Antidepressants and Suicide: A History

Do antidepressants prevent suicide, or do they cause it?

Yes.

Well, maybe.

It's a no-brainer, right?  People who commit suicide are depressed.  Take away the depression, and how better than with an anti-depressant, and you decrease the risk of suicide.

So what's with the question?  Here is the story:

History of Antidepressants

How To Tame Your Mind -- Ruby Wax

It's like training a dragon, only harder.

Ruby Wax nails depression: when your personality leaves town, and suddenly you are filled with cement.

She nails the problem: our brains don't have the band width for the 21st century.  Nobody's brain does.  Yours doesn't, either.

And she nails the solution: learning how to apply the brakes.

Andrew Solomon on Depression

I want to be Andrew Solomon when I grow up.  Only briefer.  And funny.

In the absence of blood tests, people with depression have words.  And Solomon has a lot of them.

Solomon's book The Noonday Demon: An Atlas of Depression sits by my bedside. I'll get through it someday soon, because I want to tell potential publishers that Prozac Monologues is Noonday Demon, only briefer.  And funny.

Solomon went around the world to report how the world experiences depression.  Yes, he found it everywhere.

Last week when I told my doctor I was going to Costa Rica, he asked if I would feel better there.  You know what? People in Costa Rica get depression, too.  Hard to imagine, I know.  But it's true. They have psych wards and therapists and ECT and everything in Costa Rica.  I have a card for a psychiatrist in San Jose, just in case.

Return to the Chemistry Experiment

What is it like, this chemistry experiment, you ask.  Somebody did ask, honest.

Prozac Monologues strives to be journalism, not journaling.  I write for education (mine first, then yours), not for therapy.  So when the story turns to the Chemistry Experiment, a topic I write about so often, it gets its own label, I have tried to season my prose only lightly with my personal story.

But the Chemistry Experiment has been excruciatingly personal these last several weeks.  And nowadays, the personal story is one way that journalists frame their reporting.  So here goes.

Looking Under the Hood - A Better Depression Diagnosis?

Corrected July 7, 2013

Maybe my writer's block is an Ecclesiastes issue.  There is nothing new under the sun.

But finally, there is.  No, not the DSM.  Keep reading.

The DSM. Sigh.

But regarding the DSM, and it makes no difference at all which edition, you have to wonder when somebody who is suicidal, losing weight, irritated at the drop of a hat and can't sleep gets the same diagnosis as somebody else who is immobile, gaining weight, couldn't be bothered about anything anymore and sleeps the night and day away.  It's all depression -- the DSM's junk drawer.

Finally, somebody thought to sort the junk drawer, by looking inside the brains of these two sorrowful souls, both taking the same meds for God's sake.

PET Scans - Looking Under the Hood

Helen Mayberg and her team at Emory University School of Medicine used PET scans to look under the hood (to use John McManamy's favorite metaphor).  PET scans use a radioactive tracer to determine where glucose is being used in the brain, i.e., what part of the brain is busy.

More on Mood Charts

This is my personalized mood chart.

You can find a larger and clearer image here. It was inspired by the one my mental health insurance provider sent me when I began taking mood stabilizers. Last week I described how their chart works and how people with mood disorders benefit from using any of the great variety out there.

Cigna's chart primarily tracks mood. Using theirs, I learned that lamotrigine made a difference to the course of my symptoms. After years of inappropriate prescriptions of antidepressants, I had moved to rapid cycling. No, rapid cycling means several cycles in a year. More like, I was spinning, from the depths of depression to raging agitation within each week, week after week. Lamotrigine did modify that pattern. It stretched the cycles, down from four to two a month. By recording the pattern, eventually I concluded, and I had the evidence to support it to my doctor, that the costs of the medication (dizziness, fourteen hours of sleep and grogginess a day, losing words) outweighed the benefits.

More Than Mood

But Cigna's chart was missing vital information. Mood dysregulation was only part of my experience. It was the agitation, sense of urgency, poor concentration, lack of sleep that put me on the disability roles. And, I began to suspect, these disturbances in energy levels were driving my suicidal thoughts as much as my depression was.

Mood Charts Revisited

Mood chart is one of the top search terms that bring people to Prozac Monologues. I wrote about mood charts in July, 2010, first as a recovery tool and later as a way to illustrate the differences between various mood disorders. Both posts promised sequels, promises that remained unfulfillable until now that I have spent several months doing cognitive remediation at Lumosity.com. Maybe cognitive remediation is worth another post -- later.

