mental illness issues

Stopping Self-Harm Urges Using Dialectical Behavior Therapy (DBT)

→ February 1, 2012 - 25 Comments

Stopping Self-Harm Urges Using Dialectical Behavior Therapy (DBT)

If you feel you may harm yourself, get help now.

I talked about dialectical behavior therapy (DBT) in the last post. Dialectical behavior therapy is designed to work specifically with borderline personality disorder and part of this disorder is often self-harm so DBT uses specific techniques to try to stop self-harm urges and prevent self-harm.

What is Self-Harm?

Self-Injury and Cutting

Image provided by Wikipedia, author: Hendrike

Self-harm is a huge problem for many people. It is typically a sign of borderline personality disorder (BPD) but it can occur with any disorder (or no diagnosis at all). Self-harm, also known as self-mutilation or self-injury, can be any form of self-abuse including cutting, burning, hitting and statistics often include those with eating disorders as well. Millions of people in the US practice some form of self-harm.

Self-harm is often practiced by teens and is more common in women than in men, but make no mistake about it, many adults self-harm and men do as well. It is a behavior to be taken seriously. Here are some techniques to stop self-harm urges.

Dialectical Behavior Therapy (DBT) and Self-Harm

A lot of DBT techniques are built on scientific principles. The idea is to work to change your own neurochemistry or autonomic nervous system in a crisis. This sounds complicated, but really it isn’t; the techniques are quite simple.

Dialectical behavior therapy uses many acronyms to help people remember techniques and this one is T.I.P. – Temperature, Intense exercise, Progressive relaxation.

Self-Harm Avoidance Techniques

T – Change your body temperature to change your autonomic nervous system (the part of your body that handles unconscious functions like breathing and heart rate)

  • Take advantage of your dive reflex, seen when you dive into cold water. Hold your breath and submerge your face into ice water or hold cold packs up to your face. It’s important that you get the eye socket area and under the eye cold.
  • Warm your body to relax. Soak in a warm bath or put your feet in hot water.

IIntensely exercise to calm down a body revved up by stress and emotions.

  • Engage in intense exercise even if only for a short time
  • Expend your body’s pent up energy and strength by running, walking fast, walking up stairs, playing basketball, weightlifting, etc.

PProgressively relax your muscles. (There are many relaxation and meditation techniques that work to do this.)

  • Starting with your hands and moving to your forearms, upper arms, shoulders, neck, forehead, eyes, cheeks and lips, tongue and teeth, chest, upper back, stomach, buttocks, thighs, calves, ankles and feet – tense for 10 seconds the relax each muscle and move onto the next.

Putting Self-Harm Avoidance Techniques into Practice

Only you can stop your own self-harm. You have to trust that some of these techniques are going to work for you but you have to actually do them for them to work. You have to want to stop your self-harm. You have to reach out to others. You have to get help. You can stop self-harming, but you have to do the work to make it happen.

Note: TIP self-harm avoidance techniques provided by local DBT practitioners.

Nominate a Superior Mental Health Advocate for $10,000

→ January 27, 2012 - Comments off

The National Council is an organization I recently become involved with as they have asked me to speak at their conference in Chicago this April.

The National Council

In their words, this organization,

… is the unifying voice of America’s behavioral health organizations. Together with our 1,950 member organizations, we serve our nation’s most vulnerable citizens — more than 6 million adults and children with mental illnesses and addiction disorders. We are committed to providing comprehensive, quality care that affords every opportunity for recovery and inclusion in all aspects of community life.

The National Council advocates for public policies in mental and behavioral health that ensure that people who are ill can access comprehensive healthcare services. And we offer state-of-the-science education and practice improvement resources so that services are efficient and effective.

Reintegration Awards by the National CouncilFrom what I can tell, this organization believes in community care over hospitalization, advocates for people with a mental illness and are just one quality organization.

And they’re giving away $10,000.

Amazing right? Well, I sure think so.

The Reintegration Awards

The awards are known as the Reintegration Awards and there are nine categories. The Reintegration awards have, for 15 years,

… celebrated the achievements of those in the community who dedicate themselves to improving the lives of individuals with serious mental illnesses, and the achievements of those living with schizophrenia or bipolar disorder who battle tremendous odds to improve their own lives and the lives of their peers.

And, as fun as it would be, the $10,000 is actually granted to an organization of the individual’s choice, and not the individual themselves. Most of us, though, would be thrilled to give a $10,000 cheque to a deserving organization.

