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Mental Health Parity – Finally!

Here’s the American Psychological Association press release about the recently passed mental health parity law in the U.S. This is great news for insured people suffering from mental health disorders as well as for psychologists who will now be able to receive better reimbursement for services provided. Here’s a NYTimes article on the bill.

WASHINGTON—President Bush signed mental health parity into law today, taking a great step forward in the decade-plus fight to end insurance discrimination against those seeking treatment for mental health and substance use disorders. This historic legislation requires that health insurance equally cover both mental and physical health.

Congress passed the legislation as part of a new bill that also includes tax extenders, changes to FDIC and the controversial financial rescue plan. The House passed the legislation today by a vote of 263-171. On October 1, the measure passed the Senate by a vote of 74-25.

“With passage of this bill, insurance companies can no longer arbitrarily limit the number of hospital days or outpatient treatment sessions, or assign higher copayments or deductibles for those in need of psychological services,” said Dr. Katherine Nordal, the American Psychological Association’s (APA) executive director for professional practice.

For over a decade, the APA has worked with Congress to achieve a full mental health parity law ending discrimination in health insurance coverage against those suffering from mental health disorders.

The 2008 bill closes several of the loopholes left by the 1996 Mental Health Parity Act and extends equal coverage to all aspects of health insurance plans. It preserves existing state parity and consumer protection laws while extending protection of mental health services to 82 million Americans not protected by state laws. The bill also ensures mental health coverage for both in-network and out-of-network services.

According to the National Institute of Mental Health, more than 57 million Americans suffer from a mental health disorder. According to a 2008 nationwide survey by Harris Interactive in conjunction with the APA, 25 percent of Americans do not have adequate access to mental health services and 44 percent either do not have mental health coverage or are not sure if they do.

Additionally, a 2006 survey from the Substance Abuse and Mental Health Agency reports that 49 percent of U.S. adults with both serious psychological distress and a substance use disorder go without treatment.

“Research shows that physical health is directly connected to emotional health and millions of Americans know that suffering from a mental health disorder can be as frightening and debilitating as any major physical health disorder,” said Dr. Nordal. “It’s our hope that passage of this bill will force our health care system to finally start treating the whole person, both mind and body.”

The American Psychological Association (APA), in Washington, DC, is the largest scientific and professional organization representing psychology in the United States and is the world’s largest association of psychologists. APA’s membership includes more than 148,000 researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance psychology as a science, as a profession and as a means of promoting human welfare.

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Decomposing Statistics

Statistics are used by all but understood by few. In fact, studies have shown that 94% of people have little to no understanding of statistical methods. OK, that last statistic was made up; I wrote it to make a point though. I could post something like that on this blog and people would believe it and possibly even repeat it. The sad thing is that it probably isn’t that far from reality. In social science and neuroscience research we use statistics to understand data and support hypotheses. This post will serve as a statistical primer. I will not discuss how to calculate statistics, rather I will write about the underlying assumptions and theory of statistics. I will also discuss how to properly use and understand them (and hopefully avoid misusing them). I hope to help you become a more informed consumer of statistics.

When did we start using statistics and why?

Joel Best wrote a brief history of the use of statistics in his excellent book Damned Lies and Statistics: Untangling Numbers From the Media, Politicians, and Activists. [I urge everyone to read the book to be more informed about statistics. All quotes will be from the book. It provides only a superficial treatment of actual statistical methods – which he states is the case – but it provides a good theoretical background for being a critical thinker about statistics]. He states that statistics rose in popularity as governments and social activists wanted ways to track and “influence debates over social issues” (p.11). Early statistics were used almost exclusively for political purposes, especially to shape social and governmental policies. From the beginning, statistics were used for non-neutral purposes. They gave credibility to arguments.

One assumption that people erroneously make is that statistics are neutral and that they represent truth. They are useful for aggregating a lot of data but the problem is that most statistical methods are based on certain assumptions about the underlying data (e.g., that it is normally-distributed). However, many times researchers use certain statistical methods and make conclusions based on those data when the methods are not appropriate for the data. Even simple descriptive statistics (e.g., averages) can lead to people making erroneous conclusions.

