Manifesto of a Lab Rat -- Weighing the Costs and Benefits Part I

I Am A Lab Rat.  Yes, I am.

Here is the deal.  I was lucky enough, and you were lucky enough to be born after the discovery of penicillin (1928).  Well, I don't know when you were born.  But evidently penicillin was discovered before it became a life or death issue for either of us, or I wouldn't be writing and/or you wouldn't be reading Prozac Monologues.  This is good.

In another age, my ruptured appendix might have been treated with leeches.  That would not have been good.

As far as my more immediate health challenge goes, we are barely out of the leech stage.  Okay, that's a bummer, the timing of my life, that is.  But like I said, ruptured appendix, penicillin.  It could have been worse.

Research Into Mental Illness -- Rats

In the treatment of mental illness, they have figured out that leeches don't work.  They think chemicals might. They just haven't figured out which ones.  They are working on it.  They have lab rats, rattus norvegicus to be specific, who do the heavy lifting in this Chemistry Experiment.  Some people question the ethics of what gets done to these poor rattus norvegicuses who participate with not a single informed consent form in sight.  But that not only is another post, it is another blog.

Mood Charts -- Why Bother?

Last week I discussed two barriers to using mood charts, the complexity of some charts and the life styles of those with mood disorders.  I also suggested strategies to overcome these barriers.  Perhaps today's post should have come first.  Given the difficulties -- why bother?

The chart I use is here, the same destination linked to Mood Charting on the left side of the blog, under RESOURCES ON MENTAL ILLNESS.  The second page puts my remarks in context.  The first page was written for doctors.  This post will make all that verbage user friendly.

So let me tell you about my experience and why I am still at it.

The essential point is to understand your illness better, so you can manage it better.  These are things I have learned from my chart:

Language in the Clinician's Office

This week I return to my favorite theme -- the power of language.  Those of us who have a mental illness deal with the power of language every day.  Notice I didn't call us the mentally ill.  Language forms who we are in this world.  It underpins the terms of our treatment.  It structures how we pay for our treatment.  Diagnosis is where language meets money.  And money is power, power over our lives.

Reframing is a process of becoming conscious of the power of language.  This is a standard tool in Cognitive Behavioral Therapy.  The term is used in a variant of CBT called Neuro-Linguistic Reprogramming (NLP).

PTSD: The State of Treatment

This is the second part of a series on Post Traumatic Brain Syndrome.  Let me recap last week and expand on what we know about the neurobiological mechanisms (how the brain works) of PTSD, and then discuss treatment strategies.

When something stressful happens, the brain prepares the body for action.  The hypothalamus, pituitary gland, amygdala, locus ceruleus and opioid system all release hormones to speed up respiration, raise blood pressure, reduce sensitivity to pain, all useful conditions for the proverbial fight or flight.

Under normal stressors, as soon as these hormones are released, feedback systems go into operation.  The hypothalamus tells everybody else that their job is done and they can back off.

These hormones, especially cortisol, damage brain structures, notably the hippocampus, whose job is to regulate emotion and to perform the "that was then, this is now" function.  I named it that, and am very proud of it.  My own brain has almost no "that was then, this is now" function.  Pretty much zip.

PTSD and the DSM: Science and Politics -- Again

Several weeks of what I call "swiss cheese brain" interrupted my series on PTSD.  Now with a couple posts in reserve and a two week cushion, I am trying again.  To get us back on the same page, here is a (tweaked) reprint of March 28, a history of the issue in the Diagnostic Statistical Manual and current context, to be followed by PTSD: The State of Treatment, and then PTSD: Hope for Prevention.

With the ongoing war in Iraq, Post Traumatic Stress Disorder -- PTSD is much in the news nowadays.  We can expect that to continue.

Nancy Andreasen, author of The Broken Brain, traces the social history of this mental illness in a 2004 American Journal of Psychiatry article.  The features of what we call PTSD have long been noted in the annuls of warfare.  More recently, in World War I it was called shell shock, and those who had it were shot for cowardice in the face of the enemy.  In World War II it was recognized as a mental illness and called battle fatigue.  Afflicted soldiers were removed from the front and given counseling designed to return them to battle within the week -- though there is one infamous story about General Troglodyte Patton who, while touring a hospital, cursed and slapped one such soldier for his "cowardice."

