Saturday, July 16, 2011

Dealing with the Mentally Ill

Identifying and treating physical ailments is relatively simple. Although the causes of symptoms can be difficult to specify, once discovered, there is generally a highly probable diagnosis and a related course of treatment to eliminate the illness. Things are not so clear cut when it comes to mental illness. While it is easy to decide if someone has a bacterial infection, how do you decide when a person is “depressed” and in need of treatment? Rachel Aviv provides a thought-provoking article in The New Yorker about the difficulties involved in dealing with people whose behavior does not conform to societal norms. It is titled God Knows Where I Am: What Should Happen When Patients Reject Their Diagnosis? 

The brain is a complex organ consisting of many linked components performing multiple tasks. How these components develop, perform, and interact in a given individual is a function of genetics, the environment, and random chance. Many brain functions are performed subconsciously and control what is revealed to the “conscious” brain, leaving little actual freedom of action. There is a finite probability that this construct will not function properly and severe disability will result. Those are the easy cases to diagnose.

Given such a construct for the brain, it is safe to say that there are no two identical personalities on this earth. Each of us will have different ways and means of dealing with difficult times, with anger, with self control, with fantasies…. One mental attribute we are used to dealing with is intelligence. We have excessively intelligent people and individuals quite lacking in what is considered intelligence. We do not try to “cure” either of these extremes, and we do not generally classify either extreme as a mental illness. Other mental functions can lead to antisocial behavior and societal sanctions.

The nature of life is that we will experience conditions that generate feelings of euphoria and of depression. Everyone will be affected differently. Most will quickly recover from these emotional imbalances and move on. Some will undergo periods of euphoria and depression that most would consider to be excessive, given the circumstances. Others will by subject to these emotions without any specific identifiable cause. For some these feelings will be so extreme that they conflict with living a “normal” life. At some point the people with the extreme responses run the risk of being deemed clinically depressed or manic—mentally ill.

Who gets to decide when idiosyncratic behavior becomes mental illness? And what criteria are used? And what about the rights of the individual in question? A person with a physical ailment can choose to ignore their condition and allow themselves to die if they wish. A person who is declared mentally ill can be forcibly medicated under the dubious logic that if a psychiatrist says the medication will help, the only explanation for refusing it is mental incompetence. These are the questions raised by Aviv in her article.

Aviv tells the story of Linda Bishop. Linda was a divorced mother with a seventh grade daughter when it was first noticed that she was beginning to act strangely. She suffered the delusions and fantasies that are characteristic of schizophrenia. The episodes were intermittent, but were beginning to disturb her life and that of her relatives and friends. Linda checked herself into a hospital where she was diagnosed with schizophrenia and given the medications Zyprexa and lithium. She was given a few days of “talk therapy” and released after a week or so. The doctor treating her had this conclusion:

“She now has insight into the fact that these are paranoid delusions, and a part of her is able to say that maybe some of these things didn’t happen, perhaps some of the people she felt were plotting against her really weren’t.”

Although Linda seemed to be making progress through talk therapy, she was released with only medications to help her. As Aviv points out:

“People recovering from psychotic episodes rarely receive extensive talk therapy, because insurance companies place strict limits on the number of sessions allowed and because for years psychiatrists have assumed that psychotic patients are unable to reflect meaningfully on their lives….With medication as her only form of treatment, Linda was unable to modify her self-image to accommodate the facts of her illness.”

Linda had several stays in hospitals in which all she was provided with were lectures about her illness and drug prescriptions. She was a strong-willed individual. She refused to believe she was mentally ill, and refused to take medications, complaining that “the drugs made her lethargic and caused her to gain weight.” Linda had long periods of normal behavior, but the psychotic episodes would continue to return. Eventually her actions got her into trouble with the law for a minor offense. Her behavior while in custody warranted a competency evaluation which took a year and a half to arrive at the conclusion that she would be committed to a mental hospital for a term of up to three years. After three months the hospital filed a petition to have her declared in need of a legal guardian who could approve the forcible administration of medication. Linda was apparently coherent enough to convince a judge that that she did not meet the criteria for mental incompetence. The hospital seemed to not know what else to do with her. She refused any type of therapy that might require her to admit that she was mentally ill. This refusal to admit illness made her ineligible for some group housing options that might have provided her with needed support. Not being ruled incompetent invoked privacy rules mandating that her family could not be notified about her release.

“Instead, she left the hospital with only pocket change, no access to a bank account, and not a single person aware of where she was going.”

Four days after her release, Linda broke into an abandoned farmhouse and decided to take up residence. The house was not completely empty, providing her a supply of books to read and writing materials, but her only supply of food was apples from nearby trees. She chose to stay in that house and wait for “guidance’ rather than risk being treated as a mental invalid. She stayed in that house until winter when her supply of apples ran out and she knew that she was starving. She was lucid enough to keep a notebook where she recorded her thoughts. She knew she was going to die, but chose to remain in that house rather than risk losing control of her life. It was not until her final few days that she considered leaving, but by then she was too weak to go. Aviv quotes Linda’s daughter:

“My mom made a choice—she could have walked out of that house, but she wouldn’t give up her freedom. She could never let go of that person she always wanted to be.”

At one time mental illness was relatively rare, it was episodic, and the majority of those who suffered from it learned to cope with their issues and lead somewhat normal lives. Today, mental illness is common, it is chronic, and it often leads to a lifetime of disability. What has changed?

