6. Prozac Monologues: 2009

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

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.

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.

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.

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

Sunday, October 18, 2009

Taking a Break


Into the life of every over-medicated lab rat, a little downtime must fall.  Prozac Monologues is taking a bit of a break, with apologies to regular readers.  I hope to tinker with the sidebars to add some resources, while not being able to maintain my own writing standards.

Meanwhile, let me once more recommend Knowledge is Necessity for information about the Pharma/Medico/Therapeutic Industrial Complex, and occasional good clean fun. 

Photo credit: Copyleft Attitude http://artlibre.org/licence/lal/en/

Thursday, October 8, 2009

To our Families

To that end, I am going to live with this disease the way Don lived with his. Openly -- I have a mental illness. Actively -- I will answer ignorance with education. Politically-- I will meet discrimination with change. And in community -- I will support and be supported by others who share this illness with me, so that we can survive it together.

I did get to say those words on Sunday night.  

This morning I made a list of all the things you would be reading about at prozacmonologues if only I were able to read more than three paragraphs at a time.  I am tempted to feel badly, especially for all my older readers, who come here expecting to find out about the relationship between nonsense and the anterior cingulate cortex, or Wyeth's research techniques in its effort to get Abilify approved for augmentation in the treatment of major depressive disorder, or "Akathisia: Stop it or Die," or my discourse on the concept of a failed suicide attempt. 

But down, damn ant! [automatic negative thought] You, dear reader, are not reading about all those things because sedation and supervision in lieu of hospitalization is working just fine.  ["Plan?  What's a plan?  Do I have to stand up?"] So I was able to speak my piece on Sunday night, the candlelight vigil that began Mental Illness Awareness Week.

Everybody thinks I am a wonderful speaker, and they told me so and the local paper quoted me, and that was very nice.  But somebody also needs to say that it was possible, not only because God was willing, but because my spouse has turned her life upside down to take care of me right now.  She is negotiating with her workplace, she is working from home, she is attending Family to Family meetings, she represents my interests, she fights my battles, she keeps my meds, she does the dishes, she walks the dog.  She is exhausted.  And she comes home from Family to Family meetings and tells me that there are other families, too.

Mental illness is a family disease.  And when I say that we survive it together, well, family is a very big word.  Some of us become family, because we choose to be.  I am so grateful for four friends who attended that sexuality talk that didn't turn out to be quite what we thought it would be, but instead has become the germ for the Loony Review, by the Not Ready for Discharge Players!  [A potential addition to next year's program?]  We are family because we choose to be, because to not choose to be wouldn't be insane, it would simply be stupid.

But some of us are family because that's how we started out, when we didn't know what it would cost.  The members who do not have the diagnosis, boy, do they still get to have the disease!  And pay the cost.

Some of us who have the diagnosis don't have the capacity or the wit to say it.  I do.  So today I will say what they would if they could.  Thank you.  We owe you our lives. We wish it didn't have to cost you so much.  Sometimes we lie to you, or are mean to you, or even desert you.  And you aren't always right.  And sometimes you DO make it worse.  But mostly we know that we owe you our lives.  Not all of us survive.  But those of us who do, we survive it together.  Thank you.





Thank you, Helen. 



photos in public domain 

Saturday, October 3, 2009

Hello, my name is Willa, and I have a mental illness

I try to post more often.  The last week has been spent in a story so stereotypical that those readers who have or have tried to get disability benefits will find it banal.  And until it has an ending, I can't tell it in Prozac Monologue mode: reflections and research on the mind, the brain, depression and society. I am not reflecting yet.
So I tempt fate with the following.  Si Dios quiere, God willing -- I will say the following at the opening of Mental Illness Awareness Week Sunday, October 4, 6:30 PM, at the Anne Cleary Walkway, University of Iowa Campus, Iowa City, Iowa, a candlelight vigil to remember those who have died from mental illness and to support those who hope to survive it.

Hello, my name is Willa and I have a mental illness.

Hello, I am the Reverend Willa Marie Goodfellow, an ordained minister, an Episcopal priest who has served congregations, campus ministries, and diocesan staff in Iowa for 27 years. And I have a mental illness.

I have major depressive disorder. The mortality rate of breast cancer is 23%. The mortality rate of congestive heart failure is 50%. My disease has a mortality rate of 15%. Of course, if you’re dead, your mortality rate is 100%. If you’re alive, 100% is your survival rate.

