Bipolar disorder is a brain disorder that causes changes in a person's mood, energy, and ability to function. People with bipolar disorder experience intense emotional states that typically occur during distinct periods of days to weeks, called mood episodes. These mood episodes are categorized as manic/hypomanic (abnormally happy or irritable mood) or depressive (sad mood). People with bipolar disorder generally have periods of neutral mood as well. When treated, people with bipolar disorder can lead full and productive lives. People without bipolar disorder experience mood fluctuations as well. However, these mood changes typically last hours rather than days. Also, these changes are not usually accompanied by the extreme degree of behavior change or difficulty with daily routines and social interactions that people with bipolar disorder demonstrate during mood episodes. Bipolar disorder can disrupt a person’s relationships with loved ones and cause difficulty in working or going to school. Bipolar disorder is a category that includes three different diagnoses: Bipolar I, Bipolar II, and Cyclothymic disorder. Risk Factors: Bipolar disorder commonly runs in families: 80 to 90 percent of individuals with bipolar disorder have a relative with bipolar disorder or depression. Environmental factors such as stress, sleep disruption, and drugs and alcohol may trigger mood episodes in vulnerable people. Though the specific causes of bipolar disorder within the brain are unclear, an imbalance of brain chemicals is believed to lead to dys-regulated brain activity. The average age of onset is 25 years old. People with bipolar I disorder frequently have other mental disorders such as anxiety disorders, substance use disorders, and/or attention-deficit/hyperactivity disorder (ADHD). The risk of suicide is significantly higher among people with bipolar I disorder than among the general population. Bipolar I Disorder Bipolar I disorder is diagnosed when a person experiences a manic episode. During a manic episode, people with bipolar I disorder experience an extreme increase in energy and may feel on top of the world or uncomfortably irritable in mood. Some people with bipolar I disorder also experience depressive or hypomanic episodes, and most people with bipolar I disorder also have periods of neutral mood. Symptoms of Bipolar I Disorder Manic Episode A manic episode is a period of at least one week when a person is extremely high-spirited or irritable most of the day for most days, possesses more energy than usual, and experiences at least three of the following changes in behavior: Decreased need for sleep (e.g., feeling energetic despite significantly less sleep than usual Increased or faster speech Uncontrollable racing thoughts or quickly changing ideas or topics when speaking Distractibility Increased activity (e.g., restlessness, working on several projects at once) Increased risky behavior (e.g., reckless driving, spending sprees These behaviors must represent a change from the person’s usual behavior and be clear to friends and family. Symptoms must be severe enough to cause dysfunction in work, family, or social activities and responsibilities. Symptoms of a manic episode commonly require a person to receive hospital care to stay safe.Some people experiencing manic episodes also experience disorganized thinking, false beliefs, and/or hallucinations, known as psychotic features. Hypomanic Episode A hypomanic episode is characterized by less severe manic symptoms that need to last only four days in a row rather than a week. Hypomanic symptoms do not lead to the major problems in daily functioning that manic symptoms commonly cause. Major Depressive Episode A major depressive episode is a period of at least two weeks in which a person has at least five of the following symptoms (including at least one of the first two symptoms): Intense sadness or despair Loss of interest in activities the person once enjoyed Feelings of worthlessness or guilt Fatigue Increased or decreased sleep Increased or decreased appetite Restlessness (e.g., pacing) or slowed speech or movement Difficulty concentrating Frequent thoughts of death or suicide Treatment and Management Bipolar disorder symptoms commonly improve with treatment. Medication is the cornerstone of bipolar disorder treatment, though talk therapy (psychotherapy) can help many patients learn about their illness and adhere to medications, preventing future mood episodes. Medications known as “mood stabilizers” (e.g., lithium) are the most commonly prescribed type of medications for bipolar disorder. These medications are believed to correct imbalanced brain signaling. Because bipolar disorder is a chronic illness in which mood episodes typically recur, ongoing preventive treatment is recommended. Bipolar disorder treatment is individualized; people with bipolar disorder may need to try different medications before finding what works best for them. In some cases, when medication and psychotherapy have not helped, an effective treatment known as electroconvulsive therapy (ECT) may be used. However, there can be short-term or long-term effects