Wednesday, December 30, 2009

Spiritual Practices for the Dark Night -- Giving Thanks



I don't believe in New Year's resolutions.  They tend to be such cliches.  Quit smoking.  Exercise.  Lose weight.  Well, if you are serious about losing weight, you gather information, you set goals, you plot a course, you prepare your house, you find a buddy (just like in AA), you plan each day, you think a lot and you practice.  It's worth doing, and I did.  The point of all of the above is to change the way you eat.  Permanently.  So I did all of the above and I feel great (at least about the way I eat).  I wish you all the success in the world.

Christians get a second shot at the diet thing in Lent, which begins sometime in the middle of February.  It doesn't fare any better than New Year's diets, because so few people want to change their life.  They want a quick fix for that swimming suit or class reunion.  That's why Lent.  It's time limited, forty days, with Sundays not counting.  Sundays are free days, for all the bad habits you resume once Lent is over.

Me, I am interested in changing my life.  You may be, too, if you too have peered into the dark abyss and something still holds you back from the edge.  We are tired of living on that edge.  It's just too scary.  It wears us out.

So I take advantage of whatever reflecting you might be doing on your life this time of year to introduce some spiritual practices that could change it.

Now don't get twitchy because I use the word "spiritual."  Yes, I am a priest; and yes, I have a charge on my life; and yes, I do my best to follow Jesus.  It causes me pain that many of you do not have access to that most powerful juju, because of how badly Jesus is represented by some people who have such strange ideas about how to follow him.  And I ask him and you also to forgive me for how little I ever do about that.

But give me a hearing.  I even changed the title for you.  I could have called it "spiritual disciplines," which is how I think of them, and which connects these practices to their deep roots in my own and other religious traditions that have been around a lot longer than you or I, so that you might give them a chance to find out why they have stuck around so long.

Anyway, "practices" gives the sense that if you mess up one day, well, that's what people who are practicing do.  Then they practice some more.

Having spent so much space on the title, I can't get to all three practices today.  For which I am glad, because I do better when I don't have to figure out what I will write about, and now I know for three weeks, because I have just created another series.  I hope I will remember the second practice, which I don't right this minute.

I try, I don't always succeed, but I try to start each day with three things for which I am thankful.  I an not particularly profound, nor even moved.  I just notice three things.  Today I am thankful that the sun came up.  It didn't come out, but I can cut it slack some mornings.  I haven't been out yet either.  But it came up.  That's a start, for which I am thankful.

I am thankful that I have a psychiatrist who listens to me.  Let's not spend any time on the one who didn't.  Let's focus on the present, for which I am thankful, because she listens to me.

I am thankful that my sweet Mazie is still alive.  She has renal failure, and every day we notice more signs.  It began with weight loss, then bad breath.  Now she needs to go out several times a day, instead of three.  I am the one who takes her for two long walks, and that gets me out, as well as up, whether the sun is joining us or not.  Which is good for my mental health and for my heart, and so I am thankful.

Three things for which to give thanks makes me mindful, makes me pay attention to the present, which is a gift, which is why it is called the "present."  For those of us who have peeered into the dark abyss, the present is indeed a gift.  Because we can imagine not receiving it.

Sometimes I forget to practice this practice.  But I almost always give thanks at mealtime.  That covers me three times a day.  I give thanks for the food, for the hands that prepared it, and sometimes for those who grew it and picked it, and those who packed and delivered it.  When appropriate to the menu, I might thank the chicken or the pig, and while I am at it, I apologize to them that I am not yet a vegetarian.

When I am in Central America, I hear my friends giving their thanks in quiet and rapid Spanish, so rapid that I can barely pick out a few words.  But I hear them pray for those who do not have food, and for a world in which everyone will have food every day, like we pray in the Lord's Prayer: Thy will be done.  Another word for this kind of prayer is mindfulness.

I was at a restaurant once on "A Day Without Mexicans," when lots of people from Central America stayed home from work to demonstrate how much the rest of us depend on them.  I overheard a woman ranting at this demonstration, and how "they should go back to where they came from."  All the while, she was eating a big beautiful salad.

Since that day, sometimes I pray, "Bless this food and the hands that prepared it.  May it bless us or curse us, according to how we treat those who brought it to us."  That is mindfulness, too.

I treat this practice gently.  Once in a while I wonder who I am thanking, and that reminds me how mad I still am at God about this disease.  I don't know how to give thanks for that yet.  Part of my dark night is this alienation from God.  Even alienation is a relationship.  But it's not one I want to press too hard.

Don't press it too hard.  Thankfulness will do its work over time.  Treat it as an experiment, to find out what it will work in you.

Happy New Year.

thank you to Stefan Mayrhofer who took this photo and placed it in the public domain

Saturday, December 26, 2009

OMGThat'sWhatTheySaid! -- Stigma

On November 26th, the New York Times published an article about the presidential policy not to write letters of condolence to the families of service men and women who commit suicide in a war zone.  These letters of condolence have gone out since Abraham Lincoln started writing them during the Civil War.  Given the upswing of suicides in the Armed Services lately and the attendant publicity, this policy of silence, which began in the Clinton era, is coming under scrutiny and challenge.
In response to this article, psychiatrist Dr. Paul Steinberg wrote an Op-Ed commentary titled "Obama's Condolence Problem," winning him this month's OMG Award for -- oh, it's hard to choose.  There are so many prize-worthy lines.  But let's call it for: Indeed, there is nothing wrong with stigmatizing suicide while doing everything possible to de-stigmatize the help soldiers need in dealing with post-traumatic stress and suicidal thoughts. I will deconstruct this sentence after putting it in context.

Dr. Steinberg is concerned that any recognition of suicide, even the reporting of it, glorifies it and makes the taking of one’s life a more viable option. If suicide appears to be a more reasonable way of handling life’s stresses than seeking help, then suicide rates increase.

Dr. Steinberg is clearly in the voluntarist camp, believing that people make a conscious, reasoned choice to kill themselves.  Suicide, in his view, is an option, a way of handling life's stresses.  He is in, if not good, then plentiful company, who believe that even while the thought processes of those who commit suicide are impaired, their will is not. They remain responsible for their choice.

Regular Prozac Monologues readers know that I am not in the same company.  Dr. David L. Conroy gave me the words.  From Out of the Nightmare: Recovery from Depression and Suicidal Pain, "Suicide is not chosen; it happens when pain exceeds resources for coping with pain."

Conroy describes the many ways that people who are suicidal attempt to reduce their pain and save their own lives.  Those who are suicidal sometimes use the language of choice and reason.  Conroy, who speaks from personal experience, says it is terrifying to have such little control over our own emotional state that it can shove us headlong over the abyss.  This lack of control is part of, and adds to suicidal pain.  To claim that we have considered the options and are making a reasoned decision is a grasping for the image of control; it is an effort to relieve pain.