Following last week's tale of misdiagnosis and mistreatment, this week's long delayed return to mood charts seems timely.

What is a Mood Chart

Hypomania Goes To A Blog Party

The American Psychological Association is throwing a blog party.  Today!!  Why didn't anybody tell me about it until today?!  Maybe because they have heard about me and parties?

I didn't know about me and parties.  I didn't figure it out until I discovered I have bipolar II.  -- Not bipolar I.  Everybody knows about that kind of crazy.  Bipolar II is -- well, you never know what you're going to get.  Sometimes what you get makes you the life of the party.  Sometimes in a good way.  Sometimes it makes you crazy productive and successful at work.  That is why it years and years to get a bipolar II diagnosis.  Nobody goes to the doctor because they feel great, are having fun, and are the apple of the boss's eye.

Sometimes the family member knows about the evil twin.  But chances are, the doctor doesn't ask the family member.

Grief/Depression IV - Not the Same/Maybe Both

So a woman goes into the doctor's office, three weeks after her husband died. I got through the funeral just fine. But now I feel awful. There is this ten ton weight on my chest. I'm exhausted; I don't have the energy to wash the dishes. I'm trying to pack up my husband's things, and I am too weak to pick up his shoes. I can't eat. Sometimes I get hit so hard with this wave of anxiety, I think I'm going to throw up.

What are the chances the doctor will say, Of course you feel awful. These are all very natural symptoms of grief. You just need time. But if you still feel like this a month from now, call my nurse and set up an appointment. What are the chances the doctor will not pull out the stethoscope and listen to her chest?

Answer: It depends on whether the doctor is stupid.

Or a psychiatrist.

These are classic symptoms of heart disease. There is significant overlap between the symptoms of heart disease and the experience of grief. But there is no Bereavement Exclusion for a diagnosis of heart disease. Instead, family physicians and cardiologists take the time to examine whether the person presenting these symptoms may have both.

Grief/Depression III - Telling the Difference

Once, when I was seriously under and still headed down, a friend said to me, There have been times in my life when I was sad, so sad I couldn't imagine being any sadder. But it seems that what you and others with depression are describing is a whole different level that I know nothing about.

See, that's what would be helpful, instead of, I know just how you feel. I remember when [fill in the significant loss]... I knew that he knew times of deep sadness, because I knew some of those times, and because he is a person is thinks and feels deeply. And listens deeply. Everyone should have such a friend.

It was Social Hour. We were in a corner to protect me from all those people being social. I leaned against a wall, because I was very tired. I guess the wall gave me the idea. I said, Yes, there are times I have been so sad I couldn't imagine being sadder. It's like the sadness became a wall I could lean against, because I was so tired. But Depression IS different. Imagine if the wall gives way. Imagine there isn't a limit. You lean and the wall gives way.

Grief/Depression II - Rise in Rates of Mental Illness

Are we really getting sicker?

A New York Times article, When does a broken heart become a diagnosis? sells papers with its usual technique - latch onto a fringe element and substitute good writing skills for substantive analysis.

I am all for good writing skills, and perhaps stumble in the same direction at times. But depression is my beat. So God willing and the brain permitting, I am going to beat this bit to the ground. Two weeks ago I discussed three contexts for the discussion, the cost of health care, the scientific value of the DSM and the hobby horse of the author featured in the Times article. I promised more contexts to come.

Are We Getting Sicker? - Context IV

James Wakefield's thesis is that we are turning natural human emotions, (the ones we want to get rid of, because they are unpleasant), into a diagnoses. His beat is depression, as well, but the Times is on this bandwagon with autism and no doubt other diagnoses to come.

Well, I grant some validity to the concern in general. Is it shyness or Social Anxiety Disorder? Is it artistic nonconformity or Attention Deficit Hyperactivity Disorder? Is it the sleep disruptions of normal aging or Overactive Bladder Disorder? Was it all those wings, doritos and beer you guzzled Superbowl Sunday (and most Sundays), or Gastroesophageal Reflux Disease?

Grief? Depression? Both?

The New York Times reports this week on a proposed change to the definition of depression for the Diagnostic and Statistical Manual (DSM) V. Asking, When does a broken heart become a diagnosis? it raises the specter that normal grief at the death of a loved one could be classified as a psychiatric disorder.

