Inkwell: Authors and Artists

    
>I have to say that
it's a bit frightening to read a statement from a clinician who
believes that "the insight" of a patient suffering from serious
delusions of persecution is "worth the suffering."


Uh, I think that what I said is that if you ask a person with
schizophrenia if their insight is worth the suffering, they wil lby and
large tel lyou no. I think I also said that the notion that
schizophrenia is sanity in an insane world is a romanticized one, and I
thought I implied by that that it is a misguided one. But I don't
think that it is possible to deny that in some cases, a person's
psychosis is also insightful. That is what led people like RD Laing to
romanticize it in the first place. But let me be clear: I don't wish
schizophrenia on anyone, I think it is a disease, and a horrible one at
that.
  

    
>With atypical antipsychotics
like Seroquel and Abilify proving successful in treating BD with fewer
side effects than older meds, I'm told that drug companies are pulling
out all the stops to market them, and to broaden the classification of
bipolar illness to do so.

That already happened, with the introduction of Bipolar II, which is a
form of bipolar illness in which you never get manic and which can
(and is) easily applied to people who are moodier than they want to be
or than doctors think they ought to be. 

This one is strange because, like schizophrenia, bipolar disorder (or
manic-depression) very nicely fits tjhe disease model: unexplained
onset and remission, predictable course, fairly uniform response to
treatment, etc. In fact, manic depression and schizophrenia (then known
as dementia praecox) were the first mental illnesses identified as
medical diseases back around 1895. It took awhile to sort them out from
each other, and there's still some overlap and confusion, but if I had
to vote for some forms of psychological suffering that really belonged
in the same camp as diabetes or cancer, these would be my choices. But
bipolar II seems like piling on, an attempt to ride the disease
coattails, exactly as you describe.
  

    
>Every time I think about this topic, I run up against the way support
is tied to diagnosis.  As long as that is the case, and as lon as
there are people who can't afford to purchase support on their own, I
don't see another work-around.  I wonder how providing support without
regard for diagnosis, particularly in the field of mental health, would
affect diagnosis rates and favored treatments, Big Pharma aside.

I think this is a crucial point, and really spot=on. The health care
funding tail wags the treatment dog. 

In a way, the embarrassments of the Diagnostic and STatistical Manual
are the direct result of a decision made by American doctors in the
late 1920s to limit the practice of psychoanalysis to physicians. Freud
deeply opposed this move, fearing that it would turn analysis into a
branch of medicine, meaning that doctors would now start to look at
mental illness with the same tools and concepts as physical illness,
and as a result try to cure people. AS the health care "system"
evolved, this increasingly meant that psychotherapy in general was paid
for by insurance companies and starting in the 1970s, they began to
ask for accountability--which was totally their right. (This was around
the same time that the homosexuality contorversy and other debacles
were taking place, all of which made psychiatry look really bad.) The
best way to provide this was to make diagnosis and treatment look more
like "real medicine," and forty years later we have this diagnostic
system that is designed primarily to take care of doctors.

I'm biting the hadn that feeds me here. Is there any way I could
charge the average Joe or Josephine $120 an hour for my sage counsel if
there weren't a third party payer? Probably not, although a surprising
number of people are willing and able to pony up something like that
amount out of their own pocket. But I think most of us in the health
care field are going to see reductions in pay over the next years, and
there is some value in making the field honest again.

As for treatment without diagnosis, I assure you that many, if not
most, clinicians, in many if not most of their cases, think about
diagnosis very rarely, and then mostly for purposes of reimbursement.
One of the things I write about in my book is how the reformulation of
the DSM and the evolution of the health care financing system have
created perverse incentives to render diagnoses, which in turn ramps up
the numbers, whcih in turn provides markets for drug companies, which,
when their drugs work, in turn reinforces the idea that psychological
suffering is biochemical in origin. NOt a conspiracy, just one of those
viral things.

 
  

    
>One more point to clarify: there's a whole lot more to the diagnosis
of ADHD than excessive fidgeting out of boredom as well.  It is no
more absurd than ASD.

There is supposed to be a whole lot more to it. But there sometimes
isn't. I;ve seen many cases in which doctors have diagnosed ADHD and
prescribed stimulants to kids who just didn't meet the criteria. But
the improvement in the child's behavior--stimulants do increase focus
and concentration, after all--retrospectively confirms the diagnosis.

And here again,  the strange way we pay for health care (and in the
case of ADHD and ASD, for education) is a driver in diagnosis rates.
One real advantage to these diagnoses, and especially  Asperger
syndrome, is that they become a way to force the school system to
provide services to children. That's part of the reason that many
people don't want Asperger syndrome to be folded into the autism
spectrum: they fear a tightening of diagnostic criteria, hence loss of
services. 