So, please nominate a spectacular mental health advocate or worker here. People who work hard for us deserve our support. And act fast because nominations close on the 31st of January.

Learn more about The National Council’s initiative here.

Why are People Antipsychiatry? Part 3/3

→ January 24, 2012 - 98 Comments

So, I’ve talked about what antipsychiatry is and the history of antipsychiatry a little, and in this third and final part in the series I look at why people are antipsychiatry.

Now, I understand that this is a theory and will only be true for a percentage of people. And I understand that no matter what I say, I will have a deluge of people disagreeing with me.

Nevertheless, I write:

Antipsychiatrists are Scared

Antipsychiatrists are scared of psychiatry, scared of what psychiatry does and scared of mental illness in general. I understand. These are scary things. I’m pretty sure I’m scared of all of them too but rationally, I live with them all.

Psychiatry is Powerful and Scary

Antipsychiatrists Are Angry from FearThere is no arguing that psychiatry is powerful. Doctors of all types are powerful but some might argue that psychiatrists are even more so as they have the right/duty of treating people without consent in very limited circumstances. (And, of course, any doctor can have a person held or treated without consent, not just a psychiatrist, but psychiatrists are likely the ones making the call.)

Moreover, a psychiatrist’s primary function is to treat serious mental illness and they primarily do this with drugs. Very powerful drugs. They’re not as powerful as, say, oncology (cancer) or HIV/AIDS medication, but they are powerful nonetheless.

So when I think of a person who has the power to wield these drugs and lock me up against my will, I can quite reasonably be scared of that person. I have been scared of that person. For many years I was scared that a doctor was going to throw me into a psych ward against my will.

However, no psychiatrist ever has or has even discussed it. And as one person who has had the experience said, “There’s no reason to be afraid of involuntary treatment.”

Our Past Makes us Scared of the Present

I understand fear based on the past. It’s something we all have in a variety of areas of our lives. Our experiences are how we learn. Our past tries to tell us how to avoid pain in the future. It may not do the best job of it, however.

And as the saying goes, once bitten, twice shy. If psychiatry has bitten you, you are likely going to be shy, scared, of it in the future. In my case I had a very bad experience when my vagus nerve stimulator (VNS) was turned on (doctor error) which resulted in immediate agony and terror; and yes, I have been scared of getting it adjusted ever since. Not scared enough not to do it, but certainly scared enough to have a butterfly farm in my stomach when it has to be done.

Mental Illness is Scary

And as is obvious to anyone who has a mental illness – mental illness is scary. It’s terrifying to have a brain that doesn’t work. It’s terrifying to have delusions and hallucinations. It’s terrifying thinking of the pain of depression or bipolar disorder.

Fear and Antipsychiatry – Fear is Easy

So it’s much easier to deny and decry what we fear than it is to face it head-on. It’s easier for me to rile against the evils of VNS than it is for me to simply say that it didn’t work for me, it caused me pain, but other people have had other, more positive experiences.

[push]It’s easier to believe that my experience is the only experience and that everyone should change based on that no matter whether I am the exception to the rule.[/push]

It’s easier to avoid psychiatry than accept the fact that one day one psychiatrist may decide I need involuntary treatment.  It’s easier to scream and holler against an evil conspiracy than simply to admit that sometimes Bad Things Happen to Good People and sometimes that person is me.

It’s always easier to act out of fear and anger than it is to stand up and deal with the complex intricacies of life-altering, stressful, painful decisions of treatment.

Hate and Anger Stem From Fear

So when it comes down to people who hate me, I get it. They fear what I represent. This comes out as anger and hate. No problem. It’s pretty natural.

But I don’t let fear rule my world. I don’t let the fear of becoming the exception stop me from trying to become the rule. And the rule is most people get better with treatment. The exceptions are bad. The exceptions are worth noting. The exceptions are worth keeping in mind. But it’s the rule on which I base my thoughts. It’s rationale and it’s hope on which I base my thoughts. And that’s just the kind of person I want to be.

What’s the Worst Mental Illness?

→ January 17, 2012 - 49 Comments

What’s the Worst Mental Illness?

I, as a good little webmistress, keep an eye on my web analytics. So yes, I know some things about my audience, and one of the things I know is what people are searching for when they find me. This sometimes influences what I write about, like today: What is the worst mental illness?

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Antipsychiatry History – How Did We End Up With Antipsychiatry?

