Technical but Interesting Anyway

Here is a medical research article that is interesting although medically technical.

Original Article

Magnetic resonance imaging brain activation in first-episode bipolar mania during a response inhibition task

Stephen M. Strakowski, Caleb M. Adler, Michael A. Cerullo, James C. Eliassen, Martine Lamy, David E. Fleck, Jing-Huei Lee and Melissa P. DelBello

Division of Bipolar Disorders Research, Department of Psychiatry, and the Center for Imaging Research, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA

Correspondence to Dr Stephen M. Strakowski, Department of Psychiatry, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML0559), PO Box 670559, Cincinnati, OH 45267-0559, USA. Email: Stephen.Strakowski@uc.edu

Copyright Journal compilation © 2008 Blackwell Publishing Asia Pty Ltd

KEYWORDS

bipolar disorder • first-episode mania • fMRI

ABSTRACT

Aims: Impulsivity is common in bipolar disorder, especially during mania. Understanding the functional neuroanatomy of response inhibition, one component of impulsivity, might clarify the neural substrate of bipolar disorder.

Methods: Sixteen DSM-IV first-episode, manic bipolar patients and 16 matched healthy subjects were examined during a first manic episode using functional magnetic resonance imaging while performing a response inhibition task. All subjects were studied using a 4.0 Tesla Varian Unity INOVA Whole Body MRI/MRS system. The response inhibition task was presented using non-ferromagnetic goggles, and task performance was recorded during scan acquisition. Imaging data were analysed using analysis of functional neuroimages. Group contrasts were made for the specific response inhibition measure.

Results: The groups performed the task similarly, although both demonstrated relatively poor rates of target response, but high rates of successful 'stops'. Despite similar behavioural results, the groups showed significantly different patterns of functional magnetic resonance imaging brain activation. Specifically, during response inhibition, the healthy subjects exhibited significantly greater activation in anterior and posterior cingulate, medial dorsal thalamus, middle temporal gyrus, and precuneus. The bipolar patients exhibited prefrontal activation (BA 10) that was not observed in healthy subjects.

Conclusions: Bipolar and healthy subjects exhibit different patterns of brain activation to response inhibition; these differences may reflect different functional neuroanatomic approaches to response inhibition between the two groups.

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Bias learned from the Liberal Media?

This article also discusses the stigma viewed by many in America of the mentally ill. It is stated here and questioned about how the stigma gets introduced into the minds of the average American anyway. One theory is through the media which I find as a funny dichotomy, almost an oxymoron. The liberal media should embrace the mentally ill, they are usually outside the mainstream in their thinking which should be right "up the alley" of the media.

Patient Groups Tackle Stigma Attached To Bipolar Disorder And Other Mental Illnesses With New Tools

Mental illness is one of the last surviving stigmas in today's liberal society. Class, race, religion, gender and sexual orientation, are all off-limits now as reasons for discrimination, social exclusion, jokes or disparaging remarks of any kind. Where these are concerned, we've come a long way in terms of tolerance, fairness and sensitivity to the feelings of others; as a rule, words are chosen carefully so as not to offend and legislation ensures fair treatment. Mental illness, however, despite affecting one in four of us at some point in our lives, still provokes prejudice, especially in the workplace. Job applications frequently ask potential employees to declare treatment for a mental illness. Those who answer truthfully are invariably unsuccessful and those in work who report mental illness can find themselves passed over for promotion. As a result many people with mental illness experience rejection, unemployment and a sense of social isolation through no fault of their own. Fewer than 20 per cent manage to hold down a job, according to patient advocacy groups.

"Living with mental illness is tough enough without having added to the burden of illness, the pain and rejection of stigma," points out John Bowis, a member of the European parliament. But it's not just employers who are to blame. "We all contribute to the stigmatisation of people, who if they had a physical problem, would receive our sympathy and support," he suggests.

Stigma attached to mental illness appears to remain a worldwide problem, affecting people of all cultures. In a recent survey among people with bipolar disorder, conducted globally by the pharmaceutical company AstraZeneca, 88 per cent said they felt stigmatised and socially isolated on account of their condition. Bipolar disorder, characterised by severe and recurring mood changes along a spectrum ranging from overactive, excited behaviour (mania) at one end to deep depression at the other, usually requires pharmacological treatment and psychosocial training in behavioural strategies to maintain mental equilibrium. Therapies are available that could potentially help many people who are currently keeping their illness to themselves, struggling on without medication. Treatment would give them a better chance to lead fulfilling lives at work and home. Unfortunately, perceived stigma is a major factor stopping them coming forward for diagnosis and treatment. The issue is a serious one because there is a high risk of suicide among inadequately managed people with bipolar disorder.