Steinberg asserts that choosing suicide over treatment is deserving of shame.  Now that first-rate treatments for depression and post-traumatic stress have evolved and are readily available, and people with emotional problems do not have to suffer quietly, are we taking away the shame of suicide?  When he decribes depression treatments as first-rate, he parts company with the National Institute of Mental Health and many doing research in the field, who acknowledge the true state of treatment.  At least a third of those who seek treatment are not able to find a medication that is effective and tolerable.  Meanwhile, certain side effects of these first-rate treatments themselves increase the risk of suicide, doubling it in the case of insomnia, a frequent side effect of SSRI's and SNRI's.  Akathesia (called "inner restlessness" on prescribing information sheets) is one of the most under-reported side effects, due to euphemisms, and among the five top risk factors for suicide among hospitalized patients.  [Side note: when you read "inner restlessness" on your prescribing sheet, did you realize that "inner restlessness" could significantly raise your risk of suicide?]

Steinberg believes that letters of condolence to family members could be an inadvertent incentive to suicide.  In light of the condolence-letter controversy, the administration is appropriately reviewing the policy that has been in place for at least 17 years — and may indeed want to consider leaving it as it is. But as a country, let’s focus our energies on doing everything we can to diminish inadvertent incentives that might increase self-inflicted deaths.  And elsewhere: We need to find the right balance between concern for the spouses, children and parents left behind, and any efforts to prevent subsequent suicides in the military.

I feel downright silly answering this argument.  But here it is:

First, the shaming of suicide is indeed one of the resources that we possess against it.  But it is an even more significant reason why people do not acknowledge and seek help for thoughts of doing it.  Shame interferes with willingness to report symptoms.  And failure to report symptoms is a significant factor in failure to recover.  To think that we can shame suicide and prevent it at the same time is fanciful. There is no balance to be found here.

Second, it is well known that surviving family members are themselves at greater risk of suicide.  Shame increases their pain, including their suicidal pain.  It is a barrier that prevents them from seeking support and prevents friends from offering it.  A letter from the President could go some distance in reducing the shame of family members and providing comfort in the midst of their pain.  If prevention of suicide is the goal, here is the most direct intervention the President could make.

Now back to the beginning.  Indeed, there is nothing wrong with stigmatizing suicide while doing everything possible to de-stigmatize the help soldiers need in dealing with post-traumatic stress and suicidal thoughts.  Putting to one side the impossibility of de-stigmatizing the second while stigmatizing the first, let's take a closer look at what Dr. Steinberg wants to de-stigmatize -- the help soldiers need.  What help would that be?  Psychiatry, leading the mental health professionals.

Steinberg wants to stigmatize suicide and de-stigmatize himself.  That's natural enough.  Nobody likes to be the object of stigma.  People who experience suicidal pain can identify with him in his desire. But I took a fanciful direction upon reading this op-ed piece.  I imagined Dr. Steinberg as a chaplain taking a course in Clinical Pastoral Education.  Are my clergy readers following me here?  Think back to your CPE experience.  Imagine the conversation in group after Dr. Steinberg says Indeed, there is nothing wrong with stigmatizing suicide while doing everything possible to de-stigmatize the help soldiers need in dealing with post-traumatic stress and suicidal thoughts.  Somebody from my CPE group would surely have asked, "How does it feel to be the object of stigma?"  And if he returned the question with a quizzical look, "How do you feel to know that people would rather commit suicide than come to you for help?  What does that mean to you personally?"

To my psychiatrist readers (do I have any?), do you have any training like CPE, where you are asked to examine your personal feelings and consider how they affect your judgments and your treatment of patients?  Does it include your judgments about suicide?  How do you feel about yourself when one of your patients commits suicide?   How do you feel about that patient, and the next patient with suicidal ideation?  Can you acknowledge those feelings?  Is shame part of your own experience?  Where have you put your shame?  Your feelings are just that, feelings.  Can you use them to inform your understanding of your patients?

I posted a facebook status last week with a link to Dr. Steinberg's article, asking, "Do patients with any other disease face such disrespect from their doctors?"  I am going out on a limb here.  But I wonder if many psychiatrists have not yet dealt with their feelings about their patients' dying.  When oncologists did, the treatment of cancer patients changed.  Now, who even remembers that cancer once was shamed?

Wednesday, December 23, 2009



In the bleak mid-winter frosty wind made moan,
Earth stood hard as iron, water like a stone;
Snow had fallen, snow on snow, snow on snow,
In the bleak mid-winter long ago.


Our God, Heaven cannot hold Him nor earth sustain;
Heaven and earth shall flee away when He comes to reign:
In the bleak mid-winter a stable-place sufficed
The Lord God Almighty
Jesus Christ.

Angels and archangels may have gathered there,
Cherubim and seraphim thronged the air,
But His mother
only in her maiden bliss
Worshipped the Beloved with a kiss.


What can I give Him, poor as I am?
If I were a shepherd, I would bring a lamb,
If I were a Wise Man, I would do my part, –
Yet what I can I give Him, give my heart.


poem by Christina Rossetti. 1872
painting by Ivan Shishkin, 1890 

Thursday, December 17, 2009

Prozac Monologues at the Movies

Oh, boy!  Butter up the popcorn, slip in a dvd, relax.  This is one very safe and friendly way to spend time with people during the holiday season, and my final installment of this year's Prozac Monologues holiday survival series.  I want my doc and everybody else to notice the implication, that I will survive to do another series next year.

Well chosen movies can fill time, avoid awkward conversation, provide common ground and keep you in the present, always a good thing for the mentally interesting.  Here are my selection criteria for holiday diversion movie viewing:

Movies For Fun

Gay people used to make the mistake of coming out to the whole family over some holiday.  Don't spring your new diagnosis on a crowd.  Trust me, it won't go well.  Family viewing is no time for controversy, education, or consciousness-raising.  So even though The Soloist is a fabulous introduction schizophrenia and how to treat those who have it with dignity, save it for the right moment, when the person you want to watch it with can give it the attention it deserves, like, when it is not followed up eggnog and cheese ball.  

Instead, head for the Christmas classics, A Christmas Story, How the Grinch Stole Christmas, It's a Wonderful Life, A Charlie Brown Christmas, Mister Magoo's Christmas Carol, Polar Express. Don't you wait all year to see them again?

No?  Then move along to another genre --

Movies For Escape/Adventure

When what you want is a way to be in the same room with people who are getting on your nerves, go to another universe.  Harry Potter, Lord of the Rings, Star Wars, Indiana Jones -- nineteen choices right there, and all guaranteed to get you into a different world than the one you are avoiding.  There's also Sherlock Holmes and Imaginarium, in theaters for Christmas, if you are going out for your movie viewing.