The DSM I, from the post-WWII era, recognized battle fatigue as Gross Stress Disorder.  It was removed from the DSM II in the early 1960s , when U.S. society was not regularly confronted with this cost of war.

National Blog Post Recyling Day -- I Am Not SAD

"In order to do my part for Earth Day, I am participating in a new national celebration in conjunction with Earth Day called “National Blog Post Recycling Day.” Other than the sentences you are reading now, I will be posting no “new” content on my blog today. Grab your lap top, your smart phone or your iPad, sit under a tree and enjoy some digital recycling."

From April 12, 2009 -- I Am Not SAD

What month has the highest rate of suicides in the northern hemisphere? What about the lowest? You will find the answer at the end of this post.

PTSD and DSM: Science and Politics -- Again

With the ongoing war in Iraq, Post Traumatic Stress Disorder -- PTSD is much in the news nowadays.  We can expect that to continue.

Nancy Andreasen, author of The Broken Brain, traces the social history of this mental illness in a 2004 American Journal of Psychiatry article.  The features of what we call PTSD have long been noted in the annuls of warfare.  More recently, in World War I it was called shell shock, and those who had it were shot for cowardice in the face of the enemy.  In World War II it was recognized as a mental illness and called battle fatigue.  Afflicted soldiers were removed from the front and given counseling designed to return them to battle within the week -- though there is one infamous story about General Troglodyte Patton who, while touring a hospital, cursed and slapped one such soldier for his "cowardice."

The DSM I, from the post-WWII era, recognized battle fatigue as Gross Stress Disorder.  It was removed from the DSM II in the early 1960s , when U.S. society was not regularly confronted with this cost of war.

OMGThat'sWhatTheySaid! -- They

"We are more alike than we are different."  That was the first thing they wrote on the whiteboard at my Peer to Peer class.  And that was the first thing I wrote in my new notebook.  I had a sense that a revolution was coming.  But I didn't know yet what it was.

The next week we introduced ourselves by how we are different, our differential diagnoses.  We were Mary Obsessive Compulsive Disorder, Frank Bipolar, Sarah Borderline Personality Disorder, Peter Bipolar Antisocial Schizoaffective Disorder ("But I'm not so sure the schizoaffective part is right"), James Schizophrenia, Anna Major Depressive Disorder, Henry Bipolar Alcoholic, Willa Major Depressive Disorder ("But I wonder about Bipolar II").  Of course, I have changed the names.

The power of naming -- the third week we sorted out our seating arrangements.  That wasn't part of the class.  It just happened, when we entered the room and chose our seats.  The OCDs sat with the OCDs.  The Mood Disorders sat with the Mood Disorders. Interestingly enough, those with Schizophrenia did not sit together.  They dispersed themselves among us Mood Disorders.

DSM 5 and Mood Disorders, Part III -- The Way Forward

 

Lost Creek Wilderness 

I have been writing about the newly released draft of the Diagnostic and Statistical Manual -- DSM V for the last few weeks.  Let's recap:

The DSM V -- What's at Stake: The pharmaceutical and health insurance industries have a huge financial stake in who gets diagnosed with what in the mood disorder section of the Diagnostic and Statistical Manual.  This stake has skewed the new draft version of the DSM to support the status quo/current market conditions.

The DSM V made almost no changes in the Mood Disorders section.  (Well, a few, not so minor for children and the bereaved.)  This despite the evidence that the current criteria for bipolar II exclude people who are instead diagnosed with recurrent unipolar depression, but who get much worse when treated as though they had recurrent unipolar depression, and who eventually are diagnosed with bipolar II anyway, if they are still alive.  Women spend eleven years on average before being diagnosed correctly.  That's eleven years of a lot of suffering on a lot of antidepressants.  One helpful modification in the bipolar II area will become important below.

The Draft DSM V -- How Did We Get Here?: Advances in the treatment of  depression have come about by serendipitous discoveries, followed by pharaceutical companies' desires to improve their own market share.  These have been genuine advances.  However, their manipulation of research to support their products is a national disgrace.  The AMA is finally embarrassed by it.

That is where last week's post left us, at Mile Marker #3 in "Up a Creek Wilderness" -- the sorry state of research on this map that is owned by the pharmaceutical companies.