What has changed is the field of psychiatry. Psychoanalysis was at one time the standard treatment for people with mental problems. This process was lengthy and not very efficient at arriving at “cures,” but at least it did no harm. About thirty years ago psychiatrists decided that they would devote themselves to using medications as a more efficacious path to “cures.” This was coupled with an aggressive campaign to redefine mental illness that would end up capturing many more people. Close to three hundred types of mental illness were listed in what could be called the “bible” of psychiatry: Diagnostic and Statistical Manual of Mental Disorders. Fidgety boys, cranky two-year-olds, grumpy senior citizens, and shy adolescents could now be claimed to have a mental illness and be medicated. With the help of the drug companies, psychiatrists convinced the public, Congress, and other medical professionals that they could treat mental illness with medications. Most tragically of all, they convinced themselves that this was true.

Psychiatrists and drug companies have tried for decades to find a biological basis for mental illness and have failed. The notion that their psychoactive drugs address mental illness has no scientific support. The drugs applied have side effects that produce changes in behavior that appear to be alleviating symptoms. This is easily misrepresented as a cure, or the beginning of a cure, but it is merely the substitution of one set of symptoms for another. The brain is affected by these drugs and tries to respond to the changing conditions. It appears that if the drugs are used for long periods the changes in brain function become irreversible. This makes it difficult to stop taking drugs once one starts. Changing effectiveness leads to higher dosages or addition of other drugs. Often there is a cascading effect. One drug produces a side effect that is countered with another drug which, in turn, has side effects that must be countered. It is not unusual for patients so captured to be fed a cocktail of five or six drugs in order to maintain equilibrium. Psychiatrist love to talk about short term improvements in people under medication, but they seem to have little concern for long term effects. What data is available is apparently too frightening to contemplate.

There is some evidence that Linda might have responded to talk therapy that could have focused on coping techniques to utilize when her delusions began to reappear. That sort of therapy is barely available now. Few psychiatrists are practiced in the necessary skills. Instead, she was given drugs as the only choice. Would she have lived longer if she had accepted medication? Probably. Would she have had a happier, more satisfying existence under medication? Probably not. The picture Aviv paints of Linda, through Linda’s own notes, is of someone intelligent and capable of clear thoughts, but someone who had delusions that could not be countered by reality once she isolated herself in that abandoned house. Most poignantly of all, she seemed at ease with her fate. She seemed to realize that medication would make her into someone else—someone she did not want to be. This outcome could have been much different if other treatment options had been available.

There is a role for medications in treating patients who are, in some manner, out of control. There will be some few individuals for which the only effective treatment is being drugged into submission. In most cases drugs should only be used, as necessary, to calm a patient sufficiently to allow other forms of therapy to be applied.

Psychiatrists and drug companies control what is known about mental illness. This unholy alliance is too driven by self-interest, greed, and corruption to be allowed to define public policy. Daniel Carlat, in his book Unhinged: The Trouble with Psychiatry—A Doctor’s Revelations About a Profession in Crisis, provides this data:

“It is true that [drug] companies spend plenty on R&D—$30 billion in 2007 alone. But they spend twice as much on marketing—close to $60 billion in that same year. Some 90 percent of this marketing money is spent on sales activities directed toward physicians.”

According to Carlat, psychiatrists are the most productive targets for their marketing. Activities include bribing doctors to use their drugs with gifts and other financial rewards, paying doctors to put their names on research papers written by drug companies, and encouraging doctors to use drugs for purposes not approved by the FDA. Since this $60 billion of marketing money shows up in the cost of drugs, and the government pays about half of all medical costs, about $30 billion of public funds are used to promote the use of drugs. One wonders how much money is spent on non-drug therapy development for mental illness. The first step in breaking this drug/drug-dependence cycle is to develop alternate therapy approaches that are effective. This is not a hopeless proposal. Even the unconscious brain can be trained.

A second step would be to reassess the costs of healthcare for mental illness. Since the advent of this drugs-only approach, the number of people on long-term disability due to mental illness has exploded. If drugs work so well, why are so many people being driven into a lifetime of government support and a lifetime of drug use? If the true costs of psychoactive drug use were known, perhaps support for alternate approaches would appear.

The FDA is perhaps the most incompetent organization on the face of the earth. It routinely allows worthless and dangerous drugs to be foisted on an unsuspecting public. It often appears to be constituted in such a way as to have the mission of being a servant of the mighty drug industry rather than a regulator. This has to change.

There must be a reconsideration of patients’ rights. As the case of Linda Bishop indicates, once one is labeled as mentally ill there is a real risk of losing all control over your own life. If you disagree with a doctor’s diagnosis, that can be construed as mental incompetence. If you refuse drugs, that can be construed as mental incompetence. Schools threaten parents with the expulsion of their child unless they put him or her on drugs. Foster children and juvenile offenders are routinely medicated to make them easier to handle. Where does this end?

Thanks to Rachel Aviv for providing such a wonderful article. She manages to give a short course on mental health issues while telling Linda Bishop’s story in a manner that rises to the level of literature. Rachel raises questions, but does not answer them. The opinion in this piece is mostly mine and is derived from other sources. She lets the reader decide how to view Linda’s outcome. Was she a fool, or a tragic heroine? After much consideration, I see a bit of the heroine in her.

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