→ January 15, 2012 - 32 Comments

Last week I discussed the antipsychiatry movement in general, including some of their critiques of psychiatry – in this piece I will look at why antipsychiatry exists at all. After all, there doesn’t seem to be an anti-cardiology or anti-oncology group – what makes psychiatry so special?

Again, Henry A. Nasrallah, MD’s article: The antipsychiatry movement: Who and why nicely encapsulates this topic, but for those of you wondering about the history of antipsychiatry, here goes.

History of Antipsychiatry – the 1960s

As I mentioned in my last article, I think historical critiques of psychiatry are next to useless as they simply show our lack of understanding and knowledge at the time and bear little resemblance to the issues psychiatry and psychiatric patients are dealing with today. Nevertheless, if you want to know where antipsychiatry came from, you have to look back.

Antipsychiatry and David Cooper

The term “antipsychiatry” was coined in 1967 (although the movement had been around a long time by then) by psychiatrist David Cooper who seems to me is no one to hold up an entire movement. Among other things, 

Cooper believed that madness and psychosis are the manifestation of a disparity between one’s own ‘true’ identity and our social identity (the identity others give us and we internalise). Cooper’s ultimate solution was through revolution.

And, my favorite, a quote from his writing in 1980,

Madness is permanent revolution in the life of a person…a deconstitution of oneself with the implicit promise of return to a more fully realized world.

Ah, so madness is good then. Tell that to everyone who’s been through a psychotic episode.

Antipsychiatry, Foucault and Szasz

How did antipsychiatry come to be?At this time, Foucault, one of the seed-sowers of antipsychiatry seemed to like the idea of prescribing, “travel, rest, walking, retirement and generally engaging with nature” as a treatment.

Psychiatrist Thomas Szasz was a big part of the creation of antipsychiatry too although he decried the moniker and its adherents, instead, collaborating with the Church of Scientology to create the Citizen’s Commission on Human Rights in 1969. (I know that sounds like a good thing but all you have to do is wander around on their website for about 3 minutes to see why it’s not. They’re one of the most hate-spreading, propaganda-promoting groups I’ve ever seen.)

I suspect this is why many people right off all antipsychiatry groups as merely Scientologists (but they’re not).

According to Wikipedia:

It was later noted that the view that insanity was not in most or even in any instances a “medical” entity, but a moral issue, was also held by Christian Scientists and certain Protestant fundamentalists, as well as Szasz.

(And if someone were to tell me that my mental illness was because of my morals, well, it wouldn’t be pretty. My morals are fine, thanks.)

Also around this time:

  • The idea that psychiatry is just an agent of social control began becoming popular.
  • Psychiatry from the 1900s, 1930s and other eras was criticised (and rightfully so).
  • Psychiatry was tied to the Nazis and the holocaust.
  • One Flew over the Cuckoo’s Nest was also written and became a best-seller.

The History of Antipsychiatry – the 1970s

The “psychiatry survivors” began entering the antipsychiatry movement. These are people who claimed past abuses of psychiatry. (I rather despise the name, personally, because, of course, it makes it sound like psychiatry is something you “survive” rather than simply a medical specialty. It’s particularly insulting to me and those in psychiatry, I feel.) Of course, some of these people had, and have, genuine complaints about how psychiatry treated them, particularly before the proliferation of psychiatric medication when few options (pretty much all bad ones) were available.

Some would claim that antipsychiatry worked to successfully remove references to homosexuality as a mental illness, but I would suggest that the gay rights movement really lays claim to that particular gain.

Antipsychiatry Today

Today, antipsychiatry argues against the biomedical model of psychiatry (as it always has) and it decries the ties to the pharmaceutical industry (once much worse than it is today). They also fight the idea of psychiatric diagnoses altogether and the Diagnostic and Statistical Manual of Mental Disorders (the DSM) in particular.

Antipsychiatry is still marginalized within psychiatry and within the mental illness community at large. Although an exception to this seems to be online where antipsychiatry people and ideals are absolutely everywhere.

Thoughts on the Antipsychiatry History

Antipsychiatry Balances PsychiatryThere is no doubt that there are things to fight against in psychiatry. I do it. Other people do it. It’s pretty common. A good example is the DSM-V discussions which hotly debate all sorts of mental illness topics.

