Bernards Voices

For the upcoming HOP mental health awareness event, a topic that generates a great deal of conversation is “navigating the mental health system”, specifically regarding insurance. All agreed that, especially with the recent health care reform laws that will be enacted over the next few years, this is an area that we need to spend some time on during Mental Health Week, May 10th through 15th.

As it turns out, I opened the Science Times section of The New York Times this morning — it is entirely devoted to helping consumers decipher the new health care legislation from both a policy and clinical standpoint; I highly recommend checking the whole section out on line if you can’t pick up a copy. And, lo and behold, there’s an excellent article entitled “Mental Health Experts Applaud Focus on Parity”. The focus is two-fold: the mental health care parity laws that will go into effect this July, providing that coverage for mental health treatments can be no more restrictive than for medical and surgical treatment; and how health reform will amplify these new parity laws to the benefit of those who need treatment for mental illnesses.

See related post on Obama administration rules for a single deductible.

The Healthy Outcomes Partnership is planning mental awareness events throughout the week of May 10th. Dr. Brad Sachs, author of The Good Enough Teen, will be talking Thursday evening, May 13th.  Please take our survey so that we make sure we cover the right topics.

I finally got around to reading Louis Menand’s article on psychiatry in the March 1, 2010, The New Yorker. The article covers the same ground, though much more comprehensibly, that many of my recent posts (also Jan. 13, Jan. 6 ) have–kicking off with a review of Gary Greenberg’s Manufacturing Depression (2010).  It is a worthwhile read.  Menand asks all the questions we’ve been asking, and if he leaves us with any point of view it is that “science will never answer them.”

Do not read the psychiatric literature. Everything in it, from the science (do the meds really work?) to the metaphysics (is depression really a disease?), will confuse you. There is little agreement about what causes depression and no consensus about what cures it. Virtually no scientist subscribes to the man-in-the-waiting-room theory, which is that depression is caused by a lack of serotonin, but many people report that they feel better when they take drugs that affect serotonin and other brain chemicals.

Other books covered in the article:

• Irving Kirsch’s The Emperor’s New Drugs (2010)
• Christopher Lane’s Shyness (2007)
• David Healy’s The Antidepressant Era (1997)
• Andrea Tone’s The Age of Anxiety (2009)
• David Herzberg’s Happy Pills in America (2008)
• Jerome Wakefiled and Allan Horwitz’s The Loss of Sadness (2007)
• Peter Kramer’s Against Depression (2005) and Listening to Prozac (1994)
• and older books from the 50s and 60s.

As I read my way through the article, I found myself often agreeing with the skeptical point of view, but I had to kick myself back awake.  Mental illness is real.  Bad things can happen.  People’s lives get destroyed.  The fact that there is energetic debate within and outside the industry shouldn’t lead people to the conclusion that these diseases are not real and shouldn’t be treated with the best tools available.

As a branch of medicine, depression seems to be a mess. Business, however, is extremely good. Between 1988, the year after Prozac was approved by the F.D.A., and 2000, adult use of antidepressants almost tripled. By 2005, one out of every ten Americans had a prescription for an antidepressant. IMS Health, a company that gathers data on health care, reports that in the United States in 2008 a hundred and sixty-four million prescriptions were written for antidepressants, and sales totalled $9.6 billion.

What a successful [drug trial] typically shows is a small but statistically significant superiority (that is, greater than could be due to chance) of the drug to the placebo.  So how can Kirsch [in The Emperor's New Drugs] that the drugs have zero medicinal value?

His answer is that the statistical edge, when it turns up, is a placebo effect.  Drug trials are double-blind: neither the patients (paid volunteers) nor the doctors (also paid) are told which group is getting the drug and which is getting the placebo.  But antidepressants have side effects, and sugar pills don’t.  Commonly, side effects of antidepressants are tolerable things like nausea, restlessness, dry mouth, and so on.  (Uncommonly, there is, for example, hepatitis; but patients who develop hepatitis don’t complete the trial.)  This means that a patient who experiences minor side effects can conclude that he is taking the drug, and start to feel better, and a patient who doesn’t experience side effects can conclude that she’s taking the placebo, and feel worse.  On Kirsch’s calculation, the placebo effect—you believe that you are taking a pill that will make you feel better; therefore, you feel better—wipes out the statistical difference.

One objection to Kirsch’s argument is that response to antidepressants is extremely variable. It can take several different prescriptions to find a medication that works. Measuring a single antidepressant against a placebo is not a test of the effectiveness of antidepressants as a category. And there is a well-known study, called the Sequenced Treatment Alternatives to Relieve Depression, or STAR*D trial, in which patients were given a series of different antidepressants. Though only thirty-seven per cent recovered on the first drug, another nineteen per cent recovered on the second drug, six per cent on the third, and five per cent after the fourth—a sixty-seven-per-cent effectiveness rate for antidepressant medication, far better than the rate achieved by a placebo.

