The Road Map For Loonie Liberation

First they ignore you.
Then they laugh at you.
Then they fight you.
Then you win.

This is a preview of next week.  Me -- taking a mental health break.

photo of Mahatma Gandhi in public domain

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

image of red ribbon in public domain

photo of coffins of members of the 101st. Airborne in the public domain

photo of chocolate molten cake by rore and used under the Creative CommonsAttribution-Share Alike 2.0 Generic license

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

Health Policy of Sleep

Pharma/Research/Medicine Industrial Complex

A psychiatrist friend directed me to PharmedOut.org, a  source for all things seedy in medical research, medical education, and the sale of pharmaceuticals.  I don't need to repeat what you already know about ghost writing research articles, how pharma gets around restrictions on bribes by paying doctors to "teach," the sample scam, etc.  I am not spending time this week on what I didn't know until now about the editorial/advertising relationship in medical journals, or that the drug companies are the major subscribers to these journals and give them to doctors, and are the major purchaser of reprints (at inflated prices) to be distributed by drug reps to doctors.  But it is more of the same.  Just thought I'd mention it.

We go round and round about this.  Still, every research article ends with a cry for more funding, which will come from just one source.  Every doctor gets everything he/she knows about medications ultimately from just one source.  Every friend and family member who wants to help repeats the message taught by one source -- Keep trying.  Translation: keep buying drugs.

Addicted To Big Pharma

Sleep -- The Real Antidepressant

Your sink has backed up three times in as many weeks.  This time the plunger won't work, and it's beginning to stink.

The hardware salesman says you need a new garbage disposal -- $169.00.

Your plumber takes the pipes apart and clears the plug.  Depending on the plumber, she might show you how to do it yourself next time.  (My plumber is a woman.) -- $60.00 in my neighborhood.

Your brother says, stop putting banana peels in the garbage disposal.  (My brother owns rental property, and tells me what the plumbers almost always find in the plug.) -- $0.00.

The hardware salesman says a better garbage disposal could handle banana peels, and whatever else might also be causing that plug -- $249.00.

All of them are trying to help.  Each of them is working with the tools at his/her disposal.

Okay, now let's look at your depression.

Remember last week's list?

DSM On Depression -- The Chinese Menu

Why Antidepressants Don't Work

Diagnosing Depression

You go to the doctor complaining that you don't feel like yourself.  You aren't having fun, you are tired, you don't sleep well, you have no appetite and feel pretty worthless about your inability to exercise control over anything in your life.  Sometimes you feel like just ending it all.

Your doc asks whether you have a plan (sometimes you think about how you might do it), if anyone in your family has bipolar (not that you know of) and checks your thyroid and glucose levels.

DSM On Depression -- The Chinese Menu

But before the blood tests come back, your doc has already checked the magic list from the Diagnostic and Statistical Manual of Mental Disorders:

Column A:

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

Column B:

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.

4. Insomnia or hypersomnia nearly every day

5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

6. Fatigue or loss of energy nearly every day

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

Ding, ding, ding.  One from Column A, four from Column B. (Your weight loss has been too gradual to count.)  That is all the doc needs to write out a prescription for an antidepressant.  Zoloft is the latest favorite, being the newest.  But if your drug coverage is lousy, you get fluoxetine -- Prozac in its non-generic incarnation.

Depression As A Chemical Imbalance?

You are not sure you want to take an antidepressant.  But your well-educated neighbor assures you that there is no shame in it.  It's not your fault.  Depression is a chemical imbalance in the brain, and antidepressants fix the imbalance.
 

I call this the chemical stew theory.  Your brain is too bland.  Add some salt and you will be good to go.

What a great marketing technique.  It's simple.  It's morally neutral.  It's even kinda manly, if that's an issue for you -- chemistry, you know.  And your next door neighbor, whose education comes from TV ads, is part of a sales force which has been so effective that one out of every ten people in the United States of America is taking an antidepressant right now.

Too bad it hasn't worked out.

No -- Antidepressants Do Not Fix A Chemical Imbalance

There are a couple reasons (at least) why adding a chemical to the stew does not solve the chemical imbalance.

The first reason is that your brain is not a stew.  If you like the food metaphors (and as you can see, I like the food photos), adding a chemical to your brain is more like adding it to a souffle.  The chemical balance in your brain is finely tuned to a variety of interacting factors.  Changing one of the factors has multiple effects, not all of them intended, and not all of them so good for you.

For example, a souffle has fat in it.  Maybe the problem with your souffle is not enough fat.  But when you mix fat into the egg whites, the whole thing falls flat.

The second reason antidepressants fail to do their intended job is that they do not address the problem at the right location. The theory suggests you can fix the imbalance by increasing the serotonin in your synapses.  But scientists have figured out the problem occurs farther upstream.

Or at least that is what the scientists say who fund their labs with money from the pharmaceutical companies who still want to add a chemical to your brain, just maybe a different chemical than the ones whose patent protections have expired.

