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Category Archives: Medicalizing Mental Health


Part 1 of a several part post

Introduction-What is the structure of Human Performance?

The definition of Human Performance: the part of human functioning that accomplishes tasks according to measurable standards of efficiency, completeness and accuracy. In other words, performance is that part of our function that literally represents the purpose of our lives. Forming a coherent and rational understanding of human performance seemed obligatory to me as a practicing clinician; I began this pursuit two years ago. As in all scientific and philosophic inquiries, I knew that I needed to find the right question to answer which, as always, meant going back to basics. Recalling that nothing can function without possessing structure my inquiry into the nature of human performance began with my asking myself the following question, “If our performance is a part of our function, what then is the structure of our performance?”

The structure/function relationship is the basis of all rational scientific thought. In essence, structure and function is the same thing.  Take a simple sheet of paper; when you place it on a flat surface it functions as something upon which you can write; fold it in a specific way, and it can fly like an airplane; crumple it tightly into a ball and you can toss it into a trash can ten feet away. Regardless of how many ways you may change the same sheet of paper, the relationship of its structure and function remains constant and immutable. While the proof of the existence of sub-atomic particles long ago disproved Plato’s conception of the atom as the smallest and indivisible form of matter, the concept that the structure of any physical object in the universe is inseparable from its function continues to hold firm and regardless of scale, whether sub-atomic, microscopic or astronomical. A single proton in its core, or nucleus, is all that separates the 112 individual elements on the periodic table from those to its right or left. The element, Hydrogen with a single proton in its nucleus functions perfectly as a trigger of an atomic reaction; inhale the next element to the right on the periodic table, Helium, which has two protons in its nucleus and you will speak with the voice of a Munchkin from the land of Oz; skip the next four elements and we come to the Carbon atom with its 6 protons, that functions as the exclusive template upon which all life on our planet was manufactured for 3.5 billion years and counting. Finally, on the astronomical scale, with a structure more than 1300 times the volume of Earth, Jupiter functions as a gravitational shield, protecting our relatively tiny world from catastrophic collisions with the orbiting debris left over from our solar system’s creation some 5 billion years ago. In essence, Jupiter’s structure provided the Carbon atom the opportunity to function as the designated element for all life on Earth. What’s more than its sublime, ubiquitous even poetic nature is the relevance of the structure-function relationship to our understanding human performance. What follows is the answer to the question that I asked my self two years ago, “just what is the structure of human performance?”

Human Performance; a window to Human Health

Human performance is an aggregate of actions or behaviors that take place exclusively in the physical world and it is executed entirely by the human body; its skeleton, muscles, joints and connective tissues. Examples of human performance include speech, driving a car and making love; separately or all at the same time. In turn, each of these constituent behaviors or actions is a direct reflection of an ever-changing or plastic structure of the human central nervous system (CNS). At the core of the brain’s plasticity is a process called, neurotransmission which is the communication via chemical-electrical signals between one brain cell, or neuron and another. In all there are one hundred billion such neurons originating in the human brain, each having as their final destination a muscle fiber somewhere in the human body. At the molecular level of this inter-neuron communication process are chemical-electrical messengers, or neurotransmitters each of which has a unique chemical structure limiting its interactions to only with, structurally compatible, molecules located on the surface of the neuron known as receptors There are trillions of these chemical-electrical signals communicated in the human brain every second, thus giving the brain a nearly fluid, or plastic molecular structure which over time actually change the visible, or macroscopic structure of the brain. Hence the recent addition of the term, neuro-plasticity to the vernacular of neuro-science.

Within this neuro-plasticity framework, we can conceptualize human health as the sum of all forces, internal and external, which affect the plastic molecular structure of an individual’s central nervous system. Examples include exposure to a stressor such as Hurricane Katrina or a medical illness such as an infection. The extent to which any such force, whether external or internal, will impact an individual’s performance is limited by, or is to the same exact extent to which this force impacts, or molds the plastic structure of the individual’s brain. Conversely, only if a given force, whether internal or external, impacts the plastic structure of an individual’s brain will it have any impact on an individual’s performance. Within this framework, which represents the consensus scientific view, health and performance are the structure and function, respectively of  any individual human being. Thus, an individuals’ health and performance are indivisible and direct reflections of each other.

My health-performance proof shows that an individuals performance is a surrogate for their health and vice a verse. The clinical implications of this relationship are profound and far reaching. My understanding of this fundamental relationship between our health and our performance has served as my main cognitive tool for providing medical care to my patients that is far above the prevailing standard of care in our healthcare system. In my next post I will show how this tool is easily scalable and can be applies potential to fundamentally  change our healthcare system for the better and enhance its real value.

End  Post

Mitchell R. Weisberg, MD, MP



Introduction

This is an update of our nation’s mental health crisis  from my perspective. I define the crisis and look at at its causes and  impact on the American people. In addition, I explore the perspectives of this crisis in the American healthcare system, the American workplace, and the American employer. Following this update I will propose my solution to the American mental health crisis. 

