A tale of Mental Health in two settings

This is an up date of the mental health crisis  in this nation from my perspective; its causes, its impact on the American people, the American Healthcare System, the American Workplaces and on American Employers. What will follow from this update, is my proposal for a solution to this crisis. 

Setting 1 

Mental Health in the American Healthcare System

• One in four American adults (59 Million people) has a diagnosable mental health problem impairing their ability to lead a normal and productive life. (1)

• For American adults with any form of chronic medical condition the likelihood of  also having a diagnosable mental health problem is higher than those in the same age group that are unaffected by a chronic medical condition. (2)

• Among American adults that have a chronic medical condition as well as a mental health problem, those that have their mental health problem diagnosed and properly treated will demonstrate better outcomes of their chronic medical condition than those that are not diagnosed and properly treated for their mental health problem. (3)

• People with an undiagnosed, untreated mental health problem use the healthcare system more frequently than people of the same age group that are unaffected. (4)

• Between 70 and 90% of American adults with mental health problems will have a significant reduction of their symptoms and improved quality of life with medical treatment. (2)

• Of the 59 million American adults with mental health problems, less than one in 3 of these will ever even be diagnosed. (2)

• For recognizing Americans with mental health problems, this is our healthcare system’s worst of times.

Setting 2 

• American Employers’ indirect costs  as a result of— Employee Mental Health problems is 4 fold greater than their total direct costs for Employee Healthcare. (5)

• Employees with mild or even “sub-threshold” mental health problems have measurable productivity problems early on; well before more serious health effects set in.

• Based upon the enormity of indirect costs we can conclude that Employers remedies for these productivity problems are not adequate. (5)

• —Employees with untreated mental health problems in the workplace are responsible for the majority of Employers’ indirect costs. (2)

• In conclusion, American Employers are paying for their employee’s mental health problems twice; once as a result of the direct costs of frequent healthcare utilization and once again as a result of the indirect costs such as higher levels of absenteeism, presenteeism, disability, employee turnover and a reduction in the the levels of talent attraction and retention.

• For American Employers and their workers with mental problems, this is the worst of times.

There is an epidemic in our nation for which our healthcare system has highly effective remedies but routinely fails to recognize while for our nation’s Employers the opposite is true; they have developed sophisticated systems of effectively recognizing their employee’s mental health problems but do not have effective remedies. Perhaps when there is a better line of communication between our nations Employers and our Healthcare System it will be the best of times.

End Post

Mitchell R. Weisberg, MD, MP

Weisberg Medical Consulting offers Employers a clinical perspective to their Balanced Scorecards; aligning the health of their Employees with the health of their Enterprises.

Organizations Balanced Scorecard

by

Mitchell R. Weisberg, MD, MP

• Employers’ indirect costs (absenteeism, presenteeism, employee turnover, diminished talent attraction-retention and successorship) resulting from Employee Mental Illness is 4 fold greater than their direct costs for Employee healthcare. (1)
• Arguably, at least some part (in this physicians informed opinion, the majority) of this burden is due to the ever-increasing cognitive demands on the American Workforce that was the result of a continuous servicization of the American Economy that began with the dawn of the information age just under 6 decades ago. It was within this time period that our national economy transformed (I say, evolved) from one highly dependent on its workforces’ brawn to one almost entirely dependent on its brains. *
• In spite of the fact that people with mental illness use the healthcare system much more often than does the general population, most (2/3) of Mental Illness is never recognized (diagnosed) or treated. (2)
• Once diagnosed, Mental Illness is highly treatable with between 70 and 90 percent of people having significant reduction of symptoms and improved quality of life with a combination of medication, talk therapy and other supports. (2)
• A major obstacle to recognizing mental health disorders is their lack of symptoms in the traditional sense of the word thus making mental illness the invisible epidemic. (3)
• Identifying mental illness is dependent upon an awareness of a person’s functional status such as their social-interpersonal functioning and workplace (vocational) performance.
• People with any form of chronic medical (physical) condition such as Diabetes or COPD, experience minor mental health or cognitive impairments as well as full-blown mental illnesses much more often than their healthy counterparts.
• Not uncommonly chronic medical conditions may initially manifest with mental health impairments including full-blown mental illnesses.
• The recognition and effective treatment of mental illness in people with other chronic medical conditions results in better overall outcomes than those in whom their mental illness remains unrecognized and untreated.
• The early recognition and effective treatment of mental illness has a profoundly positive impact on human health in general.
• Since there is evidence that even workers with mild or “sub-threshold” problems begin to show productivity problems early on – perhaps long before they experience other health consequences – employers are in a unique position to effect significant change in the way services are delivered. (1)
• Over the past two decades The Balanced Scorecard has been widely employed as the Business Management tool of choice by most major employers worldwide. (4)
• The Balanced Score Card aligns the goals of an Organization with the personal goals of its Employees for the purpose of achieving optimal performance at the Organizational level.  (5)
• Periodic measurements of Employee Performance in terms of achieving their personal goals (employee performance metrics) are an essential part of an effective Balanced Scorecard. (5)
• Contained within the core of Employee Performance Data is vital information about Employee Health in general as well as the most essential and most overlooked information required for the early recognition of Employee Mental Health in particular. (1)
• Since there is evidence that even workers with mild or “sub-threshold” problems begin to show productivity problems early on – perhaps long before they experience other health consequences – employers are in a unique position to effect significant change in the way services are delivered. With more than 2 decades of clinical experience as both a Primary Care Physician and a Mental Health Care Provider and a career commitment to optimizing the health and performance of his patients, this physician is in a unique position to aid employers in getting healthy returns on their health and human capital investments. (1)
• This physician can show the stakeholders of any Organization that there indeed is a tremendous value in adding a clinical perspective to their Balanced Scorecard.

1. Improve employee health habits (56 percent)
2. Lower the health care cost trend (49 percent)
3. Decreasing worker health risk (44 percent)
4. Increasing participant awareness of health issues (37 percent)
5. Enhancing participation in health improvement/disease management programs (37 percent)^*

FAQs

Q: How are Employee Performance Metrics relevant to Employee Health?

A: The relationship between Employee Health and Employee Performance is well established and not a new concept in the area of Employer based Health and Wellness Programs. What is new, however, is using measures of Employee Performance to drive a more efficient utilization of Employer Based Health and Wellness Programs. All health disorders, whether classified as physical or mental in origin will have an impact on an Employee’s work performance. For example, persons with Type 2 or, Adult Onset Diabetes Mellitus (AODM) have a 3 times higher likelihood of developing a Major Depressive Episode than their age matched counter parts that do not have AODM. Functional changes, such as a change in work performance are often the earliest indicator of Depression and other Mental Health Disorders. There are numerous other examples of how health issues ranging from chronic pain conditions to adverse medication reactions and everything in between can impair a person’s functional capacity; thus, sophisticated and objective measures of Employee Performance serves as an early detection system for some of the American Workforces most common health issues.

Q: What form would a Performance Driven Employee Health and Wellness Program take?

Q: If Employers leave well enough alone and only focus their Health Initiatives on those Employees with suboptimal performances, won’t they miss silent diseases such as Hypertension, Diabetes, Obesity, etc.?

Q: How would an Employer link Employee Performance to their Health Initiatives?

Q: How is the leaving well enough alone approach different from Employee Assistance Programs (EAPs)?

Q:

Basic Principles

Just as I eliminated the word, diet from my vocabulary because of its common association with self deprivation, I also refuse to use the word, exercise because it has become synonymous with the word, torture. Rather, I refer to it as physical activity and liken it to an essential nutrient which for our optimal health and performance we need to get our recommended daily requirement. Just as we must eat first to live and function (not to lose weight), similarly we must get regular physical activity. In order to make sure we  meet our physical activity requirements we must first  overcome our own inertia.