I just don’t agree with most of what antipsychiatry fights. Their raison d’être seems to be getting people off medication en masse, and that’s something I could never support. Antipsychiatry started at a time (pre-1960s) where conditions for the treatment of the mentally ill were deplorable and inhuman and wrong but they have continued into times when that’s just not the case. If anything people need more access to psychiatry, not less.

Antipsychiatry Benefits

While I’m hard-pressed to argue for antipsychiatry I will say that antipsychiatry provides checks and balances to a very powerful system. I feel these checks and balances could be better handled, but nevertheless, they are of benefit. While I don’t think psychiatrists should have to defend their profession in general (as with any other doctor) it may be helpful for them to cast a critical eye over what they do as what they do is very important and affects people greatly.

In short, naysayers (on this blog as well) force us to look at ourselves which can be seen as a benefit, but you really have to want to see it.

Next time: Why Does Antipsychiatry Exist – Beyond the History

Antipsychiatry – What, Who and Why? Part 1

→ January 9, 2012 - 24 Comments

Antipsychiatry. Yes, I’m against it. I’m what you might call anti-antipsychiatry; if that didn’t sound just so darn silly.

But in saying that, perhaps we should take a greater look at antipsychiatry and what the possible benefits are of such a group (other than giving me writing fodder, naturally).

Do I Know what Antipsychiatry is?

People have accused me of not understanding antipsychiatry. Well, if you say so, but:

  1. The answer’s kind of in the question
  2. Far too many people identify as such for there to be any one definition

Luckily for me, Henry A. Nasrallah, MD put out an article: The antipsychiatry movement: Who and why. He expresses many of my thoughts on the group very nicely. He responds to their criticisms and admits that they can be seen as a useful force in psychiatry.

What is Antipsychiatry?

For those of you who don’t know, the term “antipsychiatry” is one given to a group of people who are, well, anti-psychiatry. Some would consider these people skeptics and questioners and not necessarily antagonistic, per se, while others consider this group a bunch of radical zealots that harm people with a mental illness. Any given antipsychiatrist will naturally fall somewhere within that continuum. And, as I’ve said, there is no single definition as many groups have taken this word as a label.

What are their Criticisms of Psychiatry?

Common to antipsychiatry though is the critical claims of the movement, such as, historically (as outlined by Dr. Nasrallah):

  • Locking people up and “abusing” the mentally ill (abuse is an arguable issue)
  • Medicalizing madness (contradicting the archaic notion that psychosis is a type of behavior, not an illness)
  • Drastic measures to control severe mental illness in the pre-pharmacotherapy era, including excessive use of electroconvulsive therapy (ECT), performing lobotomies, or resecting various body parts
  • Use of physical and/or chemical restraints for violent or actively suicidal patients
  • Labeling slaves’ healthy desire to escape from their masters in the 19th century as an illness (“drapetomania”)
  • Regarding psychoanalysis as unscientific and even harmful
  • Labeling homosexuality as a mental disorder until American Psychiatric Association members voted it out of DSM-II in 1973

And more recently:

  • Serious or intolerable side effects of some antipsychotic medications
  • The arbitrariness of psychiatric diagnoses based on committee-consensus criteria rather than valid and objective scientific evidence and the lack of biomarkers (this is a legitimate complaint but many physiological tests are being developed)
  • Psychoactive drugs allegedly are used to control children (antipsychiatry tends to minimize the existence of serious mental illness among children, although childhood physical diseases are readily accepted)
  • Psychiatry is a pseudoscience that pathologizes normal variations of human behaviors, thoughts, or emotions
  • Psychiatrists are complicit with drug companies and employ drugs of dubious efficacy (eg, antidepressants) or safety (eg, antipsychotics).

Each of these claims has merit, although many of the claims are exaggerated.

Historical Antipsychiatry Claims

Antipsychiatry CriticismsI really think historical claims are quite pointless. Did psychiatry make mistakes? Yes. Did they make big ones? Yes.

So did every medical specialty. We don’t judge surgeons because surgeries were once done without anesthetic because that was due to our medical understanding at the time. Psychiatry, and what we now consider atrocities, is like that – history that speaks to our lack of knowledge and understanding at the time. Now that we know better, we do better.

Current Antipsychiatry Claims

That still leaves many of the criticisms against today’s practice of psychiatry. I recommend you read Dr. Nasrallah’s whole article for his view, but I’ll look at a three.

