Friday, May 8, 2009

My Top Ten Mental Health Stories

Following is what I view as the ten most significant events or trends affecting all of mental health in my ten years researching and reporting on my illness. Obviously, had I been reporting on say schizophrenia rather than bipolar my list would be different. Then again, only one entry here is bipolar-specific. So, without further ado, in no particular order:

Recognition of child bipolar

Ten years ago, virtually everyone thought you had to be of voting age to qualify for a bipolar diagnosis. A lot of the credit for changing that misconception goes to the parents, who have taken it upon themselves to educate clinicians and educators. There has been a noisy public backlash over labeling and medicating kids, but the alternative of turning your back on them is totally unthinkable.

Key people: Demitri and Janice Papolos, authors of "The Bipolar Child"; Joseph Biederman, Harvard child psychiatrist and paradigm-shifter.

Bottom line: A child who jumps out of a moving vehicle has something very serious going on. Finally, we have woken up and are doing something about it.

Coming of age of borderline personality diagnosis

Surely, the thinking went, there could be no biological basis to this Freudian artifact. Guess what? The brain scans tell a different story. The scientific evidence, coupled with proof that interventions such as DBT work, not to mention the realization that borderline may be one reason why many so-called bipolar patients do not get better, is slowly shaking psychiatry out of its denial and raising public awareness.

Key people: Marsha Linehan, developer of DBT; Paul Mason and Randi Kreger, authors of "Stop Walking on Eggshells."

Bottom line: Countless individuals currently living tortured lives can look forward to a fresh start.

Brain science research

Where to start? The mapping out of stress-vulnerability and thought and modulation pathways, new revelations about plasticity and brain cell growth, new discoveries into how neurons work, new insights into how the brain interacts with the environment, the emergence of brain development as an explanation for mental illness, plus a host of candidate illness genes and the mapping the human genome ...

Key people: Eric Kandel, Arvid Carlsson, Paul Greengard, who shared the 2000 Nobel Prize in Medicine for their work in how neurons communicate.

Bottom line: Very smart people are changing the way we think, and - eventually - how we live.

Validation of talking therapies

CBT, interpersonal therapy, and other short-term therapies focusing on the here and now have been around since at least the seventies. But only in the last decade do we have the studies to prove just how useful these interventions are. Their popularity is growing, along with new applications, including CBT for schizophrenia (once regarded as a waste of time).

Key people: Aaron Beck and David Burns, founder and popularizer of CBT, respectively.

Bottom line: Growing numbers are learning to actively take charge of their own brains.

The spectrum concept

It's not whether you have bipolar - it's how much bipolar you may have. In other words, your depression may be more than just depression. In addition, the spectrum concept is encouraging researchers and clinicians to more closely examine various relationships between supposedly separate illnesses such as schizophrenia and autism - not to mention how such things as temperament and illness interact - and come up with original insights.

Key people: Hagop Akiskal, bipolar spectrum proponent; Robert Cloninger, personality pattern-spotter and paradigm-shifter.

Bottom line: The brain is not organized according to the DSM. Thank heaven for that.

Recovery movement

Earth to psychiatry: We want to get well, not just stable. We want to have lives, not just subsist as over-medicated zombies. In response, patients have taken matters into their own hands, with a growing grass roots recovery movement that trains peer specialists and encourages patients to take positive steps to move their lives forward.

Key people: Mary Ellen Copeland, proponent of WRAP; Daniel Fisher, recovery rabble-rouser; Eugene Johnson, founder of Recovery Innovations.

Bottom line: Psychiatry makes us stable. Only we can make ourselves well.

Patients and loved ones figure out the internet

Suddenly, we weren't alone and isolated. We could talk to each other online, support each other, learn, organize, and advocate. In addition, we could find information on our own from expert sources, then become our own experts. The downside, of course, is what happens with this tool in the hands of the ignorant and unprincipled.

Key people: Martha Hellander, founder of the Child and Adolescent Bipolar Foundation, the first internet-based mental health advocacy organization; Peter Frishauf, founder of Medscape; Deborah Gray, founder of "Wing of Madness," the template for many patient sites to follow.