An estimated 8 to 10 million people lose a loved one every year, and something like a third to a half of them suffer depressive symptoms for up to month afterward, said Dr. Jerome Wakefield, author of The Loss of Sadness. This would pathologize them for behavior previously thought to be normal.

Okay, before we get our knickers in a twist -- oops, too late. Knickers in a twist is the current US national pastime. Nevertheless, there is a larger context here. Several, in fact.

DSM Context I - Follow The Money

Prozac Monologues - How It Began

First conceived as a stand up comedy routine, birthed as a book, morphed into a blog, on August 29, 2011 Prozac Monologues came full circle at Happy Hour at the Pato Loco, Playas del Coco, Costa Rica.  This was the very spot where in January 2005, the book was originally written over the course of eight heavenly (my wife wouldn't use that word), hypomanic days.  Micah pulled out his laptop.  Patricia set it up on top of a bar stool.  And I held forth.

You can hear a bit of our little beach town's rush hour in the background.  So here is the text:

Prozac Monologues - How It Began

2004 was not a good year for me.  My doctor tried to make it better by prescribing Prozac for major depression.  Only Prozac didn't make it better.  So she prescribed more Prozac.  And that made it so much more not better that I concluded the only way I could describe how much more not better would be a stand-up comedy routine.  And thus was planted the seed for what has become Prozac Monologues.

So I went off Prozac, and on January 25, 2005, I boarded an airplane for Costa Rica, armed with a yellow legal pad and a ball point pen. 

Hypomania In Action

For eight days in beautiful, tropical Costa Rica, my wife went to the beach, explored neighborhoods, visited with family, tried new foods, while I wrote.  And wrote.  And wrote.  When I filled up one side of the yellow legal pad, I wrote on the back.  When I filled up the back, I wrote in the margins.  When I filled up the margins, I wrote between the lines.

I came home with seven chapters.  Two weeks later, the book was done.

I told my doctor about my book and maniacally writing it.  That word maniacally raised a red flag.  So she screened for bipolar.  She said, Are you manic?

I said what anybody who thought she was Jesus Christ come back as Jessica Christ might have said, I'm not manic.  I'm excited!

Oh.  Okay.  So she prescribed the second antidepressant, and began what will have to become a new book, but I haven't recovered enough to write it yet.

Was I manic?  No, I was hypomanic.  But I didn't know that word.  And maybe you don't know it either.  So I submit for definition and for evidence the first four pages of

Prozac Monologues

by

Willa Goodfellow

Chapter One

Bizarre: In which I decide to write a book

Okay, let's start with the basic Prozac dilemma.  Just who is the crazy one around here?  If, after you read the morning paper, you are happy, content, secure, at peace, able to get up, go out and carry on your activities of daily living, full of confidence and a sense of purpose, then tell me -- are you pathologically delusional?

Or are you on Prozac?

Citizens of the United States of America (called Americans and thereby hijacking the identities of thirty-eight other nations in the Western Hemisphere -- Remember Canada?  Every heard of Paraguay?) make up 5% of the population of the planet and consume 24% of its energy resources.  We spend more on trash bags than the gross national product of 90 of the world's 130 nations.

What was that?

We spend more on trash bags than the whole gross national product of 90 nations.

So who is the crazy one around here? 

The Crazy Delusion 

We get such a sliver of time to enjoy this wildly extravagant planet, and we spend precious moments of it, watching couples on TV compete for cash prizes on the basis of how many maggots they can eat. 

Until the maggot-eating is interrupted by somebody who wants to sell you an air freshener that uses an electronically operated fan to circulate chemical compounds around your living room to make you think you are out of doors. 

The fan is the latest advance in civilization which will enable you to stop feeding your Shiatsu little treats, which you previously had to do to get it to wag its tail to disperse the chemical compounds around your living room. 

So now you have to take Prozac, so you can get yourself up off the sofa where you have been sitting in a semi-catatonic state, watching the maggot-eating and dog-treating, out of your pajamas and into your four-wheel drive SUV, which you were compelled to purchase after viewing those commercials of SUV’s climbing over mountainous terrain beside raging rivers,

But which you happen to use to commute an hour and forty-five minutes on some freeway to work in a cubicle with a picture of mountainous terrain and raging rivers and some motivational caption underneath, so you can buy the air freshener with its self-contained and electrically-operated fan that disperses the chemicals that make you think you are out of doors, because you wouldn’t want actually to go out of doors – the air is so nasty from the fumes of your SUV.  Who is the crazy one around here? 