The Brain As Machine

The new meds are not going to work either, because they are working with, not a food, but a mechanical metaphor.  So second millennium!

Like this:



If only they can find the right place to change the course of the inevitable falling blade?  I don't think so.  Your brain is not a machine.

The Brain As A Living System

Here we go:

Your brain is a whole world.  Those who would tinker with it need to understand its ecology.

Put the internal combustion machine onto this planet, and the whole rest of it experiences the consequences.

Block serotonin from reentering your neurons, and your tear ducts and intestines dry up.  And your sex life.  Put enough of us on antidepressants and we could become an endangered species.

So if you want to do something about depression, if you have it or love anybody who has it, then you have to pay attention to the ecology.  Your interventions will have complex consequences.

And -- this would be a third reason and most intractable reason why antidepressants don't work -- the planet/body/brain/ecosystem is always working to restore balance to the system.  Up the serotonin in your synapses and eventually another part of the brain adjusts to overcome your interference.  In ecology this phenomenon is called homeostasis.  Psychiatry calls it Prozac Poop-out.

I kept complaining about insomnia, one of my Chinese menu choices that did not go away.  A psychiatrist told me my symptoms were caused by my depression.  Address the underlying depression and eventually the symptoms would be relieved.  Never mind about the symptoms that replace them.  Those symptoms are not on the depression menu, and have nothing to do with the psychiatrist.

A Twenty-First Century Approach To Depression?

But systems theorists tell us that any intervention will move the whole rest of the system.  This works in the environment, the economy, the workplace, the family dinner table.  And in the brain.

So what if we go back to that menu and devise some interventions that are not the equivalent of a chemical sledge hammer?

That brings me back round to last week's post about insomnia, when I promised that the next installment of my sleep series would be:

The Good News About Sleep Deprivation and Suicidality 

The good new is coming next -- implications for treatment of mood disorders and other causes of suicidal thoughts and behavior.

It just took me an extra week to get there.  So what else is new.  It's a Prozac Monologues series.

photo "Loneliness" by  Graur Razvan Ionut, from FreeDigitalPhotos.net 
photo of Chinese menu by Hoicelatina, permission to copy under the terms of the GNU Free Documentation License 
photo of bell by Salvatore Vuono from FreeDigitalPhotos.net 
representation of serotonin in public domain 
 photo of pote asturiano by jlastras and used under the Creative CommonsAttribution 2.0 Generic license 
photo of chocolate souffle by Akovacs.hu at the wikipedia project, who has released it to the public domain
representation of lactic acid in public domain
NASA photo of the Earth in public domain
photo of Anthia goldfish in public domain

More on Sleep and Mental Illness

Last week's post on postpartum depression and sleep led me to a ring of articles about the link between sleep and mood.  So here we go again -- I have stumbled on another series!

My opening shot is piece my son and I used to watch from a Sesame Street bedtime video.  If it inspires you to go take a nap, that's fine by me.  You can read this post later.



Only, one line isn't correct.  It really doesn't matter, don't you know it's so.  'Cuz you sleep in so very many ways.

Sleep Matters

It does matter.  That guy yawning over his book might have pulled an all-nighter.  If he does that often, or stays up late, or changes shifts, he might be sleep-deprived.  Which puts him at risk for depression and suicidal thoughts.

Really.

Not to mention that goose egg.

What Is Suicidality

The studies I will be citing refer to suicidality.  So let's start by defining that term.  Actually, the word is used loosely, refering to a range of behaviors, in some places as the intent or attempt to kill oneself, in other places as anything from occasional thoughts to attempts.  Any of which is unpleasant, much of which is terrifying.

Suicidality And Depression

Doctors used to think that only people who were depressed committed suicide.  If somebody with schizophrenia committed suicide, they concluded that the diagnosis had been in error, because people with schizophrenia don't commit suicide.  So the theory went.  Notwithstanding what you have been taught about people who call themselves scientists, even in science it is easier to change your facts than to change your mind.

The general public still tends to accept that idea, suicide=depression.  When somebody they know commits suicide, the assumption is that they missed the signs of depression.

The vast majority of those who commit suicide are depressed.  However, not necessarily so.  People who have other mental disorders, or are in chronic pain, or have been diagnosed with a terminal illness, or have suffered a failure or humiliation, or just too many things and finally one thing too many are all at risk.  As David Conroy explains, Suicide is not chosen; it happens when pain exceeds resources for coping with pain.  Whatever the pain. 

Suicidality As The Tip Of The Iceberg

The Diagnostic and Statistical Manual of Mental Disorders (DSM -- psychiatry's bible) lists suicidal thoughts and behavior as just one symptom in their Chinese menu approach to depression -- one from column A, five from columns A and B.  You don't have to be suicidal to get the diagnosis.  But it is the symptom that really gets their attention.

