Millions of yearly visits to the ER involve patients with mental disorders and substance abuse problems

Not every emergency room visit involves a physical problem. Out of 95 million visits made to emergency rooms by adults in the U.S. in 2007, 12 million, or 12.5%, had to do with mental disorders, a substance abuse problem, or both.

The findings are from a report recently put out by the U.S. Agency for Healthcare Research and Quality, part of the Department of Health and Human Services.

Of those 12 million visits, about 66% involved patients with mental disorders, about 25% involved patients with substance abuse issues and the rest involved patients who had both a mental disorder and a substance abuse problem.

Almost 41% of those 12 million visits resulted in the patient being admitted to the hospital, which is more than 2.5 times the rate of hospitalizations for other conditions.

Almost 54% of the mental health/substance abuse-related visits were from women. About 47% of the visits were by people age 18 to 44, and about 35% were by  people age 45 to 64.

The top five conditions that made up 96% of all the mental health/substance abuse cases were (in order) mood disorders, anxiety disorders, alcohol disorders, drug disorders, schizophrenia and other psychoses, and intentional self-harm. One patient could have multiple diagnoses.

As for how the 12 million visits were billed, 30% went to Medicare, 26% went to private insurers, 20% went to Medicaid and 21% of patients were uninsured.

-Jeannine Stein

Photo credit: Mark Boster / Los Angeles Times

Borderline personality disorder? Whatever. Darth Vader had it? Tell us more!

Emotional instability. Mood swings. Relationship troubles.... Those are just a few of the hallmarks of borderline personality disorder, a difficult-to-treat and under-recognized condition that can destroy the lives of people with it and, not that they may notice, but the lives of those around them as well. So thank goodness for Darth Vader. We'd have hated for it not to be taken seriously.

L.A. Times staff writer Shari Roan wrote last year  of people with borderline personality disorder:

"They have the thinnest skin, the shortest fuses and take the hardest knocks. In psychiatrists' offices, they have long been viewed as among the most challenging patients to treat.

"They are the kind of people who drive a friend away for interfering and subsequently berate that friend for abandonment.

"But almost 20 years after the designation of borderline personality disorder as a recognized mental health condition, some understanding and hope have surfaced for people with the condition and their families." Read full story here.

She was referring to increasing awareness of the disorder and of discussions about it at the American Psychiatric Assn. meeting. Time magazine took a similar approach in this article: The Mystery of Borderline Personality Disorder.

But French psychiatrist Eric Bui has done them one better  in the "raise awareness" arena -- at least we hope that's what his contention amounts to. He and his colleagues at Toulouse University Hospital contend that Anakin Skywalker -- Darth Vader of "Star Wars" fame -- probably had the condition. They'll be making their case in an upcoming issue of the journal Psychiatry Research.

Here's a LiveScience article that lays out their Anakin-Skywalker-had-borderline-personality-disorder talking points. (We note that it lacks any explainer of the potential effect of midi-chlorians.)

If you're one to bemoan the fact that a life-destroying condition might not be taken seriously as a result of this pop culture tangent, keep in mind that -- as my in-box attests -- any publicity is generally taken as good publicity. 

Besides, the Paging Dr. Gupta blog post over at CNN, What is Darth Vader's diagnosis? doesn't seem to buy the possible borderline-personality-disorder diagnosis. 

There's that whole evil-emperor thing, it points out.

Here's an overview of borderline personality disorder from the National Institute of Mental Health.  

-- Tami Dennis

Photo: Borderline personality disorder? Or played far too easily by an evil emperor? In any case, here's Hayden Christensen as Anakin Skywalker.

Credit: Lucasfilm Ltd.

About 1 in 10 Iraq veterans develops a serious case of PTSD, researchers say

It’s well known that combat takes a toll on the mental health of soldiers -- for instance, studies of people who served in the ongoing conflicts in Iraq and Afghanistan have found that those who experienced combat were two to three times more likely to develop post-traumatic stress disorder than their counterparts who remained out of harm’s way. But studies have been less consistent in determining how many soldiers develop PTSD and other mental health disorders after deployment.

So a group of experts from the U.S. Army Medical Research and Materiel Command examined 13,226 anonymous surveys completed by veterans of Operation Iraqi Freedom. Some of those veterans were part of active duty Army divisions, and others served in National Guard infantry brigades.