Kirsch suggests that the result in STAR*D may be one big placebo effect. He cites a 1957 study at the University of Oklahoma in which subjects were given a drug that induced nausea and vomiting, and then another drug, which they were told prevents nausea and vomiting. After the first anti-nausea drug, the subjects were switched to a different anti-nausea drug, then a third, and so on. By the sixth switch, a hundred per cent of the subjects reported that they no longer felt nauseous—even though every one of the anti-nausea drugs was a placebo.

Later studies have shown that patients suffering from depression and anxiety do equally well when treated by psychoanalysts and by behavioral therapists; that there is no difference in effectiveness between C.B.T., which focusses on the way patients reason, and interpersonal therapy, which focusses on their relations with other people; and that patients who are treated by psychotherapists do no better than patients who meet with sympathetic professors with no psychiatric training. Depressed patients in psychotherapy do no better or worse than depressed patients on medication. There is little evidence to support the assumption that supplementing antidepressant medication with talk therapy improves outcomes. What a load of evidence does seem to suggest is that care works for some of the people some of the time, and it doesn’t much matter what sort of care it is. Patients believe that they are being cared for by someone who will make them feel better; therefore, they feel better.

In 1980, the F.D.A. required that anxiety medications carry a warning stating that “anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic.” The anxiety era was over. This is one of the reasons that when the SSRIs, such as Prozac, came on the market they were promoted as antidepressants—even though they are commonly prescribed for anxiety. Anxiety drugs had acquired a bad name.

The position behind much of the skepticism about the state of psychiatry is that it’s not really science. “Cultural, political, and economic factors, not scientific progress, underlie the triumph of diagnostic psychiatry and the current ‘scientific’ classification of mental illness entities,” Horwitz complained in an earlier book, Creating Mental Illness (2002), and many people echo his charge. But is this in fact the problem? The critics who say that psychiatry is not really science are not anti-science themselves. On the contrary: they hold an exaggerated view of what science, certainly medical science, and especially the science of mental health, can be.

Progress in medical science is made by lurching around. The best that can be hoped is that we are lurching in an over-all good direction.

The DSM lists only disorders—clusters of symptoms, drawn from clinical experience—not diseases. Since people manifest symptoms in an enormous variety of combinations, we get a large number of disorders for what may be a single disease.

Depression is a good example of the problem this makes.  A fever is not a disease; it’s a symptom of disease, and the disease, not the symptom, is what medicine seeks to cure.  Is depression—insomnia, irritability, lack of energy, loss of libido, and so on—like a fever or like a disease?  Do patients complain of these symptoms because they have contracted the neurological equivalent of an infection?  Or do the accompanying mental states (thoughts that my existence is pointless, nobody loves me, etc.) have real meaning?  If people feel depressed because they have a disease in their brains, then there is no reason to pay much attention to their tales of woe, and medication is the most sensible way to cure them.  Peter Kramer, in Against Depression (2005), describes a patient who, after she recovered from depression, accused him of taking what she had said in therapy too seriously.  It was the depression talking, she told him, not her.

Depression often remits spontaneously, perhaps in as many as fifty per cent of cases; but that doesn’t mean that there isn’t something wrong in the brain of depressed people.

Depression is episodic. It starts and stops. Then starts again. Kramer argues that is progressive, and episodes worsen (deepen) over time.

In the case of mood disorders, it is difficult to find a test to distinguish mental illness from normal mood changes. The brains of people who are suffering from mild depression look the same on a scan as the brains of people whose football team has just lost the Super Bowl.

Given the current scanning technology, and where and how we choose to look.

Science, particularly medical science, is not a skyscraper made of Lucite. It is a field strewn with black boxes. There have been many medical treatments that worked even though, for a long time, we didn’t know why they worked—aspirin, for example. And drugs have often been used to carve out diseases. Malaria was “discovered” when it was learned that it responded to quinine. Someone was listening to quinine. As Nicholas Christakis, a medical sociologist, has pointed out, many commonly used remedies, such as Viagra, work less than half the time, and there are conditions, such as cardiovascular disease, that respond to placebos for which we would never contemplate not using medication, even though it proves only marginally more effective in trials. Some patients with Parkinson’s respond to sham surgery. The ostensibly shaky track record of antidepressants does not place them outside the pharmacological pale.

At the bottom of column 15, in a 18 column article, we have arrived at the most important part of the article for me. I hope everyone reads this far.