People who create statistics all have a purpose for them. Researchers are all biased and have agendas. It just may be to get their research published or it might be for other ulterior reasons. Social activists use statistics to create social problems (see p. 14); they are not the cause of the “problem” but they try to raise awareness of it by turning it into a “problem” that we need to pay attention to and solve. This can often be a good thing but activists are using statistics to give credibility to their cause (e.g., “According to the World Health Organization, between 12 percent and 25 percent of women around the world have experienced sexual violence at some time in their lives.” source). Governments also use statistics to defend their position (e.g., “Crime rates decreased by XX% from last year. See! we are doing our job.”) and sometimes to counter the claims of activists.

The media pick up on statistics, on activists, because they present a new story and might even be controversial and controversy sells. Businesses also use statistics to promote their causes. Not everyone or entity will collect data in the same way either – one police station might have different criteria for counting an assault than another one has.

The author Best proposes three general questions to ask when seeing a statistic used.

  1. Who created this statistic?
  2. Why was this statistic created?
  3. How was this statistic created? (pp. 27-28).

Many times people don’t even know enough to ask those questions or to research the answers to those questions. After all, as Best points out, we are largely an innumerate society (this holds true world-wide). Innumeracy is the math equivalency of illiteracy. A majority of people are uncomfortable with even basic mathematics and completely oblivious to statistics. After all, mathematics is abstract and requires a lot of mental effort to use and understand. It is often not taught as well as it can and only reluctantly learned in school. Once out of school, people rarely need to use more than basic math and so they forget what they learned. The other problem that we have is that we accept math (and by extension, statistics) to be perfect and infallible (Gödel demonstrated in effect that this is not the case). Best describes this fallacy:

“We sometimes talk about statistics as though they are facts that simply exist, like rocks, completely independent of people, and that people gather statistics much as rock collectors pick up stones. That is wrong. All statistics are created through people’s actions: people have to decide what to count and how to count it, people have to do the counting and the other calculations, and people have to interpret the resulting statistics, to decide what the numbers mean. All statistics are social products, the results of people’s efforts” (p.27; emphasis added).

So what do you do when you view a news program on TV or read an article or hear an activist or politician quote a statistic? If it makes you go, “Wow!” then that is one sign you need to step back and really scrutinize it (which you should do even if it doesn’t surprise/scare/etc. you). If you agree with the point the show, article, or person is trying to make then you really need to step back and critique the statistic. This means you need to understand your biases. It is easy to only want to confirm our hypotheses and beliefs and ignore anything that might contradict them. This is generally adaptive to help us process a lot of information but it can be a problem when we don’t critically view statistics, especially when they are “bad statistics” (which you can never discover without critiquing them). When you view or read a statistic, that is the time to ask yourself those 3 questions Best proposed and go from there. You might discover something interesting.

I’ll post more on this subject later.

Reference

Best, J. (2001). Damned Lies and Statistics: Untangling Numbers From the Media, Politicians, and Activists. University of California Press, Berkeley and Los Angeles, CA.

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An Introduction to and Overview of the Brain

bi sang by seung ji baek

The human brain is a wondrous thing. It is the single most complex organ on the planet. It sits atop the spinal cord. Gazing upon the brain, one sees four main distinct areas – two roughly symmetrical hemispheres, a cerebellum stuck up underneath the posterior part of the brain, and a brainstem sticking out and down from the middle of the brain. Each cerebral hemisphere is divided into four visible lobes: frontal, temporal, parietal, and occipital. The frontal lobes jut out at nearly a 90 degree angle from the spinal cord and are the largest part of the human brain. The temporal lobes stick out the sides of the brain, like thumbs pointing forward at the side of a fist. The parietal lobes are harder to distinguish. They are just posterior to the frontal lobes and dorsal to (above) the temporal lobes. The occipital lobes are at the very back of the brain, like a caboose on a train.