• Drop the all or nothing approach to fitness. Not having the time to get to the gym for an hour is no reason not to do any physical activity at all.
• Get at least 10 minutes of moderate physical activity such as calisthenics within the first 60 minutes of waking up in the morning.
• Incorporate more physical activity into you activities of daily living such as making shower time into fitness time.
• Throughout the day, for every hour that you are sedentary get 3 to 5 minutes of physical activity.
• When you can get to the health club for an exercise class or a work out, that’s terrific but you should not rely on this as the only way to get your daily dosage of Physical Activity.

Examining its derivation, diet came into the world as a positive word. From Greek, diatia, literally, way of living and diaitasthai, to lead one’s life. Seemingly ironic that we must banish a word whose original meaning we should emulate as a means of surviving the current epidemic, was it not for the fact it was the corruption of the word diet that is responsible for this current epidemic; a corruption that began a mere two centuries ago and climaxed in a fury of commercialized chicanery over the last 50 years. Diet is just one more example of guilt by association; association with the likes of Grapefruit, Cabbage Soup, Low Fat, Low Carb and Cleansing. Conspicuous by their absence from this list are the snake oil salesmen that commandeered the word diet for nothing other than their own benefit. By its falling in with the wrong crowd we may no longer utter, hear or see the word diet without associating it with self deprivation. Once an innocent four letter word,  by its association with this evil cabal, diet has been rendered one more publicly unutterable four letter word; collateral damage in our species ongoing battle for survival. Although, it hardly seems adaptive that we humans would wage a battle against, what in biological reality, is the sole financier for all evolutionary advances for our entire 2 million years of human existence; food. Scarce since the dawn of humanity, through the ingenuity of the human mind food has become overly abundant in just the past century. One might conclude that the current Obesity Epidemic is the price our species must pay for its evolutionary success but for the fact that, based on current trends this epidemic promises to affect 100% of people in the United States by the middle of the current century. Furthermore, drawing such a conclusion would fail to correctly recognize the chief perpetrators and perpetuators of the Obesity Epidemic, allowing them to carry out their clandestine operations within our midst. I am referring to the very industry that perverted the word diet for its own profits; profits that promise to grow in perpetuity, as long as they continue to conspire to propagate their mis-characterization of the word diet as a compulsory masochistic ritual we humans are obligated to perform if we are to gain salvation from our sins of excess; hypnotizing us into believing that they alone hold the proprietary rights to these rituals which we too may obtain if we pay the price physically, emotionally and financially. They guarantee success, all the while knowing that woven into the fabric of their programs design is certain failure. Then they dupe us into blaming ourselves for failing at what was an impossible task all along; rigged as if some carnival shell game for the purposes of justifying their raison d’être and perpetuating their ill gotten gains.

Every week 10 million viewers look on as morbidly obese people torture and denigrate themselves vying for the honor of winning the title, The Biggest Loser implying that all the other contestants are just typical losers, all of whom are made to believe that they have failed, leaving the show in tears and a cloud of shame. One need not look further than this obscene example of obeseploitation and opportunism to see that it is none other than the Diet Industry that is most culpable for the Obesity Epidemic and for the untimely demise of the word diet; a word that once meant life itself.

Regardless of its own innocence, the die has been cast and this ancient word must now be laid to rest. We may take comfort in viewing this as a necessary sacrifice, the requisite first step in a worthy mission to eradicate this scourge from our societies; an industry that, for nothing other than its own rewards, brazenly exacerbated the epidemic for which they feigned a deep concern and commitment to “curing“. Only once the Diet Industry is eradicated from our midst will we return to what was, after all, the original meaning and intent of the word diet; a way of living and to lead one’s life.

Mitchell R. Weisberg, MD. MP

While every patient is unique, my general game plan applies to every person I treat. In my lineup Nutrition, Sleep and Physical Activity bat first, second and third, with my prescription pad batting cleanup and only when needed. With this as my system of healthcare , I offer general medical, prevention and wellness services.

Specialties

In addition to providing the full range of general medical services, I offer individualized programs for Adolescents and Adults impaired by:

• Addictions

• Anxiety Disorders

• Attention Deficit Hyperactivity Disorder

• Chronic Pain Syndromes

• Eating Disorders

• Menopausal Management

• Menstrual Disorders

• Mood Disorders

• Overweight/Obesity

I view that my eliminating my patients’ symptoms as simply clearing the pathway to reaching their destination; their optimal health and performance.

Mitchell R. Weisberg, MD. MP

In its description of the story of Creation, the book of Genesis, or B’rashit describes each day as beginning in the evening.  Is there some message in this about how we should conduct ourselves as human beings? As a Jew I believe that while, indeed, there is a G-d and that She created us in Her image, that Creation was not simply a historic event that occurred at sometime in the past. To the contrary, our Creator, being infinitely creative, created the Universe much like the playwright created Tony & Tina’s Wedding; we are never mere observers (a passive audience) of the events that occur all around us. We play as much a part in how the show ends as our Creator, Herself. In Yiddishkeit, this  is called Tikun Olam or repairing the Universe. Tikun Olam reconciles the seemingly paradoxical concepts of an omniscient Creator while each of Her creations have free will. While we mere mortals do not have the power to change the past, we can, by exerting our will, change the outcome of anything that has already occurred. An unfortunate but powerful example of Tikun Olam in action is the Holocaust. Two out of every 3 Jews living in Europe in the 1930s and 40s were systematically exterminated by the Nazis and their collaborators and, try as some may, there is nothing anyone can do to change this fact. However, within 3 years of being liberated by the Allied Forces (including the former Soviet Union), many of the survivors of the Holocaust garnered their collective will and not allow Hitler to reign triumphant they instead repatriated with their ancient Homeland in the newly formed modern State of Israel!

So you may ask, what does this have to do with whether our day starts at midnight versus when we decide to wake up in the morning or at sundown? The answer is that to live a life where we effect the world in which we live and not it affecting us, we better bring our A Game every day.Modern neuroscience teaches us that we can only function (perform) optimally when our Circadian Rhythm (our internal clock) is aligned with the rhythm of our planet, such as night and day (Diurnal Rhythm). After all, Hashem created us here, on the 3^rd rock from the sun. If our Creator wanted us to be angels perhaps we would have wings and be floating somewhere up in the atmosphere but, instead She planted us firmly here on the ground otherwise known as the planet Earth; and us Earthlings must begin today with some preparation this evening. Rabbi Tarfon taught: “It is not your responsibility to finish the work [of perfecting the world], but you are not free to desist from it either” (Pirkei Avot-2:16). That being said, each day must have a beginning and an end. Just as we know that if we want our beloved Personal Computers (PCs) to function optimally each day when we turn them on, we need to close down each open Window, one at a time before we shut it off, we Earthlings share this same need.  Our G-d given human effectiveness runs on the same set of tracks as our sense of wakefulness, which peaks soon after awakening and gradually degrades as the day progresses into evening, when we become drowsy and the cycle starts anew. While feeling drowsy is something with which we all can identify, diminished effectiveness or our executive function (the neuroscience equivalent of Tikun Olam) is not as noticeable. Never the less, executive function is the first of our brain’s functions to decline when we are sleep deprived or drowsy. A major review conducted in 1996 suggested that the oil spill of the Exxon Valdez, the destruction of the space shuttle Challenger, the nuclear accident at Chernobyl (costing over 4,000 lives) and the near nuclear accidents at the Three Mile Island and Peach Bottom reactors were all associated with sleep deprivation of the people involved. Sleepy driving causes as many car crashes as driving under the influence.