Movies for Escape/Sports

This is another version of ESCAPE.  Most movies about sport are fantasies, even when actually true.  Invictus is currently in theaters, and gets a high recommend from me.  It's about rugby, which is pretty traumatic to watch, so will satisfy the vicariously violent in the crowd.  It's also about Nelson Mandela, for the idealists -- great crossover appeal.  Others on dvd: Cool Runnings (bobsledding), Field of Dreams (baseball), Seabiscuit (horse racing), The Hustler (pool), Chariots of Fire (track).  Oh, let's include Butch Cassidy and the Sundance Kid (bicycling, swimming, horseback riding, bank robbery?) and Sound of Music (yodeling)!
 
The Brain On Humor

Laughter is the best medicine.  In brain science language, we're talking about "nonserious social incongruity," which already sounds funny.  The definition suggests the anterior cingulate cortex, one of my favorite brain sites.  But humor excites many different sites.  If you are interested in the science, see Functional Anatomy of Humor: Positive Affect and Chronic Mental IllnessThey actually did research on funny movies in the psych ward.  The results suggest they might be just the ticket to reduce anger and improve social competence within your family of origin.

Movies For Laughter

Among my favorites are Up, Singing in the Rain, Jumpin' Jack Flash, and anything with Steve Martin.  I asked my family, and they added California Suite, Tommy Boy, European Vacation, Ice Age (#3 now in theaters) and anything by Mel Brooks.  Not suitable for intergenerational viewing, but still a hoot: Burn After Reading. 

Is mental illness funny?  Well, that would be the whole premise of Prozac MonologuesI have a soft spot in my heart for another Coen brothers movie Fargo, which was featured in Prozac Monologues the book.  I try to bend my humor north toward Fargo. 

I would be interested in your comments on this point.  I think it's a issue of laughing at or laughing with.  Watch these if the audience is sympathetic: The Dream Team, Harvey, You Can't Take It With You, Rain Man, Finding Nemo, Fifty First DatesLittle Miss Sunshine is darkly hysterical (my favorite kind of hysterical), if nobody is going to freak over Steve Carrell whose wrists are wrapped in gauze.

And saving the best for last, Some Like It Hot was voted the best American comedy ever by the American Film Institute.  And by me, too.  Enjoy!

photo of popcorn by Francesco Marino
flair images from facebook
Some Like It Hot from amazon.com

edited and reformatted 11/27/10

Friday, December 11, 2009

Don't You Love the Holidays!

Ah, the holidays!  Time when far flung family members travel home and grow close around the Christmas tree.  Time to renew friendships in a round of parties and frivolity.  Time to go crazy?

There are stresses this time of year.  Routines are disrupted, people stay in crowded quarters, those who have reason to avoid each other are thrown together, negotiations between exes require professional mediation, alcohol is consumed in greater quantities, expectations for love and good cheer are bound for disappointment.  Loonies and normals alike need to tend to their mental health.

So Prozac Monologues contines your handy holiday guide, with an assist from NAMI's Peer to Peer class and the University of Iowa Adult Behavioral Health department, covering the basics, planning ahead, mindfulness and quick getaways. 

The Basics:  Keep to your routine as much as possible.  If you can't eat like you do at home, get at least one nutritious meal every day.  If your family of origin was a little whacked, and your root chakra could use some assist, concentrate on protein (meat, fish, tofu, beans), root vegetables (carrots, beets, onions) and red stuff (beets, strawberries, cranberries, cherries -- jello does not count.)  Don't go to parties without some protein already on board.  At the buffet table, carrots.  Skip the dip, limit your lipids.  You will sleep better for it.

Remember Lloyd Bridges in Airplane?  The holidays are probably not a good time to stop sipping, smoking, snorting, sniffing...  You get the idea.  On the other hand, ultimately substance abuse is a greater hazard than help in negotiating tricky family dynamics.  So keep it under control.

Sleep -- not so easy if you get the couch in the family room.  Borrow somebody's bed for a nap.  If you anticipate a problem, I'm all for an occasional pharmaceutical assist, as an alternative to the straight jacket, which is where you may be headed if you don't get good sleep. This is true for everybody, essential for people with bipolar.

Safety -- no, you do not have to hang around anybody who is abusive.  If that is an issue, have your escape plan ready, your keys and your credit card in your pocket, your alternative crash pad arranged.

Oh, and water -- with all your meds, you are probably supposed to push water, as it is.  Even more so in the dry winter air.  Even more so when dehydration can be mistaken for hunger, leading to more cookie consumption, requiring more water.  Especially even more so with greater alcohol consumption.  Be kind to your liver.  Drink water. 

Planning Ahead:  Many a family feud could be short circuited with some conversation ahead of the storm.  Which chores does the host want or expect help with?  Which chores does the guest want to volunteer to do?  In any relationship, 50/50 does not work.  You have to give at least 60%.

Is there any tradition, activity, food, game that will blow your anterior cingulate cortex if it doesn't happen?  Take some responsibility for it.  Laugh about it, and let people know.  And if it doesn't happen, well, that will give you material for your next therapy appointment.  And you already know what your therapist will say, don't you.

How many events are planned?  Which ones can you skip?  Is there room for negotiation?  What would you like to do in a group?  When will you want to go off by yourself?  When will the one who abused you as a child be around?  Where will you be instead? 

What are your needs?  What are others' needs?  Talk to each other.  Listen to each other.  Remember, there is no Hallmark Family Christmas, except in Hallmark commercials.  These are ads, people.  They are not your family, and they are not mine, and they are not anybody else's, either.  Give yourself and your family a break.  Your relatives, your tree, your cookies and cocoa are infinitely more entertaining, anyway. 

Mindfulness:  "I am here, this is now."  That's my chant, accompanied by some deep breathing, calling me out of the unhappy past and the uncertain future.  Look up, listen up, and notice.  You don't have to participate.  Just notice.

When things get especially bleak for me, I go outside, regardless of weather, and try to replace the running voices in my head with a minute description of what I see around me.  "There is a little girl.  She has pink leggings on.  Her hair is in ponytails on either side of her  head.  The woman is pushing the stroller.  The tree is a pin oak and still has its leaves.  The passing car is a Volvo.  We used to have a Volvo.  It always... -- no, that's the past.  This Volvo is dark green..." You get the idea.

When you can't get outside, like during Christmas dinner, become an anthropologist.  Who are these people?  What do they think?  How do they treat each other?  What are their eating habits?  What happens after three beers?  You are not responsible for any of it.  You do not have to stop what you don't like.  You don't even have to like or not like.  You are simply an observer.

Mindfulness is a practice.  Practice is what people do when they want to get better at something.  Remember, if you can't pull off mindfulness every time you need it, that's okay.  You just need more practice. 

Quick getaways: There is one more thing you need, some handy lines to get you out of the inevitable spot.  Let's see how many of these you can anticipate.