There are factors that increase my particular risk of death, how long I have had this disease, the number of episodes, the severity, the anxiety features.

There are factors that decrease my risk. Having strong relationships within a truth-telling community through my church is one of them. A couple weeks ago I returned to a congregation I served in the past, and told them that I am going on disability because my depression has not responded to medication. I knew what would happen. I knew there would be tears. I knew that at the back of the church, while shaking hands, somebody would tell me that he has a mental illness, too. A woman told me that it took thirty-five years for her husband to find a med that finally seems to be working. At coffee hour, somebody else told me about his mother’s antidepressants. 

We are not alone. When I feel crazy because I cannot see this disease, I cannot show you the broken bone, I still know that I am not the only one. I can call on friends who know exactly what this is.

Once I did a funeral for a recovering addict. Well, it was one part funeral, three parts Narcotics Anonymous meeting. After I welcomed everybody, “Hello, my name is Willa and I am a sinner,” and said some prayers, then people told their stories. I will never forget what the convener of the NA group said, “We are celebrating tonight. We won this one. Don died clean and sober.” And ever after I have hoped that somebody would stand up at my funeral and say, “We won this one. Willa died of... natural causes.”

To that end, I am going to live with this disease the way Don lived with his. Openly -- I have a mental illness. Actively -- I will answer ignorance with education. Politically-- I will meet discrimination with change. And in community -- I will support and be supported by others who share this illness with me, so that we can survive it together.

photo by Nevit Dilmen,  Permission granted to copy under the terms of the GNU Free Documentation License

Saturday, September 26, 2009

Loss

John McManamy has been on a theological kick.  So I thought I'd take a turn, it being my profession anyway.

The relationship between GoD and DoG is one of those enduring theological themes.  Here is one contribution to the discussion:



This dog reminds me a bit of my own, named Mazie -- Amazing Grace.  Except there are too many stars in the lower right corner of the constellation, a leg that she lost a long time ago.  Move those stars up to form her crown chakra.  For twelve of her thirteen years, people have watched her run and said, "That's Amazing!" -- the inspiration for her name.

Mazie is a therapy dog.  Not officially, she never received the training.  Now she has renal failure and it's too late.  But everywhere she goes, she finds the person who needs her.  When I took her to visit the shelter for victims of the Iowa floods in '08, she stopped to visit with each one.  After an hour, I was depressed and weary -- the start of my latest relapse.  I thought it was time to go.  But no, she pulled on the leash and told me she hadn't talked with that man who was isolating, sitting by himself under that tree.  And she had to hang around until the Red Cross worker got off shift, to give her some of her grace, too.

People have to ponder a three-legged dog.  After a few years, I stopped making smart remarks to the same question I heard over and over.  I came to realize that through her, people consider their own experiences of loss, and the consequences of loss, and the life she leads without even noticing her loss.

How did she come to be a therapy dog?  We don't know the before story.  We only know the after, the kindness of a farmer who went out of his way for an injured stray, a no-kill shelter that is very picky and does home studies of the people who want to adopt, a vet and staff who treat her as a queen, the strangers who flock to her and, I believe, bring their own need for gentleness to the gentleness with which they approach her.  And she responds in kind.

Will she get her leg back in heaven?  I don't think so.  On earth, the only handicap it causes is that she can't pivot to the right at a full run without falling down.  I think her only wish is that in heaven she will lose the leash, so she can do what she loves to do, to run like the wind in three quarter time.

I knew somebody who was born with a foreshortened arm.  It ended at the elbow, with a stump of a hand.  She always objected when some religious person reassured her that she would be whole in heaven.  She said she was already whole.  And she was.

What does it mean for those of us with mental illness to be whole in heaven?  All of the life experience that makes us who we are includes the experience of mental illness.  Will we lose that?  Who then will we be?

All of the loss in this world -- a friend is reading a midrash of Exodus.  [In Midrash, the rabbis explore the meaning of Scripture through story-telling, expanding and deepening the levels of the text.]  One interpretation of Moses at the burning bush is that he initially refused the call to go free the Israelite slaves in Egypt, because -- what about the ones who were already dead and buried in the walls of the pyramids that they died while building?  Who would let them go?