During the course of our hectic days, there are multiple Windows open in our brains, as it should be when we are putting our signatures on the world. However, just as our PCs, our brains cannot switch from having multiple open Windows to off without some untoward effects upon reopening these same Windows come morning time. In order for it to be fully restorative, we must not only get the proper measure of sleep, we must get the proper quality of sleep, as well. Many people, under the incorrect assumption that work time and sleep time is a zero sum game, will continue to attempt to problem solve up to the minute they fall asleep. In reality, their productivity is reduced by this habit. Just as with our PCs, to keep our performance of Tikun Olam at an optimal level, we need to start the process of closing down some of our open Windows well before it is time for sleep. The 90 minutes we spend chilling out and relaxing in the evening is a mandatory pre-requisite for restoring our ability to do Tikun Olam come morning time; it was evening and it was morning.

End

Mitchell R. Weisberg, MD. MP

“Elimination of Mental Health Benefits

Effective October 1, 2010, no amount is payable under the Welfare Plan for claims connected with the treatment of a Mental Health Condition. A Mental Health Condition is generally defined as a condition or illness that affects an individual’s emotional or psychological well-being. Mental Health Conditions include, but are not limited to, dementia, delirium, anxiety disorder, schizophrenia, depression, bipolar disorder, delusions, obsessive-compulsive behavior, Anorexia, Bulimia, attention deficit disorder, mental retardation and autism.”

Below is KP’s Résumé:

• Current Position: (held for the past 18 months): Field Superintendent/ Project Manager with a 35 man Plumbing Company. He began as an entry-level plumber and within 3 months was promoted to his current position; second in command only to the company’s owner. A company with $3M annual revenues at the time of his promotion it has since grown to revenues of $15M the year following KP’s promotion. Every member of the company, including its owner, would attribute this explosive growth in the face of a down economy to KP’s performance as their Superintendent. They would tell you about his innate leadership abilities, his ability to command respect while being perceived as a genuinely nice guy who cares about the people he works with. This quality, combined with the treasure-trove of plumbing wisdom KP absorbed in his quarter century in the field, has made this explosion in his company’s growth seem effortless. Not being one for accolades, I do know that KP takes pride in the fact that he is the first one there in the morning and the last to leave; this is just who he is and this is just the way he does things.
• October 2006 to Present: With his sheer willpower and the support of his family and his physician (yours truly), KP became a Recovering Cocaine Addict.
• October 2006: KP in another failed suicide attempt took an overdose of medicine which I prescribed to treat his Mood Disorder.
• From 1967 to October 2006: KP, like 25% of the American population, was functionally impaired due to  a Mental Health Disorder and, as is the case for two-thirds of the members of this population, KP went unrecognized and untreated in spite of his frequent use of the healthcare system. (1)
• Career Path: As are nearly 10% of persons in this country, KP was born with Attention Deficit Hyperactivity Disorder (ADHD). (2) By the age of 14, KP went on to acquire Bipolar Disorder when he effortlessly met the stringent requirements for achieving his first full-blown Major Depressive Episode.  It was at about this time PK began dabbling in something in which he fortunately never became very proficient; suicide. A novice in the skill of snorting cocaine at 17, he rapidly ascended to become a full fledged functional Cocaine Addict by the age of 21. No surprise really, since most 17 year olds with PK’s diagnoses that do not receive treatment become substance abusers and addicts by the time they turn 21, with cocaine being the usual drug of choice. (3) Until 2005, KP continued to self medicate with an addictive, deadly and illegal substance in his futile attempt to treat the agonizing symptoms of mental illness. Miraculously, due to his strong faith, his will to live and his having family and friends that loved and believed in him, he is now the 12 Million Dollar Man; twice as good as any TV superhero.

While KP is, indeed, a rare person his diagnoses are all too common. He came to me in 2005 to find out why he was experiencing severe pain from a relatively minor back injury, he had gained about 60 pounds and was having digestive problems. Had I not done 2 minutes worth of screenings for Depression, Bipolar Disorder and ADHD, as I do on every new patient to my practice, these symptoms never would have come out from KP’s spontaneously elicited complaints. (4) (5) (6) Fortunately, when I reviewed the Mental Health Screeners with KP he was open, honest and quite frankly, relived to share with me the details of the symptoms from which he suffered  silently for the previous quarter century; and his silence was not due to his fear of being stigmatized. KP, as intelligent a person as he is, simply never even considered that these symptoms were relevant to any physician.  You can imagine his surprise when I told him that he was suffering from a medical condition as treatable as Congestive Heart Failure but, more common and with a far better prognosis. He trusted me enough to commit to taking 4 medications per day for the rest of his life.

I am recounting the case of KP the Plumber, not to show my readers what a great physician I am. What I accomplished with KP does not require the skills of a great physician, just a good one. The treatment of mental illness is as straight forward as the treatment of Asthma, Hypertension or any other common disorder physicians treat on a daily basis. Yet, two-thirds of persons suffering with mental illness are simply not recognized; and this is not due to their not accessing the healthcare system. (7) Persons with undiagnosed mental illness use the healthcare system more than those persons without mental illness. (7)They most commonly do so for the evaluation of the physical symptoms that are actually a common component of mental illness. (7) Recognizing mental illness is as simple as asking every patient if they have it or not; this is simply not being done and until it is there will continue to be needless human suffering and an excessive waste of healthcare dollars.

In the 18 months during which KP increased his company’s annual revenues by $12M, the total expenditure on his health care, including my treatment and his medications, was a grand total of $13,500.  Stated another way, for every $1 invested in KP’s mental health his company realized a return of nearly $900. Any venture capitalist would gladly have purchased as many shares as possible of KP Inc. Unfortunately for KP he is not a publicly traded company on the NASDAQ and unfortunately for The Trustees of the Plumbers’ Union Welfare Fund they only consider cost and not return on investment when they make healthcare decisions. This gives me cause to seriously question their sanity.

END

Mitchell R. Weisberg, MD. MP

Medicalizing Mental Health:

A Rational Approach to an Emotional Topic

My mission is to provide readers with my perspective, as a practicing physician, of Mental and Behavioral health which is in keeping with the same clinical paradigm that applies when helping my patients in all other aspects of their health and well-being. If I accomplish nothing other than providing people suffering with Mental-Behavioral Disorders, with an alternative perspective from which to view themselves and some of their painful experiences other than blaming themselves and others, then my writing this book will have been worth the effort. However, I know that until we, as a society, collectively Medicalize Mental Health, its recognition and treatment will continue at a status quo which is entirely incompatible with our nation’s continuing its role as a beacon to the whole of humanity.

Chapter 1

Medicalizing Mental Health:

The Structure of Behavior

The relationship between structure and function is a foundation of scientific thinking. In essence, structure and function is one and the same thing. Like lightning and thunder, which to our perception is seemingly two separate things, in reality are two manifestations of one thing; an electrical discharge. They are separate yet, one. Just as a sheet of paper upon a desktop functions as a writing surface, fold it a certain way and it flies like an airplane, crumble it up and you can toss it in the trash can. Regardless of how many ways we change the same sheet of paper, the relationship between its structure and function remains inseparable and constant. This structure-function relationship holds regardless of scale whether sub-atomic, microscopic or astronomical. A single proton in its nucleus is all that separates each element on the periodic table from each of the other 111 elements. Having six protons in its nucleus as its structure endowed  the Carbon atom  to function as the exclusive template upon which all life on our planet arose. Jupiter’s enormous structure endowed it to function as Earth’s gravitational shield, protecting the smaller planet from catastrophic collisions with debris from the solar system’s formation;  in essence providing the Carbon atom the opportunity to set up shop.