There you are, being an anthropologist, mindfulnessing away.  And Uncle You Know Who turns to you and says...  What will it be this year?  Health care?  Global warming?  What he thinks about all this therapy you're doing?  He knows your triggers like the back of his hand, because he trips them every year.  Well, write this one down on the back of your hand, "That's very interesting.  I'll have to think about that."  That one can get you out of all kinds of arguments.  Sometimes it even gets my therapist off my back.

Or there you are, seated next to the cousin you haven't seen since she tried to drown you in the pool when you were kids.  Remember, you are here, this is now.  Try, "Seen any good movies lately?"  It matters not a whit if that line is a dud, because it sets up your next line, "What do you do with your time nowadays?"

Then there is the open-ended "How about them Hawks?" Or Vikings, or whatever.  Do a little research ahead of time, so you know a team near the person you are addressing.  For the sport challenged, here is a starting point: it's football season.  And if that line is a dud, follow with... are you with me yet?  "What do you do with your time nowadays?"

When you must escape the person or the room, there's:  "Excuse me, my drink needs more ice; I'm going out for a smoke/some air/to make snow angels;" and, "Do you know where the bathroom is?"

And when you have had your limit: "I really must go.  Thank you so much for the party.  Merry Christmas."  With a normal host, I mean really normal, not "undiagnosed" normal, you don't need to explain anything.

If the host is in the "undiagnosed " category, then try: "My puppy/probation officer/Nurse Ratchet is waiting up for me."  Or, "I'm sorry, suddenly I'm feeling flu-ish." You can play the flu for all it's worth this year.  Or even, "Oops, my meds are wearing off.  Gotta go!"

If somebody else in the room should be on meds, a simple "I'm outa here" will suffice.

Make yourself a crib sheet, and these few lines will help you navigate a wide range of social situations.  Do you have anything else you want to recommend to fellow readers?  Make a comment!

There is one more strategy, diversion. I will cover diversion, in the form of recommended movies for the holiday season next week.  Put your recommendations (and reasons) in the comments this week.  I am happy for all the help I can get!

Families -- you gotta love 'em.  And you can always laugh.  It really works better if you do.  Happy Holidays!

clipart from Microsoft online

Friday, December 4, 2009

Unintended Consequences.

A few posts ago, John McManamy and I began a conversation about brain surgery to treat mental illness.  You can follow that thread at his blog.  The link will take you to November.  The comments under Me, Captain Ahab and the Anterior Cingulate Cortex are that conversation.  


It seems that brain surgery for mental illness is the topic of the season.  Yesterday the New York Times published the story of Henry Molaison, who had surgery in 1953 to remove part of the medial temporal lobe, including most of his hippocampus.  1953 was four years after António Egas Moniz received the Nobel Prize for his lobotomy procedure, targeting the frontal lobes, and fourteen years after Moniz retired, when he was paralyzed by a former patient who shot him in the back.

The intented result of the surgery in 1953 was to relieve Mr. Molaison's seizures, which he had since childhood and were getting worse, so much so that at the age of 26, he consented to this experimental surgery.  And the surgery was in fact successful.  It relieved his seizures.

Now everybody who has ever quit a medication because of side effects, or had ECT, or did a good deed that went horribly wrong knows about unintended consequences. It soon became apparent that Mr. Molaison's short term memory was gone.  If you have seen the movie Fifty First Dates, it wasn't gone like Drew Barrymore's, who forgot every night what happened that day.  It was gone like the man in the hospital, who introduced himself to people he was having a conversation with, over and over and over.

In the letter to the Romans, chapter 8, Paul says that God makes something good come out of anything.  He doesn't say that the new good measures up to the previous bad.  But it's something.  In this case, one person's tragedy was science's incredible research opportunity.  From all the experiments subsequently conducted on Mr. Molaison, scientists learned a lot about how memories are constructed.  They learned first that the particular part of his brain that was removed is critical for the formation of memories.  Protect your brain!  They learned that there are different kinds of memory.  Mr. Molaison could no longer acquire new information, like where he put his keys.  But he still had his motor or implicit memory; he could still ride a bike.

Mr. Molaison donated his brain to science.  I am curious about the legal implications of consent for a person who has no short term memory.  How long would it take for the docs to describe their desire for the donation and for him to absorb the information and make a decision, one which presumably he would not remember the next day?  Is it informed consent if the next day, (not to mention 52 years later, before he lost his life to pulmonary complications), he would not remember his consent to be able to withdraw it?  Would the law school readers and human research subject reviewers weigh in here?  Let me add that with his memory intact but his seizures undiminished, Mr. Molaison might not have survived to the age of 82.

Anyway, continuing the one enormously good, though unintended consequence, right this very minute they are busy shaving off pieces of his frozen brain in coronal slices, and photographing each slice, to give the most detailed pictures in existence of the structures of the brain.  These slices are measured in microns.  They will get 2500 of them out of this most famous brain.


My spouse, who works for Nancy Andreasson, the researcher in schizophrenia, (Broken Brain) says that the brain images they have from MRI's measure a millimeter.  They get 196 slices (that's what they call them, but they are pictures, really) out of the coronal view.  The side view is pictured here.  Imagine slicing it like a loaf of bread.  Your face is the left end of the loaf.  When you put the slice flat on a plate, you are looking at the coronal view.

And actually, as I write, they began a break at 8:40 AM, California time, while they change the blade.  They have already passed the damaged part of Mr. Molaison's brain, and expect to finish sometime this evening.  These images will be studied for years, maybe decades.

Obviously, nobody is doing the procedure used on Mr. Molaison anymore.  I believe that they do experiment with a pacemaker-like device that gives a periodic electrical charge to the brains of people with epilepsy.  A similar technique is one of the experimental procedures used on the anterior cingulate cortexes of people with OCD, obsessive compulsive disorder, and people with depression.  The advantage of the pacemaker device, called deep brain stimulation (DBS) is that presumably it is reversible and can be removed if the unintended consequences are not so good.  The other psychosurgeries that involve actual cutting or burning are not reversible.

These experiments are conducted only on the people who are most desperate for relief.  Sometimes they get relief.  Often they get something else, as well.  When weighing the pros and cons, I suppose that one of the pros is , however it turns out, they will advance what we know about the brain.

Photo from MIT 
Permission is granted to copy image under the terms 

News Flash -- Unintended Consequences

If it's still Friday and if you pay attention to science or technology or the brain, or if you think that live feeds are cool, then zip on over to the lab at UC San Diego RIGHT NOW where scientists are peeling 2500 slices off of a man who was brain damaged 57 years ago, during an experimental surgery to relieve his seizures.  Ever after, his short term memory was good for 15 minutes at a time.  He donated his brain to science, and this is what they are doing with it, to study memory.