A Lexicon to help the media avoid negative stereotyping

How public perceptions of mental illness are formed and give rise to stigma is debateable. The role of the media may be merely to reflect rather than shape public perceptions; but many people believe misrepresentations of mentally ill people are constantly reinforced unnecessarily by all kinds of media from newspaper and broadcast news-reporting, to literary fiction, TV drama and film. In Spain, the US and the UK, over half of people with bipolar disorder, and their carers, said they believe the media is a major propagator of discrimination against people with mental illnesses.

Ignorance is the root cause of stigma. Overcoming it requires education and greater awareness at public level of what mental illness involves and how recovery is possible with treatment, say organisations such as the World Federation for Mental Health (WFMH). As they see it, the media could be potential allies in changing public attitudes.

The WFMH and six other patient advocacy groups recently collaborated on a publishing initiative for journalists titled "The Lexicon: International Media guide for Mental Health" with the help of an educational grant from AstraZeneca. "The Lexicon" has been designed in consultation with people with first-hand experience of mental illness as well as senior journalists, to help journalists promote responsible and accurate coverage of mental health issues and to give a balanced perspective. Journalists can consult "The Lexicon" when writing news stories involving a mentally disturbed person to select appropriate terminology and to write with sensitivity instead of opting for pejorative labels. It includes expert contact details, facts and statistics about mental illness, the correct definition of much misused terms like "schizophrenic" and "split personality", and gives examples of good and bad reporting.

Discussing "The Lexicon" at a recent AstraZeneca media event, WFMH immediate past president Dr Patt Franciosi said: "It shows journalists how to replace words that hurt with words that could help". Instead of terms no better than playground insults such as "nutter", "psycho", "schizo" and "sicko", The Lexicon suggests instead using the person's correct diagnosis or a term such as "disturbed" which does not carry condemnation. Before publishing a story involving a mentally ill person, Dr Franciosi suggests journalists should ask themselves if mentioning a diagnostic label is relevant. She advises. "Read it through and ask yourself - is this offensive? If it involved a relative of yours, would you want someone to say that about them?" The Lexicon is available from the website www.forum4mentalhealth.com/lexicon.

"Learning about Bipolar Disorder"

Another publishing initiative from the WFMH, also supported by an educational grant from AstraZeneca, is an educational 'tool-kit' titled "Learning about bipolar disorder". This is aimed principally at people seeking help for mood disorders but includes a special section for healthcare professionals.

"Until the nature of bipolar disorder is better understood, and until stigma is reduced, many people with mood disorders will avoid or delay seeking help and remain in denial," believes Dr Franciosi. "In the process, marriages are wrecked and jobs lost." Around 27 million people worldwide are affected by bipolar disorder. It is the sixth leading cause of disability, yet much of it goes undiagnosed for years, she points out. The tool-kit is designed to empower people with bipolar disorder and their families by giving them the information they need to recognise, accept and manage symptoms more effectively. Of equal importance is the inclusion of advice directing them on how to create and maintain a healthy lifestyle, she notes. "Over half of people with bipolar disorder abuse substances such as alcohol. This has to be recognised and help given to overcome it."

The "Learning about Bipolar Disorder" tool-kit also provides information for health care professionals in primary care to whom people with bipolar disorder are likely to turn first for help. Explaining bipolar disorder to new patients presenting with mood disorder symptoms can present a challenge Dr Franciosi acknowledges. "Primary care staff cannot be expected to teach every patient all they need to know in detail." The tool-kit offers them a way to pass on that information in a format that is quick and easy to access and in which medical knowledge is translated into layman's language.

As a patient information guide Dr Franciosi claims the tool-kit is particularly effective for a reason. "We found that what makes this special is the inclusion of personal stories. These are what hit home the most," she explained. "People read the experiences of others and find they resonate with their own." It helps them find the means to understand their own illness history and articulate it, and to see how others have learned to manage their condition. "Cultural differences are reflected in people's stories but these have nothing to with who gets bipolar disorder and who doesn't. The condition affects people of all cultures and people are vulnerable to it throughout the world."