The outside of the brain is covered with a series of bumps and grooves. The bumps are called gyri (sing. gyrus) whereas the grooves are called sulci (sing. sulcus). This outside part of the brain is filled with tiny cell bodies of neurons, the main functional cell of the brain. Some people estimate that there are 100 billion neurons in the central nervous system (brain + spinal cord). This outer layer of the brain is called the cortex (which means “bark”). The cortex is only about 5mm thick, or about the thickness of a stack of 50 sheets of copy paper, yet it is responsible for much of the processing of information in the brain.

At room temperature the brain is the consistency of warm cream cheese. If removed from the skull and placed on a table, it would flatten and widen out a bit, like jello that is warming up. The brain is encased in a series of protective sheaths called meninges. The outermost encasing is called the dura mater (L. “tough mother”), which is thick and tough and is attached to the skull. The next layer in is softer. It is called the arachnoid layer; it adheres to the brain. Just underneath this layer is where cerebrospinal fluid (CSF) flows. This fluid is produced in holes in the middle of the brain called ventricles. CSF helps cushion the brain as well as remove waste products from the brain. Underneath this is a very thin and fine layer called the pia mater (L. “soft mother”), which adheres directly to the cortex and is difficult or impossible to remove without damaging the cortex. These three layers of meninges serve to protect the brain.

The brain can be roughly split into three functional areas, each one more “advanced” than the previous. The brainstem (and midbrain), which includes such structures as the medulla, pons, and thalamus, activates and regulates the general arousal of the cortex. Damage to the brainstem often results in coma or death. The next rough functional area is the posterior portion of the brain (parietal and occipital lobes and portions of the temporal lobes). This area is heavily involved in sensory processing – touch, vision, hearing. It sends information to other parts of the brain largely through the midbrain structures. The last functional area includes the frontal lobes. This area can regulate all other parts of the brain but is essential for goal-setting, behavior inhibition, motor movements, and language. The frontal lobes are the most advanced area of the brain and arguably the most important for human functioning – for what makes us human. In summary the three areas roughly are responsible for:

  1. Overall arousal and regulation
  2. Sensory input
  3. Output, control, and planning

Underneath the cortex is a large area of the brain that looks white. This area is comprised of the axons of the neurons of the cortex and subcortical structures. These axons are the pathways between neurons – like superhighways connecting cities. The axons look white because the majority are covered with a fatty tissue called myelin. Myelin helps axons work more efficiently and transmit more quickly. The white matter of the brain is as important for normal brain functioning as the gray (neurons) matter is.

The brain is energy-hungry. It cannot store energy so it needs a constant supply of nutrients from blood. However, blood can be toxic* to neurons so the brain has to protect itself from the blood and other toxic materials through what is called the blood-brain barrier. This barrier keeps blood cells out of the brain but allows molecules of nutrients (e.g., glucose) to pass into or feed the cells. The entire surface of the brain is covered with blood vessels, with many smaller vessels penetrating deep into the brain to feed the subcortical structures. Deoxygenated blood must be removed from the brain. Veins take the blood out of the brain and drain into venous sinuses, which are part of the dura matter.

The brain works as a whole to help us sense, perceive, interact with, and understand our world around us. It is beautiful in its form and function.

*”Today, we accept the view that the BBB limits the entry of plasma components, red blood cells, and leukocytes into the brain. If they cross the BBB due to an ischemic injury, intracerebral hemorrhage, trauma, neurodegenerative process, inflammation, or vascular disorder, this typically generates neurotoxic products that can compromise synaptic and neuronal functions (Zlokovic, 2005, Hawkins and Davis, 2005 and Abbott et al., 2006).” From Zlokovic, B. V. (2008). The blood-brain barrier in health and chronic neurodegenerative disorders. Neuron, 57(2), 178-201.

Image: Bi Sang by Seung Ji Baek

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Site Going Through Revisions

I’m working on finding a new look for my site. It will be going through revisions over the next few days as I get everything situated. Please forgive any bumps in the process.