I have to get cookie dough made, and will fill out this story later.  But they might finish the live feed today.  So watch it now, and read the story later.

Thursday, December 3, 2009

Holiday Shopping for Your Favorite Normal

A friend once described what it was like to have cancer.  Like having a paper bag over your head, you can't see anything outside the bag.  It's all about you and your cancer.

Mental illness can be like that.  Try it for yourself.  Put a bag over your head.  Make sure it's not plastic!  Our issues can be all consuming, our fears, our doubts, our grief, our hysteria, our voices...  We lose track of the world outside our paper bag.

But outside that bag are friends, family, allies.  There are more of them, and they are truer to us than we can imagine when inside that paper bag.  The bag, our absorption in our own concerns, makes certain life skills difficult.

Like holiday shopping.

To do a good job at holiday shopping, you have to pay attention to something, or someone outside your own inner world.  So before I give suggestions to loonies about what normals like for Hanukkah, Christmas, Kwanzaa, here are first steps.

The first step to successful holiday shopping is to turn your attention away from yourself.  Remove that bag from your head.

The second step is to focus on the person for whom you want to shop.

The third step is to pay attention.  Engage your eyes and your ears.  Watch and listen for clues.  If you want to please this person, you need to find out what would please this person.  Write it down, if you have memory problems.  I assume that you have memory problems.

I have a hard time paying attention to the world outside myself.  I pay so much attention to my world inside that I trip over cracks in the sidewalk, bump into furniture, nick myself with a knife (but not on purpose!)  I bruise myself and don't even notice until my wife sees it and asks me what happened.  I have no idea.

When I decided to write this post, I realized I would have to follow my own advice.  I had to pay attention.  Actually, given the time constraint, I took the direct approach.  I asked Helen, "What would be a good gift to give a family member of somebody with a mental illness?"

She said, "A cure."

Such is the love available to me every day outside my bag.  Five years after Prozac, I can cry again, and I almost did.  I wrote "a cure" on my list.  Then we went on.

Of course, I got a list of things that Helen would like.  That is the point.  The people who love you are just as unique as you are, you little snowflake.  We got a catalog from Target today filled with gift suggestions.  Some of them may work for the person who loves you.  Some of them won't.  You can't trust the catalog for good guidance.  That is why I gave you the technique for figuring it out.  Talk to them about what's in the catalog.

Having observed your loved ones, so that you know their interests, having paid attention so that you might even have heard, "Gee, I wish I had...," or seen them pick up something at a store, then you are ready to go out shopping.

No, those of us with PTSD or OCD or whose meds wear us out or who feel like whale shit at the bottom of the ocean do not want to go out shopping.  The internet is our best friend, at least for the length of time it takes us to do our shopping.  Internet shopping does require a credit card, so those with bipolar might need supervision.

Simply google the source of your desired gift, Williams Sonoma for all things cooking, Eddie Bauer, Old Navy, Victoria's Secret, etc. for clothing, Cabela's or Scheel's for all things sporty, Amana for meat, See's or Godiva for chocolate.  See's makes the gold foil chocolate coins for Hanukkah's dreidel game.  Chocolate is also a fabulous Christmas gift, or for any occasion whatsoever.  [Does anyone know a tie-in to Islam?]  And it stimulates the production of dopamine.  So you might want to order some for yourself, while you are at it. Oh, and Amazon for just about anything.

If all the choices are just too much, get a gift certificate.

If your meds or your disease has destroyed your credit, so this is a cash deal, and if you can bear the public appearance, you can now buy at the grocery store gift certificates for all kinds of other stores, restaurants and websites.  Purchase your chocolate and do all the rest of your shopping in one stop.

If you are having a good day, head out to the mall for baskets of bath salts and candles, next year's calendar, movie coupons, cheesy popcorn, that toy workbench that I recommended your normals buy for you, and a truly amazing assortment of gadgets that you never knew anybody needed and that nobody will use by December 27, but it is the thought that counts. That "thought that counts" thing only works for your mother, by the way, and not really for her, either. Play with the worthless gadgets in the store.  Then give them a pass.

Weekdays, mid morning are safest for the mall.  I wouldn't dream of going there unless pharmaceutically protected.  Bring a friend who can drive after you collapse.

But if the cost of meds or the consequences of your disease (you know who you are) has destroyed your credit, you might like a more personal (read:cheaper) approach.  Write a poem or a story.  Draw a picture.  Make a collage.  Frame a photo.  Knit a scarf.  Bake some cookies.  Remember that thing about chocolate and dopamine.  Fudge!

I don't believe in those homemade coupon books filled with promises you can't keep, like how you will do your own laundry or cook dinner once a week, walk the dog, smile once in a while.  Don't promise.  Just do something that your normal has been begging you to do: make that doctor's appointment, attend that group, remove the leftover pizza from your bedroom, wash your hair...

Write a letter of appreciation.  That one works especially well with your mom.

clip art from Microsoft.com

Friday, November 27, 2009

Thanksgiving and the Anterior Cingulate Cortex



Did anybody decompensate at your Thanksgiving Day feast, when there were no pearl onions in cream sauce, notwithstanding the fact that nobody has ever eaten a single pearl onion in cream sauce, since Great grandma Libby died forty-five years ago?

Was it you?

I think I figured it out.  Unfortunately, this flash of brilliance came to me yesterday morning, in my hypomanic surge that prepared me for my speed pie-making.  Not in time for you to prevent the scene by preparing said onions.

Somebody's anterior cingulate cortex blew a fuse.

Of course, I don't know for sure.  It is one more hypothesis that I would like to test in that Million Dollar fMRI machine that I am not getting for Christmas.  But here is the hypothesis:

The bad economy, the fear-mongering health care debate, the single-payer stillbirth, the war in Afghanistan, global warning -- your anterior cinculate cortex (ACC) is doing all that it can to calm your amygdala.  That is one of its jobs, partnered with the prefrontal cortex, to exercise executive function over your amygdala, which is convinced that you are about to die and is sending out messages to your adrenal gland, telling it non-stop to keep pumping out those glucocorticoids that are destroying your hippocampus, not to mention your heart.  The amgdala must be brought under control!  So your ACC has plenty of work to do already, and needs for you to help out by deep breathing.  And yoga.  And crystals.

But it also has another job, which is to detect abnormalities in patterns.  You know those games where you are supposed to find five details that differ in two nearly identical pictures?  That's a job for the ACC.  But what with global warming and all that other stuff (and we still don't have any snow in Iowa the day after Thanksgiving, so my amygdala keeps telling my ACC, "I do so need to worry"), when somebody's ACC detected a variation in the Thanksgiving feast day table, i.e., the missing pearl onions, that was just one thing too many.  And it blew a fuse, releasing the amygdala from its cage.  And this time, the amygdala did not send out the message to freeze.  It came out fighting.

