Fighting Stigma of Mental Illness

Major depressive disorder is considered to be the most frequently encountered form of mental illness. The Global Burden of Disease study identified depression as having the third highest impact in terms of the so called disability-adjusted life years in Europe and the greatest impact of all diseases in the Americas. Although most of depressive episodes occur in patients with unipolar depression, a minority is also found in bipolar disorder. 

Actually, bipolarity is not a disorder and not a condition, but a psychiatric illness. 

The origins of the categorical approach to bipolar illness goes back to one of the founders of modern psychiatry, Emil Kraepelin. In the present classification systems, such as ICD-10 and DSM IV (or dsm5) bipolar disorder refers to a group of affective disorders in which patients experience episodes of depression, characterised by low mood, reduced energy and anhedonia, and either episodes of mania - with elevated or irritable mood, increased energy and reduced need for sleep -, or hypomania, whose symptoms are less severe than in mania. 

Patients with bipolar disorder often suffer from one or more comorbid psychiatric disorders. The most common are anxiety and substance use disorders.

As depressive patients usually seek treatment for depression, the true nature of a possibly underlying bipolar disorder with depressive features may unfortunately be not recognized and even misdiagnozed as unipolar major depressive disorder, so that these patients don‘t receive the adequate treatment. In some cases this could deteriorate the overall progression of the illness. 

Today the promotion of mental health and the knowledge about mental illness is one of the most important challenges worldwide to be met. Fighting the stigma of mental illness at the end means to improve mental health of many million people, so they can lead better and healthier lives. 

Patrick J. Kennedy, son of the late Edward Moore „Ted“ Kennedy, is co-founder of ,One Mind for Research‘, a foundation dedicated to enhancements in funding and collaboration in research of brain disorders. He is also member of the ,Kennedy Forum on Community Mental Health‘ and thereby follows into JFK‘s footsteps in order to promote improvements in treatment and care of people with mental illness, intellectual disabilities and addictions. Himself he is known to suffer from bipolar disorder. Years ago he acknowledged being a recovering alcoholic and being treated for cocaine use during his younger years. In 2006, while he was still a U.S. representative of the Democratic Party he crashed his automobile into a barricade on Capitol Hill, as it seems under the influence of prescription drugs and possibly under alcohol. He is one of the most prominent advocates fighting to end the stigma that is associated with mental illness.

Who am I - solution

Correct! The answer of course is John F. Kennedy whose 50th anniversary of his death will be commemorated on the coming November 22nd.

You find a good collection of the medical history of JFK on doctorzebra.com. 10 years ago, Robert Dallek wrote an nice article in ‚The Atlantic Monthly’ about Kennedy’s medical problems. He was given access to then newly released materials, which included x-rays and prescription records of one of JFK’s doctors. Not only did the devastating truth about JFK’s catastrophic health come to the world’s knowledge. Dallek also revealed the difficulties at that time to conceal JFK’s health problems. Obvioulsy Nixon had tried to gain access to Kennedy’s medical history. During the 1960 presidential elections thieves ransacked the office of JFK’s endocrinologist, who had been treating Kennedy for Addison’s disease, but they failed to find Kennedy’s records, which were filed under a code name. Thereafter they tried unsuccessfully to break into the office of Janet Travell, an internist, who was appointed as personal physician to the president after JFK’s election. Dr. Janet Travell reported that Kennedy was diagnosed with a sub-normally functioning thyroid gland as early as 1955. Throughout his presidency he took testosterone-pills daily. The reason for that is not really clear. A subthreshold testosterone level might have been a consequence of Kennedy’s chronic corticosteroid-treatment or a consequence of his APS II, an condition he was diagnosed with only many years after his death. Possibly he also tried to increase his weight with testosterone. He was diagnosed with Addison’s disease in 1947, but it was not related to his thyroid dysfunction at that time. Now it is almost certain that Kennedy suffered from auto-immune polyendocrine syndrome type II (APS II), which is a polygenic disorder dfined as auto-immune adrenocortical failure plus either auto-immune thyroid disease or type 1 diabetes mellitus. Other associated autoimmune dosrders include: atrophic gastritis, hypergonadotrophic hypogonadism, and celiac disease.

The 1960 presidential election campaign left him exhausted. At the press conference after his election his hands were trembling. It took him two weeks to recover. After the Bay of Pigs invasion fiasco he was seen deeply depressed, weeping. Weeks after the invasion he could not sleep.

One of his great and lasting achievements remains his Community Mental Health Centers Construction Act, signed 50 years ago on October 31st, 1963. It was the last legislation act he signed before he died. Already in February 1963 he had adressed a ‚Special Message to the Congress on Mental Illness and Mental Retardation’. The law was supposed to support the states in building up a community based treatment for the people suffering from psychiatric disorders instead of the up to then custodial confinements in the national institutions. It was therefore also a sign to de-stigmatize psychiatric disorders.

Meanwhile, about 90 percent of beds have been cut at state hospitals. But the funds provided to build up an alternative mental health system were not adequate to the task, so that nowadays there is no place for the sickest people to turn. Many of them end up homeless. The three largest mental-health providers in the nation are jails.

Indeed, also in Europe the shorting of psychiatric beds might lead to a worsening of mental health equally, when an adequate supply of outpatient treatment possibilities is about to be shortened as well.