Bottom line: For better and worse, the internet is where most of us go to for information and support.

Beginning of the end of drug companies

Everything seemed to happen at once: Patients and doctors seeing through the Pharma hype, blockbuster meds losing their patent protection, and no new meds coming out of the pipeline. No longer with any financial interest in influencing psychiatry, Pharma virtually backed out of the game. And with mega lost revenues from loss of patent protection, Pharma may lack the resources to ever get back in it.

Bottom line: Due to their arrogance and stupidity, Pharma fully deserves what's coming, but do we?

Deterioration in services

Not being able to afford meds and the doctors who prescribe them is only a small part of the problem. Lack of access to costly and time-consuming services is major. You name it - long-term therapy, psychiatric rehabilitation, higher education, crisis intervention, social services, vocational training, jail diversion, decent housing - not only is the money not there; the system is seemingly designed to fail us.

Bottom line: In this economy, things are only going to get worse.

Returning vets mental illness time bomb

Vets are returning from Iraq and Afghanistan with high rates of mental illness, or at high risk of mental illness, including PTSD and depression. Add to that the challenges in fitting back into society, then consider what many do to cope, such as drugs and alcohol.

Bottom line: Vietnam vets account for a large percentage of the homeless. Unless we act fast and plan long term, a new generation of vets will join them.

Big story of the next ten years: The current economic crisis

Whichever way events play out, society's most vulnerable will be the hardest hit, and those better off aren't immune either. Nevertheless, before we predict a pandemic of stress-related mental illness, the data shows that people actually experience better health and live longer when times are bad. Something to do with a return to core values?

Bottom line: However we come out of this, nothing is ever going to be the same again.


Anonymous said...

Beginning of the end for drug companies? I certainly hope not. While big pharma is indeed arrogant and stupid they are still the ones supplying us with our much needed bipolar meds. The current crop of meds works somewhat but it is far from perfect. Who is going to make the next-gen of meds if not the drug companies?

John McManamy said...

Hi, Anonymous. I'm just the messenger, so please don't shoot me. :)

Pharma has to contend with some $84 billion in lost revenues from blockbuster drugs going off-patent, with nothing to replace them. At the same time, Pharma has largely gotten out of the research and discovery business. These days, they only get involved after a smaller company has come up with something that looks like it's going to work - if they choose to get involved.

So anything new is going to have to be totally risk-free as an investment to them. Since these companies are extremely conservative I don't see them rushing forward any time soon with new concept meds.

So we're stuck with our old meds for the longest time.

Who loses? We do, of course.

In the meantime, with small manufacturers now supplying us with generics, Big Pharma - for the present - is largely redundant. If Big Pharma has nothing new to offer, we really don't need them. We can get along without them.

An immediate benefit is that psychiatry will be more honest, as Pharma won't be around to corrupt them. The process is already happening - fewer drug detailers are paying office visits, industry-sponsored symposia are being phased out, and infomercials dressed up as research articles are disappearing.

But where will the new drugs come from? If we the patients don't start agitating and advocating we will have only ourselves to blame. We need to take a cue from the AIDS activists.

Anyway, many thanks for bringing this up. Thanks to your feedback I'll get started on a blog post on this, and I look forward to keeping this conversation going with you.

Vincetastic said...

Hey John, this top ten list is fantastic. It is intersting to see the progression of findings in mental health over the years. What is so sad though is that there are still so many that go undiagnosed or untreated. There should definitely be more funding for research and for treatment, there's no excuse. You can post this to our site and link back to your site. We are trying to create a directory for top ten lists where people can find your site. The coolest feature is you can let other people vote on the rankings of your list.

Tami Green said...

Wow! This is really good stuff. Awesome.

Tami Green

John McManamy said...

Many thanks, Tami. Also check out the four pieces I did starting 10 or so days ago on borderline personality.

In support groups and elsewhere, I encounter bipolar patients who have a lot more going on than bipolar. These people may get better, but they don't get well.

Possible reasons:

1. One in five individuals with bipolar have co-occurring borderline. In many cases, only the bipolar is diagnosed and treated.

2. I suspect a good number of individuals with borderline are misdiagnosed with bipolar. They're sent out the door with a prescription and false hope.