So now you know.  Or would know, if somebody who does own an fMRI machine would construct the experiment.  Any takers?

Tuesday, November 24, 2009

Holiday Shopping for Your Favorite Loony


The Day after Thanksgiving, traditional start of the Christmas, Hanukkah and Kwanzaa shopping season is just around the corner.  You Hanukkah people better start cracking!  It is Prozac Monologue's attempt to be ever helpful to my dear readers. As my therapist says, " Virgo -- your destiny is service.  Get used to it." (I have a therapist who says stuff like that. The following is a holiday shopping list to guide normals who want to please their loony loved ones.

[Note: I am going to start using "loony" as a generic term, in place of "consumer of mental health services," and "normal" as the term for the "not-yet-diagnosed."  You are welcome to discuss that if you wish.]

Anyway, next week, I will turn it around to guide my loony readers into appropriate gift-giving behavior toward the normals in their lives. 

Crazy Meds can be your one stop shopping for "Straight Jacket T-shirts, when you're crazy enough to let your medication do the talking," with a range of messages for any diagnosis, medication or level of "in your face."  The lettering is made by arranging capsules, for that homemade, from the heart touch.  You can even order custom messages, but it costs more, because Jerod has to pull out his pill bottles.  If you are shopping for me, medium size, long-sleeved, and black, of course.  My favorite message: Bat Shit Crazy.

There are other gifts targeted to differential diagnoses, as well.

For the person in your life who talks back to his/her voices, but is trying to "pass" as normal, what could be more thoughtful than a blue tooth telephone?

Purse or pocket-sized hand sanitizer makes a nice stocking stuffer for your loved one with OCD -- Obsessive Compulsive Disorder.

Don't ask somebody in the "Whale Shit at the Bottom of the Ocean" stage of depression, "How can I help?"  Simply tell your friend that you are going to arrive at his/her house at whatever o'clock on whatever day to clean the house.  Your friend doesn't even need to get out of bed.  You can use the hospital method of rolling the body from side to side to change the sheets.  For the frosting on the cake, leave a pot of soup in the kitchen when you go.  For that matter, leave the cake.  Important tip: this gift may not be welcomed by somebody with OCD.

Art supplies make a nice gift for any diagnosis.  Those in the manic stage of bipolar might especially like spray paint.  Or glitter.  Again, your OC friends have certain limitations -- no clay, no fingerpaints.

Almost anybody with a mental illness could use a toy carpenter's work bench, that thing with the pegs you pound through to the other side with a hammer, and then turn over to pound through again to the original side.  The old fashioned wooden ones are charming, but if self-harm is currently an issue, they do make them in plastic nowadays.

Recently, when I was invited to a large dinner party, my very thoughtful hosts designated a safe room to which I could (and did) withdraw when things got overwhelming.

If your loony is spending the holidays in confinement, loose change for the telephone, Nicorette patches or gum, and real French Roast coffee brought in at visiting hours (and labeled "decaf") will bring a little cheer to the stay.

Deep tissue massage is a great reliever of depressive symptoms.  Some people use it weekly in lieu of medication.  Ask the potential recipient first whether massage or even a whole day at the spa would be welcome, or if it would just stir up issues.

A health club membership is nice, if your loony has expressed a desire for one, but likely to ignite a scene if you have been nagging about exercise.

I saved the big ticket items for last.  We loonies are always bemoaning that ours is an "invisible" disease.  There are no x-rays, no blood tests to prove our suffering.  But there does happen to be physical evidence, not for the diagnosis, but for the propensity for it.  People with schizophrenia have larger than normal ventricles, the spaces inside the brain containing spinal fluid.  People with depression or post traumatic stress disorder have small hippocampuses (hippocampi?)  Getting the proof will take a bit of effort.  A full MRI scan, pictures of the brain from dorsal, saggital and coronal perspectives, will run you $400-3000, depending on who orders it and who pays for it.  If that's you, don't expect a discount.  But if you can get your loony into the right research study, he/she may be able to get a slide or two of the relevant features printed -- truly a one of a kind gift.

And then there is that fMRI machine I am always wishing I had.  It prices out somewhere between $1,000,000 and $2,300,000, depending on the power, with an additional $500,000 to build the lab.  Oh well.

You know, morning talk shows, magazines, even Science Friday on NPR all have their suggestions for holiday giving.  but I do believe that this one is a first for the mentally interesting.  DVD and book selections will follow, as well as suggestions for the normals who do so much for us the rest of the year.
clip art from microsoft

Sunday, November 15, 2009

OMGThat'sWhatTheySaid! -- Language


The following post contains material that could be considered uppity, outlaw, provocative, offensive and paranoid. 


This month's OMGThat'sWhatTheySaid Award considers the nature of the vocabulary that we all use for mental illness, in particular, the language that norms the relationship between those who receive a diagnosis and those who make it.

Once upon a time, I wrote a senior thesis for Reed College on this topic.  I was a religion major, and it was 1975, when the Episcopal Church was considering the ordination of women.  My topic was what priests are called.  My thesis was that the language we use establishes the normative relationship between priest and parishioner.  I am discouraged thirty-four years later, that new, freshly graduated priests in Iowa still permit and even encourage little old ladies to call these twenty-somethings "Father."  Oh well.

In the mental health field, this kind of paternalism is out of favor, perhaps the influence of so many women in the field.  But the language has not escaped from reinforcing the power relationship, one up and one down.

I am taking a Peer to Peer (P2P) course, sponsored by NAMI, where we scratch the surface of this topic.  The course text notes that every stigmatized group that has resisted oppression has done so by claiming the language, deciding for themselves what they will be called.  Invariably, these claims are disputed, whether ladies/women, Negroes/blacks/African Americans, homosexuals/gay men and lesbians.  Sometimes the self-chosen word is turned into a form of ridicule.  Women became "women's libbers."  "Gay" is a high school put down.

Typically, those in power deny the power of their language, or do not take responsibility for it.  They cite ancient derivations and precedents, and accuse those uppity people of being over-sensitive, "It's just a word."  People with mental illness can expect no less, or even more.  Those who have power to diagnose us define us to a public that is nervous about us anyway.  They have power to mess with our medications, our disability payments, even our liberty.  For example, that sentence itself could be diagnosed as paranoia.  Has my depression progressed into psychotic features?  Consider, many who are involuntarily committed receive their sentence for something they said.

However, the mentally ill are everywhere, to appropriate another group's phrase.  We include among our ranks those who have been through the previous struggles.  For me, it was when my employer wanted to know how to phrase the announcement of my disability leave (originally called a "retirement") that I realized, I know the map.  So do a number of my peers.