on memory, therefore it should be used as a last resort as based on the severity of symptoms. It is typically recommended to have 10-12 sessions spread out over 3 weeks, otherwise there is increase risk of memory impairment. ECT involves several rounds of a brief electrical current applied to the scalp while the patient is under anesthesia, leading to a short, controlled seizure. ECT-induced seizures are believed to remodel brain signaling pathways. Since bipolar disorder can cause serious disruptions in a person’s daily life and create a stressful family situation, family members may also benefit from professional resources, particularly mental health advocacy and support groups. From these sources, families can learn strategies for coping, participating actively in the treatment, and obtaining support. Bipolar II Disorder A diagnosis of bipolar II disorder requires someone to have at least one major depressive episode and at least one hypomanic episode (see above). People return to their usual functioning between episodes. People with bipolar II disorder often first seek treatment as a result of their first depressive episode, since hypomanic episodes often feel pleasurable and can even increase performance at work or school. People with bipolar II disorder frequently have other mental illnesses such as an anxiety disorder or substance use disorder, the latter of which can exacerbate symptoms of depression or hypomania. Treatment Treatments for bipolar II are similar to those for bipolar I: medication and psychotherapy. The most commonly used medications are mood stabilizers and antidepressants, depending on the specific symptoms. If depressive symptoms are severe and medication is not effective, ECT (see above) may be used. Each person's treatment is individualized. Cyclothymic Disorder Cyclothymic disorder is a milder form of bipolar disorder involving many "mood swings," with hypomania and depressive symptoms that occur frequently. People with cyclothymia experience emotional ups and downs but with less severe symptoms than bipolar I or II disorder. Cyclothymic disorder symptoms include the following: For at least two years, many periods of hypomanic and depressive symptoms, but the symptoms do not meet the criteria for hypomanic or depressive episode. During the two-year period, the symptoms (mood swings) have lasted for at least half the time and have never stopped for more than two months. Treatment Treatment for cyclothymic disorder can involve medication and talk therapy. For many people, talk therapy can help with the stresses of mood swings. Keeping a mood journal can be an effective way to observe patterns in mood fluctuation. People with cyclothymia may start and stop treatment over time.

More than 25 years after the first federal mental health parity protections were put in place, adequate coverage for behavioral health (BH) care – including both mental health and substance use conditions –remains elusive for many consumers with health insurance.1 Federal BH parity rules require health plans that offer BH coverage to ensure that financial requirements (such as deductibles, copayments, coinsurance, and out-of-pocket limits) and treatment limits (such as day and visit limits as well as nonquantitative limits on benefits such as prior authorization) on these benefits are no more restrictive than those on medical and surgical benefits. Mental Health Parity at a Crossroads The COVID-19 pandemic has heightened awareness and exacerbated existing challenges in BH. Strengthening BH parity protections is just one part of a larger policy discussion that includes addressing the BH workforce shortage, rising BH treatment needs among children and youth, an inadequate health care infrastructure to address those in crisis, and the need for improved coordination and integration of primary care and BH care in the health care delivery system. All of these issues contribute to the access and coverage challenges in health insurance that BH parity was supposed to address. The stakes are high for coverage protection, as nearly 90% of nonelderly individuals with a BH condition have some form of health coverage. Despite having coverage, many insured adults (36%) with moderate to severe symptoms of anxiety and depression did not receive care in 2019. There have been consistent calls for more federal guidance on the specific protections in the federal BH parity law, as well as for increased enforcement. As Congress2 debates reforms to address these concerns in BH care, and as federal agencies plan to update parity regulations, this brief explains the federal BH parity requirements – including who they apply to and how they’re enforced — and sets out key policy issues. Federal BH Parity Protections Federal protections for BH coverage sought to correct historical differences in how health insurance covered this care when compared to medical/surgical benefits. The focal point of these protections has evolved over the years from the narrow initial federal law, the Mental Health Parity Act of 1996 (MHPA), to the broader protections in the current law, the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) (Appendix