The Year That Was - Almost Over, But Not Letting Go

This is the time of the year for looking back, a la Time Magazine and CNN. Following is the first installment in my personal (and highly idiosyncratic) view on how the year unfolded:

Historical Person of the Year: Genghis Khan.

It turned out my first piece of the year just happened to mention this much-maligned conqueror. His name came up in the context of traditional societies, where people have far less mental illness and recover far more quickly than those forced to cope with the demands of modern living. We can debate forever about the hows and whys until the cows come home. We did just that over the course of the year.

Nevertheless, Genghis Khan reminds us that even people living back in simpler times had cause to be stressed, which kept the discussion honest.

Later in the year, I devoted an entire piece to the man who made Alexander the Great look like a pussy. In his wake, things were never the same, which offered an excellent object lesson on thinking outside the box and paradigm change - my other major theme of 2010. Clearly, the prevailing biological psychiatry paradigm of mental illness is under threat - from its own shortcomings, from new advances in brain science, and from a growing consumer-led recovery movement. New explanations are needed.

Bottom line: In two different thematic approaches to rethinking mental illness, Genghis Khan was there.

Historical Person of the Year, Runner-Up: JFK

“We enjoy the comfort of opinion without the discomfort of thought,” our 35th President said in 1962. He could have been talking about today. Is Republicanism the New Stupid? I questioned in one blog. (Short answer: Yes, but that doesn’t mean Democrats are smart.) In numerous pieces, JFK served as the pin that punctured the fallacy that our choices are based on reason. Whether we are voting for a political candidate or buying a product or choosing a mate, new research is revealing that the thinking parts of the brain cannot make a decision without input from the primitive limbic regions. Our highly-evolved cortical areas, too often, seem to serve no other purpose than to rationalize our emotional reactions.

Kennedy had an undeniable emotional appeal, but of all things the televised 1960 Presidential debates reveal the man’s appeal to our higher reason. “What piece of work is man?” Some surprising answers are revealed by gazing into that distant mirror.

No doubt about it, Kennedy is there.

Fictional Person of the Year: Hamlet

I have of late - but wherefore I know not - lost all my mirth, forgone all custom of exercises; and indeed it goes so heavily with my disposition that this goodly frame, the earth seems to me a sterile promontory …

What is depression, anyway? Feeling sad? Lack of motivation? Psychic numbing? Is it a “normal” reaction to abnormal events or an abnormal reaction to normal events? A loss of energy or a mammalian need to hibernate? A crisis of the soul? Perhaps it’s even a part of our normal personality. Hamlet did a lot of talking, but scholars still debate the true shade of his “nightly colour.”

Obviously, no two depressions are alike, which makes one wonder why psychiatry treats them as if they were. No wonder we don’t get better. All year, on Knowledge is Necessity, we asked the type of questions that psychiatry needs to be asking. Hopefully, one of these years, psychiatry will begin to do some asking of its own.

In the meantime, Ham-o-let is there.

Fictional Work of the Year: The Draft DSM-5

As those of you who read this blog are aware, the DSM-IV bears little semblance to clinical reality. The DSM-5, which is due to come out in 2013, proudly continues in that tradition. In February, the American Psychiatric Association unveiled its draft, which amounted to (with the notable exception of personality disorders) a reissue of the DSM-III of 1980, replete nearly word-for-word with its antiquated and highly misleading symptom checklists.

This definition of depression, vintage 1980: “Depressed mood most of the day.”

Huh?

I could go on and on. For most of the year, I did. But who listens to me?
 
The DSM, the DSM, there's nothing like the DSM
It’s a text in medical shape
An illusion of authority
You may read it in a by-street
You may consult it in the square
But when we need an answer, the DSM’s not there!

Much more to come ...

Considering Ethnic Perspectives - Part II

In a recent blog piece, I reported on some of the things that came up at a one-day conference I attended on ethnic diversity in the older mental health community. The conference was put on by the Senior Mental Health Partnership, which is a program of NAMI San Diego. To continue ...

Martina Portillo RN, MPH, who is a member of the Hopi Tribe and has had a distinguished career in the Indian Health Service, reported that 57 percent of 3.3 million American Indians/Alaskan Natives now reside in urban areas. “This is a complete reversal since I was little,” Ms Portillo observed. Indians are moving to the cities for the same reasons the rest of us do - jobs and education.

Indian life expectancy, at 72.3 years, is about four years less than non-natives, a “complete improvement” according to Ms Portillo. Where the death rates are significantly higher: TB (750% higher), alcoholism (550% higher, but lower among older men than their counterparts among other races), diabetes (190% higher), unintentional injuries (150% higher), homicide (100%), and suicide (70%, very high in the young population but lower in elders than the general population).