Will God have an answer to your question?  I don't know that I want an answer.  I want it all, us all to be gathered up, none of it and none of us to be lost.

A psychiatrist tried to reassure me once about Electro-Convulsive Therapy, ECT, saying that usually the only memory loss was of the events immediately preceding the treatment.  And usually people are so unhappy before treatment that they are glad to lose those memories.

It was not a convincing argument.  I don't want to forget.  I don't want to lose any of it.  It is part of me, even the pain.  I guess I want for it to mean something.  I want to be able to ask God to answer for it -- like the Holocaust survivor who insisted that he be buried in his Auschwitz uniform instead of the traditional Jewish winding sheet.  He wanted to stand before the throne of judgment wearing the evidence that would itself say, who is judging whom?

Maybe what I really want, for Mazie, for those lost in the walls of the pyramids, and in the ashes, and for those who are in such pain that they want to lose their minds, for all of us, is to be found.

Tuesday, September 22, 2009

Alive!

Cut the top ten and go straight to the number one reason why Willa Goodfellow should never get herself committed to the psych ward:


I suck at arts and crafts.

I didn't used to.  I used to produce Christmas cookies and gingerbread houses that made adults and children alike respond, "Oh! My! God!" -- though not the way this cake does.  I used to make big gingerbread houses.  No kits. and no showing off with royal icing and special decorating tips (which might have improved this cake, if I had been able to find them).  I used Golden Grahams for shingles, individually placed sprinkles on the door wreaths, graham bears ice skating in the yard, pretzels for fences.  I made Dr. Seuss-like trees out of marshmallows and gummy savers, M&M's for roofing material, or maybe candy-canes for the Swiss chalet touch -- those were a bitch to hold in place until the frosting glue dried.  Once I used peanuts to construct a fire chimney.  All color coordinated.  I must have made thirty of those suckers, and each an original masterpiece.

Then I took Prozac.  And Celexa, and Cymbalta, and Effexor.  And part of my brain has never come back.  I think the part that departed included the "good taste" part.  Also the "give a damn what you think" part.

This cake and the guerilla party I held in the hospital lobby to celebrate the 45,000,000 people at risk for suicide who will survive it, the same hospital whose psych ward I hope never to call home, definitely come out of the "Prozac Monologues" spirit.  So does the grammar of that last sentence.

This one, I am submitting to cakewrecks.com.  So, Elaine, (a friend who happened by the party and was speechless) you can go ahead and say it.  Yes, I know.

Some people actually do get it.  One of the guests was a psychiatrist who laughed along when I bemoaned having thrown away all the meds I have stopped using over the course of the Chemistry Experiment, so that I was reduced to Smarties and Mike and Ike for decorating material.

So...

"I have a dream. Okay, technically it's a fantasy." [Elmont, Doonesbury]  That when people who survive self-injury are transferred from ICU to the psych ward, they will be greeted with a cake.  That when they get home, there will be a party, just like the party that will greet my friend who just made it through colon surgery.  A quiet party, befitting the energy level of the guest of honor.  But a party with a guest of honor, for having survived this latest round with a disease that has a 15% mortality rate.  I have a fantasy that people who survive self-injury, or manage to avoid it altogether, will be treated like people who survive breast cancer.

I have a fantasy that next year the Psych Department itself will host the party for Suicide Prevention Week, with both Emergency Room workers and the patients, out on a pass, sharing the honor.  For sure, the hospital-catered cake will look better. 

Sunday, September 20, 2009

To Survive

To all of us who are surviving treatment resistant depression.



I’m coming up only to hold you under
I’m coming up only to show you wrong
And to know you is hard and we wonder
To know you all wrong we were
Ooo Ooo

Really too late to call so we wait for
Morning to wake you is all we got
To know me as hardly golden
Is to know me all wrong they were

At every occasion I'll be ready for the funeral
At every occasion once more is called the funeral
Every occasion I am ready for the funeral
At every occasion one brilliant day funeral

I'm coming up only to show you down for it
I'm coming up only to show you wrong
To the outside, the dead leaves, they are alive
For'e (before) they died had trees to hang their hope
Ooo Ooo

At every occasion I'll be ready for the funeral
At every occasion once more is called the funeral
At every occasion I am ready for the funeral
At every occasion one brilliant day funeral

by Band of Horses

Wednesday, September 16, 2009

Ten Plagues

I dreamed about ants this morning.  Little black ants, covering every surface.  Gnats, too -- so thick I had to breathe them.  There was some kind of family gathering going on, pretty much oblivious to the ants and the gnats.