If you have yet to ponder the relationship between structure and function, I hope that I have impressed upon you that you were just one tiny proton and one massive planet away from never happening; but, what does this have to do with the structure of behavior? We are getting there, but first I need to show how physicians use the structure-function relationship every day as they treat patients. Any physician that has ever correctly diagnosed a clinical problem, unless they did it by sheer luck, did so with this immutable structure-function relationship in mind. For example, in a patient that is having trouble breathing, as the patient provides a detailed description of their symptoms, the physician is visualizing the structure of all of the organs involved with breathing from the lungs, to the red blood cells to the 4 chambers of the heart, in an attempt to correlate the patients symptoms to the malfunctioning of these organs. For example, if a patient that finds it easier to breathe when sitting up as opposed to lying down, she likely has Congestive Heart Failure  as the cause of her shortness of breath where, if her breathing is worse on exposure to cold or dusty air, Asthma is the most likely cause and if she has a fever of 103 degrees and is coughing up some ugly stuff, Pneumonia, and so on.  Just as in any other branch of science, the structure-function relationship is the foundation of clinical thinking.

What then, is the reason that most physicians and other healthcare providers fail to recognize mental-behavioral health disorders most of the times they encounter them? The classic optical illusion of The Young Lady or the Old Hag illustrates the answer to this question. When looking at this picture, depending on the viewer’s perspective they will either see a beautiful young woman or of, a not so attractive, old hag. Until the first time a person is able to see  both images separately, it is impossible for them to see both images simultaneously. This is due to the mental effort it takes to switch perspectives. In clinical medicine we were trained from a perspective that flows from structure to function; that is we derive how something functions (or malfunctions) by first understanding its structure. For example, in Medical School we study Anatomy before we take Physiology which we take before Pathology. In other words, we learned the normal structures of the body first to understand how these anatomical structures function normally before we can understand the mal-functioning of these structures. It makes perfect sense that, structure to function, is the logical sequence for our clinical education; after all, structure  is 3 dimensional. Therefore, structure is what our senses perceive; we can see structure, measure it, scan it, touch it, hear it, smell it and in some cases, though I would never recommend this, we can even taste it. So in the case of the breathless patient, a physician can listen to the patient’s heart and the lungs with their stethoscope; they can see and smell the sputum that she is expectorating and if we need to, we can take an X-ray to get a view of those structural features that are not visible to the unaided eye, etc.

But what if behavior is the principal observable manifestation of a patient’s underlying illness? Just like in the Young Lady or Old Hag picture, this takes a mental effort in order to change perspectives. My mentor, Dr. Stuart Levin told me time and again during my clinical training, “You will not find what you are not looking for.” This seems to apply most noticeably when it comes to Behavioral Health . In every other field of clinical medicine, a physician’s perspective flows from structural to functional, but when it comes to behavioral health, the flow is in the opposite direction. To clarify this point, I will define a persons’ function as the sum of their behaviors, e.g., vocational function, academic function, social function, etc. What will become clear from this perspective is that all behavior (function) is carried out exclusively by the skeletal system; the muscles, tendons and connective tissues of the body. It may be further derived that behavior cannot occur without an impulse, whether conscious or unconscious,  from the Central Nervous System preceding it.

So we have arrived to the destination of my opening chapter of Medicalizing Mental Health, the structure of behavior; it is the Central Nervous System  (the Brain and the Spinal Cord). Vague, you are saying? Then we better move on to

Chapter 2

Medicalizing Mental Health:

Performance as a Vital Sign

 Coming soon

Mitchell R. Weisberg, MD, MP

• Employers’ indirect costs resulting from Employee Mental Illness is 4 fold greater than their direct costs for Employee healthcare. (1)
• In spite of the fact that people with mental illness use the healthcare system much more often than does the general population, most (2/3) of Mental Illness is never recognized (diagnosed) or treated. (2)
• Once diagnosed, Mental Illness is highly treatable with between 70 and 90 percent of people having significant reduction of symptoms and improved quality of life with a combination of medication, talk therapy and other supports. (2)
• A major obstacle to recognizing mental health disorders is their lack of symptoms in the traditional sense of the word. (3)
• Recognizing mental illness depends on an awareness of an individual’s functional status such as their social functioning or work performance.
• Since there is evidence that even workers with mild or “sub-threshold” problems begin to show productivity problems early on – perhaps long before they experience other health consequences – employers are in a unique position to effect significant change in the way services are delivered. (1)
• Over the past two decades The Balanced Scorecard has been widely employed as the Business Management tool of choice by most major employers worldwide. (4)
• The Balanced Score Card aligns the goals of an Organization with the personal goals of its Employees for the purpose of achieving optimal performance at the Organizational level.  (5)
• Systematic  measurements of performance against the Organization’s stated goals is an essential part of an effective Balanced Scorecard. (5)
• Information contained within employee performance data, if viewed from a clinical perspective, will facilitate the early recognition and treatment of mental illness in a workforce. (1)
• The early recognition and treatment of mental illness in a workforce yields a significant Return on Investment for Employers. (6)
• Since there is evidence that even workers with mild or “sub-threshold” problems begin to show productivity problems early on – perhaps long before they experience other health consequences – employers are in a unique position to effect significant change in the way services are delivered.
• With more than 2 decades of clinical experience as both a Primary Care Physician and a Mental Health Care Provider and a career commitment to optimizing the health and performance of his patients, this physician is in a unique position to help employers effect this change. (1)
• This physician can show the stakeholders of any Organization how to realize the value of adding a clinical perspective to their Balanced Scorecard.

Mental illness is the single largest contributor to disability on the globe accounting for 33% of the total and the single largest cause of impaired work performance in the United States. (6) While 70 to 90% of people with a mental illness improve appreciably with treatment only 1 in 3 workers with mental illness are ever even diagnosed much less effectively treated. (7) What is more is that always preceding a person’s first or repeated episode of a full-blown mental illness, there is a sub-threshold form of the illness where functional impairment is the only harbinger of the malady that is to follow. (8) Organizations that effectively watch and appraise their employees work performance and align this with their Balanced Scorecard are in a unique position to leverage these performance metrics in a way that will have an order of magnitude impact on both the health of their workforce and their bottom lines.

Organizational Health in the 21st Century:

Work Performance; a New Vital Sign for a New Economy

Providers of a cognitively complex service with a global reach need only experience an episode of jet lag to understand how functioning at anything less than their optimal mental state can negatively impact their work performance, much less should they experience a full-blown mental illness. One in four members of the American workforce is impaired by a treatable mental illness; arguably, those employees providing the most cognitively complex services will be most susceptible to performance impairment. While Cognitive Behavioral Therapy (CBT), psychotropic medication or both is effective in 70 to 90% of people with mental illness, only one in three workers with mental illness actually seeks the attention that they need and only one in ten actually receives adequate treatment. (8) In addition to the burden of human suffering, there is the unrealized value of the most critical asset in an Enterprises portfolio, its human capital.

If we are to fix this problem, we first must understand why we are failing to recognize mental illness. The perceived stigma of being diagnosed with a mental illness continues to play a significant role in the under-recognition of mental illness. However, the fact that persons with non-diagnosed mental illness, on a per capita basis, utilize significantly more non-psychiatric healthcare services including non-psychiatric hospitalizations, Emergency Department visits as well as visits to Primary Care Physician that the general population points to the main culprit, and that is the  failure to recognize mental illness.

Two factors contribute to the invisibility of  mental illness.  First is lack of recognition on the part of patients that their flailing work performance may be due to a mental health condition, and thus they don’t seek the care of a professional for diagnosis and treatment.  The second is the medical school and post-graduate training physicians receive, which focuses on diagnosing and treating illnesses that are three-dimensional; that have a color, a texture or a mass that can be pointed at with a finger. In contrast, mental illness is invisible to every clinical tool that the modern healthcare provider has at their disposal.  Two clinical vignettes can best demonstrate this contrast:

-      In the first post season playoff game on the opening pitch all 50,000 fans in the stadium hear the loud popping noise that comes from the pitcher’s mound and witness him fall to the ground grabbing his right shoulder in utter agony. Neither the team’s trainer nor a single spectator need to see him throw a second pitch to diagnose the fact that something terrible has happened to the shoulder of their beloved star’s pitching arm.