A diagnosis is a ticket to social resources. IN fact, I think the best
definition of "disease" is a form of suffering that we think is
deserving of health care dollars. Biochemistry currently provides the
strongest claim, but I also think that as time goes on and more and
more diseases prove resistant to the magic-bullet model, we will see
other ways of identifying particular miseries as diseases. 

I think Type 2 diabetes and depression are probably the most likely
diseases to lead the way on this. There is no denying that rates of
both have skyrocketed in the last twenty years. In the case of
depression, this is due to a diagnostic largesse that is largely
unintended--between the fact that the diagnosis relies on self-reported
response to leading questions and that all consideration of the
context of the suffering is eliminated, it's no surprise that more
people qualify. But this doesn't mean people aren't suffering. The
great advantage to our new depression awareness is that it helps us
identify a widespread problem.

But what kind of problem? That's where the diabetes comparison becomes
really interesting. Type 2 diabetes is not the result of a pancreas
ceasing to function. It's the result of your cells losing their ability
to absorb and use insulin, and this in turn is generally the result of
obesity and other challenges to metabolic regulation, largely caused
by poor diet, sedentary lifestyle, etc. One grou pof studies shows that
many people eating a typical Burger King meal can develop insulin
resistance nearly immediately. Type 2 diabetes is notoriously difficult
to treat with drugs, but it can be reliably prevented or averted with
changes in lifestyle. So it could turn out that the treatment for it
will be social rather than biological. Supermarkets in the inner city.
Better school lunches. Taxation and regulation of dangerous food.
INcentives for physical fitness. All of which are hard to get our heads
around, especially to the extent that they are coercive, but in the
end no stranger or more noxious than taking drugs that may not work but
will reliably have side effects.

Depression may turn out to be the same kind of problem. Even if there
proves to be a single biochemical pathway, or maybe just a few, or it
turns out to eb an inflammatory illness, it is very likely to be so
complex, and we are so far from understanding the intricacies and
feedback loops of brain metabolism, that drug treatments will never
surpass their current unimpressive efficacy. But perhaps we could
identify the conditions, other than diagnostic bad faith and greed,
that lead to this suffering. What do my depressed patients complain
about? What do I complain about when I'm depressed? Worries about the
future--paying for college, retirement, health care. Difficulties in
juggling family and job and leisure. Marital strife. Lack of
fulfillment, a sense of having failed to achieve the kind of selfhood
we're supposed to achieve. Now, this may all just be noise generated by
a biochemical signal, but it could also be that these problems are
real, and that resolving them might actually lower rates of depression.
I wonder how much less depression there would be if we had a more
humane economy. I wonder how much less suffering there would be if we
thought of disease as a ticket to social resources other than drugs.
  

    
There is an example for this kind of "treatment,"
 although it was largely inadvertent. That was when John Snow
convinced the authorities to take the handle off the pump dispensing
cholera-contaminated water to a neighborhood in London. No need to
identify the germs or find drugs to treat it, or to understand the
mechanisms of the disease. The treatment for an indisputably medical
illness was social. PUblic health measures tend to be more reliable,
less dangerous, and vastly cheaper than private health measures. What
would be the public health measures to relieve depression? I don't
pretend to know the answer, but a little bit of imagination here could
go a long way.
  

    
>What would be the public health measures to relieve depression?

I think this is about community. And I am also becoming a big fan of
community clinics, maybe through county health departments. First the
sense has to get around that I am not alone in feeling this way. From
there people talking about fixing it. Hard for us to gather and talk
about our concerns. And maybe even harder to share weaknesses and talk
about disease. But I think you are on to something with the idea of
integrated community health care. There certainly seem to be a lot of
social aspects to depression and anxiety.
  

    
The question of whether the specific things that concern one during
episodes of depression are causes or noise... that would be an
interesting challenge to tease out.  The basic problem is that you
can't create two otherwise equivalent societies and start controlling
for cultural factors.  Cross-cultural comparisons are an one solution -
but you run into the difficulty of defining depression itself, since
different cultures may view the whole issue differently (not the same
as comparing, say, rates of heart attack deaths).

I guess the other thing you can do is look at rates of depression
among people in the same society (hence same culture, etc.) but in
different circumstances.

I would assume there's been some attempts to pursue these approaches,
right?
  