3. All of us have unresolved personality issues that do not necessarily rate an Axis II diagnosis. But if they are not addressed, then recovery is going to be problematic. My guess is the insights of the people in the borderline field would greatly assist those struggling with personality issues.

Anyway, I'd love it if you were to do a guest blog here. Let's keep in touch.

Pat Risser said...

1. Regarding "borderline," brainscans are wrong. First of all, biology isn't destiny. More and more findings indicate that there is a certain plasticity or resiliency in the brain. Coupled with the fact that nearly 100% of people diagnosed with Borderline are survivors of abuse, neglect and trauma, pathways in the brain may have been altered as a learned or survival mechanism but, those pathways can be relearned or retrained. There are effective "treatments" but they aren't emotionally stifling drugs. Treatments that focus on healing the damage of abuse, neglect and trauma help.

2. Kids jump out of cars but not necessarily because of "bipolar." Despite all the time, money and effort spent, there is no actual proof of mental illness. There are no biochemical markers, no biological tests, no hard evidence at all, to "prove" the existence of "mental illness." By proof I mean the ability to demonstrate a reliable association between a clearly specified pattern of observables and other reliably measurable event(s) that operate as antecedents. (This is same level of proof used for TB, cancer, diabetes, etc.)

3. While it is difficult to change our thoughts, moods, feelings and emotions we should not turn to drugs as a first resort. We can learn to control our behaviors. We should start there and then work on the rest. I think BigPharma will be proven to be as diabolical as BigTobacco. They'll pay out Billions (a mere pittance when weighed against the new markets they're growing in Asia and elsewhere around the world).

Our entire system of care for people with emotional distress is built around illness. This is a negative approach. We diagnose illness. We complain of illness. We treat illness. We label illness. Even wellness means an absence of illness so we treat the symptoms of illness. Recovery means getting over illness. The person who is well is one who causes no community disturbance, no matter how incapacitated they may be.

We have never sat down and defined mental health. Other than understanding it from the negative of an absence of illness, we haven't yet set out to define what might constitute health. What does someone who is healthy look like? What might be the implications for the system if we were to shift the discussion and change the paradigm to one of health instead of illness?

If we were to define mental health, we would do more than look at the circular reasoning of an absence of illness. We would move toward the positive and look at those things present in someone who is mentally healthy. We might start by looking at an innocent and healthy baby. One of the things that we might note is the capacity to feel joy. While joy may not always be present, that capacity might become one of the pieces of a definition of mental health. Other pieces of the definition of health might include the ability to create and maintain relationships or the ability to appreciate solitude. We might discuss the ability to draw upon spirituality as a strength.

I believe that sitting down and creating a model of actual mental health will lead to the next great step in our progression forward. It will be necessary to support health care reform and move more toward a public health model of care.

Pat Risser

John McManamy said...

Hey, Pat. To reply point by point:

1. "The brainscans are wrong." What? They accidentally snapped a shot of someone's kidney? PubMed Minzenberg and get back to me.

Re plasticity: No lectures, please. Been writing about it for years, both in relation to brain science and recovery.

Re "nearly 100 percent ... abuse." So deficient anterior cingulate structure and function is irrelevant?

2. "No biological proof of mental illness." Only if you believe the brain is not a biological organ.

3. "As diabolical as big tobacco." Why don't we settle for "as stupid as Detroit"?

Re paradigm shift to health: If I have a rat gnawing at my brain, first I want that rat dead. Then I can think about well.

"Model of mental health." Based on what? Your belief that mental illness has no biological component?

To readers: Pat Risser has been one of the most influential voices in the recovery movement and in challenging the conventional wisdom of psychiatry, which is in constant need of challenging.

His voice is a vital one that well serves our population. Nevertheless, I could not allow his flat assertions to go unchallenged. Please interpret my blunt response as collegial disagreement.

cal_scoul said...

I was diagnosed with Bipolar disorder about 10 years ago and although I'm open to any advice regarding possible treatment whether by conventional pharmaceutics or even the unconventional herbal remedies etc I find Pat risser's blog disturbing and ill-informed. His rant suggests that spirituality and controlling our behaviour are paths to mental health. It is because we as Bipolar disorder sufferers are unable to control our emotional mental state that we have to have drugs and therapy to combat against this condition effectively.