Two Weeks to Go

I am not expressing an opinion of either Presidential Candidate on this blog, but the following information should be read. The information in this article shows where each candidate stands on an issue that is close to the heart of a lot of us in America. Please stay informed, make informed, educated decisions on the issues that affect us. Don't just expect "someone else" to take care of things for you.

The 2008 Presidential Election Mental Health: The Candidates & Party Platforms

Explore the Candidates

In early 2008, the National Alliance on Mental Illness (NAMI) sent a questionnaire to all presidential candidates in each party. We encouraged candidates to provide us with other relevant materials or explanations of their positions on issues involving mental health even if they did not have time to respond to the questionnaire.

NAMI offers these responses and excerpts from party platforms for educational purposes only. NAMI is a non-profit, non-partisan organization. Non-profit charitable organizations, including NAMI state and local affiliates, are prohibited by law from endorsing specific candidates. This information should not be used by any NAMI affiliate to endorse any candidate.

Democratic Presidential Nominee

Sen. Barack Obama of Illinois

• Questionnaire response

Republican Presidential Nominee

Sen. John McCain of Arizona

• Sen. McCain provided NAMI with a Mental Health Statement in lieu of a response to our questionnaire. The Campaign informed NAMI that it is his policy not to respond to questionnaires.

View statements or responses of former presidential candidates who responded.

Explore the Party Platforms

NAMI offers excerpts from the Democratic and Republican party platforms that are relavent to mental health.

• Health Care
• Education
• Veterans

See also the full Democratic and Republican platforms.

Presidential Candidate Sites

www.johnmccain.com
Official website of the McCain campaign

www.barackobama.com
Official website of the Obama campaign

New Bill Explaination

Here is one good explaination of the new mental health bill that was passed tagged along with our bail-out plan.

Parity legislation helps people with mental illness

By DOMINIC HODGKIN and CONSTANCE HORGAN
GUEST COLUMNISTS

More than one in four Americans will suffer a mental or addictive disorder at some point in life. Lawmakers have now granted them a level playing field in health insurance. Congress took a historic step when, as part of the financial bailout package, it passed legislation prohibiting insurers from discriminating against people with mental illness and addictive disorders.

This is great news for the 113 million Americans who faced unequal treatment under insurance plans that apply tougher benefit limits or higher copayments for mental illness or addiction treatment than they do for medical and surgical conditions.

For decades, science has been gradually lifting the curtain on mental illness and addiction, making effective treatment available for many disorders. With this watershed legislation, policymakers are helping to close the door on the age-old culture of stigma toward people with mental illness or addictive disorders.

The bill's passage may prove unexpectedly well-timed. With the economy in trouble, there will undoubtedly be more need for mental health services. Research shows that economic recessions lead to more family stress, suicides, drug abuse among teenagers and binge drinking.

News of the bill's passage was buried by the drama-filled bailout. Indeed, some derided it as an earmark tacked on to the package, like the one for wooden arrows. These comments were off-target. The parity legislation was not a random item sheltered by the rescue package.

Leaders in both houses had been vigorously discussing the bill for months, and had largely approved it. It was the culmination of years of bipartisan efforts by Sens. Ted Kennedy, Pete Domenici and the late Paul Wellstone, and Reps. Patrick Kennedy and Jim Ramstad, among many others.

Mental illness has long been a target for discriminatory practices in private insurance markets. As a result, starting in the 1990s many states, among them Washington, passed parity laws, and the federal government passed a limited law in 1996.

But those measures had large loopholes. States often exempted important diagnoses such as addictions and eating disorders. Moreover, 82 million people are covered by employers exempt from state regulation. As for the federal law, it banned only special dollar limits on mental health coverage, allowing plans to continue using other limits and exclusions.

A Brandeis University survey of private health plans found that more than 90 percent had special annual limits on outpatient mental health and addiction treatment, and 40 percent required substantial copayments (more than $20 per visit, or 20 percent of charges). Those provisions result in high out-of-pocket costs for patients needing longer treatments.

The new federal law improves on the 1996 one in a variety of ways. First, it applies to addictions as well as mental health. Addictions are one area where the public and the patient benefit considerably from treating the problem. Successful treatment should reduce crime, car accidents and emergency room use, all of which impose costs on society. Arbitrarily limiting addiction treatment makes little sense.

