interacting with the mental health spectrum, giving it an added dimension. In the next chapter we will take a fascinating journey along the spectrum of ADHD so please continue to focus intently and pay close attention.

Mitchell R. Weisberg, MD

Optimal Performance MD

an excerpt from:

Medicalizing Mental Health:

A Rational Approach to an Emotional Topic

By

Mitchell R. Weisberg, MD

 

The starting point of our journey is at the left side of the mental health spectrum, mental wellness. The fact is, this is not the place on the spectrum at which most people are currently living, yet it is a destination that all people can get closer to than they are now. Mental wellness is the point on the spectrum where a person lives his or her life unencumbered by mental health symptoms while at the same time maintains the full repertoire of human emotional responses. Mentally well people have good days, great days and horrible days. However, their emotional responses remain adaptive and do not impair their ability to function, behave or perform optimally. Mental wellness serves as a reminder that sadness, excitement, fear or worry are not inherently negative emotional states. Rather, these are all facets of normal, adaptive emotional responses to events (stimuli) that occur in everyday human existence. It is when these emotional responses occur unprovoked by any overt stimuli or occur in an exaggerated way that they become maladaptive and impair a person’s ability to function, behave or perform optimally.

This conception of mental wellness is thus synonymous with a person’s ability to perform optimally and begs for clarification of the commonly used term, wellness and how its meaning is fundamentally different from the term, healthy. While obviously health and wellness are related to some degree, having health problems does not prevent a person from being well just as the absence of health problems is not the same as being well. For example, a person may have health issues such as high blood pressure, asthma or even cancer yet it is still possible for them to be well. However, if a person does not feel well, regardless of their blood pressure or whether they have or do not have asthma or cancer, they are not healthy. While differentiating health from wellness may seem a matter of semantics, it is actually a matter of numbers; health can be measured while wellness cannot. I am expounding upon this point due to its relevance to the hundreds of people I have had the honor and pleasure of helping get well over the past twenty-five years. Every day since I have been in practice I have seen patients who may have had their health problems “successfully” treated, yet in spite of their blood pressures and blood sugars being normalized, their kidney, thyroid or liver functions being corrected and even their tumors shrunk by chemotherapy or entirely removed surgically, they simply may not feel well and  are not yet healthy according to my standards, leaving work to be done. Within the context of Medicalizing Mental Health, mental wellness is in fact wellness itself and is what every person should strive for, regardless of their health.

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