And don’t even get me started on the taxes you will pay from your job in your cubicle to fund somebody’s research into that missile that can shoot another missile out of the sky, to protect us from the bad guys who can bring down two 100-story buildings armed with the equivalent of a Swiss Army knife.  If it’s your job to figure out how to shoot that missile out of the sky, stop taking Prozac and go do something else to do with your life.  Or just go back to your sofa.  Please. 

Okay, now I sound like Michael Moore.  Let’s just call this the Crazy Delusion, a concept not original to me, and of which you can think of your own examples, so I don’t need to continue this rant which is not really the point of this book, but only the context of our consideration of the title of its first chapter.

In short –

It’s hard to know whether depression is a problem of distorted thinking or the result of clarity. 

In either case, sitting on the sofa in your pajamas does not turn the economic engine of this great nation, no matter what you’re watching.

Except for the pharmaceutical industry’s economic engine.  They keep making money, as long as they are able to sell you images of people who are happy and confident, popping their Prozac, (nowadays it’s Abilify), which you really start to believe when you’re still sitting on that sofa, watching those images over and over and over again. 

Ads For Antidepressants

Have you noticed how all the ads for antidepressants run during the afternoon soaps?  (If you are not depressed, you haven’t noticed, because you’re off at work, turning that economic engine.)  No, those pharmaceutical guys know where to find their audience, and when, on the sofa, in our pajamas, in the middle of the afternoon. 

Now I’m talking to you, the one in the pajamas.  You thought you might get up and go for a walk, like you promised your sweetie (who has gone to work) that you would.  But here it is, two o’clock in the afternoon.  The recap of yesterday’s episode comes on, and before you can find the remote to turn it off after the last soap, that theme song begins.  It sounds inspirational, but for some reason, you start to cry. 

After the theme song, and before the start of today’s episode, it’s time for that gentle, compassionate voice, who lists all your symptoms, including another one you have, now that the voice mentions it, but up until now you didn’t realize that it also is on the list, so you must be even sicker than you thought.  Who is that voice that understands you so well, better than your doctor, it seems, and so must know exactly what you need to ask your doctor to prescribe.

Symptoms Of Depression

Here is that list, by the way: sadness (no duh!), sleep disturbance (too much, too little ) weight gain (or loss), lack of energy, loss of interest in the things you used to like to do, loss of motivation (hence, all that time on the sofa), slowed pace, poor memory, poor concentration (they don’t want you at work anyway – you might break something), loss of self-confidence (like, they really don’t want you at work – you might break something), guilt, feelings of worthlessness, suicidal thoughts or attempts.

If you have been sad or lost interest in things for at least two weeks, plus four of the others, I’m talking about you.  You and 12% of the population who will experience an episode of depression sometime in their life (that’s major depression), plus another 6% who just feel lousy all the time (that’s dysthemia), and another 6.4 who sometimes are way up and sometimes way down (that’s bipolar), or …

One in twenty people in any given month.

When you have so much company, how is it you feel so alone?

You are not alone. 

Prozac Monologues 

photo of Playas del Coco by Helen Keefe, used by permission

photo of trash bags by Yuyudevil, in public domain

photo of Cubicle Land by Larsinio, in public domain

photo of prozac by Tom Varco, used by permission

photo "Loneliness" by graur razvan ionut

Dopamine and Dementors

Dementors are among the foulest creatures that walk this earth. They infest the darkest, filthiest places, they glory in decay and despair, they drain peace, hope, and happiness out of the air around them... Get too near a Dementor and every good feeling, every happy memory will be sucked out of you. If it can, the Dementor will feed on you long enough to reduce you to something like itself...soulless and evil. You will be left with nothing but the worst experiences of your life.

-- Remus Lupin to Harry Potter

Harry Potter and the Prisoner of Azkaban

Been there?

While we wait with bated breath for the final episode of the Harry Potter movie series, here is a post on the neuroscience of Harry's worst nightmare.

Dementors, you see, are dopamine depleters.  They are not to be messed with.