Serious or Intolerable Side Effects of some Antipsychotic Medications

This is a valid criticism – that can be made of almost any drug on the market. There are people that take a pharmaceutical and get many side effects and there are people who take a drug and have none. Are antipsychotics particularly side effect laden? Well, not compared to, say, chemotherapy but yes compared to, say, the birth control pill. But the birth control pill has been known to kill people thanks to blood clots so nothing’s perfect.

Myself, I find the great majority of antipsychotics to be intolerable so I employ the extremely radical solution of not taking them. But that’s me.

Use of Physical and/or Chemical Restraints for Violent or Actively Suicidal Patients

This is a reasonable concern, to be sure. I would never want to be restrained either chemically or physically, but then I’ve never actively been a danger to anyone.

While, of course, that vast majority of us will never be in that position, what is one to do with a person who is violently out of control if not restrain them in some way? Doctors and nurses can’t run away from the danger – they must do something about it. And so what to do other than restrain? It’s unpleasant. It’s unfortunate. I wish it would never happen. But it’s an extraordinary measure for an extraordinary circumstance.

Psychiatry is a Pseudoscience that Pathologizes Normal Variations of Human Behaviours, Thoughts or Emotions

This one gets me every time. There is no doubt that people can meet some vague criteria for a mental illness and still be happy, functioning individuals.

However, this is not the issue because in every mental illness diagnosis there is a line that says that in order to be diagnosed with the illness the symptoms must cause great distress in the person’s life. Great distress. Not a bit unpleasant. Not make them quirky. But great distress. If you can manage to meet the criteria for depression and not be distressed by it, then I guess you’re not distressed – you just like being unhappy. Well goodie for you. Most of us don’t feel that way.

In the next article I’ll take a look at why antipsychiatry exists and the movement’s possible benefits.

In article three I talk about why some people gravitate towards antipsychiatry.

Top 10 Bipolar Burble Posts of 2011

→ January 2, 2012 - 6 Comments

Best Bipolar Burble ArticlesLast year was a great one here at the Bipolar Burble and saw a dramatic rise in audience numbers, so welcome readers, new and old. This means that debates were fast and sometimes fierce here on the Burble, and mostly, that’s OK with me. Although it did require the invocation of commenting rules, it also meant that more people had their say on mental illness topics.

So, without further ago, here is the top 10 list of articles people read in 2011:

  1. Worst Things to Say to a Person with a Mental Illness – number one with a bullet two years running is this piece which is a continuation of a piece I wrote on Breaking Bipolar. Everyone, it seems, wants to know what not to say to a person with a mental illness.
  2. Bipolar Disorder Type I: Mania and Delusions of Grandeur – this piece was written at the behest of a reader and includes readers’ experiences of delusions of grandeur during bipolar manic episodes.  This is a topic not widely deal with elsewhere.
  3. Doctors Should Treat the Mentally Ill Without Consent – this highly commented-on and contentious article outlines why I think it’s reasonable to treat the mentally ill without consent in some situations. In spite of all the controversy, I still consider this position reasonable.
  4. Self-Diagnosing Hypomania – I had no idea this article would be so popular, but people are looking for this information. This piece is about how to see hypomania coming or to know once it’s already here.
  5. Suicide Self-Assessment Scale – How Suicidal Are You? – again, I didn’t realize how many people were looking for this information. However, this article is designed to point out warning signs and track one’s own suicidal feelings. It can be hard to tell how severe suicidal feelings are and this scale is designed to help.
  6. How to Get Off Antidepressants Effexor/Pristiq (Venlafaxine/Desvenlafaxine) – this is an update to an article I had written a couple of years earlier and is a huge source of Google hits. I hate to make blanket statements about antidepressants, but it really seems like venlafaxine and desvenlafaxine (Effexor and Prisiq) are bitches to get all for almost everyone.
  7. Depression, Bipolar – Feeling Along with a Mental Illness – this is a feeling that I, and I think everyone with a mental illness, has had. This piece addresses the idea that those with a mental illness are “alone” or are “freaks.”
  8. Psychiatric Myths Dispelled by Doctor – Fighting Antipsychiatry – this is one of the most controversial posts here on the Burble due to the seeming war between those who consider themselves antipsychiatry and those who don’t. This piece earned the most comments, with almost 100 pieces of feedback on this article.
  9. Depression and Lack of Want, Desire – unfortunately, may people with depression experience anhedonia – the innability to feel pleasure. This tends to lead to a lack of want for anything. It’s a devastating condition that I have battled for years.
  10. Bipolar Terminology – The Difference Between Bipolar 1 and 2 – finally, at the number 10 spot we have a piece I wrote not long ago about the difference between bipolar I and bipolar II. This answers one of the basic questions people ask about bipolar disorder every day.