-      Another pitcher has a 10 year career ERA of 1.8 until this season, in which his ERA has fallen to 4.1.  Needless to say his team did not reach the post-season. Neither his trainer nor a single fan in the stadium ever considered that this once high achieving superstar had recently begun to have depressive episodes due to an undiagnosed mental condition known as Attention Deficit Disorder. In spite of the fact that his performance on the mound is meticulously and accurately measured, none of these metrics gave any sign that his decline in performance was a direct manifestation of his underlying mental illness.  Failing to receive treatment widely recognized as highly effective in restoring function and performance, this pitcher was sent back to the Minor Leagues and was never seen in the Majors again.

In the case of the first pitcher the definitive diagnostic tool for recognizing a torn rotator cuff is the MRI.  But what most organizations, including baseball teams and companies of all types don’t realize is there is an equivalent to the MRI for detecting a range of mental health conditions.  Inherent in the Human Resource organization’s rigorous employee processes and performance tracking resides the essential information to assure that a workforce’s health is maintained at an optimal level, and to detect instances where a treatable mental health condition is  likely present.

The Human Resources professional of the 21^st century, wittingly or not, is at the front line in this nation’s battle to break with its myopic cost oriented health care system and lead us to one that is value based  with a return on investment; and who better qualified for this position than an person who actually has the term human capital in mind with every action she executes. Like a principle of an elementary school, she spends 90% of her professional life with 10% of the human capital whose professional lives are within her charge; but this is not where the similarity ends. The 21^st century Enterprise comes equipped with performance metrics or, highly advanced versions of report cards that, when executed well, hold invaluable information germane to the future continual success of the employee, manager or executive to whom it is applied.

End Post

Please stay tuned for the following posts coming soon:

• Performance-Health: The missing link in the evolution of Employee and Organizational Wellness
• What the quality of an Employee’s performance saying about the quality of their health and why it is important to know?
• Anticipating the unintended consequences of Performance as a Vital Sign

It should come as no surprise that when the term human capital first appeared in the annals of economic theory some 60 years ago it was characterized as a fungible resource similar to the machinery of what was, after all, a manufacturing based economy. (1) This characterization of human capital changed at the speed of light in the aftermath of the Soviet’s launching of Sputnik in 1957 and President Eisenhower’s determination that the United States to never again lose to another nation in the race for information, and the  Advanced Research Projects Agency (ARPA) and soon thereafter, the internet was born. (2) Prior to Sputnik, approximately 40% of the US GDP was derived from the manufacturing sector. (3)  From the dawn of the Information Age however, a virtual servicization of the US economy has occurred with 80% of US GDP in 2011 being derived from the service sector. (3) With this transition from a manufacturing to a service economy, the US workforce evolved from one dependent on its brawn to one that is based almost entirely dependent on its brains; consequently the employee health issues that are most likely to impair their work performance hav  (5) Mental illness is the single largest contributor to disability on the globe accounting for 33% of the total and the single largest cause of impaired work performance in the United States. (6) While 70 to 90% of people with a mental illness improve significantly with treatment only 1 in 3 workers with mental illness are ever even diagnosed much less effectively treated. (7) What is more is that always preceding a persons first or repeated episode of a full blown mental illness, there is a sub-threshold form of the illness in which functional impairment is the only harbinger of the malady that will soon follow. (8) Organizations that effectively monitor and appraise the performance of their employees as a component of their Balanced Scorecard are in a unique position to leverage these performance metrics in a way that will have an order of magnitude impact on both the health of their workforce and their bottom lines.

Please stay tuned for my upcoming post,

Organizational Health in the 21st Century:

Employee Performance; the New Vital Sign in the New Economy

Until then remain healthy and remain effective.

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Mitchell R. Weisberg, MD, MP

Mental Illness affects 1 in 4 Americans and is the single largest cause of disability on the globe accounting for 33% of the total. (1) (2) (3) The cost of lost productivity related to undiagnosed mental illness in the U.S. is more than four times that of all medical treatments combined. (4) Seventy to 90% of people with mental illness have improved symptoms, quality of life and level of productivity with medication, talk therapy, and other supports, yet two-thirds of people with mental illness in our country will never seek treatment of any kind. (5) Virtuaully no one in the United States unaffected by mental illness whether it be in themselves, a family member, a friend, a classmate or a co-worker.

As a launching point from which to show the more profound implications of my simple mind-body message, I offer this example from my daily clinical practice. As would any typical Internist, I treat this one patient for his asthma and high blood pressure, but unlike most other Internists, I also treat his attention deficit hyperactivity disorder (ADHD), bipolar disorder and cocaine abuse. While an extraordinary and unique person, he is typical of the patients that I see in my practice every day. What may come as a surprise to my readers is that he is typical of the patients that all physicians see every day. (6)  They, as I did at one time, are either failing or refusing to recognize it. While it is widely perceived that the stigma associated with the diagnosis is to blame, it is actually this lack of recognition, by patients and their physicians that poses the most formidable obstacle for people with mental illness from getting the help which they very much need and which is very much available. It is well established that people with undiagnosed mental health disorders have higher rates of healthcare use than the general population, yet in spite of the fact that they are seeing physicians more often, most will never receive the proper diagnosis or treatment. (7)

In our defense, the disorders that we physicians learned to recognize and treat are usually 3-dimensional, have typical appearances when viewed with a CAT scan, MRI, or under a microscope, we can detect them with blood tests and in many cases the patient can literally point their finger at the diagnosis. In stark contrast, mental health disorders do not occupy space nor do they have mass, they cannot be seen with a microscope, CAT scan, MRI, cannot be heard with a stethoscope or detected by a blood test, and the patient suffering with a mental health disorder most certainly cannot put a finger on their problem. The only manifestations of mental illness are the sufferer’s functional impairments which occur long before what are commonly called symptoms; patients nor their physicians recognize being dysfunctional as a clinically relevant issue. Further complicating things is the fact that 70% of people with mental illness experience physical, as opposed to emotional symptoms which explains why most people suffering with mental health disorders present first to their primary care physicians, with focus on the physical symptoms consuming most of the 15 minutes that they spend together. For instance, 20% of patients coming into their primary care physicians’ office have depression, but only 1% will complain of emotional symptoms. The rest will complain of physical symptoms such as fatigue, headache and vague muscular aches.  (8)

The following is the most graphic demonstration of the folly and the danger of the view of the separation of mind and body that prevails in our society. 9% of Americans suffer from a major depressive episode each year; among Americans with diabetes, this rises to 25%. In other words, being diabetic makes a person nearly three times more likely to suffer a depressive episode than someone who is not diabetic. What’s more is that when those people that have both disorders get treated for their depression they will have significant improvement in their diabetic control, require less medication to treat their diabetes and will definitely cut their risk of the vascular complications of diabetes such as heart attack, stroke, kidney failure, blindness and amputation as compared to those that do not get treated for their depression. (9) So I ask, what is diabetes, a physical illness, mental illness or both? If you are uncertain, congratulations; you are beginning to understand my point that when it comes to our health, the mind and the body are not separate!

While a seemingly invisible masquerader, mental illness is readily identifiable and treatable; that is, once you know what it is you are looking for. My mentor, and the Director of my Internal Medicine Residency program, Dr. Stuart Levin, when training me to become an expert diagnostician shared with me many pearls of wisdom, but there is one in particular that stuck with me every day for the 25 years since I heard it: “You will never find what you are not looking for”. Back in 1987, I never would have believed that such a clinical pearl from one of the world’s foremost Infectious Disease Specialists would be so àpropos when staring into the invisible face of the mental health epidemic nearly a quarter century later.