If Pat Risser has hit on a valid cure then why are we not all on his program to health.
I heard a very good lecture once by Jan De Vries who accepted that although herbal medicines have their place in the treatment of mental illness that they should be used to augment traditional drugs and only by consultation with your doctor. If Pat Risser were to say that his method of counselling patients should be adopted with appropiately prescribed medication then this might have some bearing . The evidence for mental illness is there, erratic, violent, suicidal behaviour etc to me would indicate an abnormal state in people with mental illness.
If this is a man of influence in a recovey movement then lets hope for his followers sake they see the light and move away from him!

John McManamy said...

Hi, Cat Scout. Absolutely in accord. If what Pat Risser and the rest of the antipsychiatry movement had to say were absolutely true then we'd all be sitting around in a circle singing Kumbyah. Life would be that easy.

The reality, as we all know, is far different.

Anonymous said...

The well-meaning idealism that Pat so articulately spews forth could have had me fooled, a year ago, when I went off my meds. As well-balanced and informed as they may sound, Pat's words are seriously irresponsible and downright dangerous. They shamelessly appeal to the mentally ill in the midst of finding the right combination of medication and meditation. Pat acts as if the two are mutually exclusive. He promises a world that for many just doesn't exist, where vitamin colored bootstraps and bootless retreats pave the way. I have little to add to what Cat and John replied. Just to thank them for that other, more complex, less pleasing if less punishing picture. So I can print it out and share it with my well-meaning family members....

John McManamy said...

Thanks, Anonymous. I totally agree. Denying that mental illness exists is totally irresponsible, and we can't make rational choices based on fantasy. Facing reality is a challenge, but it's the crucial step to moving our lives forward.

Anonymous said...

Mental illness certainly exists...I know because I have been diagnosed certificable. I believe that the treatment of most common mood disorders - depression and particularly bipolar 1, 2, Nos and whatever is discovered next - is appalling...Why if this disease is supposedly one of the oldest known maladies - do we still have treatments that are so inefficent? Treatments that may work, but make life not worth living.

NO drug should be taken that can murder you kidneys, destroy your liver, make you fat...therefor increasing the possibility of diabetes, heart disease, stroke, kidney failure, increased depression, suicide etc. I am sick of comments that say people stop taking meds because of their enjoyment of mania, or thinking they are actually well. its Rubbish! No one who values their health, their brain, their indepedance from corrupt mental health practitioners; ie, Pdocs, the mental health co-operatives, the few remaining hospitals, even the so called Mental Health Advocate Societies who restrict their support groups from talking about their doctors or particular treatments. Yes there is mental illness, and I believe that it is escalating...

Possibly bipolar is overdiagnosed? In my case I had seen only regular doctors who considered me to be strictly a boring unipolar, with a dash of ADHD. Than I enterred the realm of "Mental Health Care".
I was already on Adderall and Effexor. I had to get a new Pdoc. My previous one had been disbarred for alcohalism and thowing parties with his female clients. He turned out to be only competant Pdoc I've had. At least he actually had some interest in his patients. My new Pdoc decided to double my Effexor from 150 mils to 300 mls and added a large dose of Wellbutrin. I had to get off the Wellbutrin because it was causing severe problems. When my Pdoc heard that I had not followed the exact regimen, he because ballistic and threatened to either dismiss me as a patient, or give me Electric Shock Therapy. He then preceded to lower my Effexor back to 150 Mls, dumped the Wellbutrin, continue my other medications and added Lemectal. This combination he gave without tapering off the Effexor or the Wellbutrin. He gave it to a woman who weighed 91 lbs. In three days I was completely out of my mind...called my doctor; he wouldn't return my calls. When I finally reached him, I begged him to see me; he became sarcastic and said, "if I didn't like the drugs, I could get off of them - immediately. I have never recoverered.

I have met at least three other people who had been treated by this sociopath, and they all ended in the Psych Wards.

He's still praticing. And you know something, this is only the tip of the iceberg....