I woke up and thought -- the ten plagues.  [See Exodus, the second book in the Bible.  The Prince of Egypt was based on it.]  Then I remembered, last month in Costa Rica I woke up one morning from a dream and thought -- the ten plagues.  I don't remember which plague that one was.  Frogs?  Blood?  It wasn't the deaths of the first-born.  I would remember that, being one myself.

I get these dream series every so often.  For a couple years before I went back to school, I dreamed about vehicles that broke down.  The tire went flat, the axle broke, the runner fell off the sled... The first couple years of my current episode, I dreamed of a young man.  I thought his name was Steve.  I thought he was my depression, though he didn't like it when I called him that.  He always felt threatening in some way.  Then I took a leave of absence from work and learned to work with my dreams.  And in the end, he was always helpful.

I don't remember ever having a series of good dreams.  Why is that?

This morning I told Helen about my dream.  Helen is a spiritual director, and her favorite thing is dream work.  She said, "If you have a bad dream and do dream work with it, you allow it to be instructive and productive, grace-filled and gift.  If you don't do dream work with it, it will continue to feel like just a bad dream."

That proved true with Steve.  So I did a bit of work.  I carried the story forward.  I wonder which plague comes next.

Let this woman go!
photo in public domain

Friday, September 11, 2009

Suicide Prevention Cake

Okay, I know.  It's supposed to read Suicide Prevention Week.  I had a post all written, an attempt at a thoughtful response to an exerpt from Nancy Rappaport's book, In Her Wake: A Child Psychologist Explores the Mystery of Her Mother's Suicide.  I found it on Knowledge is Necessity, one of my favorite blogs to follow.

But before I ever heard about Suicide Prevention Week, I gave the topic a whole month just last June.  And I do recommend that you look at those posts, especially the ones that refer to David L. Conroy, "Suicide is not a choice.  It happens when pain exceeds resources for coping with pain."  Those two sentences open his book, Out from the Nightmare, help to make sense of a topic that people would rather hold at a distance, and give a simple program for suicide prevention.  Reduce pain and/or increase resources.

So after I did my best at one more profundity, I thought again, really, how should one mark Suicide Prevention Week?  It occurred to me, why not celebrate it?  According to Conroy, "Five million people [in the United States] now alive will die by suicide. Twenty-five million more are, or will become, suicide attempters. Suicide has been, or will be, seriously considered by more than 50 million people." [Out of the Nightmare, p. 280.]

But think about it.  In other words, 45,000,000 people now living in the United States are or will at some point be at risk of suicide, and yet their suicides will be prevented.  For the most part, by the people at risk, themselves.  We will keep asking for help until we find somebody who isn't too freaked out to give it to us.  We will take our problems apart, examine them one piece at a time, fix what can be fixed, and either learn to live with or leave behind what cannot be fixed.  We will interrupt a negative thought.  We will get a dog.  We will volunteer.  We will take our meds.  We will stop taking the meds that are making us worse.  We will find a therapist, join a group, speak out against ignorance.  Oh, it's a long list with more ideas here for how to reduce pain, increase resources and remove barriers between.

I propose one more item for the list. We will celebrate our success.  It has been some years since I went to my favorite sushi restaurant for what I thought would be the last time.  So I will go there this week to celebrate how many times I have gone there since and will again in the future. I will bake a cake for a friend to celebrate the number of times that she has prevented her potential suicide.  I will take another friend to coffee to celebrate the number of times that she checked herself into the hospital instead.

Anybody with me on this one? How will you celebrate?  And how will you give yourself cause to celebrate next year?

Tuesday, September 8, 2009

Costa Rica and Depression

This is my breakfast view on the left.  It is called patita, a vine on the edge of my porch.  I planted the seeds myself.  A stranger gave them to me when I admired it in his yard.




If I look to the right, I see "bird of paradise," outside my neighbor's door.
Some friends invited us for drinks and this view at sunset. 
 
Why the hell would anybody be depressed in Costa Rica?

