Healthcare & Psychology News 2006

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The U.S. Government Accountability Office estimated that "at least 2.4 million young adults aged 18 through 26 - or 6.5 percent of the non-institutionalized young adults in that age range - had a serious mental illness in 2006" (p. 2). This estimate was from the study "Young Adults with Serious Mental Illness" conducted by the GAO in response to a congressional request. The GAO was asked to estimate the number of young adults with a serious mental illness, describe their demographic characteristics, discuss the challenges they face, show how selected states assist them, and describe federal support for them. Adults with a serious mental illness are defined as those "age 18 and over, who currently or at any time during the past year, have had a diagnosable mental, behavioral, or emotional disorder ... that has resulted in functional impairment which substantially interferes with or limits one or more major life activities" (p. 8).

The GAO analyzed published research; interviewed government officials, mental health providers, and advocates; and conducted site visits in Connecticut, Maryland, Massachusetts, and Mississippi. The GAO report is of interest to us because of the many young adults served by MHS homeless assistance programs and our Mobile Crisis Team. MHS also operates the Young Adult Program - a specialized Supportive Housing Program providing transitional housing and intense supportive services for young adults with severe mental disorders such as schizophrenia, major depression, and bipolar disorder.

The GAO noted that the actual number of young adults with a serious mental illness "is likely to be higher than 2.4 million because homeless, institutionalized, and incarcerated persons were not included in this estimate - groups with potentially high rates of menal illness" (p. 2). The GAO also noted research showing that 50% of mental disorders begin by age 14. Eighty nine percent of the young adults studied had two or more disorders, and 56% had four or more disorders. For example, 32% had a drug- or alcohol-use disorder in addition to another mental disorder.

Intermittent explosive disorder, major depressive disorder, and specific phobias were the most prevalent of the serious mental disorders among young adults, as shown in Table 4 below, appearing on page 19 of the GAO report. However, among the 186,000 young adults who received income benefits because of a mental disability, the most prevalent disorders were mood disorders, schizophrenia, and anxiety disorders (Table 5, appearing on page 22 of the GAP report).

The MHS program designed to specifically serve homeless young adults with serious mental illnesses - the Young Adult Program - completes its ninth operating year at the end of August 2008. It is a U.S. Department of Housing and Urban Development (HUD) Supportive Housing Program. Eighteen homeless young adults of Cuyahoga County, Ohio, who have a severe mental disability, participated in the program during its 8th year that ended 31 August 2007.

The Young Adult Program serves 18-22 year-old men and women who have schizophrenic, schizoaffective, or other psychotic disorders, and who have become homeless upon reaching adulthood. Their legal status as adults means that they no longer have access to the network of community services for children. Family support is generally absent or minimal, and clients have not established a pattern of participation in the community's system of care and services for adults. They often have profound cognitive and functional impairments, and a history of parental abandonment, neglect, or abuse. Many program participants have been incarcerated at least once, and nearly all have been admitted at least once to an inpatient psychiatric treatment facility. Eighty percent have had parents who are mentally ill or substance-dependent. Without effective supportive services, these individuals are highly likely to remain homeless, to be victims of crimes, and to be involuntarily admitted to psychiatric hospitals.

Program participants live in a 4-unit (2 bedrooms each) residential facility in Cleveland while they participate in a structured program to learn critical life management skills. Clients participate in intensive case management, skill-building, psychiatric, and supportive services in order to obtain housing and income, access mainstream community resources for income and healthcare needs, and to learn the skills they need to protect their health, maintain their housing, and live independently in the community.

Jim Holbrook is the Program Manager. Caron Davies the the program's Outreach Worker. Cheryl Mays is Case Manager. Barbara McDaniel, Isabel Izarry, and Lauren Rhodes are Residential Support Workers.

Of the 10 new clients who entered the program during its 8th year, five (50%) were male; five (50%) were African-American, and all but one had substance-use disorders. (Note: Program participants are too young to meet the HUD definition of "chronically homeless persons.")

Program participants achieved notable outcomes. Of the 11 participants who left the program during its 8th year, seven (73%) moved into permanent or transitional housing, 10 (91%) achieved increased income, and nine (82%) achieved self-determination by negotiating and fulfilling the steps of an individualized healthcare plan. Five (45%) had earned employment income during the year.

The Agency for Healthcare Quality and Research, part of the U.S. Department of Health and Human Services, reports that 308,200 people were treated at U.S. hospitals for violence-related trauma in 2005, an increase of 24,000 (8%) since 2002. Hospital visits for violence-related trauma accounted for nearly 1 of 100 non-birth related hospital visits. (See Table one, below.)

Those who attempted suicide accounted for about 66% of the violence-related hospital patients - more than 200,000. (Note: The Office of Applied Studies of the Substance Abuse and Mental Health Services Administration reported that 1.7 million adults with a major depressive disorder made a suicide attempt in 2003. The AHRQ study described here concerns only those who were treated at a hospital for a suicide attempt or other violence.) Thirty one percent (31%) were victims of assaults, including rape and attempted murder; four percent (4%) were victims of sexual or other abuse. Fifty two percent (52%) of those abused were children.  Females accounted for 64% of hospitalizations related to maltreatment, and 59% of hospitalizations resulting from self-inflicted violence. Males accounted for 82% of hospital visits resulting from assaults. Young adults - those 18 to 44 years of age - comprised 62% of hospital visits resulting from self-inflicted violence, and 68% of assault-related visits.