Integrating the recognition and treatment of mental illness into my primary care practice has made my medical care much more effective as well as more fulfilling. I not only save lives, I save jobs, academic careers, marriages and families. As in my patient with asthma, high blood pressure, ADHD, bipolar disorder and cocaine abuse, on a daily basis I bear witness to the intricate inter-relatedness of seemingly disparate human maladies; while each addressed in separate chapters of a medical textbook or in separate textbooks altogether, in the real world, more often than not, they co-exist in the same person. As awe-inspiring to me today as the first time that I realized this, it pales compared to the primacy of the unique person that we call the patient that puts their non-forgeable signature on these maladies, bears their burden and somehow must transcend them if they are to reach their fullest potential in life.

Medicalizing Mental Health offers my readers a rational structure from which to view mental health, whether in themselves, their family members, classmates, co-workers, friends or patients; one which is infinitely more productive and solutions oriented than the prevailing paradigms which continue to cling to the obsolete notion that our minds and bodies are separate. Medicalizing Mental Health is my proclamation that the Emperor is not wearing any clothing and he is actually sitting right next to the elephant in the room! As enormous a problem as mental illness is, it will continue to clandestinely embezzle our world’s precious human capital unless we garner the collective will required to recognize it. While seeing the invisible may seem an insurmountable challenge, as you will certainly learn in the pages that follow, when it comes to mental health, there is much more than what meets the eye.

This is Medicalizing Mental Health: A Rational Approach to an Emotional Topic

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Mitchell R. Weisberg, MD, MP

1. The most common of the mental/behavioral health disorders (10% children and 5% of adults in the US.
2. The most inherited of the mental/behavioral health disorders (similar inheritance patterns as eye color and height.
3. The only mental/behavioral health disorder that is present at birth (the rest being acquired sometime after birth.
4. Virtually all adults with ADHD that were not diagnosed or adequately treated during childhood or adolescence, will acquire a second neuropsychiatric disorder, known as a co-morbid condition, in one or more of these 3 classes: Substance Use Disorders (SUD) and Addiction;  Anxiety Disorders and  Mood Disorders including Bipolar Disorder.
5. When a co-morbid condition is present, it makes the diagnosis of the ADHD even more difficult; yet unless the ADHD and the co-morbid condition are both diagnosed and treated, neither one will resolve fully.
6. The most functional impairments (academic, driving, vocational, financial and interpersonal) yet the least obvious “symptoms” (there are no “episodes” per say in ADHD) making those that have this disorder feel like they are under-achievers or just stupid and making it the most difficult to recognize by both patients and their physicians.
7. The only mental health disorder that seems  to involve a single neurotransmitter (Dopamine); since all others have multiple neurotransmitters involved. Moreover, most of  the mental health disorders that are co-morbid in almost all adult patients with ADHD are exacerbated by medications that enhance Dopamine. Thus, sequence of the treatments for ADHD and its co-morbidities is as crucial as the treatments themselves.
8. ADHD is the one mental/behavioral health disorder for which medication is absolutely indicated. Cognitive Behavioral (CBT) and other forms of “talk” therapy, while adequate as the sole treatment modality in many other mental/behavioral disorders and is a useful adjunctive treatment for ADHD, by itself is ineffective and inadequate for overcoming the functional impairments associated with this disorder.

Mental-behavioral health can be viewed from the same biological perspective as any other aspect of human health. For instance, to understand how the heart or any other organ in the body functions or dysfunctions, we first need to understand its structure from the macro to the micro level. The heart has 4 chambers, two on the left and two on the right; it has a pacemaker which creates electrical impulses which synchronize the contractions of these four chambers; this electrical system is further controlled by the flow of ions across heart cell’s cell membrane, and on and on it goes. Similarly, when applying these same basic steps in understanding mental-behavioral health we quickly arrive at the first principle of medicalizing mental health; behavior is physical and is executed exclusively by the body comprised of bones, muscles and connective tissues.  All behaviors, from simple to complex, originate as an impulse in the CNS (brain and spinal cord). There are 100 billion neurons within the human central nervous system and each one of them has the same final destination and that is a muscle.

1.While 1 in 4 Americans over the age of 18 has a mental health disorder that impairs their normal daily functioning, only 10% are recognized let alone diagnosed or effectively treated.(2)

2. Researchers found that absence, disability, and absence-related lost productivity cost US employers more than 4 times the cost of employee medical treatment, even when Workers’ Compensation medical costs were added in. (3)

That’s all for now, but stay tuned. The solutions are coming soon!

Mitchell R. Weisberg, MD, MP

1. http://www.who.int/whr/previous/en/
2. http://www.nimh.nih.gov/statistics/1ANYDIS_ADULT.shtml
3. http://www.nami.org/Template.cfm?Section=About_the_Issue&Template=/ContentManagement/ContentDisplay.cfm&ContentID=114538

If we have learned anything since the release of Prozac  to the marketplace in 1987 it is that mental and behavioral health disorders, just like heart disease, asthma or diabetes, also have physical and chemical components to them. However, more than any other disorder understood by modern medicine, mental and behavioral health disorders have far greater social and economic consequences; largely due to our society’s and our healthcare system’s continued insistence on viewing mental/behavioral health as if they are separate and distinct from all other disorders that impact human health. The following example (of which there are countless others) ought to suffice in dispelling this myth, allowing us to gain a more useful understanding of mental/behavioral health disorders.

9% of the United State’s population  suffers a major depressive episode each year (that is an episode of depression that impairs the ability to function normally for 2 or more weeks). If we now take a look at all people in the United States that have Type 2 or Adult Onset Diabetes (25.8 million people or 8% of the population), 25% of them suffer a major depressive episode annually (nearly a 3 fold increase over the general population). Moreover, of those 6.5 million people with both Type 2 Diabetes and Depression are effectively treated for their depression with either therapy, medications or both have better control of their blood sugar and have much fewer vascular complications from their Diabetes, such as heart attacks, strokes, amputations, retinal hemorrhages or kidney failure as compared to those with Type 2 Diabetes that are not treated for their depression. Arguably, antidepressants may play a more important role than insulin in the effective treatment of Type 2 Diabetes; possibly reducing or even eliminating the need for insulin at all! So what is Type 2 Diabetes? Is it a mental health disorder, a physical health disorder or both? If you are not sure, you are beginning to understand my point and are ready to understand mental/behavioral health in a way that may actually offer some solutions.

The Spectrum of Mental Health

The best place to begin changing such a time-honored, yet counterproductive and irrational belief as the separation of mental and physical health or the mind and body, is to view mental health disorders on a spectrum just as we view all other disorders that we treat in modern medicine. For example, the diagnosis, Asthma is used to describe  someone who wheezes only if they do athletics or if they are exposed to allergens. Asthma is also used to describe someone else that is in the emergency room twice per year for sudden onset of severe respiratory distress unrelated to any obvious exposure to physical activity or allergens. We can thus see that Asthma is on a spectrum from mild and occasional to severe and chronic with the common element to all on the spectrum being that they  all wheeze sometimes. Similarly, the diagnosis Mental Health Disorder may be used to describe someone who has a panic attack when they are in an airplane forced to  sit on the tarmac due to a delay in their flight schedule; it may also be used to describe someone else who knows with certainty that the world is coming to an end on May 21^st, 2011 because their dog told them so. As different as these two examples are, what they both have in common are aberrant  impulses in the Central Nervous System disrupting the person’s ability to think or behave rationally. Just as defining more precisely where on the asthma spectrum someone who wheezes is will help decide how to treat them, so too will determining where someone with mental health symptoms is on the spectrum of mental health.

With this as our launching point please stay tuned to my Blog for these future chapters in my upcoming book, Medicalizing Mental Health: A Rational Approach to an Emotional Topic

Depression and Anxiety: a symptom is not a diagnosis

OCD; when too much of a good thing becomes a bad thing

The Bipolar Spectrum; better to over-diagnose than miss

Psychosis; the potential endpoint for all untreated mental health disorders

Addiction; a symptom and not a Diagnosis

Where are Eating Disorders on the Mental Health spectrum? Everywhere!