    
Toward the end of my book, I pay a visit to a conference of teh
Depression and Bipolar Support Alliance. It's a group that uses a
community organizing model to provide support to patients. Lots of peer
advocacy, access to resources, political action (e.g., lobbying for
increased benefits), etc. I thought it was interesting, and a vast
improvement over the prevailing norm, but I did wish that the
acceptance of the idea that depression is a chronic biochemical illness
had been a little less uncritical.
  

    
>I would assume there's been some attempts to pursue these approaches,
right?

Sort of. The lowest rates of depression seem to be among communitarian
societies in Polynesia, the highest in the NOrthern European countries
(although recently I've been reading that Russia has an outrageously
high suicide rate, which may point to a high depression prevalence).
Scandinavia, of course, is highly socialist. So one example supports my
theory, the other contradicts it. But I think that before we can say
much about this cross-cultural stuff, we have to ask what we are
looking for and how.

The problem is a variant of the Hawthorne effect that Sharon mentioned
awhile ago. In the social sciences as much as in quantum physics, the
observation alters the phenomenon. How do you go about asking people
about their depression without simultaneously shaping their experience
by directing their attention to certain behaviors, experiences, etc.,
which you already think are symptoms. When I participated in a clinical
trial, I was surprised at how powerfully the questions shaped my
experience by directing my attention to certain phenomena I hadn't paid
much attention to. 

For example, "In the past two weeks, have you been feeling unusually
self-critical?" is a question from the Hamilton Depressin Rating Scale.
That's a really complex question, of course--how much is unusual,
exactly what is self-critical, etc.?--but the effect of it is to render
an experience as symptom, and maybe to risk false positives by
encouraging me to see what the doctors are looking for. 

I think that if you limited the questions to the kind of depression
that some people call melancholia--severe, incapacitating, unprovoked
and unresponsive to environmental changes, and marked by physical
symptoms like agitation and appetite disturbance--you would find a
fairly uniform distribution. AFter all, this is the phenomenon that has
been described by doctors since Hippocrates. But the prevalence would
be much lower than the WHO or CDC statistics indicate. AS you move away
from the severe end of the spectrum, y9ou move not only toward more
psychological symptoms (lack of confidence, procrastination,
rejection-sensitivity, etc.) but toward more culturally relevant
symptoms. Rejection-sensitivity is a different kind of problem in a
tribal culture than in an individualistic democracy. 

I have no idea how you would measure these things and still account
for cultural and linguistic differences. But I do know what happens
when drug companies set out to market depression as they did in Japan
starting in the 90s. Rates of depression go up. Maybe that was because
all the depression talk (they even coined a word meaning "cold of the
soul") encouraged people to come forward and revealed a hitherto hidden
epidemic. But maybe not. REad Crazy Like Us and see what you think.
  

    
I'll do that.

Re: Russia's suicide rate, they also have outrageous rates of alcohol
dependence, which is definitely correlated with suicide.  Of course
that raises a number of "cause or effect?" questions, e.g. do people
drink because they're depressed or get depressed because of the effects
of alcohol.

Those questions aside, alcohol is clearly a very poor way to treat
depression.  
  

    
It's not that there isn't real biochemical depression which is well
treated by pharmaceuticals, it's that some depression is better suited
to be treated by behavior modification than with drugs.  I have a
family member that has been treated pharmacologically for depression
for over a decade and it hasn't improved her situation AT ALL.  She
doesn't seek out counseling, however, because she has the meds (and can
get them changed and readjusted on a regular basis).  Her depression,
if you ask her is just as Gary said above, "Worries about the
future--paying for college, retirement, health care. Difficulties in
juggling family and job and leisure. Marital strife. Lack of
fulfillment, a sense of having failed to achieve the kind of selfhood
we're supposed to achieve."  All of these, I believe, a competent
therapist could help alleviate through counseling.  Perhaps a life
coach would be successful.  The only things the meds have done is dull
her pain - not help resolve the issues.  The issues need to be dealt
with, otherwise it's no different than smoking a joint to forget your
troubles.

This particular family member prefers the pharmacological route
because it is easier, less time consuming, and more affordable than
traditional therapy.  Also, anti-depressants are now socially more
acceptable than spending a few hours a month in therapy.  Dealing with
her issues would be hard work.  Taking a drug is easy.  Again, she
could just smoke a joint.  

The problem is the continuum of human emotions and mental equilibrium.
 On the one hand, there are the truly mentally ill - those who can not
manage their own lives, who have severe delusions, who can not control
themselves to the point of self or other-destruction.  Then there are
the rest of us, who live on a continuum from that point to what some
might call mental health.  

Most of us fall somewhere in the middle.  Some of us in the middle
just deal/suffer quietly.  Others use all the resources at their
disposal (pharma/therapy).  Others only use pharmacological resources. 
What I took away from Gary's book is not that he thinks drugs don't
work, but that he thinks drugs work for SOME people, and other people
would benefit more from non-pharmacological treatments.  