So now we have arrived at:

Goose Creek Trailhead

Mile Marker #4 -- Their goose is cooked.  They have run out of product.  There are lots of ideas out there besides the tired old "chemical imbalance/neurotransmitter" fixation on one aspect of depression.  And research is being done on other neurological mechanisms of depression.  But Big Pharma got lazy and has been slow to develop these ideas into useful medications.

Patents have expired on almost all the antidepressants on the market today.  The sleight of hand trick is to repackage the same medication by altering its formulation a little bit (Celexa/Lexapro, Effexor/Pristiq) or by doing a time-release version to add a few years to the patent (Paxil CR, Wellbutrin XL).  But that strategy has a time limit, and lack of development has caught up with these companies.

I think Eli Lilly's new product Symbyax is the ultimate in failed strategies, combining the patent-expired Prozac/fluoxetine (originally used for major depression) with the newer and controversial Zyprexa (originally used for psychosis and lately the subject of successful lawsuits).  If it really were a good idea, you could get the same results with two prescriptions, the antidepressant that worked best and an antipsychotic less dangerous than Zyprexa, instead of the two products owned by Eli Lilly.  With the combination package, you get the side effects of both: sexual dysfunction, agitation, akathisia, insomnia, etc. for Prozac and ballooning weight gain, high blood sugar, risk of diabetes, high cholesterol, tardive dyskinesia, etc. for Zyprexa.

Nevertheless Symbyox will make Eli Lilly a bit of money for a while, because it has widened the market for Zyprexa.  They need another market since that successful lawsuit reduced its use among older people with psychosis (who experience a rather nasty side effect of death from Zyprexa's off-label use for dementia.)  Symbyax now is also indicated for people with treatment-resistant depression, whose doctors need to keep coming up with something new to give them. God forbid they should reexamine the diagnosis, or that the DSM V should encourage them to do so.  People with treatment-resistant depression account for half of the depression market, the half that stays on the market, because they "keep trying," like everybody tells them they should.  So good luck, Lilly.  I hope you are in court again soon.

That's Mile Marker #4.  And it makes me as depressed as Mile Marker #3 makes me mad.

Mile Marker #5 -- It turns out that we have been traveling in a circle, and now looped back to the beginning.  This is where I find the good news.

We have another serendipitous discovery!  Lamictal was first used as an anti-convulsant.  Following the pattern of other advances in the treatment of depression, Lamictal's mood-related effects first became apparent in people with epilepsy.  Happy seizures. -- Though unlike previous medications, Lamictal works just fine for its original purpose, as well.

Lamictal (generic name lamotrigine) is now approved for use in managing seizures and bipolar I.  Its off-label uses include bipolar II and treatment-resistant unipolar depression.  (When a doctor prescribes a medication for something that it hasn't been approved for, that's called "off-label" use.)

This "off-label" use issue is critical here to advance the treatment of depression, especially for those who are misdiagnosed (using DSM V guidelines) with unipolar depression.

The rules regarding marketing of off-label use are in flux.  Currently, sales representatives may not recommend their products for off-label use, but they may direct doctors to research about such use. They may not, however, pay doctors to tell other doctors about their experiences with off-label use, at continuing education conferences and the like.  That's what got Pfizer busted, for their marketing of Geodon, another anti-psychotic like Zyprexa, while searching for their market share of dementia and depression.  The money in these cases generally goes to Medicaid and Medicare, who paid for the prescriptions.

See, there's a swamp out there between Mile Marker #5, the next serendipitous discovery and:

Mile Marker #6: Ca-ching! Ca-ching! -- that huge new money-making machine.

Doctors prescribe medications for off-label use all the time.  Drugs that have been tested and approved only for adults are tried on children.  Otherwise, there wouldn't be anything they could give to kids, because who wants to risk clinical trials on kids?  Drugs approved for one type of cancer are tried for another, because who wants to say "no" to somebody whose cancer has metastasized?

Off-label use gets turned into approved use if it works out in new clinical trials.  If it doesn't work out, it goes away.  That's the way it's supposed to work.  But if the trials don't work out, and the drug companies fudge the data and market the medication anyway, then they get sued.