Elders in the Indian population recall their culture being looked down upon as “bad”, with forced boarding schools, banned spiritual practices, and loss of land by the allotment system. Barriers to mental health include differences in cultural beliefs about mental illness, cultural labeling of different emotions, lack of mental health professionals in the system (101 per 100,000 compared to 173 per 100,000 in non-native populations, lack of large scale studies, and lack of cultural orientation for providers (such as in the healing traditions). Rarely do elders seek out available mental health services.

Shifting gears ...

A panel of presenters - Dixie Galapon PhD, Agnes Hajek MSW, and Emily Wu PsyD - from the Union of Pan Asian Communities (UPAC, which serves a vast range of Asian and Pacific Island communities in San Diego) reported that, among other things, Asian elders are confronted by a difference between how Asians and Americans view the elderly. The family matriarch, for instance, rather than enjoying an exalted seat of honor. may suddenly find herself a stranger in a strange land, even within her own family, especially if dealing with Americanized children and grandchildren.

Asian Americans whose families experience a high interpersonal conflict have a three-fold greater risk of attempting suicide compared to the general Asian population. This is true even among those who never had a history of depression. As the panel noted, this points to the strength of family values in Asian communities. Family harmony, they noted, is a value coming from Confucianist (stressing values) and Taoist (stressing balance) beliefs.

An intervention UPAC is working on includes “Problem Solving Treatment” aimed at older adults. Since depression is often caused by problems in life, the object is to help clients regain a sense of control and thereby improve their mood. For instance, people who are engaged in social activities at least two times a week have less depression than those not engaged.

Wrapping up ...

Look around you. Look within your family. The view is probably much different than it used to be. Lot of things to consider ...

On My Way Home

I'm at Oakland Airport, waiting to board my flight to San Diego. Friday morning, I picked up a rental car in San Diego, picked up a friend in LA, and drove up to Sonoma County in Northern CA for the Russian River Jazz and Blues Festival and an extended weekend in an RV camp in the hospitality of my friend Sherman and his posse.

To the left is the Tommy Castro Band blowing the roof off of this dump. Right is a great blue heron during a still quiet morning on the river.

They don't call these breaks from routine mental health breaks for no reason. Tomorrow, back to routine ...

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.

New Poll Results: Faith and Spirituality in Our Recovery

"How important is faith/spirituality in your recovery?" I asked readers here during the month of April.

Of the 200 of you who responded, nearly half (46 percent) rated "faith or belief in God" as a major part of your recovery. One in five (20 percent) regarded "spirituality" in the same light. In other words, a full two thirds of you (66 percent) regard your faith or spirituality as essential to your wellness. When we add another 12 percent who assigned a modest role to faith/spirituality, we are talking in terms of nearly eight in ten (78 percent).

Only 16 percent of you said faith/spirituality plays no role in your recovery while a mere handful of you (5 percent) thought faith/spirituality was an impediment to your recovery.

What to make of this? The two-thirds figure compares favorably to the eight in ten figure from an earlier poll result concerning the importance you assign to your meds. There is a crucial distinction, however: The faith/spirituality poll was framed in terms of RECOVERY while the meds poll was framed in relation to TREATMENT.

This distinction is crucial in regard to how we triangulate both these polls to yet an earlier poll that found only 14 percent of you reported that you were well. In light of that finding, I did not hesitate to suggest that your meds have let you down. Am I justified in coming to the same conclusion in terms of your faith and spirituality?

Not quite, no, definitely not. Treatment and recovery are like apples and oranges. In the treatment phase, our meds are doing all the heavy lifting, and we expect them to work. In the recovery phase, we know that relying on just one thing is not going to get the job done.

There have been a number of studies that convincingly demonstrate that people of faith recover more quickly from a variety of illness than their non-faith counterparts. But we're not talking knock-my-socks-off numbers. These are modest gains, precentage-wise, in the low single digits.

For our recovery to move forward, we need to incorporate our modest gains into other modest gains. The recovery literature is full of useful advice on reframing our thoughts, stress-reduction, improving our interpersonal skills, peer support, and working on smart lifestyle choices. Lately, mindfulness has been enjoying flavor-of-the month status.

It's a crowded field. We have a lot to choose from. So here's the significance of this month's poll result as I see it: Notwithstanding all the choices in our recovery we have, not withstanding all the attention commentators have devoted to these other choices, a full two-thirds of you assigned major importance to faith/spirituality.

Clearly, the people who are working with us in our recovery need to know this.

Why is faith/spirituality so vital to you? I'm guessing here, but I think it may have a lot to do with how well belief in something greater than ourselves blends with and enhances the benefits of our other recovery tools. Thus, maybe you pray to God to get you through the last phase of a strenuous physical workout. Conversely, maybe when you practice mindfulness you become aware of a higher presence, which in turn motivates you to get through the day. On and on it goes.

Finally, for most of us, faith and spirituality is a no-brainer. We've grown up with it. We're comfortable with it. So, when we finally start thinking about our own recovery, we are not contending with learning a new skill that may not be a good fit for us. Faith and spirituality is something we can incorporate into our recovery right now, with positive benefits. An overwhelming number of you - eight in ten - have told me you've already done that.