Why are there so many ridiculous comments that are missing the point? Possibly some people actually improve on these dangerous drugs. But at what cost?

Get your heads out of the idiot diversions that envelope you and look around. If you believe that mental illness is being overdiagnosed; could it be possibly be an epidemic? Could it be that many people can no longer cope? Have we become a society that is so morally and ethically bankrupt that the only things that interest us is the reflection of our own stupidity?Why can no one see the blatant truth?Are we so arrogant, so selfish, so comfortable blaming the victims - that we tolerate and condone the corruption and stupidity of the institutions that made this happen?

Why don't you get off your collective backsides and do something. Care about the fact that we have lost our souls for things tha mean nothing. After all we were spawned by the "Greatest Generation". Nobody ever suffered but us? Aren't we the center of our own universe. I'm so glad that I am crazy...

With regards....Shoshanna Shafer

John McManamy said...

Hi, Shoshanna. I agree with your general points, but with some serious qualifications, namely:

1. Mental illness is endemic, in large part I believe because the world we live in can turn normal people crazy. Remove people from the craziness and there's a good chance they will become whole.

2. But, unfortunately, that's not practical. Also, many of us will stay broken.

3. The meds suck. Psychiatry is stupid to this fact, they have bought into the pharma hype, pharma is too stupid to come up with safe and effective meds.

4. Nevertheless, these meds do work for many people. If psychiatrists were a lot smarter and weren't so intent on over-medicating us, they would work for a lot more people, as well.

5. Rather than complain, the onus is on us to be our own advocates. This sucks, but welcome to the real world.

6. I too am sick to death of psychiatrists claiming we're noncompliant because we're addicted to our manias. That's absolute crap. We're noncompliant for the same reasons the general population is noncompliant with non-psych meds, plus the fact our meds suck.

7. Even if meds work, we still have to address a vast number of issues, from our own behavior to lifestyle. Meds don't get us well - that's our job.

8. There are way too many quack psychiatrists who are abusive. The quack you had to deal with should not be practicing medicine. You were exposed to psychiatric abuse, and I can appreciate how betrayed and violated you must feel.

9. Nevertheless, I encourage you to advocate for solutions. Our community is too full of individuals who do nothing but complain and point fingers and then turn on fellow patients.

10. Thus, if you believe in humane alternatives, campaign for them. Say, funding to set up rural facilities modeled on Gould Farm, laws banning seclusion and restraints, and on and on.

11. Unfortunately, the antipsychiatry movement is the greatest obstacle to change. These are people with serious personality and anger issues who are only interested in hearing themselves abuse other patients and family members. Check out Pat Riser's comments - he's the only one here who conforms to your definition of ridiculous.

I welcome your comments. Please keep posting.

Anonymous said...

Dear John...Thank you for your inciteful comments. I didn't think anyone would answer.

I would love to advocate...I'm not one of these people who enjoy whining. I done it for kids, before I brain sizzled. Just tell me where to start.

My wonderful therapist holds me accountable - no breaks from her. When I allowed my Psychiatrist to prescribe Cymbalta without a mood stabilizier, she was furious..".She said, "Shoshie, you know better than that....See him immediately and tell him what you need"!...

.What I didn't say was how complex this problem is. There are even good, caring psychiatrist who can't do their jobs properly because its not profitalble for high salaried doctors to see patients. They schedule every 3 month appointments and ship patients off to Therapist who are expendable. This happens all over Florida. How can a patient improve with this kind of care? We don't have choices, I pay a fortune in medical care and this Company is the only placed I am allowed to go.

Another point, there is a drugs out there that is relately cheap, starts working immediately, has few side effects, uptakes Dopamine on the spot, and are being currently studied at McLean University with excellent results. This drug is Temgesic, a non-agonist used now for opiod withdrawal. It has a low profile for increasing tolerance and not a difficult withdrawal. You think the DEA is going to allow this? The drug companies would have a can't make a profit on this...and as a highly educated former pill junkie, the truth is most opiods( I can only be certain about the level three varieties), taken orally usually take about 3 days to recover from withdrawal. I have been suffering from Cymbalta withdrawal for three weeks, and its much worse than any other opiod withdrawals I heard of. The Dea knows that there are scheduled drugs out there that are better choices, do you think there is any change of them coming available?