Neither is any other kind of dopamine depletion.  Here is one clinical case, an experiment conducted on one highly-functional, never-a-whiff-of-mental-disturbance 21-year-old who received a dopamine depleting drug over the course of 25 hours.

The Future is Bright -- For Whom?

The Future is Bright for Psychopharmocology Breakthroughs --

Okay, I'll bite.

I subscribe to an online journal Psychiatric Times.  Or at least, I have access to the articles for which there is no charge.  I don't get paid for this, you know.  Anyway, I get emails that link to the articles of the week.

So that was the subject line on the email dated 4/21/11, The Future is Bright for Psychopharmocology Breakthroughs.

This I'd like to know about.

Inside the email was a link to Novel Treatment Avenues for Bipolar Depression: Going Beyond Lithium, by Roger S. McIntyre and Danielle S. Cha.

This I'd really like to know about.

The article was not what I had been led to believe.  But I learned a lot, will share some of that with you, and explore the miscommunication at the end. 

Treating Bipolar Disorder Part IV -- Summing Up

Intending to review Ellen Frank's Treating Bipolar Disorder, I spent most of April describing the treatment itself, Interpersonal Social Rhythms Therapy, IPSRT.

Part I laid the foundation in work done on the relationship between circadian rhythms (our interior physiological clocks) and mood disorders.

Part II outlined Frank's Social Zeitgeber Theory and the treatment that proceeds logically from it, a process of establishing regular daily rhythms that set our interior clocks and keep them running on time. (Zeitgeber means timekeeper.)

Part III explained how work on interpersonal issues helps people reduce stressors and prevent disruptions to their social rhythms.

This last post will pull together my appreciation, my reservations and my hopes for future directions.

Social Zeitgeber Theory

Treating Bipolar Disorder Part III -- The Interpersonal Therapy Part

Lately I have been reviewing Treating Bipolar Disorder by Ellen Frank -- the recommendation of a friend who is researching hypomania. Part I described the basis of Interpersonal Social Rhythms Therapy (IPSRT) in circadian rhythms that control the many physiological symptoms of mood disorders. Part II outlined the Social Zeitgeber Theory and described the early stages of the therapy process, history taking and stabilizing social rhythms. Today I pick up with the later stages, interpersonal therapy and maintenance.

Interpersonal Social Rhythms Therapy came to Ellen Frank in an epiphany on her birthday, July 14, 1990. Personally, I like that. I especially like that it was the day that she participated in a conference for people with bipolar, and listened to them.

Frank and her colleagues were already using interpersonal therapy for people with recurrent unipolar depression. Their theory was that certain life events, particularly losses could result in lost social zeitgebers, (timekeepers), with subsequent disruption of circadian rhythms, leading to eventual relapse into another episode of depression.

IPSRT took up from there as an adaptation specifically for people with bipolar disorder, integrating the work on issues (as in, you've got issues) with greater focus on behavioral changes to achieve and maintain daily rhythms, time of rising, time of first human contact, work, main meal, etc. The purpose of IPSRT is to help people achieve stability and then to avoid relapses into either depression or mania/hypomania. 

Why Do People Relapse?

Treating Bipolar Disorder Part II -- The Social Zeitgeber Theory in Action

So you have bipolar.  You know you have bipolar.  You are way past the denial stage.  You are into the pulling out your hair, screaming with frustration stage.  Or maybe moved on to despair stage.  Because:

1. The medication sucks.
2. You keep getting sick again anyway.
   

But contrary to what everybody has been telling you, medication is not the only thing that works.  It may be essential to your recovery and continued functioning.  But you can do better if you do more.  From my last post:

IPSRT [Interpersonal Social Rhythms Therapy] is one of three psychotherapies tested by the National Institute on Mental Health in its recent major study of best practices for treatment of bipolar disorder.  The Systematic Treatment Enhancement Program for Bipolar Disorder, STEP-BD discovered that Patients taking medications to treat bipolar disorder are more likely to get well faster and stay well if they receive intensive psychotherapy.

Do I have your attention?  Today we continue with Ellen Frank's Treating Bipolar Disorder, in which she describes this therapy of her invention.

What Happens In IPSRT

Treating Bipolar Disorder Part I -- Interpersonal Social Rhythms Therapy

Medication And Mental Illness

Medication for mental illness is just like medication for anything else.  It works better when you don't ask it to do all the work itself.