Using a strict definition of PTSD, the researchers found that roughly 1 in 10 survey-takers had PTSD that was severe enough to cause “serious functional impairment.” The prevalence ranged from 7.7% to 8.9% for active duty Army personnel and from 6.7% to 12.4% for members of the National Guard. In both cases, the numbers went up over the first 12 months of their deployments.

When adding serious depression to the mix, the researchers found that 8.5% to14% of the veterans had a mental health problem that made it “very difficult” or “extremely difficult” to function properly. The findings are published in Tuesday’s edition of Archives of General Psychiatry.

The problems of PTSD can last long after soldiers retire from combat duties, according to a second study from the same journal.

Researchers from UC San Francisco and the San Francisco Veterans Affairs Medical Center examined the health records of 181,093 vets who were at least 55 years old. They found that the vets who had been diagnosed with PTSD were almost twice as likely to have dementia compared with the vets who did not have PTSD.

It’s not known how PTSD would increase the risk of dementia, but the researchers offer several theories. Perhaps PTSD robs veterans of some of their cognitive reserve, leaving them more vulnerable to dementia. The chronic stress associated with PTSD may also damage the hippocampus, the part of the brain that plays a key role in learning and memory.

Scientists are researching ways of preventing cases of PTSD. A study released this year found that soldiers who received morphine within the first few hours of a painful combat injury were 50% less likely to develop PTSD than those who didn’t get the powerful analgesic. A hypertension drug called prazosin has also been shown to reduce nightmares in vets with PTSD.

-- Karen Kaplan

Photo: PTSD -- and its ill effects -- can linger long after combat ends. Credit: Rick Loomis/Los Angeles Times

Rodent of the Week: A link between the immune system and mental illness

Little is known about the causes of severe mental illnesses. Genes and environmental factors are thought to contribute. But more specific biological processes, still not yet clear, probably contribute to brain dysfunction that results in hallucinations, psychosis and compulsive behavior.

A clue from a study with mice has emerged that links mental illness, particularly obsessive-compulsive disorder, with immune system processes. Mario Capecchi, a distinguished professor of genetics at the University of Utah, found that mutant mice who pull out their hair compulsively (a condition similar to trichotillomania in humans and a model for mental illness in mice) were cured of their abnormal behavior when they received bone marrow transplants. The study was published online Thursday in the journal Cell.

The mice who groom compulsively, thus pulling out their hair, carry a mutant Hoxb8 gene. Capecchi transplanted normal bone marrow from mice into 10 Hoxb8 mutant mice. Four recovered from their abnormal grooming behavior and six improved. It's not clear why the treatment worked. But cells called microglia are derived from bone marrow, and these same cells are found in the brain. It could be that microglia make substances called cytokines that activate or inhibit nerve cells and influence behavior. Or, microglia might play a role in nerve-signal transmissions. Nevertheless, the connection between the two is worth further investigation, Capecchi said. "That's the surprise: Bone marrow can correct a behavioral defect," he said.

The research is preliminary, however, said Capecchi, who shared the 2007 Nobel Prize in physiology/medicine for developing a way to knock out genes in mice in order to analyze gene function. People with mental illness should not try bone marrow transplants as a cure. The compulsive grooming syndrome in mice can't be considered the equivalent of obsessive-compulsive disorder in humans, said Dr. Steven E. Hyman, a professor of neurobiology at Harvard Medical School, in an editorial accompanying the study.

"Analysis of Hoxb8 mutant mice should help to illuminate such matters as the role of different populations of microglia in the brain," Hyman said. "Moreover, these mice could give rise to sorely needed new hypotheses about the mechanisms underlying human disorders characterized by compulsive behaviors."

-- Shari Roan

Photo credit: Advanced Cell Technology Inc.

Study shows long-term success in recovery from borderline personality disorder

Borderline personality disorder has long been considered one of the toughest psychiatric disorders to resolve. There have been many questions about how to best treat the condition, which is marked by unstable relationships, unhappiness, mood changes, impulsive behavior and poor decision-making.

Advances in understanding and treating the condition have been made in recent years, however. And a new study offers hope that recovery, although challenging, can be long-lasting.