Second, the new law prohibits a wider range of discriminatory practices, such as the use of special limits on the number of days or visits per treatment episode or per year. Those changes should improve access and reduce the cost for many of the millions suffering from these disorders. However, large increases in utilization are unlikely under managed care. Plans retain the ability to deny or curtail treatment based on their review criteria (although they must now disclose those criteria).

The bill applies only to people with private insurance, but sets a good precedent for mental health coverage in any future expansion of coverage to the uninsured. It's tragic that people with mental and addictive disorders are overrepresented in this group.

With any luck, the bailout will avert an economic depression. But just in case, it's critical that many more people now have better mental health coverage to weather good times and bad.

Good News

We will see in the future how this bill will help everyone.

Mental-health parity law a big win for Kennedys

Tucked into the Wall Street bailout bill was a breakthrough for the estimated 113 million Americans suffering from mental illness - a provision making it illegal for health insurance companies to discriminate against patients suffering from psychological or behavioral disorders.

Adoption of the measure, hailed by a leading mental health advocacy group as a "great civil rights victory," marks the end of a decade-long struggle led by Senator Edward M. Kennedy of Massachusetts and his son, Representative Patrick Kennedy of Rhode Island, to ensure parity for mental illnesses in the eyes of the American healthcare system.

"The miracles of modern medicine make mental illness just as treatable today as physical illnesses," Kennedy, who is being treated for brain cancer, said in a statement. "After 10 years of debate, Congress has finally agreed to end discrimination in health insurance coverage that plagues persons living with mental illness for so long."

Kennedy added: "It will now be the law of the land that people with such illnesses deserve the same access to affordable coverage as those with physical illnesses."

The lead Republican sponsor in the Senate, Pete V. Domenici of New Mexico, singled out the Massachusetts Democrat for credit, calling his efforts remarkable. "This has been a labor of love for us," Domenici said in a statement.

The mental parity law, one of many amendments included in the legislation to broaden legislative support for the bailout package, requires health insurance companies to charge the same deductibles, copayments, and out-of-pocket expenses for mental health treatments as for all other illnesses.

Among other requirements, the law also requires the US Department of Labor to report to Congress every two years on how group health plans are complying with the law.

The nonprofit Mental Health America estimates that 67 percent of adults and 80 percent of children requiring mental health services do not receive help, in large part because of discriminatory insurance practices.

"This is a historic day and a great civil rights victory for millions of Americans who have been unable to access mental health treatment," said David Shern, the organization's president and CEO. "With approval of this bill we will tear down the walls of stigma and discrimination and open the doors to the power and promise of treatment and recovery."

Bill will Help with Insurance costs for the Mentally ill and their Employers

One of the issues in the mental illness debate is, will employers feel like giving a mentally ill person a chance to prove that they can be a productive and dependable employee. I see this in the school system. I have some teachers who will take the time and use their teaching energy in a positive way to take the extra time it takes to work with a mentally ill student. On the other hand, a lot of teachers don't have the patience to give them the benefit of the doubt and just want them out of their rooms. I say "Thank you to the educators who will give those students not only a second chance but a third and fourth chance if needed.

Lawmakers make a final push for mental health bill

By KEVIN FREKING – 2 hours ago

WASHINGTON (AP) — Talk about going out with a win.

Sen. Pete Domenici, R-N.M., has spent years fighting for legislation that would require insurance plans to treat mental health patients on par with those who have physical ailments. No more higher copays or deductibles for the mental health treatments. No more limits on visits to the doctor that differ from the caps for other patients.

Domenici, after six terms, is leaving office this year. One of his final votes was on the mental health legislation he fought so hard for over the years.

The mental health protections are part of a massive bill designed to help the economy. Dominici senses that somehow the bill will become law, even though many lawmakers from both parties are unhappy with the economic bailout.

Domenici has a daughter diagnosed with atypical schizophrenia. He got involved in the parity issue after joining a National Alliance on Mental Illness support group nearly 20 years ago. On his way home from work, he and his wife, Nancy, would meet with other parents of children with mental health problems.

"The first real understanding of how broad the problem was came from those meetings where I met with mothers and fathers who had children who were mentally ill, and they were going bankrupt because they couldn't pay the health bills, or their children were in jails instead of hospitals," Domenici said.

He said perceptions about the ability to treat mental health problems have changed greatly over the years, but coverage has also become an expensive proposition. So, he and others, such as the late Sen. Paul Wellstone, D-Minn., began pushing for health insurance parity. Pushback came from those who would have to bear most of the expense.