In the case of bipolar, once lithium and the chemical imbalance theory came along, the thinking was that medication was the only thing that worked.  Therapy by itself certainly didn't.  I wonder if therapists, worn out by their bipolar patients, were simply relieved to believe that medication was the only thing that worked.  I wonder if therapists today, worn out by their recurrent depression patients, are secretly relieved to terminate when the diagnosis changes to bipolar, because medication is the only thing that works.

Frankly, there is a lot of wishful thinking out there in pharmacotherapy land.  If only our brains were a chemical stew and the illnesses of the brain could be treated by adjusting the recipe.  If only.

But people with mental illness, especially people with bipolar, can't afford the wishful thinking behind the better living through chemistry fantasy.  Sometimes the medications do work.  But not as well nor as often as your doctor would like to think.

I have a friend who is a psychiatrist.  He challenges his colleagues who keep trying to solve this noncompliance issue, to get their patients to comply.  He reminds them, if the medication (antidepressants, in this example) worked for 40% of those who took it in the trial, and the placebo worked for 30%, that means only three out of ten people benefit from the medication itself.  So what's the big deal about seven who quit?

He says they just look at him funny.

Treating Bipolar Disorder by Ellen Frank

This same friend, God bless him, loaned me a book about a psychotherapy designed specifically for bipolar disorder titled, appropriately enough, Treating Bipolar Disorder.  The author Ellen Frank, professor of psychiatry and psychology at the University of Pittsburgh School of Medicine and director of the Depression and Manic Depression Prevention program at Western Psychiatric Institute and Clinic, and her colleagues invented Interpersonal Social Rhythms Therapy (IPSRT), a kind of mash-up between talk therapy and regulating circadian rhythms.  It gets my next few posts.

In A Nutshell... 

IPSRT [is] a treatment that seeks to improve outcomes that are usually obtained with pharmacotherapy alone for patients suffering from bipolar I disorder by integrating efforts to regularize their social rhythms (in the hope of protecting their circadian rhythms from disruption) with efforts to improve the quality of their interpersonal relationships and social role functioning.

It's Not Stigma -- It's Prejudice and Internalized Oppression

Stigma sticks to the persons stigmatized.  And sure enough, we are stuck.  Every time we repeat the word, we reinforce it.

Here is an idea.  It's not stigma.  It is prejudice and internalized oppression.

We gotta do something new, people.  We're dying out here.

Treatment For Mental Illness -- The Streets Or Jail

Ever since John Kennedy promised us more humane, community-based treatment for mental illness, we have been living on the streets.  Somebody with serious mental illness is four times more likely to be homeless than somebody without.

Or in jail.  On any given day, there are roughly 283,000 persons with severe mental illnesses incarcerated in federal and state jails and prisons.  In contrast, there are approximately 70,000 persons with severe mental illnesses in public psychiatric hospitals, and 30 percent of them are forensic patients.  Los Angeles and Cook County jails are the largest inpatient mental health facilities in the country.

No Respect=No Money=No Help

Does anybody out there live in a state where funding for mental health services is not being slashed?  Wasn't being slashed even before the last elections?

Now that we are talking money, how is this for a reality check on what we are worth -- from John McManamy's blog Knowledge Is Necessity:

In 2009, the NIH allocated $3.19 billion for HIV/AIDS research.  By contrast, research for depression (including bipolar) was a mere $402 million.

Million, not billion.  These are ratios that have held fairly steady over the years.  Approximately 1.5 million individuals in the US are affected by HIV or AIDS.  About 19 million in the US in any given year deal with depression or bipolar.  That translates to the NIH spending $2,013 per patient for HIV/AIDS research vs a paltry $21 per patient for depression and bipolar.  Putting it another way, for every dollar the NIH invests in an HIV/AIDS patient, depression and bipolar patients get one penny. [emphasis added]

Kinda puts things in perspective.

Funding By Death

But AIDS is fatal.  What about spending per death?

The number of deaths of persons with an AIDS diagnosis has stabilized in recent years at around 17-18,000 per year.  (Deaths of persons with an AIDS diagnosis may be due to any cause).  Since the beginning of the epidemic, an estimated 597,499 people with AIDS have died in the U.S.  Again, that does not mean they died of AIDS.  The figure includes heart attacks, cancer, accidents, suicide, etc.