So let's dive into it.  Doctor/patient -- See, that could be power neutral, but for the deep layers and long tradition of one up/one down behaviors and the language that supports the existing relationship.  Sticking with language, one gives doctor's orders; the other either complies or is called noncompliant.  When they do clinical trials of medications, they measure the rate of noncompliance.  Who came up with that?  Not the person with the diagnosis, who does not take the medication as directed if the reasons are not explained well enough, if the medication is not effective or is too expensive, or if the side effects are intolerable. For all the latter day talk of how doctor and patient are partners in this relationship, if the patient had the power to name his/her own experience, the word would not be noncompliant.  It would be dissatisfied.

Moving on to therapist/clientClient isn't so bad, and this one might stick around, if therapists were called by the parallel term, mental health consultants.  That would suggest that the client has certain expectations.  Imagine an intake interview in which the expectations of both parties were discussed.  The consultant has policies about cancellation of appointments and payment of co-pays.  Would it not be balanced, therapeutic even, for the client to name his/her expectations, for respect, for discussion of the diagnosis, for disclosure of what the consultant reports to the insurance company and the consultant's peer review or supervision, how confidentiality is handled in such settings, for the consultant's knowledge of side effects, so that problems with medication could be identified as such, and not misinterpreted?  How about a regular review of whether each other's expectations are being met? What expectations would you have?

Here is a big one for me: provider/consumer.  I suspect the intent of this couplet was to soften stigma and normalize the experience of therapy.  But it misses the mark.  No consumer invented the word.  It is the word that degrades the entire population.  We are a consumer society, defined by our usefulness to business.  It has become our duty to shop when terrorists threaten shopping malls, spend when business is hurting, and thereby relieve the anxieties of stock holders.  They say that the economy is improving when the owners of the economy are making money, not when there are fewer people who live in the streets or beg at street corners, not when all receive adequate health care that they can afford, not when each of us can make a meaningful contribution to the quality of life on the planet.

In the language of mental health providers, our health has become a commodity.  Mental health providers deliver mental health services, as mother and father birds drop food into the open mouths of their chicks, the consumers.

Well, there is no turning back the forces of the economy in health care until the whole system collapses.  Its voracious appetite consumes us all.  So how do we who have a mental illness claim power within the economic paradigm?  What language do we use?

This examination of language is a collaborative process which NAMI has begun, inviting peers to participate.  Already, NAMI reshapes the language, when it calls people who have schizophrenia, people who have major depression, people who have bipolar, people who have obsessive compulsive disorder, people who have been labeled with a borderline personality disorder, all of us peers.  Peers consult with one another, learn from and support one another, and come together to name and meet their own needs.  There is power in numbers, power in cohesion.  If we can recognize that there is more that unites us (our experience) than what divides us (our differential diagnoses), then together we can act.

And how to name the relationship with psychiatrists?  I propose that we are "customers."  We purchase the services and pay the salaries of psychiatrists/sales reps.  They get their commissions from the pharmaceutical companies.  Their commissions are not as big as they used to be, no Hawaiian vacations for those who prescribe/sell great quantities, unless they become the middle men, the doctors who sell the product to other doctors as speakers at conferences.  Although ethical issues have been raised about these practices, pharmaceutical companies still supply commissions in the form of research grants and pay for almost all of psychiatrists' continuing education.  Really.  We pay the salaries.  They pay the commissions.

Now let me make my own disclosure .  AstraZeneka, the producers of Seroquel, used to treat schizophrenia and bipolar, is the sponsor and funding source for Peer to Peer.  At each meeting we sign in, so that the program can report back to AstraZeneka.  If attendance falls below ten, then AstraZeneka pulls the funding.  I drive sixty miles each Thursday evening to attend this class in the next county, because NAMI hasn't gathered a full class size in my county.  Last week we did an exercise.  Each person who could state something positive about their medication finished this statement, "Without my medication, I would..."  The exercise had its desired effect, as I gave thanks for my medication.  So NAMI is part of the sales force as well.  And I receive these services gratis.

Back to psychiatrists -- If we are customers, then efforts at compliance become concerns about customer satisfaction.  Now the power balance begins to shift.

Do you have other words to suggest?  Feedback?

 Permission is granted to copy this document 
under the terms of the GNU Free Documentation License

Saturday, November 7, 2009

Nonsense and the Anterior Cingulate Cortex


John McNamany put the thought into my head, the New York Times tickled my fancy and a blog new to me gave me the illustration.

Finally, it's Anterior Cingulate Cortex Week!  This lovely portion of the brain is found in the limbic system, located just above the center, about where Iowa would be, if you flipped the image so that it faced right, as I did here.  Like a true Midwesterner, the ACC modulates emotional response.  A hard-working manager, the ACC handles motivation to solve problems and anticipation of tasks and rewards.  It also monitors for conflict, things that don't make sense.  The brain is unhappy when it cannot detect the pattern.  Confronted with anomaly, the ACC goes to work.

"Researchers have long known that people cling to personal biases when confronted with death... In a series of new papers, Dr. Travis Proulx of University of California Santa Barbara and Steven J. Heine, a professor of psychology at the University of British Columbia, argue that these findings are variations on the same process: maintaining meaning, or coherence. The brain evolved to predict, and it does so by identifying patterns.  When those patterns break down — as when a hiker stumbles across an easy chair sitting deep in the woods, as if dropped from the sky — the brain gropes for something, anything that makes sense. It may retreat to a familiar ritual, like checking equipment. But it may also turn its attention outward, the researchers argue, and notice, say, a pattern in animal tracks that was previously hidden. The urge to find a coherent pattern makes it more likely that the brain will find one." [Benedict Carey, New York Times, October 5, 2009]

To test whether confronting the absurd leads to pattern-searching behavior, they had twenty college students read Kafka, "The Country Doctor," a story that is urgent, vivid and nonsensical.  Does anybody who is not in college ever read Kafka?  Anyway, after reading the story, they were given a task, to study strings of letters that did not form words.  They were then shown a longer list, and asked to find the strings they had seen before.  The letters did have patterns, very subtle patterns.  And the students who had read Kafka did better at this task than another twenty who had not been exposed to the absurd, 30% better.  With a Kafka-stimulated ACC, they were primed to find the patterns.

I wonder if that explains the college student's propensity to read Kafka, in the first place.  Not to mention all those posters by Salvador Dali on dorm room walls.  The college student is at a crossroads, and has to puzzle through the animal tracks of his/her life, to discern the pattern, the call, the next direction.  These representations of the absurd stimulate the part of the brain needed at this developmental moment, just as caffeine stimulates the system before the exam.

I graduated from college at loose ends, with the Episcopal Church still discerning the patterns that would allow for the ordination of women.  That was a few years off, and I wasn't ready to commit to a vocation that might not be received.  But I didn't read Kafka.  Instead, I decided to read everything that Kurt Vonnegut had written up to that point, a modern day Kafka, Kafka-lite, if you will.  Today, as I am filling out disability applications, I am again at a crossroads, and again, instinctively, I am drawn to Vonnegut, whose body of work has grown since 1975.  Evidently I am stimulating my ACC and boosting my pattern/meaning/coherence finding abilities, priming myself to discern my next direction.