By the way, on pinterest you’ll find a collection of memories of the visitors of the „JFK: Three Shots Were Fired“ exhibit with recounts where they were and what they felt the day that President Kennedy was assassinated: pinterest.com/newseum/remembering-jfk/

Who am I - Auflösung

Richtig, die Auflösung heisst natürlich John F. Kennedy, dessen Todestag sich am kommenden 22. November zum 50. Mal jährt.

Eine ausführliche Zusammenfassung seiner Krankengeschichte findet man auf doctorzebra.com. Robert Dallek schrieb vor 10 Jahren einen schönen Artikel in ‚The Atlantic Monthly’ über Kennedy’s medizinische Probleme. Er hatte damals Einsicht erhalten in die erst kürzlich geöffneten Akten über die Jahre zwischen 1955 und 1963. Unter anderem fanden sich darunter auch Röntgenbilder und Verordnungen eines seiner damaligen Ärzte. Nicht nur erfuhr die Welt damit die Wahrheit über JFK’s katastrophalen Gesundheitszustand. Dallek zeigte auch auf, wie schwierig es zur damaligen Zeit gewesen sein muss, diesen zu verbergen. Anscheinend soll beispielsweise Nixon im Wahlkampf 1960 versucht haben, an Kennedy’s Krankengeschichte heran zu kommen. Diebe waren in die Praxis seines Endokrinologen eingebrochen, der ihn wegen seines Morbus Addison behandelte, fanden die Krankengeschichte jedoch nicht, da sie unter einem Code-Namen abgelegt war. Daraufhin hatten sie erfolglos versucht, in die Praxis der Internistin Janet Travell einzubrechen. Janet Travell wurde nach der gewonnenen Wahl zur persönlichen Ärztin von Präsident Kennedy berufen. Sie hatte auch festgehalten, dass Kennedy schon 1955 wegen einer Unterfunktion der Schilddrüse behandelt wurde. Während seiner gesamten Präsidentschaft nahm er Testosteron-Tabletten ein. Allerdings ist der Grund dafür nicht ganz klar. Möglicherweise war sein Testosteronspiegel als Folge seiner chronischen Kortikosteroidbehandlung gesunken, evt. auch wegen seiner APS-2-Erkrankung, die erst viele Jahre nach seinem Tod gestellt wurde. Möglicherweise war das Testosteron auch ein Mittel, um sein Gewicht herauf zu setzen. Ein Morbus Addison war schon 1947 diagnostiziert worden. Der Zusammenhang mit der Schilddrüsenunterfunktion war damals aber noch nicht offensichtlich. Heute scheint die Diagnose eines autoimmunen polyendokrinen (oder polyglandulären) Syndroms Typ 2 (APS-2) die wahrscheinlichste zu sein. APS-2 hat eine polygenetische Ursache und wird definiert als eine autoimmune Nebennierenrindeninsuffizienz, kombiniert mit entweder einer autoimmunen Schilddrüsenunterfunktion oder mit einem Diabetes mellitus Typ 1. Damit assoziiert sind oft weitere Autoimmunerkrankungen, wie z.B. atrophische Gastritis, hypergonadotropher Hypogonadismus und Zöliakie.

Der Wahlkampf von 1960 hatte ihn so erschöpft, dass seine Hände an der Pressekonferenz nach seinem Wahlsieg zitterten. Er brauchte zwei Wochen, um sich davon zu erholen. Nach der missglückten Schweinbuchtinvasion 1961 war er über Wochen depressiv, er weinte und konnte wochenlang nicht schlafen.

Eine seiner grossen und bleibenden Leistungen ist die Community Mental Health Centers Construction Act vom 31. Oktober 1963. Es war die letzte Gesetzesvorlage, die er vor seinem Tod noch unterzeichnet hatte. Schon im Februar 1963 hatte er diesbezüglich eine ‚besondere Botschaft’ an den Kongress adressiert (‚Special Message to the Congress on Mental Illness and Mental Retardation’), in der er die Hintergründe für sein Engagement für die psychisch Kranken und die geistig Behinderten dargelegt hatte. Vorgesehen war unter anderem eine staatliche Unterstützung zur gemeindebasierten Behandlung psychisch Kranker statt der bisherigen kustodialen Verwahrung in den staatlichen Institutionen und damit auch ein Zeichen für die Entstigmatisierung psychischer Störungen. Leider wurde diese Idee der De-Institutionalisierung pervertiert. 90 Prozent der Betten wurden gestrichen. Die staatlichen finanziellen Leistungen genügen nicht, um eine gemeindezentrierte Behandlung in den Staaten aufzubauen. Die am schwersten Kranken können sich nirgendwohin wenden. Sie enden auf der Strasse. Die drei grössten Psychiatrie-Anbieter in den USA sind Gefängnissse.

Tatsächlich besteht auch in Europa die Gefahr, dass Bettenkürzungen zu einer Verschlechterung der psychischen Gesundheit führt, wenn unter dem Argumentarium der ‚Mengenausweitung’ nicht entsprechende ambulante Plätze geschaffen werden (Stichwort ‚Praxisstop’).

Übrigens: auf der Pinnwand von Newseum pinterest.com/newseum/remembering-jfk/ findet Ihr eine schöne Zusammenstellung der Besucherkommentare der Ausstellung „JFK: Three Shots Were Fired“ auf die Frage: „Where were you when you heard the news that John F. Kennedy had been shot?“