Many people today are infatuated with the biological determinants of things. They find compelling the idea that moods, tastes, preferences, and behaviors can be explained by genes, or by natural selection, or by brain amines (even though these explanations are almost always circular: if we do x, it must be because we have been selected to do x). People like to be able to say, I’m just an organism, and my depression is just a chemical thing, so, of the three ways of considering my condition, I choose the biological. People do say this. The question to ask them is, Who is the “I” that is making this choice? Is that your biology talking, too?

Yes, your biology, and your psychology, and your philosophy talking.

The decision to handle mental conditions biologically is as moral a decision as any other.

The recommendation from people who have written about their own depression is, overwhelmingly, Take the meds! It’s the position of Andrew Solomon, in The Noonday Demon (2001), a wise and humane book. It’s the position of many of the contributors to Unholy Ghost (2001) and Poets on Prozac (2008), anthologies of essays by writers about depression. The ones who took medication say that they write much better than they did when they were depressed. William Styron, in his widely read memoir Darkness Visible (1990), says that his experience in talk therapy was a damaging waste of time, and that he wishes he had gone straight to the hospital when his depression became severe.

Don’t hesitate to ask someone for help.

Jane Brody reports today on body dysmorphic disorder.

A pioneering researcher, Dr. Jamie D. Feusner, and his colleagues at the David Geffen School of Medicine at the University of California, Los Angeles, recently found patterns of brain activity in people with B.D.D. that appeared to differ from those of others. The differences showed up in areas involved in visual processing. The more severe the symptoms, the more the person’s brain activity on imaging scans differed, on average, from normal levels, the researchers reported in the February issue of The Archives of General Psychiatry.

Winona Ryder, in Girl Interrupted, says “Crazy isn’t about being broken, or swallowing a dark secret. It’s you, or me, amplified…”  This is one of the difficult things about mental illness.  Symptoms range across of a broad continuum from mild to extreme, and it is easy to read an article like this and dismiss it by thinking everyone does that, or everyone feels this way.

In an interview, Dr. Phillips described how crippling the disorder can become for those who spend hours in front of a mirror trying to “fix” their “ugly hair” or disguise a facial blemish only they can see.

But when you re-check and re-lock your front door ten times on your way out of your house, or when your depression persists for two weeks, or when, as in this example, you spend hours in front of a mirror looking at your face, then the behavior is impacting your day to to day life and you should consider asking for help.  Crazy is about more … compulsion, rumination, obsession … “it’s you, or  me, amplified.”

Also today, Dr. Richard Friedman, muses on self-defeating behavior.

What was striking about this intelligent and articulate young man was his view that he was a hapless victim of bad luck, in the guise of unfaithful women and a capricious boss; there was no sense that he might have had a hand in his own misfortune.

I decided to push him. “Do you ever wonder why so many disappointing things happen to you?” I asked. “Is it just chance, or might you have something to do with it?”

His reply was a resentful question: “You think it’s all my fault, don’t you?”

Now I got it. He was about to turn our first meeting into yet another encounter in which he was mistreated. It seemed he rarely missed an opportunity to feel wronged.

Perhaps there is a hidden psychological reward.

The American Psychiatric Association found itself in this position when it included a category for self-defeating patients in an earlier version of its Diagnostic and Statistical Manual of Mental Disorders.

Partly in response to social and political pressure, the notion of masochistic character has disappeared from the manual altogether, even though the behavior is a source of considerable suffering and a legitimate target for treatment.

March 19th, The New York Times Deborah Sontag reports on Haiti’s mental health system after the earthquake.

The foreign psychiatrists emphasize that they have found Haitians to be impressively resilient, but the disaster has nonetheless set off reactions ranging from anxiety through psychosis. Most worrisome are cases like that of Guerda Joseph, a 41-year-old woman who tumbled into a catatonic depression shortly after she was pulled from the rubble of her home. Mute and nearly immobilized ever since, she lies on floral sheets at the General Hospital, her Bible tucked beside her pillow, her 25-year-old adopted son by her side day and night.

More common, though, is what Dr. Lynne Jones, a child psychiatrist and disaster expert with the International Medical Corps, calls “earthquake shock,” a persistent sensation that the earth is still shaking, which makes the heart race and causes chest pain.

“This is an understandable response, and it’s important to let people know, ‘You are not crazy,’ ” Dr. Jones said. “I use a kind of metaphor: ‘Your body has a very effective fire alarm. One of the reasons you’re alive today is that it went off during the earthquake. You ran out of that building. Great, you survived. Unfortunately, the fire alarm is now sensitive and goes off when you don’t want it to, or maybe it never shut off.’ ”

An earthquake offers extreme examples of how mental illness takes hold and progresses. This analogy of a fire alarm, that doesn’t shut off, is a useful way to think about anxiety and panic in our lives.