Setting 1

Mental Health in the American Healthcare System

This is the worst of times for people with mental health problems in the American healthcare system. One in four (58 million) American adults suffers from a diagnosable mental health problem, preventing a normal and productive life. (1)

In general, people with undiagnosed and untreated mental health problems use the healthcare system more often than people of the same age group who are unaffected. The services most often used in the healthcare system include Emergency Room visits, non-psychiatric hospitalizations, and primary care visits. (2)

For American adults with any form of chronic medical condition, the likelihood of also having a diagnosable mental health problem is higher than for adults in the same age group who do not have chronic medical conditions.  Furthermore, those people with both a chronic medical condition and a mental health problem who have their mental health problem diagnosed and properly treated will show more improvement in their chronic medical conditions than those who do not receive treatment for their mental health problems. (3)  Between 70% and 90% of those with mental health problems experience a significant reduction of their symptoms and an improved quality of life with a combination of medications, talk therapy, and other support mechanisms. (4)

So why is it the worst of times in the American healthcare system for people with mental health problems? In spite of using the healthcare system more often, less than one in three of the 58 million American adults with mental health problems have their problem diagnosed and one in ten receives the treatment they need to get well and lead a normal, productive, and fulfilling life. (5)

Why does our healthcare system, which has highly effective remedies for mental health disorders, fail to recognize them most of the time? The explanation leads to the solution to the American mental health crisis.

To begin, take a full minute look at this optical illusion. When you first look at this picture, you may see either a young woman or an old hag. But the longer you look at it, eventually the one that you did not see initially will appear. This demonstrates the limits of our human senses. We may not see, hear, smell, or feel what we are not looking for, even when it is right in front of us. Similarly, our healthcare system fails to recognize mental health disorders in most cases. While all health problems impact a person both structurally and functionally, our health care system tends to focus exclusively on the structural part of health problems.

For example, a 50-year-old man sees his doctor because he is feeling severe pain in his left lower abdomen. The doctor’s evaluation reveals that the man experiences discomfort, especially when the doctor gently pushes on his left lower abdomen. A CAT scan shows severe inflammation in the left side of his colon (a condition called diverticulitis). After 5 days in the hospital with nothing to eat or drink, and a regimen of intravenous fluids and antibiotics, the man recovers completely. This man’s inability to work or take part in family or community activities is an expected functional byproduct of his structural health problem (diverticulitis). Thus, information about this man’s functional status was not required to successfully diagnose and treat his medical problem.

Now let’s imagine that this same 50-year-old man sees his doctor for the same complaints.  The doctor’s evaluation is the same as in the first scenario, except the CAT scan shows that all structures, including the colon, are perfectly normal. The physician tells this man that he likely has something called Irritable Bowel Syndrome (aka, functional bowel syndrome) and in spite of the man’s bowel being structurally normal, the doctor advises him to increase the fiber in his diet and prescribes a medication to cut the bowel spasm when the abdominal pain occurs. While these remedies may or may not help, one thing is certain: this man’s problem has not yet been identified or resolved. Therefore, he will suffer more and  go back to his doctor or the emergency room.

Had this man’s physician looked at him just a little longer after his extensive and costly evaluation, much like we looked a little longer at the picture of the young woman and the old hag, he would have been able to do more for his patient than simply assure him what disorders he didn’t have. Had he looked at his patient from a functional perspective using a sophisticated diagnostic tool such as asking him, “How are you doing?”  the doctor may have discovered that his patient had not been performing too well at work and had not engaged in family and community activities for the past six months. This information could have uncovered the primary diagnosis and lead to the proper course of treatment, reducing this patient’s suffering and prevented him from continuing to return to the healthcare system again and again. In this man’s case, his abdominal pain was a physical manifestation of an Anxiety Disorder and had this been recognized and treated appropriately, not only would his abdominal symptoms have subsided he would have been able to function a lot better at work and at home, as well.

When functional impairments, such as poor work performance or lack of participation in family or community activities, do not accompany an identifiable structural process, neither the person nor his physician necessarily recognizes this as a medical problem. Unfortunately, this is the exact scenario experienced by of one in three of all disabled adults on our planet all of whom have a diagnosable and treatable medical problem called mental illness.

Our healthcare system fails to recognize and treat our mental health because it is purely a structure driven system. Our system is more adept at telling us what structural health problems we do not have, than at actually identifying those health problems that most impact our ability to function fully. For instance, a person suffering from severe headaches may see a Neurologist and have a normal neurological examination and a normal MRI of his brain. The Neurologist will tell him that his headaches are not caused by a brain tumor or an aneurysm. While the reassurance may offer a temporary sigh of relief, it does not resolve the man’s health problem; the system fails.

I assure you that the next time any of us see our primary care physician or go to the emergency room, we will be looked at structurally, regardless of the reason for our visit. The nurse will measure our height, weight, blood pressure, temperature, pulse, and respiratory rate. Then,  a physician will ask us to point to where our problem is. The doctor will look at, touch, listen, probe, and possibly scan the area in 3D. With almost equal certainty, neither the nurse nor the physician will ask us how we are doing at work or in school, or if we take part in activities with family or friends, or in our communities.  Not looking for or seeing a person’s functionality or performance is the deficiency of our nation’s healthcare system that makes this the worst of times for Americans with any degree of mental health problems.