I prepare my answer for friends back in Iowa.  Most of my friends already know the answer, or else are too discrete to ask.  I really just ask myself.  Why the hell am I depressed in Costa Rica.

Five years into studying this disease, it still baffles me.  I know the answer, too, and yet it baffles me.  There are psychiatrists in Costa Rica.  There are psych wards in Costa Rica.  I have seen the boxes of Effexor on the shelf of the pharmacy where I go to buy contact lens solution.  There is even Electro-Convulsive Therapy in Costa Rica.  I have read the brochure.

So there must be depression in Costa Rica.  I am simply one of the people who have it.  There is something about the way that my brain works, as there is something about the way that other people's brains work, that give us this condition that is found across the planet, in every culture, even in a place where plants grow that are called "bird of paradise."

If other people have trouble believing that it is real, why should I be surprised?  I still wake up mornings and think, "This is crazy!  Snap out of it!"

When I packed for my latest trip, I didn't pack enough medication.  Oh, I knew I couldn't get nortriptyline here in the formulation and dosage that I take -- a question I had asked in a previous trip.  So even though they aren't as effective as they used to be, I counted those particular pills carefully.  But the Valium that takes the edge off until my psychiatrist and I can find the next solution, or at least decide on the next chemistry experiment -- well, who would need Valium in Costa Rica?

So last week I found myself in the pharmacy again, asking about Valium.  It is one of the drugs for which you have to have a prescription.  (You don't for Prozac, nor for Viagra, if that might influence your travel plans.)  It turns out that the eighteen year old with the ponytail who was talking with the staff is the doctor.  No, he must be older than eighteen, not a blemish on that beautiful skin.  I went to his office yesterday, where he had his prescription pad, and he was very understanding.  Still not wanting to believe that I take Valium, I kept underestimating how many I would need before I got back to Iowa.  But he convinced me that if I truly had enough, then I wouldn't worry about it.  I had  said that at the pharmacy, that I was worried about it.  He heard me, and he remembered.  For an eighteen year old, he is really good at paying attention.

Then I asked about Lunesta.  I don't take it very often.  Insomnia is not a side effect of my current med.  I just need it when I get caught at night reliving a living nightmare.  I wondered if I could find a cheaper source.  No, they don't have that one in Costa Rica.  But that started a conversation about side effects, insomnia, SSRI's and all those things I think about.  He said they have a different attitude in Costa Rica.  These side effects are terrible, he said.  So they don't use these heavy duty meds like Zoloft, except as a last resort.  First they try psychotherapy, then very small doses of tricyclics.

I know that Prozac became so popular because it was supposed to work better and have less side effects than the older meds that they prefer in Costa Rica.  And I realize a lot of people swear by it.  But I don't get it.  Over time, SSRI's and SNRI's have turned out to be no more effective than the TCA's.  As far as side effects go, maybe fewer people have them with the newer meds -- I don't know.  That's what the drug reps say.  But if you have to choose between hard core insomnia (Prozac/SSRI) and dry mouth (Elavil/TCA), between suicidal impulses (Cymbalta/SNRI) and constipation (Pamelor/TCA), I have experienced them all, and I'm going for the Costa Rican approach.

Meanwhile, back in the world of publishing papers, there is a current buzz about an old idea, that depression serves a purpose for the species.  It may surprise you to know, but not every culture and every time has tried to extinguish the Grim when it rears its head.  The approach of the European Middle Ages was to classify it as one of the four humours, melancholia.  It may cause difficulties when the humours are out of balance.  But there is a place in this world for the melancholic.  We are good gardeners, night watchmen, writers.  Paul Andrews and J. Anderson Thompson argue for Depression's Evolutionary Roots, that it exists because it "is not a malfunction, but a mental adaptation that brings certain cognitive advantages," among them the ability to ruminate, to think carefully about complex issues and solve problems.  That is not the way my therapist talked about rumination.

I will keep reading and thinking about these ideas, because that is one of the things I do.  I ruminate.  So you will find out more about rumination in the coming months.  Meanwhile, I have a new determination to treat my depression, my body, my mind gently, to discover what I can do with what I have been given.  I am not quite ready to call it a gift.  But I am disinclined to poison myself in order to get rid of it.

Costa Rica is a gentle place.  
photos by Helen Keefe