My doctor told me that Lamictal is the "go-to drug" for bipolar II, evidently very common off-label use.  I don't know how she knows, whether she read the research, whether the medical journals have been flooded with articles commissioned (or maybe not) by GlaxoSmithKline, whether she heard about it from other doctors who are on (or maybe not on) GlaxcoSmithKline's payroll, or whatever.  It is also on the top of her list for treatment-resistant unipolar depression.  I am not expressing doubt about Lamictal's effectiveness.  I am simply explaining how off-label use works in clinical practice.

So we are currently at Mile Marker #5.  Now we start climbing that hill to #6.  Just like they did with tricyclics and SSRIs, everybody is asking, "How does Lamictal work?"  They think it has something to do with calcium, but I won't go into that here.

The answer to the "how" question is particularly important to the other pharmaceutical companies, because they will use the answer for a grab at their market share, by trying to improve on the side effect profile.

Lamictal's side effect profile isn't so bad, as far as mood stabilizers go.  It is light years better than Lithium, which is beyond nasty, but desperate people take it, because it has been their only relief.  Lamictal also is not so bad compared to antidepressants.  It causes fatigue, headaches, muscle pain, but not in as many people.  Its big drawback is this pesky rare (but potentially fatal) skin rash.

Potentially fatal.  Wow.  Now, one in 500 people get this rash, and all you have to do to get rid of it is stop taking the drug.  I am not sure why this rash is the major concern about the medication.  Except there is no denying the cause.  Antidepressants cause suicidal ideation and behavior at a much higher rate than Lamictal causes rash.  But try to prove it in your case.  You already have a disease that carries a risk of suicide.  And even on the antidepressant in question, it might be that your disease is simply progressing.  You are as likely to get your dose increased as discontinued.  And you will not get your day in court.  Lamictal causes some kind of rash in 1 of 10.  But even if your rash is caused by the new soap you are using, looks nothing like the bad rash, and even if you are free from suicidal thoughts for the first time in a decade, you get yanked off Lamictal.

So here is an excellent opening for other companies, to come up with something with no rash, or even a rash that only one in 1000 get.  We can expect other mood-stabilizers to reach clinical trial stage in the near future.  Ca-ching!  Ca-ching!

Mile Marker #7:  At that point, interests will align, of the pharmaceutical companies and those who have been misdiagnosed because of the not-yet-published but already dated DSM V.  The pharmaceutical companies are looking for Ca-Ching! Ca-Ching.  And depressed people are looking for better medications.  We finally reach the operation of the free market system.  This is the United States of America.  Fortunately for depressed people, there are enough of us to make it profitable to treat us.

The fly in the ointment is the DSM V.  It does loosen restrictions on the diagnosis of bipolar II a bit.  The DSM IV said that a hypomanic episode brought on by antidepressant use does not count as a real hypomanic episode, and the person has unipolar depression -- suggesting to more conservative doctors that they keep looking for a better antidepressant.  The DSM V says that an episode brought on by antidepressant use is a real hypomanic episode, with a diagnosis of bipolar II -- pointing doctors toward mood-stabilizers.

So the task of the drug reps will be to direct doctors to the research demonstrating:

• more than half of those with severe depression eventually are diagnosed on the bipolar spectrum;
• incredible harm is done to these patients when given antidepressants;
• therefore these depressed patients might benefit from receiving a mood-stabilizer from the very beginning of treatment, particularly the mood-stabilizer of which the drug rep happens to have samples.  

The true conservative treatment course might be to treat all depressive people with mood stabilizers, unless the doctor has time to sort between those with genuine unipolar depression (presenting their first episode and no history of anything that looks even slightly like hypomania) and those who have recurrent depression (or "cycling" depression), especially when Lamictal and future mood-stabilizers have better side effect profiles.  First do no harm.

Never mind what the DSM V says.

If the meds work, if they increase their makers' market share, then the pharmaceutical companies will continue to find ways to do their own education of doctors, including education in how out of touch the DSM V is with clinical practice.  These same market forces will make irrelevant the DSM's refusal to define a diagnosis for pediatric bipolar.  If the meds work, children may receive a nonsensical diagnosis, but they will also receive the appropriate medication.

Mile Marker #8:  Now all hell breaks loose with health insurance and HMOs.  They depend on the DSM for billing.  But the gap between the DSM and clinical practice in mood disorders will be so wide that case reviews and billing procedures will fall apart.  Doctors will either code according to the DSM and treat according to reality, or code according to reality and ignore DSM criteria.