Figure 1). With MHPAEA, an initial focus on ensuring that consumers were not subject to higher cost sharing and more restrictive day and visit limits for BH shifted to looking at disparities in treatments limits in coverage that are not expressed numerically. These so-called “nonquantitative treatment limits” or NQTLs include plan features that limit the scope or duration of care such as prior authorization requirements and medical necessity reviews, standards for provider admission to a network, and provider reimbursement rates. Federal regulations implementing parity for commercial plans and for Medicaid and the Children’s Health Insurance Program (CHIP) have set out substantially similar protections (See Appendix Table 1 for major differences between commercial parity and Medicaid). These are detailed and complex standards making it a challenge for consumers with coverage to know what practices violate the law. Federal agencies have issued FAQs and other guidance for both commercial and Medicaid/CHIP to explain how these standards work. The basic protections are described below. Who does the law apply to? Federal BH parity rules apply to most health coverage, public and private, but do not apply to Medicare. Table 1 summarizes the basic rules and exceptions. Parity applies to all health coverage in the individual, small and large group insurance markets, as well as to all private employer-sponsored plans (insured and self-insured) with the exception of self-insured employer plans covering groups of no more than 50 employees, “retiree only” plans, short-term limited duration coverage and coverage considered “excepted benefits.”3 It also applies to self-insured state and local governmental plans (called nonfederal governmental plans), though these plans have the ability to opt out of MHPAEA protections, as hundreds of plans across 31 states currently do. Source: Kaiser Family Foundation

It is astonishing at the rate for death for children and teenagers from firearms in the US, compared to many other countries across the world (particularly industrialized countries). The graph reflect the nature of death amongst children and teenagers, illustrating that their needs to be more stringent regulations on the right to bear arms and safety measures, as weapons can be easily found by children/teenagers. Such preventative measures may include safe, lock box, etc. Access for fatal weapons are killing the youth in the American more than motor vehicles accidents, bodily injuries. US demonstrates a widespread epidemic of mental health issues relating in substance issues and intentional suicidal completions or accidental fatality through firearms, which continues to be on a rise. Source: Kaiser Family Foundation

In 2020 and 2021, firearms contributed to the deaths of more children ages 1-17 years in the U.S. than any other type of injury or illness. The child firearm mortality rate has doubled in the U.S. from a recent low of 1.8 deaths per 100,000 in 2013 to 3.7 in 2021. The United States has by far the highest rate of child and teen firearm mortality among peer nations. In no other similarly large, wealthy country are firearms in the top four causes of death for children and teens, let alone the number one cause. U.S. states with the most gun laws have lower rates of child and teen firearm deaths than states with few gun laws. But, even states with the lowest child and teen firearm deaths have rates much higher than what peer countries experience. In 2020 and 2021, firearms were involved in the deaths of more children ages 1-17 than any other type of injury or illness, surpassing deaths due to motor vehicles, which had long been the number one factor in child deaths. In 2021, there were 2,571 child deaths due to firearms—a rate of 3.7 deaths per 100,000 children, which is an increase of 68% in the number of deaths since 2000 and 107% since a recent low of 2013. While the rate of firearm deaths among children has increased since 2000, the rate of motor vehicle deaths is now significantly lower than it had been. The number of motor vehicle deaths among children in 2021 was 49% lower than in 2000, though it did grow during the pandemic by 22% from 2019. Though fewer in number than firearm deaths among children, deaths due to poisonings, which include drug overdoses, have also grown, increasing 186% since 2000 and 103% since 2019. Provisional CDC data from 2022 indicate that firearms continued to be the number one factor in child deaths for the third year in a row. Because peer countries’ mortality data are not available for children ages 1-17 years old alone, we group firearm mortality data for teens ages 18 and 19 years old with data for children ages 1-17 years old in all countries for a direct comparison. On a per capita basis, the firearm death rate among children and teens (ages 1-19) in the U.S. is over 9.5 times the firearm death rate of Canadian children and teens (ages 1-19). Canada is the country with the second-highest child and teen firearm death rate among similarly large and wealthy nations. As might be expected, teenagers have higher firearm