As I’ve said, I consider 2011 to have been a break-out year for the Bipolar Burble and I thank you all for being a part of it.

And don’t forget, if you have questions or if there are subjects you would like addressed here at the Burble, you are welcome to contact me anytime or leave a comment. I am at your service.

Laura’s Law – Assisted Outpatient Treatment – Follow-Up

→ December 28, 2011 - 38 Comments

Well now, that was quite the number of impassioned comments. I did realize that by writing about Laura’s Law (Assisted Outpatient Treatment) there would be some contention, but I didn’t realize quite how much. Thanks to everyone who wrote in well clear, thoughtful comments. (For those whose comments weren’t of that ilk, please review the comment policy here at the Bipolar Burble.)

Due to the number of responses, I have been unable to address them each individually, but I would like to point a few things out in general.

Misperceptions of Laura’s Law (Assisted Outpatient Treatment)

To be clear, and this is something most people seemed to miss in the first article, Assisted Outpatient Treatment (AOT) in California and other states cannot force medication. While medication may be part of a treatment plan, medication cannot be given without consent without going through the normal court procedures already in place. I don’t know how frequently this is done but it seems infrequent.

“Laura’s Law,” “Kendra’s Law” vs. Assisted Outpatient Treatment

Assisted Outpatient Treatment Issues

As one person astutely pointed out, it is emotionally charged to give the law the name of a previous victim. I’m sorry to add to this as I know it’s political in nature but unfortunately people won’t necessarily know what I’m talking about if I don’t use those names.

Studies on Assisted Outpatient Treatment

Additionally, there was much disagreement on the numbers I cited regarding Assisted Outpatient Treatment. To be clear, some of those numbers come from New York where “Kendra’s Law” is in place and has been for longer (and thus has been more studied).

Numbers from California are based on a tiny population (as it turns out) and thus are of low quality.

Randomized Controlled Studies of Assisted Outpatient Treatment

A reader commented on how studies have rarely used randomized controlled samples when reviewing the Assisted Outpatient Treatment programs. This is a fair statement, but I have an issue with this concept of a randomized controlled sample in this group. How would this be possible? If a person qualifies for the AOT program, how could you include them in a study and not put them in a program? Does it not go against ethical standards to offer no treatment to a person who needs it? In short, I’m just not sure it’s possible. People who are selected for the AOT program are always going to be different than those who are not selected by very definition of the program.

An Example of One Such Study

One reader did point to a study that attempted to use randomized controlled samples to evaluate AOT-type programs in the US. While they did come up with some interesting conclusions, there are problems with their data.

What this review found is that there was no difference in those in an AOT vs. those who were not on the following measures:

  • Readmission to hospital by 11-12 months
  • Compliance with medications by 11-12 months
  • Arrest by 11-12 months

They did find that those in AOT significantly had fewer:

  • Arrests for violence by 11-12 months
  • Homelessness
  • Victimization by 11-12 months

Those look like pretty big wins to me.

However, there was a significant increase in those in AOT programs who perceived coercion in care.

However, as I said, there are issues with this data:

  • Data quality is considered “low” by study authors
  • Data does not include those with a history of violence (For some reason the studies excluded these people. I suspect their inclusion would change the numbers substantially.)

And by excluding those with a violent history, you’re actually excluding most of the people who would even be affected by Laura’s Law (Assisted Outpatient Treatment in California).

Check out more resources on Laura’s Law questions and answers.

Question for Those Who Are Anti-Assisted Outpatient Treatment

So, a question for all those who wrote in an said that Assisted Outpatient Treatment was horrible.

If I were to take a person who would fall under the qualifications for Laura’s Law:

  • The person has a serious mental illness
  • The person refuses treatment
  • The person has a history of violence
  • The person has been in jail twice in 3 years

What would you have the system do with this person? What is the right thing to do? Someone please suggest something other than outpatient/inpatient treatment or incarceration that would work. Because what I’m seeing is a person in desperate need of help and who are we if we do not offer any?

Laura’s Law – Forced Treatment, Saved Lives

→ December 19, 2011 - 71 Comments

Laura’s Law – Forced Treatment, Saved Lives

Some of you may have heard of Laura’s Law in California or Kendra’s Law (similar) in New York. These laws, and similar laws across 42 states, allow for court-ordered treatment of mental illness as a condition of community living.