The cost of Mental Health Disorders; The Neuroscience of a Service Economy

The cause of ADHD symptoms related to defective Dopamine Transport in an area of the brain that, for all practical purposes, acts as an In Box for tasks to be completed. With normal Dopamine Transport, these tasks travel along a Super Highway from the In Box to the specific region of the Brain that would normally carry out that specific task, relaying the orders to the Body which ultimately is responsible for carrying out all tasks (all behaviors begin in the brain and end in the body). In the absence of these Dopamine Transporters tasks must, instead, take detours (side streets). When several tasks, even relatively simple ones, present themselves simultaneously, a traffic jam can quickly occur in the Brain; simple tasks thus become difficult causing the person with ADHD to feel overwhelmed most of the time. When taking this aerial view from a traffic helicopter it becomes clear why Individuals with ADHD can become easily frustrated, have short fuses and be generally irritable; much like we all feel when we are in an actual traffic jam.

Drugs known as the stimulants cause a generalized increase in Brain Dopamine levels and by the simple process of diffusion gets to the Brains’ In Box allowing the tasks stored there to travel along that Super Highway. This typically results not only in improved productivity, but clears up all of those traffic jams, thus allowing the person to engage more comfortably in those activities that are not related to tasks, such as interpersonal relations and leisure activity, etc. Ironically, this enhanced processing ability that stimulants provides actually makes people with ADHD feel like their brains have actually slowed down and not are no longer constantly churning as if driven by a motor.

With that said we must always remain mindful that ADHD seldom lives alone and most often keeps the company of other disorders. In fact, almost all adults with ADHD that were not diagnosed and treated in childhood will have a second disorder, referred to as co-morbidities. These co-morbid conditions include Mood Disorders (Depression, Bipolar), Anxiety Disorders (Generalized Anxiety Disorder, Panic Disorder or Obsessive Compulsive Disorder) and Substance Use Disorders including Addictions; and often there may be more than just one co-morbidity present in the same person. Thus, when prescribing a stimulant, equally important as making the diagnosis of ADHD is identifying the company that it keeps; failure to do so may have deleterious outcomes. Stimulants, by increasing the level of Brain Dopamine may exacerbate anxiety, mood disorders even causing Mania and Psychotic features in people that never had such symptoms before stimulant exposure. In fact, the purported mechanism of Mania and Psychosis is excess Dopamine in a specific Brain Dopamine Pathway, of which there are a total of 4.

If, as I just explained almost all adults with ADHD have co-morbid conditions that may actually be made worse by treatment with stimulants, how are we to treat the adult with ADHD? Should stimulants not be used? The answers to these questions will be coming soon in my next post: The Importance of Sequence in  Treating ADHD and the company it keeps.

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Mitchell R. Weisberg, MD, MP

Medicalizing Mental Health: A Rational Approach to an Emotional Issue

Our efficiency and accuracy in performing tasks runs parallel to our sense of wakefulness which peaks soon after awakening and gradually degrades as the day progresses until evening time when we become sleepy and the cycle starts anew. While feeling sleepy is something with which everyone can identify, diminished executive functioning (our ability to identify and fulfill tasks) is not as obvious. Never the less our executive functioning diminishes as the day progresses being the first brain function to decline when we are sleep deprived or drowsy. To prove this point, a major review conducted in 1996 suggested that the oil spill of the Exxon Valdez, the space shuttle Challenger disaster, the nuclear accident at Chernobyl (costing over 4,000 lives) and the near nuclear accidents at the Three Mile Island and Peach Bottom reactors were all associated with sleep deprivation of the people involved. Sleepy driving causes as many car crashes as driving under the influence.

During the course of our hectic days we too have a whole host of open programs in our brains, which is as it should be when we need to execute tasks and move our agendas forward. Just like our personal computers, our brains cannot go from having 6 open programs to off without some adverse consequences when we go to re-open these same programs tomorrow. In order for sleep to fulfill its restorative function we must get both the proper quantity and quality of sleep. People that work right up until the time that they fall asleep are deluded if  they think this increases their productivity; however this habit actually decreases productivity due to their inefficiency and error of performing tasks while drowsy.  Just like with our computers, we need to start shutting down our open programs, one at a time, starting well before sleep time. Time management, as it relates to human performance and productivity is not a zero sum game. The 90 minutes we spend “chilling” before we sleep is not 90 minutes of work lost; it is actually a pre-requisite for restoring our ability to function “executively” the next day.

My message is, shut down your open programs and chill out for a while before trying to go to sleep tonight; it may just prevent a disaster from happening tomorrow.

Mitchell R. Weisberg, MD, MP

Footing for at least 1/3 of this nation’s healthcare expenditures, the continually rising costs in this sector is a cancer that threatens the life of U.S. Business. In the past 2 decades healthcare expenditures have increased 300%; a rate that is 5 times that of inflation for this same time period.  This represents 16.2 % of GDP (gross domestic product), giving our nation the unflattering distinction as the leader of the industrialized world in this category.(1)  Based on the current spending trajectory, by this nation’s tricentennial nearly one half of its collective productivity will be consumed by healthcare expenditures. (2) Characterizing this issue as a terminal illness is not simply a convenient medical metaphor; absent an unprecedented fundamental change in how healthcare is provided in the near future, the long-term prognosis for U.S. Business is certainly a grim one.  

The Diagnosis: US Business became so fixated on cost they have completely forgot about value

For the past 3 decades Corporate Americas’ prevailing healthcare strategy has been to outsource to third-party payers. While initially cost-effective, based upon the statistics just cited, this is clearly no longer the case. In its effort to survive spiraling health care costs, US Business has adjusted its strategy to cost shifting to its employees.This has only served to deepen the crisis by disenfranchising the workforce during an economic climate in which US business can ill afford to do this. While US unemployment is at its highest post Depression rates, recruitment and retention of talent and successorship are also at a critical mass in our nation; at the same time, global competition has never been more intense. Most importantly, cost shifting is only postponing the inevitable need to grapple with what, after all, is the elephant sitting on the sofa; an overvalued healthcare system. By conservative estimates 1 dollar of every $3 spent on healthcare in this country is wasted outright.(3)

This physician’s proposed course of Treatment

Sound business principles dictate that curing the malignant growth in health care spending be derived from novel combinations of proven remedies already in existence. In house strategies, such as on site wellness programs is one such proven remedy. Such programs have consistently demonstrated healthy returns on investment of $3 to $6 return on every $1 invested. While still an emerging trend, on site health services have higher employee participation and employer satisfaction rates than most other health programs. (4) In contrast to the negative PR generated by cost shifting, companies offer on site programs to stay competitive in the marketplace and use such programs as a recruitment and retention benefit. While clearly a breath of fresh air, in-house strategies have inherent limitations that keep them from making any more than a small dent in our current healthcare crisis. However, with some creativity these limitations may be easily overcome. When organizations have  invested in on site wellness programs they typically realized returns quickly. Unfortunately, due to the inherent selection bias of such programs, these returns seem to plateau just as quickly. Selection bias would predict that those employees most likely to participate  in an on site wellness program will be those already wellness minded. As a result if this phenomenon, these programs will tend to help those employees that least need it while leaving those employees that have the most to gain, behind. Overcoming this limitation would require a method to easily identify those employees that would derive the greatest benefit from an on site wellness program and provide them with the incentives to take part in it. Such methods of employee selection will appropriately raise the ethical and legal concerns regarding an employees privacy and a multitude of other such issues. However, with what this physician has in mind, such issues will be of no concern. Before addressing this issue, it is necessary to provide the clinical background information upon whicn this authors solution for healthcare is founded. Please stay tuned for my next post, The Neuroscience of a Service Based Economy

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Mitchell R. Weisberg, MP, MD

(1) http://www.kaiseredu.org/topics_im.asp?imID=1&parentID=61&id=358 http://www.measuringworth.com/ppowerus/.