"Those who stood to lose fought hard and that was principally insurance companies and businesses," Domenici said.

Employers and insurers were concerned that legislation would have required plans to cover a "telephone book" of conditions, raising costs beyond what companies and their workers could afford and potentially negating companies' ability to offer any health coverage at all.

The legislation now before the House does not mandate that group health plans cover mental health or addiction treatment, only that when plans do so, the coverage must be equitable to other medical coverage. The insurance industry is now a strong supporter of the parity legislation.

In 1996, Sens. Wellstone and Domenici won passage of a law banning insurance plans that offer mental health coverage from setting lower annual and lifetime spending limits for mental treatments than for physical ailments.

The pair again teamed up in 2001 on a predecessor to the legislation now before the House. After Wellstone was killed in a plane crash in 2002, Sens. Edward Kennedy, D-Mass., and Mike Enzi, R-Wyo., took on larger roles in getting a bill passed in the Senate.

The requirement for equal treatment in insurance coverage would apply to health plans that cover more than 50 employees — potentially reaching 113 million people nationwide.

Health officials contend that equal protections for mental health conditions would lead to a healthier, more productive work force.

"There's a phenomenon ... where you've got a psychiatric illness and you're able to get around but you can't do your work at the same quality you did before," said Dr. Nada Stotland, president of the American Psychiatric Association.

"Many workers today are in the service industry. If a person on the other end of the line is depressed, they may have shown up to work and they may be present, but they will not necessarily make us happy about the company that we're calling. They'll be slow, unhappy and maybe irritable, and their powers of concentration won't be good. So, more and more companies want to see their employees treated."

Overall, the parity legislation is expected to cost the federal government about $3.4 billion over 10 years. That's because employers will have more health expenses that they can deduct from their income taxes.

Continuing Progress on Mental Health Bulls

Editorial: Time for parity for mental health coverage

by The Grand Rapids Press Editorial Board

Sunday September 28, 2008, 3:00 AM

WHY IT MATTERS

Mental illness can be just as terrible and even deadly as physical illness, but isn't treated that way by some insurers.

Diseases of the mind aren't always as visible or obvious as those of the body. But depression, schizophrenia and other serious ailments can be just as debilitating and deadly as diabetes and heart disease. Still, mental illness is too frequently treated differently by health insurance companies.

Last week, the U.S. House of Representatives passed a bill that will improve insurance coverage for people with mental illness. The bill caps more than a decade of debate on the question, and marks an important step forward in addressing diseases that are increasingly treatable and beatable, provided they receive proper attention and care.

The legislation mandates mental health parity, making it illegal for insurance companies to set lower limits on treatments than are set for physical ailments. The bill prohibits higher co-pays for mental health treatment, too. And it requires equal treatment for substance abuse, provided that it is offered by a medical plan.

Those provisions would end restrictions in many insurance plans that can force people with long-term illnesses such as bipolar disorder or anorexia to pay for their own treatment or forgo treatment altogether because they can't afford the cost.

A mental health parity bill has already passed the Senate by a vote of 93 to 2. The House legislation passed by a vote of 376 to 47.

The two versions need to be reconciled. President Bush has expressed support.

Nearly every member of Michigan's congressional delegation -- Democrat and Republican -- voted for the measure. The sole exception was Rep. Peter Hoekstra, R-Holland.

The bill could raise costs. Any hike in insurance premiums is difficult, especially given the skyrocketing price of health care generally. However, the Congressional Budget Office projected that an earlier version of the parity bill would increase premiums for group insurance rates by only four tenths of one percent.

Untreated and under-treated mental illness carries costs of its own, from worker absenteeism to family break-up. Building a better system of healing and prevention for mental illness will decrease those expenses to individuals and society.

The bill contains safeguards for small business, exempting those with fewer than 50 employees. The legislation does not mandate that mental health coverage be made available by businesses that don't currently offer health coverage. And it does not specify which mental illnesses should be covered, allowing health plans discretion to deal with more controversial and questionable diagnoses. If coverage is rejected, the bill requires a health plan to explain why.

In all, the measure strikes the right balance between costs and the health care needs of ordinary people. Those who suffer from mental illness -- estimates are as many as one in four adults in the United States -- know those conditions can leave them alone and adrift. Congress and the president can throw them a lifeline by completing and signing this important legislation.