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Patient Presentation and Mood States

When writing or talking about medical patients or therapy clients, it is helpful to describe their presentation. You cover things such as appearance and grooming, mood, openness, language, and thought process. How a client looks can reveal a lot about their lives, stressors, and their overall cognitive functioning. How open they are with you as a doctor or therapist is also important to note. Sometimes people are reticent to talk about themselves (which is understandable) and distrustful in general. Some people also don’t know how to talk about themselves, so they don’t.

The language people use also reveals their underlying cognitive functioning. Tangential language, disjointed speech, and slowed speech, for example can mean different things – a thought disorder, depression, acquired brain injury, and so forth. Related to language is a person’s thought process; this is apparent from their language but also in how they describe their problems or their lives.

When discussing mood, there are three general terms doctors use. The first is euphoric – extremely happy. Sometimes it is appropriate for people to exhibit this emotion but it can also be a sign of mania, especially if the positive mood was not seemingly triggered by anything. The next term for a mood state is euthymic, meaning normal, slightly positive mood. This is the mood that most people exhibit most of the time. It is neither positive nor negative (although often interpreted as having a slight positive lean). The last descriptor for mood is dysthymic, which means depressed or having negative affect.

Using these labels when describing patients provides a common, concise set of terms. It is, however, usually better to describe behaviors than just give a label. This means when writing about a patient or client, a report might state, “[The patient] presented as dysthymic, not smiling, becoming tearful at times….” Labels are concise, descriptions are precise.

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The Death of Psychotherapy

I’m going to preface my post by stating that the following post was written to help me think through the relationship between neuroscience and therapy. As such, it is a philosophical journey through some of my thoughts and is not even necessarily what I really believe because I’m still working on discovering what I believe. Thought processes like this are one way I try to keep some of my beliefs about psychology and neuroscience balanced. If I start leaning too strongly one way, I’ll start looking for things that disconfirm those beliefs and see what I discover. It’s a bit of playing the Devil’s Advocate with myself and a bit of philosophizing. Some of my friends and I used to do things like this in junior high and high school – having philosophical discussions where we discussed things and even tried to argue for things that we didn’t necessarily believe (e.g., classic topics such as supposing that this world and universe really aren’t real but are just reflections of reality. Again, that’s not something I believe but we would speculate). What does this all have to do with psychology and neuroscience?

The brain is what drew me to psychology initially. However, I vowed I would never go into clinical psychology because I didn’t think I would like therapy or dealing with people’s problems. Over time I discovered neuropsychology. Most neuropsychologists are clinical psychologists so in order or me to be a neuropsychologist, I had to be trained as a clinical psychologist. There are many things I enjoy about clinical psychology but therapy is not one of those things. Granted, most neuropsychologists do not actually do therapy, but we have to be trained in it. I enjoy talking with people in sessions but I haven’t been that impressed with therapy as a whole so far. Maybe that’s just because I haven’t exactly found the particular type of therapeutic method that really “clicks” with me. Cognitive-behavioral therapy is fine but so much of actual therapy in practice is just plain common sense. However, not everyone has a lot of common sense so they need some training in it. Part of me recognizes the validity of therapy but another part of me struggles with it. Now on to my main article.

The more I study the brain and the more exposure I have to therapy (giving, not receiving), the more biased towards the brain I become. What I mean is that we continue to discover more about the brain and as we discover more, the more behavior we can explain based on biology or neurophysiology and the less important I think therapy is. I’ve written about this topic in the past but wanted to briefly revisit it. This is somewhat of a second chapter to that post. Before I continue I wanted to expose one of my biases; I believe humans have free will. Even though some of my beliefs about the brain could be seen as mechanistic and deterministic, I do not believe that a strongly-biological foundation for behavior rules out free will. You can still assume biological foundations without assuming determinism. If, for example, you have a monistic set of assumptions that incorporates both mind – “nonmaterial” – and body – “material” – in one. [I have quotes around nonmaterial and material because mind is not necessarily nonmaterial and body is not necessarily material, well at least philosophically speaking]. Monism is a similar idea to a unified field theory (e.g., Grand Unified Theory) or the Theory of Everything for which some theoretical physicists are searching. That’s not what I’m going to write about and if it didn’t make sense, then don’t worry about it (I discussed this topic in a couple different posts: here {I linked to that post previously} and here). To summarize, I view behavior through a strong biological bias but I do not assume determinism.