Annual treatment costs for violence-related hospital visits was $2.3 billion.   Hospitals and taxpayers paid for 50% of all violence-related hospital visits (23% uninsured, and 27% Medicaid), compared with 22% of hospital visits not associated with violence (5% uninsured, and 17% Medicaid).

The study underscores the alarming magnitude of suicidal attempts that result in hospital visits, and the treatment costs of these attempts - more than $1 billion annually. Also notable is that "young adults and children were disproportionately hospitalized for violent traumas." As stated by the study authors, "Nearly three out of every four (74.1 percent) violence-related hospitalizations occurred among patients younger than 45 years old, as compared to 36.6 percent of hospitalizations not associated with violence."

The MHS Mobile Crisis Team assessed 3,367 adults and children in 2007. More than one of three referrals are by or for individuals who are suicidal. Of the 3,065 adults who were assessed, 32% were admitted to inpatient services at the Cleveland campus of Northcoast Behavioral Healthcare System. Many others participated in MHS outpatient crisis and psychiatric services, or were referred to other community mental health centers for treatment.

Results of two recent studies have reached disturbing conclusions about the effectiveness of newer antidepressant medicines, as well as the selection of evidence used in the evaluation of these medicines. The studies were featured in a story in The Economist of 28 February 2008.

The first study was conducted by Irving Hirsch and his colleagues at the University of Hull in Great Britain, and published in the open-access journal, Public Library of Science (PLoS) Medicine. It was not an original study, but a meta-analysis, in which results from a large number of original studies are converted to a common metric and then examined to determine the magnitiude of the effectiveness of the medicine (or other intervention) being studied.

Biased selection of clinical trials may lead to erroneous estimates of SSRI effectiveness.

What makes the Kirsh study unique is that it included results not only from published studies, but also from studies that had never been published, but had been submitted (as required) to the U.S. Food and Drug Administration (FDA) during the time the FDA was being asked to approve the drugs for the treatment of depression. Kirsch and his colleagues obtained these unpublished studies through Freedom of Information Act requests. They limited their analyses to studies of one class of antidepressants, called selective serotonin reuptake inhibitors (SSRIs), that are believed to help relieve depression by enhancing the amount of the serotonin, a neurotransmitter, available to neurons in the brain. Prozac (fluoxetine) was the first drug of this class to be approved for use as an antidepressant in the U.S. The other SSRIs studied were Effexor (venlafaxine), Serzone (nefazodone), and Paxil (paroxetine).

After analyzing data from all studies (including unpublished studies), the authors concluded that "we find that the overall effect of new-generation antidepressant medications is below recommended criteria for clinical significance. We also find that efficacy reaches clinical significance only in trials involving the most extremely depressed patients, and that this pattern is due to a decrease in the response to placebo rather than an increase in the response to medication." For those with depression of mild to moderate severity, SSRIs were only slightly more effective than placebos, but the difference was so small it wasn't considered clinically significant.

More evidence of the biased selection of clinical trials.

How, then, did SSRIs ever get to be approved for the general treatment of depression if they are effective only for those with severe depression? Dr. Kirsch believes that restricting an analysis to published studies leads to "an exaggerated view of a drug's benefit." Results of a study published this January in the New England Journal of Medicine are consistent with this view, demonstrating that 94% of the published studies, compared with only half of the unpublished studies, showed that the drug being studied was effective. Study authors concluded "We cannot determine whether the bias observed resulted from a failure to submit manuscripts on the part of authors and sponsors, from decisions by journal editors and reviewers not to publish, or both. Selective reporting of clinical trial results may have adverse consequences for researchers, study participants, health care professionals, and patients."

However, SSRIs reduce suicides, especially among the young.

Additional insight into the effects of SSRIs is provided by the National Bureau of Economic Research (NBER), whose researchers examined data on suicidal deaths and the sales of SSRIs in 26 countries during a 25-year time period. They found that

"an increase in SSRI sales of one pill per person per year -- about a 12 percent increase over year 2000 sales levels -- is associated with a decrease in deaths from suicide of about 5 percent. Furthermore, now that SSRIs are off patent, spending an additonal $20,000 on them in the United States could avert one death from suicide; that is a cost per life saved far below the cost of most other public health or regulatory interventions. ... Furthermore, despite clinical evidence that antidepressant use may increase the risk of suicidal behavior in pediatric patients, the authors find that the protective effect of SSRI sales on suicide mortality is largest, both in proportional and absolute terms, for people aged 15-24" (emphasis added).

These results are not necessarily inconsistent with those of the Kirsch study. Clinical trials of the kind reviewed by Kirsch and his colleagues generally evaluate drug effectiveness by looking for changes in quantitative measures of the severity of depression, including patient reports of subjective distress, appetite and sleep disturbance, and functional (social, academic, and occupational) impairment. It is quite possible that those taking antidepressant medicinces felt no relief, and noticed no improvement in their functional status, yet thought about suicide less often, and were lest likely to act on suicidal impulses.

What do these studies tell us?

First, and most important, if you are now in treatment for depression, it is imperative that you discuss any contemplated changes in treatment with your doctor or counselor before making changes. Individuals may (and do) benefit greatly from SSRIs, even though the average response is "below recommended criteria for clinical significance." You may also be taking a combination of medicines, not just a single SSRI, and the effects of combined therapy were not examined in any of these studies. Remember, the information presented here is never meant to serve as medical advice or treatment recommendations. The responsible management of your health requires that you act in honest partnership with your doctors and counselors.

Perhaps the most significant finding to emerge from these studies is that our system for evaluating the effectiveness of drug treatments is flawed, and needs to be changed in a way that promotes the unbiased analysis of all studies, not just those with the desired results.