But our health care delivery system is already broken, and will collapse anyway, long before we reach Mile Marker #8.

 

sign at Goose Creek Trailhead photographed by Steven Bernard

in public domain

photo of Lamictal by Parhamr and in the public domain

money bag from Microsoft clipart

"Book Burning" is licensed under the  Creative Commons Attribution 2.0 Generic license.

DSM 5 and Mood Disorders, Part I -- What's at Stake

Earlier this month, the American Psychiatric Association released the long awaited proposed revision of their Diagnostic and Statistical Manual of Mental Disorders (DSM-5).  It is available now for public comment, with an anticipated publication date for the final version in May 2013.  To call this the Bible of Mental Illness is to overestimate the significance of the Bible.


The DSM was first written to give clinicians and researchers a common vocabulary and a common understanding of the various diagnoses of mental illness.  John McManamy has related this history on his blog Knowledge is Necessity.  I refer you to his thorough account, found in the links at the bottom of his post. -- [Hey, John -- I recognized your image for "Few Surprises."  It was one that I considered for this post!]

The way the DSM works always reminds me of a Chinese menu.  For example, if you have one symptom from Column A and at least five from columns A and B, for over two weeks, you have Major Depressive Disorder.  You can upgrade your core diagnosis with specials offered alongside the basic menu.  These lists of symptoms provide a common vocabulary and simplify diagnosis, so that family practitioners commonly diagnose depression and prescribe antidepressants, without referral to psychiatrists.  This practice provides a boon to the pharmaceutical industry, which markets heavily to family practitioners.  If patients had to see a psychiatrist to get a prescription, fewer people would take antidepressants, since there is greater stigma attached to treatment by a psychiatrist, psychiatrists are in short supply in many parts of the country anyway, and health insurance plans provide inadequate coverage for psychiatric care. So family practitioners prescribing for depression sells more antidepressants.  Big Pharma wants to keep the DSM simple.

Over time, even as therapists have become more eclectic in their therapies, the sequence of DSMs has more narrowly defined the illnesses which therapists treat, adding more specificity.  The DSM gives a numerical identifier for each diagnosis, along with decimal points after the numbers to indicate variations and severity.  Health insurance companies rely on the DSM to determine coverage.  If you don't have a number, you don't get reimbursed.  But they have become concerned about the multiplication of diagnoses, raising the number of claims.  Health insurance companies want to limit the number of diagnoses and limit the number of people diagnosed.

Release the Kraken!!

Well, it's one of those weeks in a remitting/recurring disease. "Release the Kraken!" -- my favorite line from Clash of the Titans, a 1981 movie to be remade and released this summer.  Oh, you gotta check out that link to the trailer!

My apologies to regular readers who are looking for a new post.  It's an interesting one, Shadows.  Maybe I will be able to write it next week.  Come to think of it, the image on the right would fit that post, too. (Anonymous, in the public domain for copywrite expiration). For now, here is a reprint from last July:

What is Depression, Anyway?

When I thought the meds would work, I didn't ask this question (referring to the title, not the caption!) Depression is a disease of the brain and also of the mind. The best results are obtained by working on both fronts. Take your meds. Talk to your therapist. Simple.

Then I discovered that the meds made me worse. Whenever I say that, I rush to say that, my experience notwithstanding, for most people they work. They can save your life. And then I rush to say, but not for everybody. If you think they make you worse, you might be right.

The rhetoric keeps shifting on this point, depending on what the speaker is selling. I think the current prevailing stats are that the meds help half of us, harm a quarter of us, and for another quarter, they just don't work. And for most of us in any of those groups, the disease does go away on its own anyway, though it leaves its wreckage behind. But that is what I am gleaning from the research. Nobody in the scientific community has summed it up so simply.

Prozac is Talking -- Anybody Listening?

Anybody know this story?  You get a new prescription.  Responsible consumer that you are, you read carefully the PI [prescribing information] sheet.  It says, "If xx happens, call your doctor immediately."  Sure enough, xx happens.  You call your doctor, who does not call back.  After persistent calling over several days, the doc says, "Really?  We'll keep an eye on it."

The other day, I had a nosebleed that wouldn't stop.  The PI sheet says my new med can interfere with platelets, admittedly not very high on the list of side effects.  But I contacted the doc.  "Really?"  she said, "Where did you hear that was a side effect?"  My answer, "On the PI sheet you gave me."  It turned out, my blood work was fine, and the humidifier took care of the nosebleeds.