mortality rates than children. In the U.S., teens ages 18 and 19 have a firearm mortality rate of 25.2 per 100,000, compared to a rate of 3.7 per 100,000 for children ages 1-17 in the U.S. Even so, the child firearm mortality rate in the U.S. (3.7 per 100,000 people ages 1-17) is 5.5 times the child and teen mortality rate in Canada (0.6 per 100,000 people ages 1-19). If the child and teen firearm mortality rate in the U.S. had been brought down to rates seen in Canada, we estimate that approximately 30,000 children’s and teenagers’ lives in the U.S. would have been saved since 2010 (an average of about 2,500 lives per year). This would have reduced the total number of child and teenage deaths from all causes in the U.S. by 13%. The child and teen (ages 1-19 years) firearm mortality rate varies by state in the U.S. from 2.1 deaths per 100,000 in New York and New Jersey to 17.6 deaths per 100,000 in Louisiana. Even in New York and New Jersey, which have the lowest child and teen firearm mortality rates among those with available data, the rate is still over three times that in Canada. Because there is no comprehensive national firearm registry, it is difficult to track gun ownership in the U.S. Instead, we look at the correlation between the number of child and teen firearm deaths and the number of gun laws in U.S. states (based on the State Firearm Law Database, which is a catalog of the presence or absence of 134 firearm law provisions across all 50 states). States with more restrictive firearm laws in the U.S. generally have fewer child and teen firearm deaths than states with fewer firearm law provisions. Even so, these states on average have a much higher rate of child and teen firearm deaths than that of Canada and other countries. Among comparably large and wealthy countries, Canada has the second highest child and teen firearm death rate to the U.S. However, Canada generally has more restrictive firearm laws and regulates access to guns at the federal level. In the U.S., guns may be brought to states with strict laws from out-of-state or unregistered sources. Source: Kaiser Family Foundation

In recent years, many people have experienced poor mental health, with over 30% of adults in the United States reporting symptoms of anxiety and/or depression in February 2023. Substance use and death rates due to substances have also worsened in the U.S. – drug overdose death rates increased by 50% from 2019 to 2021 (21.6 vs. 32.4 per 100,000), primarily driven by fentanyl. Further, after a brief period of decline, suicide death rates increased in 2021 but remained just below the peak death rate in 2018 (14.1 vs. 14.2 per 100,000). Increases in drug overdose deaths and suicide deaths have disproportionately affected many people of color. Negative mental health and substance use outcomes have also affected youth and young adults. This increase in mental health and substance use issues comes at a time when resources are already strained, and people with mental health diagnoses often face barriers to care. Among adults with symptoms of anxiety and/or depressive disorder in 2022, over 20% report needing, but not receiving, mental health counseling or therapy. In the state fact sheets below, we examine state and national-level data on mental health and substance use. We find that mental health and substance use outcomes and coverage vary from state to state. Share of Adults With Symptoms of Anxiety and/or Depression, February 1 – 13, 2023 Source: Kaiser Family Foundation

Mental Health in America - is this country in a crisis? The research is staggering as 90% American adults think that there is a mental health crisis in this country, particularly about young children and teenagers, as suicide rates continue to escalate. It is an ongoing trend that the age of onset of mental continues to rise as young children/teenagers have increasingly reports symptoms of anxiety and depression. On factor that influence this lack of intervention in cost of health care particularly among the vulnerable population, with limited resources and access to care. 80% of adult americans say that the cost of mental health care is a big problem in the US, compared to other countries such as Europe (which has the NHS - which tends to have its own limitations as it sometimes tends to take 2-3 months to see a medical doctor, let alone a child or adult psychiatrist. Approximately 51% of adults report that a family member has experienced a severe mental health crisis. Often limited to Federally Qualified Health Centers, Rural Health Clinics, Community Mental Health Centers, it can take months to get an appointments. Covid-19 had a strong impact on mental health in the US due to isolation and limited access to care. 47% of parents say that Covid-19 pandenmic has had a negative impact on their children's mental health. If you are in the crisis, please contact 988 (suicide/crisis hotline). Active suicidal thoughts, thoughts of self/harm, fearful for your safety? I have provided a extensive list of resources for State of Missouri: Federally Qualified Health Centers, Rural Health Clinics, Community Mental Health Centers