Many Zanarini of McLean Hospital in Massachusetts studied 290 hospitalized patients with BPD over 10 years. Half of the patients recovered from the disorder after 10 years of follow-up. Recovery was defined as at least two years without symptoms and both social and vocational functioning. Overall, 93% of patients achieved a remission of symptoms lasting at least two years and 86% for at least four years.

The research suggests that while it may be difficult to achieve recovery, once recovery has been attained it appears to last. While many treatments focus on symptoms, therapy should include work on improving relationships and functioning in the workplace, areas that vastly boost the odds of long-term recovery, the authors said.

The study is published online Thursday in The American Journal of Psychiatry.

-- Shari Roan

Photo credit: Wesley Allsbrook  /  For the Times

Child bipolar diagnosis is a poor fit for many

Over the last decade, more children with behavior and emotional troubles have received a diagnosis of bipolar disorder. This is a condition in which moods swing dramatically between depression and mania. Traditionally, bipolar was diagnosed only in adults.

A fierce debate has raged in recent years over diagnosing children with bipolar illness because the symptoms vary so much in children compared with adults, and because the medications used to treat the disorder carry some serious side effects. The American Psychiatric Assn. has proposed changes to how the diagnosis is made in children for the next edition of its diagnosing guide, the Diagnostic and Statistical Manual, or DSM-5. An expert panel has suggested two new diagnoses to account for the symptoms seen in children: "severe mood dysregulation" and "temper dysregulation disorder with dysphoria."

There appears to be growing support for backing away from the child bipolar diagnosis. In a paper published this week in the journal Child and Adolescent Psychiatry and Mental Health, experts from the Hastings Center summarized findings from a series of workshops on the issue and concluded that it may be better to avoid giving a child a diagnosis of bipolar disorder. The authors say the label simply does not fit many children who have been given it over the last decade. Moreover, there is still too much debate and confusion over what the children's symptoms represent. For example, it's unclear what mania really looks like in children compared with a much more precise concept of mania in adults.

"Using new labels such as SMD or TDD reflects that physicians do not yet know exactly what is wrong with these children or how to treat it," Josephine Johnston, a co-author of the study, said in a news release. "Facing up to this uncertainty could lead to better treatment recommendations and more accurate long-term prognosis."

This is not to say that these children and their families don't need help, the authors state. The concept of treating troubled children and their families without pinning a firm label on the behavior is a good idea. Unfortunately, health insurers often demand such labels in order to provide coverage for care. I wonder if insurers will cover care for "severe mood dysregulation" in the same way they would for "child bipolar disorder."

-- Shari Roan

Photo credit: Susan Tibbles  /  For The Times

ABC News' '20/20' reports on Jani Schofield

The June 29 L.A. Times story "Jani is at the mercy of her mind," touched off a long-running discussion among Times readers about the need for services for young children with severe mental illness and support for their families. Friday evening, the ABC News show "20/20" airs a program on Jani Schofield, 7, and two other California children with crippling mental illness.

Correspondent Jay Schadler follows Jani and her family as they try to remain united while living in two separate apartments -- a measure needed to protect Jani's toddler brother from her occasional violence. The hour also includes interviews with a 9-year-old child Jani befriended while an inpatient at UCLA's child psychiatry inpatient unit, Rebecca Stancil; and a 13-year-old who fears hurting her siblings, Brenna Wohlenberg.

In the report, titled "Haywire," cameras catch the profoundly disturbing behavior that the children and their families experience almost every day. The effect of severe mental illness on the patients' siblings is heartbreaking, and the stress on parents is frightening. It's not easy to watch. But it's a telling look at the tragedy of an illness that remains stigmatized and hidden from most of society.

Here's a preview. The show airs Friday at 10 p.m.

-- Shari Roan

Photo credit: Lawrence K. Ho / Los Angeles Times

Ending use of the R-word

First the president made a wisecrack about the Special Olympics and then his chief of staff called opposition to the healthcare reform plan "retarded."

Advocates for people with intellectual disabilities have long sought to banish the term "retard" from common use. Officials for the Special Olympics, for example, have launched a public awareness campaign to eliminate the pejorative use of the words "retard" and "retarded."