In other words, they strong-arm people into treatment and this could be seen as treatment without consent. (It’s hard to argue consent when your ability to live outside a locked facility is in jeopardy.)

And this is a very good thing. It is saving lives (among other things).

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Drug Trials, Antidepressants and Placebo Effect – Is it Bad?

→ December 12, 2011 - 6 Comments

When drug trials are conducted, the gold standard (and requirement for FDA approval) is a double-blind placebo-controlled study. In this kind of drug study participants are randomly assigned to receive either the medication or an inert (does nothing) pill known as a placebo. Neither the doctor not the patient knows whether they are getting the placebo or the real drug.

The study then compares what happens to those who received the real drug versus those who received the placebo and determines the efficacy of the real drug.

The Placebo Effect

This is critical because of something known as the “placebo effect.” The placebo effect is this odd scenario where people get better just because you give them a pill, even if the pill does nothing. Doctors and scientists don’t understand the placebo effect but not only will people get better on a placebo, but they will even experience side effects – something that isn’t possible given that the placebo is inert. But the brain is a powerful thing and something we don’t fully understand.

Treatment vs. No Treatment OutcomesAnd one of the problems with antidepressants (and many medications) is that sometimes they aren’t better than the placebo. Additionally, sometimes when they are better than the placebo, it’s only by a small margin. Drug companies have to prove that their drug is statistically significantly better than a placebo in order to get FDA approval but even this statistically significant amount can be very small.

However, this isn’t a piece about how effective are when antidepressants are compared to placebos. This is a piece about how effective antidepressants are compared to no treatment.

Depression Treatment vs. No Treatment

Now, each disorder would have to be studied individually, but basically the question is, if you put treatment vs. placebo vs. no treatment, what would happen? ^

I can tell you what would happen – the people who received no treatment would do worse than those who received a placebo.

To the best of my knowledge there is no exact study like this, likely because it wouldn’t make it past an ethics board. If you determine a person is ill and needs treatment it is unethical to offer them none.

There is, however, a comparison of treatment vs. no treatment that I’m aware of. Here, they study people who have received treatment vs. those who have not. (They break down those who have not into three additional groups: those that don’t think they need treatment, those who think they need treatment but don’t get it, and those that don’t need treatment.) Note that “treatment” isn’t specified so it could be of any kind.

What they find for depression is that those who receive treatment go from around 30 to 24 on a depression scale in one year and those that need treatment but don’t get it go from about a 27 to 23 in one year (in both cases a higher number indicates greater depression).

So, treatment moves them 6 points and no treatment moves them 4 points. Approximately.*

No Big Deal?

Well, it depends if you’re the one depressed.

Firstly, it’s important to note that those in treatment were more depressed than those who weren’t. This should be noted as those people would likely have worse outcomes in one year. (The study wasn’t designed to take this into account but does note that symptom severity at outset is the biggest predictor of poor outcomes.)

Secondly, it’s worth noting that 2 points on a 35-point scale can lead to a significantly greater quality-of-life for the person in general. Many people with treatment-resistant depression I know would kill for that kind of improvement.

Thirdly, this improvement marker isn’t the only relevant one; it’s just the only one I have to go on.

Numbers on the kind of improvement seen in treatment versus no treatment vary, but everyone agrees that no treatment is worse. (The above estimate is rather conservative.)

What, No Placebo?

Unfortunately, no. There is no placebo in this study. Sorry.

But as we do know that people on a placebo do almost as well, and sometimes better, than those on the drug, we can guess (yes, guess; again, sorry) that people on a placebo would land somewhere in between the two above outcomes.

Question: How Do We Improve Outcomes without Giving a Placebo?

So the question is, if people on a placebo do better than no treatment (but not as well as those treated) then is there a way to preserve that gain? Doctors can’t prescribe placebos, it’s unethical.

Or is the placebo effect when being given an antidepressant such a bad thing? If, really, you respond to a real medication because of the placebo effect (and you wouldn’t know the difference, no one would) is that really all that bad? Does that not have a value?

People decry the placebo effect saying it proves that antidepressants are worthless. But I say how would all those people benefiting from them, even from the placebo effect, get better without them?

^ See the comment Placebo Effect in Depression as well. 