In contrast, the Center for Disease Control reports that 34,598 people died by suicide in 2007.  We are pushing 900,000 deaths by suicide in the same period as the 600,000 people with AIDS who died for whatever reason.

But people with AIDS are now living longer.  Today, for every death of a person who has AIDS, two people die by suicide.  Far from stabilizing, the suicide rate has been rising since 1995.  [Side note: so much for that claim that increased antidepressant use caused the rate to go down.  There are more of us on them now than ever, and more of us dying anyhow.]

Depression is not the cause of suicide in all cases.  Research indicates that 90% of those who die by suicide have a mental illness.  That 70% have a mood disorder is a low ball estimate.  But that would yield 24,218 deaths by suicide among persons with mood disorders.

So the NIH spends $for 187,647/year for every death of a person with AIDS and $16,599/year for every death of a person with a mood disorder.

Oh, it's not so bad after all.  If we look at death rates, the disparity is down to $11 for somebody who has AIDS and dies by any cause to $1 for somebody who dies from depression.


Feelin' all warm and gooey inside now. 

No Political Price To Pay

Here is the politics at work.

The Ryan White Act was enacted in 1990 and named after a twelve-year-old who was kicked out of school because he had HIV/AIDS.  The act provides funding of last resort for poor people with HIV/AIDS and technical assistance to state and local organizations dealing with HIV/AIDS.  This is on top of the NIH research funding.

The money is not much, just over $2,000,000.  But it has held its own in the last decade, with modest increases every year until 2010.  Up for expiration in 2009, it was renewed by unanimous vote in the Senate and 408 aye/9 nay/15 abstaining in the House.

Now I am totally in favor of the Ryan White Act and the amount is stingy.  But I ask you to consider, do people with mental illness have anything like the Ryan White Act?  And can you imagine a legislator who thinks there will be any political price to pay for the cuts he/she is voting right now to services for people with mental illness, or for teaching laws enforcement how to handle mental health emergencies?

We could run the numbers for other diseases.  Breast cancer would reveal similar results.  Please, please understand me.  We are not on different sides here.  The AIDS example is especially valuable because we can draw lessons from what AIDS activists have accomplished. 

Stigma Busting Is A Bust

The problem is that people don't think of mental illness as real illness, right?  The solution is more education about the biological basis for mental illness, right?

No, not so much.  Researchers at Indiana University and Columbia University examined changes in understanding and attitudes in the US between 1996 and 2006.  Education has indeed increased understanding that mental illness is a biological condition.  54% of people knew that about depression in 1996, 67% in 2006.  Let's give the pharmaceutical companies some credit for their share, probably the lion's share of that change.

On the other hand, do they want to work with, socialize with, marry or live next door to us?  Nope.  Those numbers did not budge in the same time frame.  More telling for the task of designing stigma-busting strategies, there is no difference in attitudes between those who know that mental illness is biological, and those who do not.

In fact, those who understand the neurobiological basis for depression are more likely than those who do not to think that we pose a danger to them.

I'll kill 'em.  I swear, I'll kill 'em.  Just as soon as I can get out of bed.

What we are doing against stigma -- it's not working, folks.

How come?

Evidence-Based Stigma Busting

A study from the University of Kent in Cambridge, UK uncovered one flaw in typical stigma-busting efforts.  To bottom line it, how the listener responds depends on who the speaker is.

When allies (such as doctors or family members) make positive statements about people with mental illness, they are less credible than when people who have a mental illness speak for ourselves.  They is a word that doesn't cut it in stigma-busting, regardless of intention or attempt at sensitivity.  The authors cite previous research regarding other stigmatized groups showing that positive statements about them can be perceived as patronizing. 

This Is Good News

1. We were never worth much and now are worth less.

No, I mean it.  This is good news.  As my therapist used to say, The facts are friendly.  These are the facts, and they will be our ammunition.

2. We can do better.  In fact, the bar is set pretty low.

3. We have others, even among us, who have fought prior battles and can point the way.

Next week we take advocacy to the next level.


 

photo from La Brea Tar Pits by 3scandal0 and in the public domain

photo of homeless vet by Matthew Woitunski and used under the Creative Commons Attribution 3.0 Unported license

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photo of Ryan White taken by Wildhartlivie and used under the GNU Free Documentation License
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photo of Thomas Insel, director of NIMH in public domain