Cynbalta, Effexor, Paxil are probably some of the most popular drugs on the market and doctors, drug companies, sometimes even the internet doesn't mention the horrors of these drugs. They say these drugs are not addicting because you don't crave them. Sich people are forced to take these drugs which only make them sicker because they have no recourse.

Now PA's fresh out of school, nurse practioners, doctors who haven't read a medical article in years; all prescribe these drugs. I believe that the FDA has just OK'D Cymbalta as a pain releiver for Fibromenalgia.

Our mental health system is a disaster. Why half of the psychiatrist don't get sued and have their licenses suspended is beyound me. Our thriving drug companies have duped the public, possibly ended lives and certainly have made even more people crazy.

And yet countries with good 'Socialized' medical care still blow Mental Care. No where in the civilzed world is there compassionate care for mentally interesting.

Sincerely Shoshanna Shafer

Anonymous said...

Hi John,

I think Ms Shafer's comments bring up several good points that no one else seem to mention.

Does the Anitpychiatry movement have any real power? Does anyone really take them seriously?

If you really think about it aren't there most serious problem? Isn't it realistic to worry about the fact that if you have bipolar or any other mental problems it may be impossible to even get health care?

Also think about Big Pharma? They are making making a great deal of money out of Cymbalta. Doesn't it bother anyone that people who think this is a real pain killer maybe surprised when they can't get off of it.

What about the FDA? Or the DEA. The first one, 'approves', the second one 'meddles'. Do you think they exist for the benefit of humanity?

John McManamy said...

Hi, Suzy. I can address both yours and Shoshanna's comments here:

1. Our meds leave a lot to be desired, but it is possible to get decent outcomes with smart meds strategies.

2. For smart meds strategies to work, we need both educated patients and doctors who listen.

3. Unfortunately, we have way too many quack psychiatrists, whose tendency is to over-medicate.

4. Drug companies have a lot to answer for, first for not coming up with better meds, second for passing off old technology meds as "new and improved," third for duping psychiatry. Fortunately, their influence is waning very quickly.

5. Unfortunately, the blogosphere is over-run by antipsychiatrists who operate out of fear and ignorance. Naive patients and patients with bad meds experiences who take antipsychiatry at their word are seriously risking their health.

6. Antipsychiatry focuses on what is wrong. They do not focus on solutions. They are nihilists who do not believe in anything. Whining and complaining is not going to get us well. Being smart - in terms of seeking solutions for ourselves and our community (personal advocacy and public advocacy) - is our best shot.

7. So we have dumb psychiatry meeting dumb antipsychiatry, with tragic results. In places like CA, antipsychiatry is well-entrenched and funded by state agencies. They interfere with all kinds of reform. Unfortunately - and ironically - they are partners of established interests. If you are an agency or an organization with a vested interest in the status quo, you get consumer representative on your boards who have no ideas for change. Antipsychiatrists fit the bill.

8. We need the same access to psychiatric care as others have to medical care. Unfortunately, who wants access to crappy psychiatric care?

9. Meds care is only one piece in the equation. Psychiatrists are specialists in the one small piece. If we want to get well, it's our responsibility to assemble the other pieces. Blaming psychiatry for only focusing on meds is like blaming Starbucks for focusing on coffee.

10. The FDA regulates the sale of medicine, not the practice of medicine. Good psychiatrists regularly prescribe meds "off-label." A classic example is SSRI "antidepressants" for anxiety. These meds actually work better for anxiety than for depression. But the FDA only gives specific approvals after drug companies make the first move. Until that happened, there was no anxiety indication for SSRIs (now there is). That's the way it works. When the FDA approves a drug, we know what we are getting in terms of quality and benefit and safety and risk. This contrasts to "natural" remedies that are unregulated.

11. The DEA is a police agency, a whole different kettle of fish. Keep in mind, the vast majority of psychiatric meds are not recreational street drugs that people abuse or sell illegally.

12. This blog is about all of us helping each other gain insights into ourselves and the world about us. The smarter we are, the better chance we have. Welcome to Knowledge is Necessity, and keep posting.