As I said earlier, the more I learn about the brain and behavior (through research and observation), the more I lean towards neuroscience and away from “traditional psychology.” However, I still appreciate the psychosocial aspects of behavior; the nature versus nurture dispute will never be resolved because both are important. The environment is important  – all external stimuli are important – but the problem with downplaying biology is that it is the medium of behavior. What I mean is, everything we think, sense, perceive, or do is translated and transmitted through the firing of neurons. This means that all abnormal behavior, which is what psychologists often are interested in, originates in a neuron or related cell. Whether or not the cause of that behavior was internal or external is irrelevant. All events and stimuli are translated into patterns of neuronal firings.

This is why I think that understanding the biology of the brain is the best way to understand a person’s behavior. However, because we have an imperfect understanding of the biology of the brain, we have an imperfect understand of the biological foundations of behavior. This means that until we have a perfect understanding, we cannot ignore the psychosocial aspects of behavior; even with a perfect understand we couldn’t either because even if we understand the “translation” process we may not understand the origin of what needs to be translated. This is where traditional talk therapy can be most beneficial. However, I still believe less and less that talk therapy is the best solution for dealing with many psychological issues. Over time as we discover more and more about the brain, therapy will become even less important.

That is a fairly radical position to take as a student of clinical psychology – it’s more in line with psychiatry, or rather, I believe it’s more in line with neuroscience. I’m not saying that therapy is useless, I’m just saying that as we gain a more perfect understanding of the brain and how various chemicals interact in the brain, we will have less need for people to help others by “talking” through their problems. The better we understand the physiology of the brain, the more natural our pharmaceuticals will be. In other words, it will be easier to mimic and create normal brain functioning. Of course, many will ask, “What is normal?” That’s a good question.

Some may argue that with depression, for example, many people will have negative image and self-evaluations, which can lead to depression. That is true but it’s the classic chicken and egg question. Which came first? Did the negative thoughts cause the depression or did the person experiencing negative thoughts have a biological predisposition to those thoughts and depression? In other words, it is possible that biology originally led to the negative thoughts and not vice versa. This is all speculation but I think there is increasing evidence for this view.

The big problem with my point though is that at some point, it does become a deterministic system in that it’s possible that we could medicate away people’s free will. This is an unacceptable outcome. There would be a lot of power with this knowledge and many opportunities for abuse. That’s an ethical discussion for a later time.

To summarize, I think that as we (speaking in the collective) gain a more perfect understanding of the brain (and even individual differences in the brain) we will be better able to eradicate and prevent many or most psychological disorders. We could potentially stop schizophrenia through genetic engineering or other modifications. Again, I’m not addressing whether or not we should but I believe we will have the ability to at some point. This is why, at the moment I lean more towards neuroscience than I do psychotherapy. Of course, tomorrow I could [I won’t] write a post that completely contradicts this one. As I said, this is a process. I think it’s important to argue both sides of the issue.

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Epilepsy – Social and Cognitive Considerations

A few days ago I wrote another post for Brain Blogger about some of the issues people who have been diagnosed with epilepsy face.

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Learning and Recall – Hippocampal Firing

Today in Science a team of scientists (Hagar Gelbard-Sagiv, Roy Mukamel, Michal Harel, Rafael Malach, and  Itzhak Fried) at the Weizmann Institute of Science in Israel, UCLA, and Tel Aviv University published their research where they directly recorded via implanted electrodes the firing of hippocampus neurons during learning and free recall. This represents the first time in humans this has been done. Here’s the abstract from Science:

The emergence of memory, a trace of things past, into human consciousness is one of the greatest mysteries of the human mind. Whereas the neuronal basis of recognition memory can be probed experimentally in human and nonhuman primates, the study of free recall requires that the mind declare the occurrence of a recalled memory (an event intrinsic to the organism and invisible to an observer). Here, we report the activity of single neurons in the human hippocampus and surrounding areas when subjects first view television episodes consisting of audiovisual sequences and again later when they freely recall these episodes. A subset of these neurons exhibited selective firing, which often persisted throughout and following specific episodes for as long as 12 seconds. Verbal reports of memories of these specific episodes at the time of free recall were preceded by selective reactivation of the same hippocampal and entorhinal cortex neurons. We suggest that this reactivation is an internally generated neuronal correlate of the subjective experience of spontaneous emergence of human recollection. (Published Online September 4, 2008; Science DOI: 10.1126/science.1164685)

The New York Times also has an article about the research.

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Brodmann’s Map of the Cortex

I’ll be writing some basic neuroanatomy posts over the coming months (I started with my previous post about the corticospinal tract). I recently finished an intense neuroanatomy course where I learned how much I love basic neuroanatomy. It’s exciting to look at a brain or brain slices and try to figure out what and where different structures are.

In the early 1900s Korbinian Brodmann studied the cytoarchitecture (organization of the cortical layers of neurons) of human and non-human brains. His work was painstaking and thorough. He created a topographic map of the cortex containing 52 (50 in humans) different areas. In my class we were not required to learn all of Brodmann’s cortical areas but had to learn some of the major ones. Brodmann’s Areas (BA) 3,1, and 2 compose the primary somatosensory area of the brain. BA 4 is the primary motor cortex. BA 5 is somatosensory association cortex just posterior to BA 3,1,2. BA 6 is pre-motor cortex, which connects directly to BA 4. BA 7 is more somatosensory association cortex that lies just posterior to BA 5. BA 8 is the frontal eye fields, which among other things is responsible for initiating horizontal eye saccades (i.e., quick movement to the left or right). BA 17 is the primary visual cortex, a credit card sized area that lies both dorsal and ventral to the calcarine fissure in the occipital lobe. This area processes most of the basic visual information. BAs 18 and 19 are visual association cortices. BA 22 is Wernicke’s Area, which is involved in the comprehension of language and is in the dorsal-posterior temporal lobe on the border between the temporal and parietal lobes. BAs 41 and 42 are the primary auditory cortex, which processes auditory information from the cochlea; this lies on the transverse temporal gyrus in the dorsal part of the temporal lobes (it is hidden from view unless the cortex around the Sylvian Fissure is pulled away). BAs 44 & 45 are Broca’s area, which is involved in the production of language and is in the lateral frontal lobes.

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The Corticospinal Tract

The corticospinal tract is a descending motor pathway originating in the Primary Motor Cortex (Brodmann’s area 4) and terminating at various levels in the ventral horn of the spinal cord. The corticospinal tract descends through the posterior limb of the internal capsule then down through the cerebral peduncles into the brainstem. In the brainstem the corticospinal tract remains in the ventral portion, passing through the pyramids on its way down. In the caudal brainstem (just above where the spinal cord starts) 90% of the the corticospinal tract decussates (crosses) to the contralateral (opposite) side and continues down through the dorsolateral spinal cord. This portion controls limb movements. The remaining 10% remains in the ventral spinal cord and is largely responsible for bilateral axial (trunk) movement. From the dorsolateral spinal cord, the axon (that started in the cortex) enters the ventral horn of the spinal cord at the appropriate level (e.g., cervical for arms or lumbar for legs) then exits through the ventral root to terminate on the appropriate muscles.

Through this tract, the cortex controls much of the movement of the body; as such, it’s vitally important for our functioning. Damage to the tract results in an upper motor neuron disorder, with paresis (weakness instead of complete paralysis) and the Babinski reflex fairly common symptoms. Soon after damage, a patient might have flaccid paralysis though with little to no movement of the affected limb(s). As the body starts to recover slightly, spastic paralysis usually sets in with jerky, often uncontrolled limb movements. The corticospinal tract is one of the largest pathways in the central nervous system; it’s one of the most important for motor functioning as well.

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