Setting 2

Mental Health in the American Workplace

For American employers and employees, with mental health problems, this is also the worst of times to deal with mental health problems. Employers’ indirect costs arising from their employees’ mental health problems–in the form of short- and long-term disability, absenteeism, and presenteeism–is four times greater than  a company’s direct costs for employee healthcare. (5)

Why do these employees with mental health issues contribute more to healthcare costs? In a service-based economy such as ours, an employee’s productivity is most dependent on her cognitive abilities, such as deductive reasoning, task management, effective communication, and creativity. Health issues of all types will likely impact a service workers’ performance. Workers with mild or even “sub-threshold” mental health problems have measurable productivity problems early on, well before they experience more serious health effects. (5) And these employees tend to use the healthcare system more often than people of the same age group who do not experience mental health issues. In essence, American employers are paying for their employees’ mental health problems twice–once for the direct costs of frequent use of healthcare services, and again for the indirect costs for the diminished productivity of the affected employees.

Two facts emerge from employers’ data on the impact of mental health on the productivity of a workforce. First, based on the current numbers, it is clear that employers have not yet found a remedy for an extremely costly problem in both financial and human terms. Second, based upon the numbers, employers prove capable of measuring its workforces’ performance in a way that accurately identifies a health problem that eludes identification in the healthcare system; our healthcare system has proven remedies for the problem but fails to recognize it. When employers demand their money’s worth from a healthcare system for which they are paying, it will be the best of times.

For a detailed plan of how employers can get what they and their employees need and deserve from the healthcare system, contact me @ drweisberg@wmchealth.com

End Post

Mitchell R. Weisberg, MD, MP

Weisberg Medical Consulting

Weisberg Medical Consulting adds a clinical perspective to an Organizations Balanced Scorecard, aligning the health of their workforce with the health of their enterprise.


to an

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.
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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.
 

My fitness formula

C3

Cardio

From a rest, start your physical activity at a low intensity level and gradually increase it so you are at your target heart rate after 5 minutes; keep up your target heart rate for 10 to 30 minutes and then cool down so that you return back at your resting heart rate after 5 minutes. Try to do this 3 to 5 times per week. There are many ways to get your cardio fitness with equipment or without it.

Core

The core is our body’s center of gravity and is the area from the bottom of our rib cages to the top of our hips. The benefits of strengthening  the core is to improve our balance and prevent common injuries such as low back pain. As little as 5 minutes per day of core strengthening has significant health benefits. To begin strengthening your core, you simply need to get on the ball.

Cortical

This is the most important yet most neglected part of fitness especially in the western world. After all, it is the cerebral cortex that distinguishes humans from all other animals on the planet. It is our seat of reason and creativity and it is the part of our brain that most influences what we actually do in the course of our lives. Without cortical fitness, the lower centers of our Central Nervous Systems will have undue influence on our behaviors and place limitations on our reaching our personal potential and leading fulfilling lives.  It is my professional opinion that cortical fitness is the missing link to achieving  and maintaining our optimal levels of health and performance.

Now that you have the formula, apply it to your life for just 30 minutes per day and I am certain that you will see that this small investment of time will pay you significant dividends.

End Post

Mitchell R. Weisberg, MD, MP


There was evening and there was morning……

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 3rd 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


Below is an excerpt from a letter my patient, KP received from The Trustees of the Plumbers’ Welfare Fund in September 2010:

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 2006KP 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 PathAs 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



  • 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.
End Post

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 a fungible resource similar to the machinery of what was, at that time, a manufacturing based economy. (1) This characterization literally changed at the speed of light with the United States response to the Soviet’s launching of Sputnik in 1957 and the advent of  what is now commonly called the World Wide Web(2) As a direct result of this development, there has been a continual servicization of the US economy ever since with 77% of US GDP in 2010 being derived from the service sector. (3) In this same 60 year time span, the US labor market had to transition from one based almost entirely on its brawn to one that is now based almost entirely on its brains. The implications of this transition we are only now beginning to collectively witness. For instance, it is the cognitive evolution of our nations economy that resolves the seemingly paradoxical coexistence of Depression level unemployment with the critical low mass in attraction and retention of talent and successorship in Corporate America(4) When viewed from this cognitive” perspective it also should come as no surprise that absencedisability and unrealized productivity related to issues of employee mental health cost employers more than four times the cost of current employer-based medical treatment. (5) Leadership, both public and private, continues to fixate on spiraling health care costs while perilously neglecting the value of the most important asset in our national portfolio; our Human Capital.

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 21st 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 21st 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
Thank you for sharing your comments and insights!

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.

End

Mitchell R. Weisberg, MD, MP


What would your computer guy say to you if you had 6 programs running simultaneously and you shut off your computer? He would say thank you because you would be doing damage to your computer which means more work for him and orthodontia for his daughter. Every one that has ever used a PC knows that we need to shut down each open program, one at a time before saying good night to our beloved PCs. Have you ever noticed the similarities between the human brain and the personal computer; no coincidence since the PC is a creation of the human mind.

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