Oh boy, I found another fMRI experiment!  There is a study in the Journal of Pain (what a title!) that discovered, when people were prompted by pain-related words to remember painful autobiographical episodes, the fMRI machines showed that it was -- you guessed it?! -- the anterior cingulate cortex that lit up.

"This person loved me; this same person abused me" -- two memories in conflict.  Put them together, they cause pain. They call it dialectical thinking if you can hold two seemingly contradictory ideas in the same head at the same time.  But dialectical thinking is a highly developed skill.  Before anybody ever suggested to me that I could employ it to reduce my pain, I spent (and still do spend) enormous amounts of energy trying to make sense of events that were absurd.

Some of us had Kafka-esque childhoods.  I wonder, does the ACC becomes quiet if we engage in dialectical thinking?  I wonder. Does it can blow a fuse, if we don't?

If you are searching for Christmas gift ideas for the Prozac Monologues blogger, an fMRI machine would certainly be well received. 
image of brain from NIMH 
artwork found at Glocal Christianity

Friday, October 30, 2009

Weighing the Risks and Benefits - Will My Life Be Better?


"You have to weigh the risks and benefits."  That is what the doctor says.  It's your body, your decision, your responsibility.

But how do you weigh them?  There is that list of side effects.  They sound pretty scary, but the doctor assures you they are usually manageable.  Then there is the potential benefit of feeling better.  Well, that would be the gold ring, now wouldn't it?  Being able to get back to your family, your job, your life?

It's not a hard sell.  Reach out your hand and the pharmaceutical company will place in it that most precious of all commodities, hope.

Perverse little smarty pants that I am, after my hopes had been dashed six times, I started to read.  For four years I read journal articles about clinical studies.  The basic format begins with a measurement of depressive symptoms, usually the Hamilton Rating Scale for Depression, HAMD, depressed mood, suicidal ideation, sleeplessness, loss of appetite, etc.  You get points for severity.  Unlike your junior high math exam, the higher the score, the worse off you are.  In fact, if you ace this test, they will administer electric shocks to your brain (yes, I know, you will be unconscious at the time and won't feel a thing) until you forget how bad you feel and get a lower score.

So there are two groups, as alike as possible, Group A averages a HAMD score of 21.6, Group B's average is 22.1.  That's the mid range for moderately depressed, and the typical test subject score.  They don't include you in medical trials if you keep getting a high score, because now it's the medication that is being tested, and they want an audience that is easier to please.  Group A gets the medication being tried, Group B gets the placebo.  After 8 weeks, Group A's HAMD score is 8.2, Group B's score is 10.9, both in the mildly depressed range, but the difference is "statistically significant."  [That would depend on how big the sample is, and I am not doing the math.]  More people in Group A than Group B reached remission, a HAMD score of 6 or less.  A certain number dropped out because of side effects, so they don't count.  And there we have it.  The medication improves depressive symptoms by a statistically significant amount and is well tolerated, and you should get yours today.

But you know what?  That study with all its statistics did not answer your question.  Will you feel better?  Will you get your life back?  It told you what the odds are that your depressive symptoms would be reduced.  But that is not the same thing.  Not at all.

For example,the truck driver who is sad, not sleeping well, has no appetite, worries a lot and feels guilty is given Zoloft by his family practitioner.  Now he's eating better and is learning to put past sins behind him.  But he is too dizzy to drive, gets in fights with his friends and can no longer satisfy his wife, or even himself in bed.  So he decides to quit his meds.  The doctor is focused on his HAMD score and is very concerned, convinces him to try another med, then another.  But each time he gets the same side effects, and meanwhile has lost his job.

The truck driver has weighed the risks and benefits, asking is my life better? No, it isn't.  Let's hope his doctor knows that Cognitive Behavioral Therapy is often as effective as antidepressants for mild and moderately depressed people.  Ditto aerobic exercise, which could help his lose those extra pounds, improve how he feels about himself, and change the nature of what happens when they turn out the lights.

It turns out there are lots of psychological tests.  Many try to do what the HAMD does, and their inventors think that their tests do it better -- measure depressive symptoms.  But there is also a test that asks the real question: Are the lives of the people who take this medication better?  The Sheehan Disability Scale is a three question test, answered by the patient.  On a scale of 1-10, how much have the symptoms disrupted your work/school, your social life, your family/home responsibilities this past week?  It's simple.  It's easy.  It's what the people who are taking the meds want to know, will my life be better.  The people doing the research are focused on symptoms, not on the patient's life.  So that is how I read journal articles for four years and had never heard of the Sheehan Disability Scale (SDS).

For some reason, the clinical trials for Abilify decided to ask the patient's question, using the SDS.  Actually, they used seven different tests.  When the journal articles came out, they reported only one, the Montgomery-Asberg Depression Rating Scale (MADRS), a substitute for HAMD.  My September 4 post, OMG!! That's What They Said! Significant, reported its not particularly impressive, but FDA passable,  "statistically significant reduction in depressive symptoms."  The other test results disappeared.

But somebody noticed, and called them on it.  That is when I learned that the SDS even existed.  Why would they go to all the trouble of doing seven different tests, and then publish the results of only one?  Turns out that while Abilify.com says that "Clinical studies of adults with depression showed that adding ABILIFY to an antidepressant helped to significantly improve depressive symptoms compared to adults treated with an antidepressant alone," as far as the people who actually swallowed the stuff were concerned, it was a wash.  When you weigh symptoms and side effects, they reported that there was no improvement in their work/school life, a little improvement in family life.  But overall, it was a wash.

What was the author's response?  "Robert Berman from Bristol-Myers Squibb wrote... "this may be due to the lower sensitivity" of the measure."  I got that from "Abilify, Depression and the Memory Hole" at clinpsyc.blogspot.com.  Robert Berman, chief author of the research report, is not only an employee of Bristol-Myers Squibb, his compensation also includes stock options -- a little side note on how medical research is conducted in a for-profit health care system.

Okay, so the Sheehan Disability Scale is not sensitive enough to pick up what were pretty small decreases in depressive symptoms anyway.  That isn't its purpose.  What it will do is weigh your risks and benefits. Will Abilify improve my life, at work, at home, at play?  Nope.  Not if you are taking it for depression.  It won't.

What Prozac Monologues wants to know is what the Sheehan Disability Scale would tell me about Lamictal, the medication I have just added to my antidepressant instead of Abilify.  But as far as I know, nobody asked.

photo by Hans Anderson, This file is licensed under the Creative Commons Attribution ShareAlike 3.0