I think it is important to understand which people need which kind of
treatments and to then insist that our insurance/medical providers
provide that kind of treatment.  If in fact the history Gary points to
is correct, the diagnoses of depression are solely due to the
practitioner having no other way to get paid for treating the person
who is suffering.  While we all agree that each of us should be treated
appropriately, what appropriate is may need to be reevaluated.

  
  

    
slipped
  

    
Gary, I was surprised at this statement:

<That already happened, with the introduction of Bipolar II, which is
a form of bipolar illness in which you never get manic and which can
(and is) easily applied to people who are moodier than they want to be
or than doctors think they ought to be.>

I am sadly too familiar with Bipolar II, thanks to a family member who
suffers with it, and "in which you never get manic" is, well, a bit
inaccurate, to put it politely. 

Lisa, I'd just like to point out, after reading what you said, that
long term therapy is so far out of reach for people who aren't either
wealthy or indigent that I sometimes wonder why therapists don't
collectively resolve to see, say, two or three patients a day who pay
$20-40 an hour instead of $120 or more. 
  

    
>I am sadly too familiar with Bipolar II, thanks to a family member
whosuffers with it, and "in which you never get manic" is, well, a bit
inaccurate, to put it politely. 

Well, you may be surprised, but the surprise is in the DSM, which says
a single manic episode rules out a Bipolar II diagnosis, and not with
me. Here are the diagnostic criteria:  


A. Presence (or history) of one or more Major Depressive Episodes.

B. Presence (or history) of at least one Hypomanic Episode.

C. There has never been a Manic Episode or a Mixed Episode.

D. The mood symptoms in Criteria A and B are not better accounted for
by Schizoaffective Disorder and are not superimposed on Schizophrenia,
Schizophreniform Disorder, delusional disorder, or Psychotic Disorder
Not Otherwise Specified.

E. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
  

    <scribbled by gberg Tue 9 Mar 10 08:34>
  

    
>Lisa, I'd just like to point out, after reading what you said, that
>long term therapy is so far out of reach for people who aren't either
wealthy or indigent that I sometimes wonder why therapists don't
collectively resolve to see, say, two or three patients a day who pay
$20-40 an hour instead of $120 or more. 

 
Getting therapists to agree on anything is hard. It's like herding
cats. But many of us, including me, do exactly that. I see my high
fees
as an opportunity to institute some socialism by distributing other
people's (and insurance companies') wealth.

 
  

    
Gary, it's the hypomania where you and I part ways. It is a form of
mania, it is certainly real, and it is damaging, in many cases and many
ways.

It is also difficult, it seems, for some practitioners to define the
bright line between hypomania and full-blown mania. 
  

    
We;re not parting ways. I don't disagree with you. You're parting ways
with the DSM, and so is your relative's doctor. None of which is to
say that hypomania isn't a bad thing or that your relative, and the
poeople who love him or her, doesn't suffer from something really bad
and that may well respond to the mood stabilizers or even the atypical
antipsychotics. Just that Bipolar II is a diagnosis designed to apply
to people whose mood swings stop short of mania, and is often, in my
experience, applied to folks (and especially kids) whose hypomania does
not even approach that line. 

As for that bright line, I think it is very difficult for anyone to
make that distinction consistently and reliably, which may be an
indication that there's soemthing wrong with the categorical approach
to diagnosis. 
  

    
Here's an example of what I mean. 

I saw a kid for awhile who was living with a mother who was severly
bipolar, made several serious suicide attempts, and a father who was
mostly checked out of the situation--a nice guy, just in way over his
head-which often left the kid in charge. His mother was alternately
seductive and rejecting with the kid (who was 18), and 
had pronounced learning disability, which had gone largely undetected
because his parents were preoccupied. So not surprisingly, he had a bad
temper (punched holes in walls a coujple times a year, etc.) and could
be pretty feckless, but mood-wise he was relatively stable, especially
consdiering what he was contending with. I worked with the family
mostly to get the mother stable, to get the father to take some heed of
the situation, and to help the kid with his temper.

Anyway, a few months after I stopped seeing him, he started stealing
side view mirrors from expensive cars and selling them on ebay. The
local constabulary, confronted with a rash of side view mirror thefts,
went on ebay and saw them offered, complete with photos that showed the
kid's bedroom. When they came to bust him, he jumped in his car and
drove into a tree hard enough to eject the engine. He was mostly
unhurt, but he had left a suicide note. The parents called me to find
out what to do--I told them to tell the hospital doctors about the
note. He was put into the psych ward, and diagnosed as Bipolar. I never
heard if it was I or II, but I presume it was II.