Environment Matters

Late afternoon, San Diego: I step out of the airport terminal into brilliant surfer dude weather. I strip off my sweater and jacket, but even with a tee shirt and jeans I feel way overdressed. This is definitely shorts and flip-flop weather.

San Diego was unseasonably brisk when I left for a health journalists conference in Seattle five days before. The bracing Seattle spring - with some actual sunshine - was just my style, and I was very impressed by the parts of Seattle I saw, but I know I could never live there.

Way back in the mid-70s, I lived for a year in Vancouver BC. Beautiful city, lovely people. But the whole time I was there we had maybe 20 days where the sun made an appearance. Back in those days, people didn't know what seasonal depression was. I never knew what hit me. Now that I do, I would never expose myself to that situation again.

I collect my car, and an hour later I'm 3,500 feet up in the mountains in an environment that has nurtured and healed me the last 28 months. (The picture you see is typical of the views I get when I take my daily walks.) Generally, our surroundings get thrust upon us. I found mine serendipitously after my marriage broke up in late 2006.

I know the climate of the Pacific Northwest is a tonic for a good many people, and there are days here where I wish I could import some of that in short bursts. SImilarly, anytime I'm in New York, I feel I have been re-equipped with fresh batteries. Never underestimate your environment. The right job with the right income in the right relationship in the right neighborhood in the wrong part of the world for your particular psyche may be a disaster for you.

Me, I'm staying put.

On a similar note: My Seattle trip was my first air travel in nearly a year. I may have moved to a nurturing environment, but I nearly blew it in 2007 by going on the road 11 times, including four cross-country trips. By late summer I was showing clear signs of brain fatigue and by the end of the year I was running on fumes.

In 2008, I cut my road trips to one, not counting going to New Zealand to attend my daughter's wedding. For the first part of that year, I also pretty much stayed put on "my mountain," keeping my local and regional travel to a bare minimum, with a reduced work and social schedule.

I'm pretty much back up to full strength, but I would be crazy to go back to my 2007 killer routine. There's a conference coming up in San Francisco next month and another one in Pittsburgh in June. I will have to think very carefully about what else I want to include on my schedule. There are many things I want to do, but my brain clearly has limits.

Environment matters. Know thyself. Live well ...

Waterfall!

I could write a thousand words on how moving to southern California from New Jersey two and a bit years ago dramatically improved my mental health, but this short video will actually show you.

Today, I drove two miles to the entrance of a state park and trekked a short distance in. It had been a rainy week, which meant a special treat - waterfall!

In the summer it will be gone, but then I will have different sites and sights to savor. Enjoy ...

We All Have a Dream

I have a dream ...

So does fellow mental health blogger Therese Borchard. Last year, on Martin Luther King day, she served notice that:

"I have a dream that one day I won't hold my breath every time I tell a person that I suffer from bipolar disorder, that I won't feel shameful in confessing my mental illness."

You might say we missed the civil rights bus. Ignorance, fear, stigma, discrimination - it's still out there. And every year, our society harvests a strange fruit:

"I have a dream that suicide won't take more lives than traffic accidents, lung disease, or AIDS, that together we can do better to reduce the 30,000 suicides that happen annually in the United States, and that communities will lovingly embrace those friends and families of persons who ran out of hope, instead of simply ignoring the tragedy or attaching fault where none should be."

A lynch mob of indifference. A broken healthcare system, pathetically little devoted to research, a society that turns its head the other way. We're on our own, facing the new day with unreliable brains, living in dread of the failed boot-up:

"Mostly, I dream about a day when I can wake up and think about coffee first thing in the morning, rather than my mood - is it a serene one, a panicked one, or somewhere in between? - and fretting about whether or not I'm heading toward the black hole of despair. I dream that I'll never ever have to go back to that harrowing and lonely place of a year ago. That no one else should have to either. But if they do (or if I do), that they not give up hope. Because eventually their tomorrow will be better than their today. And they will be able to dream again too."

A dream that we can dream. Against all odds, we are still standing. You, me, Therese. Think of your worst moments. Those dark days, when a dream that you could dream was all that kept you going.

A dream that we can dream. Our population, more than anyone, knows the power of a dream.

"We have some difficult days ahead of us," Dr Martin Luther King told a gathering in Memphis. "But it really doesn't matter with me now, because I have been to the mountain top ... and I've seen the Promised Land."

It was as if he knew what was coming next. The next day, a bullet raised him into Heaven.

I, too, have a dream. I dream a Martin Luther King will emerge from our ranks. He or she will unite us, lead us, shame society, break down barriers. We may not get to the Promised Land in our lifetimes, but he or she will get to the mountain top, give us a vision of the Promised Land.

And our children and our children's children will give thanks.