 * In case you were wondering, people who were depressed but didn’t think they had a problem were less depressed than those that perceived a need for treatment; however, they only moved down the scale from about 18 to 16 in one year.


Personal Story of Medication Noncompliance

→ December 7, 2011 - 27 Comments

It is politically incorrect to say medication “noncompliance.” I suppose this is because it gives the idea that the person taking medication is “complying” to some authority figure and not consciously making the decision on their own.

I get that. But whether you call it medication noncompliance or medication non-adherence, the result is the same – the person is not taking their medications as prescribed by a doctor.

And medication noncompliance can lead to devastating consequences not only in the short-term but in the long-term as well. One reader shares her experience in her own words.

A Story of Medication Noncompliance

. . . I got manic in September without being aware of it. I was over productive, spent a lot of money, barely slept, very irritable . . . While manic, I thought I was normal, since I was stable since several months. I was only on a small amount of an antidepressant, mood stabilizer and a tiny amount of antipsychotic.

All this disappeared suddenly. I was out of energy. I was barely able to move, depressed and the most important: productivity disappeared. Couldn’t move or concentrate . . . for the first time of my life maybe, I started having anger crisis, uncontrollable ones. It was like I push a button and become extremely angry. I went through irritability before but never knew such anger. It was all verbal, no violence but very embarrassing.

I got so angry and stupidly stopped my medication.

Why Were You Angry?

I was mainly angry because high productivity was over. I was angry and frustrated, thought I finally became stable. I was angry for being bipolar. I didn’t want to live (by the way I always think about suicide even when I am high). I hated myself and this life and wanted to punish myself.

I wasn’t thinking logically. What I was thinking: I was taking medication and all was fine for several months and in spite of all this, I had mania so why to continue to take the medication! Plus I wanted to suffer physically, to have tangible pain.

What Happened When You Stopped Taking Your Medication?

Drug NoncomplianceI stopped taking medication although I knew from previous experience (several years ago) that withdrawal is terrible. I thought that since I was on low doses, the effects won’t be that strong. Well I discovered I was wrong.

The first week I was doing more or less fine. Then I started feeling dizziness, nausea, restlessness. I started feeling than something inside me was boiling. I was extremely tired, empty. I could feel that even my eyes were empty. I was very irritable.

I told my therapist (psychologist) about messing with my medication. He tried for several sessions to convince me to take them again. At the beginning of the third week, I couldn’t continue anymore. Told the psychiatrist, he told me to take a mood stabilizer for few days and an antipsychotic and wait. But my situation was going worse. By the end of that week, I agreed with both the therapist and the psychiatrist that I needed to be hospitalized.

I had to be hospitalized because I couldn’t continue on my own. I was about to collapse. I was crying all the time, not able to work, extremely irritable and tired. And I didn’t trust myself that I could force myself to take medication as prescribed. Any single trigger would have pushed me to stop or to take an overdose. I was very suicidal.

I took me 4 days on an IV antipsychotic to start to improve. What helped me the most is that I knew I was safe there, protected against myself.

How Do You Feel Back on Medication?

I am on more medication now. I am still angry about being bipolar but dealing with this in the therapy. But physically I am doing better and I am less suicidal. And I trust myself that I can control myself concerning taking medication.

How Do You Wish You Had Handled the Situation?

I should have told my doctor first place that I stopped the medication. I should have been more aware about the symptoms of mania. I should have set a system or informed my family about the “warning” symptoms of mania. But overall, I took a good decision by asking to be hospitalized.

Wanted to share it with other bipolars and tell them that it is very very bad and harmful to stop medication.

If You Want to Change Your Medication

As always, it is your right to change your treatment plan but as this reader has shared, if you do it the wrong way, you may end up in the hospital or worse. Whenever you make a change it needs to be overseen by a doctor.

And if you do make a mistake and stop taking your medication – be honest and tell your doctor so they can help you. This person did the right thing by admitting she needed help. She got it, and now she’s able to share this message with you. Listen to her.

A Damaged Brain and a Mind Trying to Deal with It

→ November 30, 2011 - 37 Comments

A Damaged Brain and a Mind Trying to Deal with It

My Twitter bio says I have, “a damaged brain and a mind trying to deal with it.” This confuses a lot of people. It’s OK. I get it. Most people don’t differentiate between the mind and the brain. But I do. In fact, I consider it a critical distinction for people with a mental illness.

Your mind is who you are; your brain is just what you are.

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