Now, I took a pretty good history with this kid, from him and his
parents. There wasn't anything resembling a hypomanic episode, nor were
there notable periods of depression, certainly nothing approaching a
major depressive episode. In fact, for an adolescent, he seemed
unusually un-sullen, and about normally moody, which is to say pretty
moody. 

So whence the diagnosis? Confronted with an impulsive kid who'd just
made a serious suicide attempt and had a history of volatility (and I'm
guessing was pretty labile in the hospital, what with his recognition
that he was about to get into really big, life-changing trouble with
the cops and lawyers and all, plus his parents were really pissed off
and distraught and the whole thing was clusterfuck city), his docs had
some choices: intermittent explosive disorder, conduct disorder, maybe
antisocial personality disorder (before he hit the tree, he wiped out a
car and injured its occupants), and the old standbys, mood disorders.
But mostly what they saw was a very agitated kid who wasn't psychotic
and whom they really wanted to help. The most helpful drugs in that
situation are often the mood stabilizers, which aren't really
diagnosis-specific (at least not in the way that, say, amoxicillin is
for bacterial infections or acyclovir for herpes viruses), but still
require a diagnosis. Plus bipolar is a very sympathetic diagnosis for a
kid in deep shit, and will probably be very helpful when it comes to
adjudication time. 

What it isn't is accurate, according to the DSM. (Unless of course the
kid and his father and motehr all concealed the same history from me
in tghe same way, whcih is certainly possible, and another hazard of
psychiatric diagnosis--you're entirely dependent on what people tell
you.) 
  

    
<You're parting ways with the DSM, and so is your relative's doctor.>

I'm not sure how you can conclude that from what I said, let alone
decide that the doctor in question is not adhering to the diagnostic
criteria, so I'd be really interested in how you concluded that from
the little bit that I said.  

<None of which is to say that hypomania isn't a bad thing or that your
relative, and the poeople who love him or her, doesn't suffer from
something really bad and that may well respond to the mood stabilizers
or even the atypical antipsychotics.>

That reads as really condescending. Did you intend that? 

You slipped, and I wonder how you would have diagnosed this kid?
  

    
In my book, I write about a study in which standardized
patients--people trained to present diseases to doctors, or, more
likely, medical students--went to doctors' offices and presented
symptoms of either adjustment disorder with depressed mood or major
depression. The independent variable in both case was mentioning an ad
for Paxil. The study found that mentioning an antidepressant was more
likely to result in a prescription. It also noted, but didn't comment
on, the fat that mentioning the drug also increased diagnosis rates.
Putting the doc in mind of the disease made him or her more likely to
diagnose.

But the real revelation, to me, was that people could go into a
doctors office and fake a case of depression and leave with a
prescription. Try that with diabetes.
  

    <scribbled by gberg Tue 9 Mar 10 09:43>
  

    
>I'm not sure how you can conclude that from what I said, let alone
decide that the doctor in question is not adhering to the diagnostic
criteria, so I'd be really interested in how you concluded that from
the little bit that I said

WEll, perhaps I misread this

>I am sadly too familiar with Bipolar II, thanks to a family member
who
suffers with it, and "in which you never get manic" is, well, a bit
inaccurate, to put it politely. 

to mean that your family member had had a manic episode. Is that not
waht you meant? If not, I apologize. My only point is that officially
speaking, if a person has had a manic episode at any time in his or
her
life, he is disualified from the Bipolar II diagnosis. I also thought
you were challenging my claim that Bipoloar II people can't be manic,
as if I had invented it or advocated it. That was the DSM's idea, not
mine. 

As for sounding condescending, what I was trying to say there is that
my commenbts about your relative not having Bipolar II (a
determination
I make not as a diagnostician, but only from your comment about
his/her having a manic episode, which as I say above I may have
misunderstood, in which case, forgive me and forget I said anytthing)
is only a technical point. It was not meant to say that your family
and
your relative don't suffer. SOrry if I came off as dismissive, and
espcially so since I was trying to express sympathy while still
maintaining the critical distinction in the diagnostic category.

 
  

    
Stepping back for a moment and looking at the industry again for a
moment, what change would show the most promise?  Regulations? Consumer
boycotts? Physician education?
  

    
Gary, I don't think I expressed myself clearly at all. My point was
that while bipolar II may, in fact, be a catchall dx, in your opinion,
there are people who actually do meet the diagnostic criteria, and that
hypomania can be, in some cases, as damaging as a full blown manic
episode.