The New York Times Contributing Family Writer Lisa Belkin discusses everything a parent may want to to read about in her Motherlode Blog.  Subjects are culled from the news, from her own experience as a parent, from the latest books and studies and from reader input.  Of interest to readers of BernardsVoices.org, Belkin’s most recent post discusses depression and suicide ideation in teens, precipitated by yesterday’s article in the NYT about three recent student suicides at Cornell University.

A key difference between ordinary teen angst and depression is how long the “angst” lasts and the effect this mood has on the teen experiencing it. For example, if a young person’s mood seems to be affecting his or her ability to engage in family and school activities and peer relationships and is coupled with physical symptoms such difficulty eating and/or sleeping for a period of at least two weeks or longer, it is worthwhile to seek outside help.

Please see the attached flyer for this great event which will help to bring awareness to Bipolar Disorder.

There will be a reception for the 3 Y’s Guys (Paul Kiell, Martino Caretto and Doug Munch) on Tuesday, March 16th from 12:30 – 2pm  at the Somerset Hills YMCA in the main level multi-purpose room.  If you’d like to attend, please RSVP to jpascarella@somersethillsymca.org.

If you would like to contribute to Swim for Richard, details are on the attached flyer.

Bill, I think I’ve found the answer to your question regarding Whiskey emulsification.  Check out the Single Cask section on this page. It appears that the “Reduction” process adds traces of oil to the whiskey, which makes it cloudy if/when water is added to the whiskey. However, the Scottish manufacturers filter out the oil. But as a result some of the flavor is lost.   So, if you want the real thing, you’ll have to go to Scotland and get it before it’s bottled for export.   It’s not because they add Glycogen, as you were suggesting, although apparently this has been done by unscrupulous manufacturers.   Here is a short PDF file distributed by a company called “Leco” which makes Gas Chromatograph Mass Spectrometers.   The PDF details how the mass spectrometer can be used to determine if whiskey has been “adulterated” by the addition of Glycogen and Propylene Glycol (see Figure 3).  Propylene Glycol?!?!? Isn’t that antifreeze? Phooey!!!!!

– Telly

Community Hope invites individuals with disabilities, mental health consumers, family members, mental health professionals, health care professionals, disability providers and the general public to our Annual Mental Health Forum “Maximizing Advocacy: Exploring and Pursuing Avenues for Change”, featuring keynote speaker Shauna Moses, Associate Executive Director of NJAMHA. Forum to be held Friday May 21st 9:00am-3:30pm at the Morris County Public Safety Training Academy, 500 West Hanover Ave, Parsippany, NJ.  For registration and other information visit the Events page at www.communityhope-nj.org.

The Bernards Township Planning Board is having a Master Plan review on Tuesday night, March 16th at 7:30pm in the courtroom of the Municipal Building.  Public comment is encouraged.

The Master Plan is relatively quiet on the quarry.  The content, quoted below, is basically lifted unchanged from the 2003 Master Plan.  In 2003 that brevity may have been appropriate.  But six years later, as quarry operations have basically stopped, we will soon be stuck with a big hole in the ground.

Most of us agree that there are health (eg. ground water, Passaic river watershed) and safety issues (eg. someone falling, drowning) that have to be dealt with.   My personal belief, although some may argue with this, is that the township is in the best position, ultimately, to properly manage those issues.  We can’t rely on a homeowner association or private landowner to take proper care for the long term.

The Master Plan states their goal, in relation to the quarry, is to “preserve open space,” but why not expand that a bit to say something like “preserve open space, protect citizens health and safety …”? We all know the risks, and we all feel this is a very important issue.  What is gained by ignoring the issue?  Lodging those concerns in the Master Plan will give weight and support to future arguments in regard to the eventual quarry rehab plan, etc.

Please come join me at the meeting. Or you could send me an email, or comment here, and then I can pass on your concerns to the PB.

Relevant sections in current master plan draft:

On page 7:

I. Goals and Objectives Element
Section: Non-Residential Development

6. Future uses for the quarry that can preserve open space and protect the Long Hill ridgeline should be explored.

On page 23:

II. Land Use Element
Section: Mining District

This district encompasses the existing Millington Quarry lands where an active Quarry operation continues. In recognition of the future conversion of this use to a residential end use after Quarry operations cease, low-density residential development is intended in this area, at a density of 1 unit per 2 acres. The Quarry District accounts for slightly over 1% of Bernards Township’s land area.