The message may be seeping out. Tuesday, the American Psychiatric Assn. announced its first draft of a new edition of the text book that defines mental illnesses and proposed replacing the term "mental retardation" with "intellectual disability." The latter term, the APA noted, is now used by the Department of Education and other disciplines.

Government bodies, too, are taking steps to discourage the R-words. Last year Ohio passed a bill that prohibits use of the term in county boards and departments. Other states are considering similar actions. And late last year, U.S. Senator Barbara A. Mikulski (D-Md.) introduced Rosa’s Law, a bill that would eliminate the terms “mental retardation” and “mentally retarded” from some federal laws.

"Mental retardation" and "mentally retarded" are terms that were, at one time, not considered objectionable. But they are now, and there are other, more acceptable, terms to describe people with lower-than-normal IQ. The Special Olympics organization is holding a "Spread the word to end the word" day March 3. You can pledge to support the idea at this website.

-- Shari Roan

Photo credit: Special Olympics

Internet browsing: Searching for happiness?

People who are addictive Internet searchers should probably browse for a phone number to the nearest therapist. Though almost everyone uses the Internet to conduct business, connect with people, pay bills or find information, the people who spend hours each day aimlessly surfing the net are more likely to be depressed, according to a new study.

Psychologists at the University of Leeds in Britain evaluated the Internet use and depression levels of 1,319 people ages 16 to 51. Of this group, 18 people (1.2%) were classified as Internet-addicted. When these 18 people were compared with 18 similar people who were not Internet-addicted, the researchers saw striking differences in depression. The 18 non-addicted people were not depressed while the 18 Internet-addicted people were classified, as a group, as moderately to severely depressed.

The addicted people tended to use the Internet more for sexual gratification, gaming and chat rooms, compared with the non-addicts. The authors of the paper, published in the journal Psychopathology, concluded that these people are replacing real-life socializing with Internet surfing. 

They say, however, that it's not clear which comes first: the Internet addiction followed by depression or depression followed by Internet addiction. Regardless of the answer to that question, depression and heavy Internet use appear to be a bad mix.

Here's a link to The Center for Internet Addiction.

-- Shari Roan

Photo credit: Greg Baker / Associated Press

Fish oil can head off first psychotic episodes

In the lives of young people at high risk for developing serious mental illness, heading off that first psychotic episode can mean a world of difference. A new study has found that for a year after it was completed,12 weeks of dietary supplementation with Omega-3 fish oil reduced progression to full-blown psychosis in a large group of adolescents and young adults.

The study subjects were young people who did not yet meet the criteria for full-blown mental illness, but whose grip on reality had begun to come loose, prompting them to seek psychiatric care. 

At the same time, Omega-3 long-chain fatty acids--found in a range of ocean-going fish and edible sea life--improved many of the symptoms that identified these young patients as likely schizophrenics and bipolar disorder sufferers. Among the 81 young patients under observation for psychosis in an Austrian hospital, those taking fish oil supplements for two weeks showed fewer signs of disorganized or delusional thinking, more motivation, and better overall functioning than those in a comparison group, who got psychotherapy alone.

For as long as a year after their diets were supplemented by 12-weeks of fish oil capsules, patients in the intervention group continued to function better, have fewer symptoms, and were less likely to suffer a psychotic episode than those who did not get the fish oil. Roughly 5% of those on fish oil went on to develop full-blown psychosis during the study period, versus 28% of those who got psychotherapy alone.

Psychiatrists are actively debating how--and how aggressively--to treat patients with so-called "pro-dromal" signs of mental illness, or symptoms that are considered warning signs of full-blown illness to come. Studies, among them some funded by the companies that make antipsychotic medications, have found preliminary evidence that prescribing antipsychotic medication for early symptoms can head off full-blown psychosis. But, for adolescents especially, even brief use of the medications in question poses significant risks of weight gain and metabolic changes--not to mention the stigma associated with identification as a patient with a chronic mental condition.

In a measure of relative effectiveness, the present study found that fish oil supplements--which come with a wide range of unrelated health benefits (among them cardiovascular disease prevention) and no more serious side effects than "fish burps," were as effective at preventing psychotic episodes as antipsychotic medications.

-- Melissa Healy