No harm done.  Right?

On the other hand, five years ago my GP had me on Prozac.  After a couple months, I couldn't sleep, was irritated, agitated, couldn't concentrate, had thoughts of harming myself and others.  The PI sheet said I should tell my doctor.  My doctor increased the dose.

Thus began a series of antidepressants, and a downward spiral that has ended with disability.

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

Holiday Shopping for Your Favorite Normal

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

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

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

Like holiday shopping.

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

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

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

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

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

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

She said, "A cure."

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

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

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

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

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

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

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

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

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

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

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

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

clip art from Microsoft.com

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.

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.

The Chemistry Experiment -- Placebo

Wouldn't you know.  I take a few days off before my placebo post, and wired.com scoops me with Placebos are Getting More Effective.  Drug Makers are Desperate to Know Why, by Steve Silberman 08.24.09.  Well, Steve put a lot more into his article than I intended for mine.  It makes for a fascinating read, about the history and current study of the placebo effect, beginning with its discovery during World War II, when an Army nurse lied to a soldier in pain.  They were out of morphine.  So she told him the injection of saline solution was a potent new pain killer.  And the patient's pain was relieved.  

That story is the essence of the placebo effect.  "When referring to medicines, placebo is a preparation which is pharmacologically inert but which may have a therapeutical effect based solely on the power of suggestion." -- thefreedictionary.com.  

In 1962, the Food, Drug and Cosmetic Act began to require that medications prove their safety and effectiveness against placebos.  One group takes the medication.  Another group takes a placebo, or "sugar pill."  Their rates of improvement and side effects are then compared, to find out whether the medication itself causes the healing, or something else does, like the belief  in the medication, which marshals the body's own healing powers.  

Fast forward to the last decade, when more and more antidepressants have "failed trials," meaning that they perform no better, or not much better than the little sugar pills.  It seems that the new neurological medications are performing just as well as the old ones.  (I think this usually means that within 8-12 weeks, about 30% of people who take them improve their scores on various questionnaires that measure levels of depression.)  But oddly, over time, the placebos are performing better.  Which means the bar that the new meds have to cross to get approved is getting higher.

Depression and the Shackles of Shame

There is no blood test for depression, no x-ray nor sonagram.  Depression is the label that is given to a constellation of symptoms.  There are theories about the cause of the symptoms.  But the diagnosis is more like tea leaves. 


Depression Diagnostic Criteria 

· Lasting sad, anxious, or empty mood
· Loss of interest or pleasure in activities once enjoyed, including sex
· Feelings of hopelessness or pessimism
· Feelings of guilt, worthlessness, or helplessness
· Decreased energy, a feeling of fatigue or of being “slowed down”
· Difficulty concentrating, remembering, making decisions
· Restlessness or irritability
· Sleeping too much, or can’t sleep
· Change in appetite and/or unintended weight loss or gain
· Chronic pain or other persistent bodily symptoms without physical cause
· Thoughts of death or suicide, or suicide attempts.

If you have five of the above, including one of the first two, for more than two weeks, and without appropriate reason (like, your mother died) then that's depression. You've got the Grim at the bottom of your teacup. 

Guilt

I have done enough intake interviews that I recognize the differential diagnostic tree when it's coming at me. I used to get nervous when they asked about guilt. No, I don't actually feel guilt, except appropriate guilt for recent misbehavior, not the horrible self-judgment for imagined offenses. I don't feel guilty for my depression. I am not the offender but the offended.

Shame

No, what I feel about my depression, and events that are related, is shame.  And what I really feel shame about is feeling shame.

I Am Not SAD

What month has the highest rate of suicides in the northern hemisphere?  What about the lowest? You will find the answer at the end of this post. 

Seasonal Affective Disorder

Some people get depressed in the winter.  Along about October or November, they start to feel lethargic.  They want to sleep a lot.  They crave carbs and gain weight.  They may lose interest in their normal activities, not want to see people, feel hopeless, think about death.  The deeper the winter, the sadder they feel.  In April, they start to feel better, regain their energy, and even feel giddy by the time May comes round.  It happens almost every year.

This is a specific kind of Major Depressive Disorder called SAD, Seasonal Affective Disorder.  It is no fun.