(2)  http://www.cbo.gov/ftpdocs/89xx/doc8947/01-31-TechHealth.pdf

(3) http://thomsonreuters.com/content/press_room/tsh/waste_US_healthcare_system

(4)  http://www.hewittassociates.com/_MetaBasicCMAssetCache_/Assets/Articles/2010/Hewitt_Survey_Findings_TheRoadAhead_2010.pdf

When we think about this from an Evolutionary perspective, this makes perfect sense. 100 % of the 1 or 2% difference between Chimpanzee and Human DNA went into the design of the Human Cerebral Cortex; the seat of our superior ability to reason, speak, discover, create and deceive. For better or for worse, it follows, that the part of us that makes us distinctly human,  our Cortex needs to be in command of the rest our beings; when it’s not,  our health and our performance is rendered suboptimal.

From this vantage point, one will see just how arbitrary the border separating the mind from the body is. For example, 9% of Americans suffer from a major depressive episode each year. Amongst people with Type 2 Diabetes, 25% have a major depressive episode annually. A single chronic health condition is associated with a nearly three-fold increased risk of Depression! What’s more, in people that have both Type 2 Diabetes and Depression, those that have their depression treated have much improved control and reduced complication rate of their diabetes than in those that do not have their depression treated. The implication of this for me as a physician is that for me to optimally treat Type 2 Diabetes, the most common chronic condition in the United States, I must also be able to optimally treat depression.

I use Diabetes and Depression simply as a graphic example of the folly and the danger of the prevailing view of the separation of Mind and Body that continues to persist in our society in general and in our healthcare system in particular. With our ability to perform in our world being such a cerebral experience, anything from a bad night’s sleep, to skipping meals to chronic pain or having multiple chronic health disorders will have an effect on a persons’ ability to learn, work or interact socially with family members friends and co-workers. The time has come where we must completely reject this concept of the separation of  mind and body or physical and mental; our lives and our livelihoods depend on it!

Welcome to the Evolution.

References

http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml 

http://www.nimh.nih.gov/science-news/2010/diabetes-and-depression-associated-with-higher-risk-for-major-complications.shtml 

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Mitchell R. Weisberg, MD. MP

Breads in general should contain 2 grams or more of fiber per slice.

Crackers: > 3 grams per serving (Kashi brand)

Fruits and Vegetables in general are good sources of fiber

Soy,  is a vegetable that is high in fiber as well as protein: Edamame; try Melissa’s brand; Boca Brand of burgers and sausages (it’s all soy and actually tastes great); Morning Star is another brand of the faux meat products (and I am not a vegetarian)

Trail Mixes: these are extremely practical because of how portable they are. Trail mixes can vary in their content quite a bit; some are more candy than anything else. Just check the nutrient content for the 5 grams of fiber and go for it. This is something you can keep in the car at your desk in backpacks, purses, brief cases, etc.

Energy Bars: Look for > 5 grams of fiber per serving:  Cliff Bars and Kashi GoLean are both excellent choices in this category. 

Here is a plug for Starbucks; they seem to get it. They have prepackaged trays such as their protein breakfast with apple; peanut butter; whole wheat bagel; hardboiled egg; some cubes of cheese and grapes. They have a fruit and cheese tray. Most of their sandwiches are on high fiber breads. They sell individual small packages of trail mixes. Granted they are pricey, but I do have to give them credit for offering this type of food.

OK; you got it? Good, then go and have something to eat before you get hungry.

End

Mitchell R. Weisberg, MD. MP

Albert Einstein said if he had just 60 minutes to save the world he would spend 55 minutes defining the problem and 5 minutes deriving the solution. Similarly, when optimizing an individuals’ health, I spend most of my time illuminating their symptoms, which I define as anything they perceive as impeding their ability to function, be it physical, mental or emotional. My 21 years of clinical experience as an Internist and Psychopharmacologist has allowed me to develop a unique clinical method in which I pinpoint the region(s) of the Central Nervous System (Brain and Spinal Cord) from which their symptoms originated. Next, I match these symptoms with the functional impairments they are experiencing. This  is referred to as “deconstructing the syndrome” and serves as the key to my transcending the imaginary boundary separating physical and mental health (mind and body). This process requires I spend about 2 hours, face to face, with an individual; once completed navigating a path to achieving Optimal Health and Performance, just as Einstein would have predicted, is the relatively simple leg of the journey.

While honoring the uniqueness of every person, my general management strategy never varies. In my lineup optimal levels of Nutrition, Physical Activity and Sleep bat first, second and third; with my prescription pad, when needed, batting cleanup.

With this as my own personal healthcare system, I offer comprehensive individualized Health and Performance Optimization Programs for Adolescents and Adults impaired by:

• Addictions
• Anxiety Disorders
• Attention Deficit Hyperactivity Disorder
• Chronic Pain Syndromes
• Eating Disorders
• Menopausal Management
• Menstrual Disorders
• Mood Disorders
• Overweight/Obesity

By Medicalizing Mental Health I resolve my patients’ symptoms; removing the stumbling blocks obstructing the path leading to their Optimal Health and Performance.

End

Mitchell R. Weisberg, MD, MP

Employers did not need Mental Health Parity Legislation to have a bottom line motivation to invest in the mental health of its workforce. Absence, disability and lost productivity related to mental illness cost employers more than four times the cost of employee medical treatment.(2)

It appears that mental health disorders are not only difficult to identify clinically, their exorbitant cost has no designated column on a balance sheet, either.

This physician’s diagnosis is that we have a Societal Disability to rationally confront the issue of mental health. If we do not raise our standards  from simply shooting an even par, I am afraid that our prognosis is grim.

End

Mitchell R. Weisberg, MD, MP

(1) Ann Intern Med April 20, 2010 152:JC4-13;

(2) Partnership for Workplace Mental Health, A Mentally Healthy Workforce—It’s Good for Business , (2006), www.workplacementalhealth.org.

I originally met this 43-year-old gentleman when he presented to my office in January 2006 with depression severe enough that he was contemplating suicide. Over the ensuing 10 months, I diagnosed him with Bipolar Disorder and Attention Deficit Disorder (a combination that is fairly common). In spite of initially responding well to his medical regimen, in October of 2006, my patient took an intentional overdose of his medications in an attempt to end his life. Fortunately, he did not succeed and after his release from the hospital he was determined, for the sake of his wife and children to get well. I was equally determined to provide him the medical support he required in order to help  him get well. By early 2007, we did it! Together we found the right combination of medications, 4 of them to be exact, that helped get my patient to remission, which he has remained in ever since. Now, just like the rest of us, my patient has his good days and he has his bad days, but he has not had a relapse of depression or suicidal thinking in nearly 4 years. He has been functioning to the potential that he always knew that he was capable of; and his talents were recognized by his employer and  he has since been promoted to a management position and is an asset to his company. Things worked in my patient exactly as my training and experience as a Psychopharmacologist taught me to expect; when you get your patient’s mental health disorder to a complete remission, their functional capacity (performance) in every aspect of their life improves.

I am providing you with a link to the letter my patient received last week just 10 minutes before he called me to share the insanity. I ask that you read it and try to imagine how my patient felt when he read this letter.

 The dropping of mental health benefits

I will leave you with this thought; the health care crisis in our nation is not, nor has it ever been, primarily about healthcare cost; it’s about productivity lost. I am going  to attempt to convince The Trustees of The Plumber’s Welfare Fund that this is, indeed the case and I hope for their sake that these Trustees can trust me for they, like my patient, stand to lose a great deal by their shortsightedness.

I will let you know how it goes.

Mitchell R. Weisberg, MD, MP