If you have suicidal thoughts or behavior, then something is going on.  The odds are depression, but at least something.  And obviously, it's not fun.  So it is worth addressing, before it sinks your ship.


Sleep Disturbances And Suicidality

So here is a study that discovered, whatever else is going on in your life -- insomnia more than doubles your risk of suicidal thoughts, planning, action.

It doesn't matter whether you have depression, anxiety disorder or other mood disorders, or chronic medical conditions such as stroke, heart disease, lung disease and cancer.  It doesn't matter whether or not you are abusing drugs or alcohol.  Age, gender, and marital and financial status don't matter.  All of these are risk factors in themselves.  But whatever risk factors you may or may not have, insomnia more than doubles your risk of suicidal thoughts, planning and/or action.

Insomnia comes in three flavors in the medical world: trouble falling asleep, waking in the middle of the night, and waking too early in the morning.  The last has the greatest risk.

Irregular Bedtime And Suicidalality

There are other studies that examine particular applications of the poor sleep/suicidality connection.  Here is one that examines what happens to young adults when they don't go to bed at the same time every night.

The Florida State University Laboratory for the Study of the Psychology and Neurobiology of Mood Disorders, Suicide, and Related Conditions discovered that actively suicidal undergraduates got an average of 6.3 hours of sleep a night -- way not enough sleep.  This we could anticipate.

Then they examined another factor, how much their bedtimes varied -- an average 2.8 hours.  For example, they might go to bed some nights at midnight, other nights at 3 AM.  So they sorted subjects by the second factor, how much bedtime varied.  Regardless of the severity of an individual's depression, the more variable the bedtime, the more suicidal the student became over the course of three weeks.

Get that?  All by itself, how much bedtime varied, all by itself, predicted increasing suicidality.

Varied bedtime also predicted the intensity of mood swings.  Which is significant, because suicide is associated with mania as well as with depression.  Both are indicators of poor cognitive function and poor impulse control.

Not to mention a bad report card.

Adolescent Bedtimes And Suicidality

So here is one more, this one on teenagers.  (Teen do not have the highest suicide rates.  But they do seem to get the most press and the most research dollars.)

James Gangwisch, PhD, of Columbia University studied the sleep habits of 15,659 teens.  He reports that teens whose parents enforced a midnight bedtime were 24% more likely to have depression and 20% more likely to have suicidal thoughts than teens whose parents enforced a 10 PM bedtime.

The 10 o'clockers got an average of eight hours and ten minutes of sleep at night, compared to seven hours and thirty minutes for the midnight crowd.  Both were short of the nine hours that teenagers need, which would account for the general crankiness of most teenagers you know or are.

Oh, and that Nobody else's parents make them... argument?  More than half of parents enforce the 10 PM bedtime.  And 70% of teens comply.

I didn't find a study on the relationship of sleep and report cards.  But some scientists surmise from this and other studies that sleep deprivation may be the real reason for the United States' slip in global competitiveness.

The Good News About Sleep Deprivation and Suicidality

The good new is coming next -- implications for treatment of mood disorders and other causes of suicidal thoughts and behavior.

Now get off the computer and go to bed.

photo of scales from Deutsche Fotothek of the Saxon State Library

 photo of Chinese menu by Hoicelatina, permission to copy under the terms of the GNU Free Documentation License

photomontage of iceberg created by Uwe Kils (iceberg) and User:Wiska Bodo (sky), permission to copy under the terms of the GNU Free Documentation License

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The Insomnia Cure for Postpartum Depression -- AKA Stupid Science Reporting

My niece just gave birth to twins, and friends are bringing home their newborn.  So this report on sleep deprivation is personal.

Last year's Best of Stupid Science Reporting comes from (drumroll, please...) the New York Times: In Sleepless Nights, a Hope for Treating Depression by Terry Sejnowski.

Don't Believe Everything You Read In The New York Times

Evidently, 75 published papers with over 1700 subjects in the last forty years have documented that the depressive symptoms of new mothers are relieved after a sleepless night.  Now let's remember the number one rule of research publishing -- for all we know, the same study may have been published 75 times.

On the other hand, if the author didn't double count studies, that would be an average of 23 participants per study.  Whatever the results, with those numbers, they would not be robust results.  A review of literature cited below examined some of these studies.  One had nine participants.  One had three.  These are not studies.  They are anecdotes.

Sleep Deprivation And Euphoria

Moving on.  Anybody with bipolar disorder or for that matter, any student who has pulled an all-nighter can tell you that sleep deprivation lifts mood.  After we talked until 5 AM my freshman year, the most natural thing to do in the world was to go invade a nearby garden and pick somebody's blackberries. 

Sleep deprivation used as a treatment for depression is efficacious and robust: it works quickly, is relatively easy to administer, inexpensive, relatively safe and it also alleviates other types of clinical depression, Sejnowski reported.

Unfortunately, There Is This Little Problem

But before you throw away your pills, read the but.

Continuing from the article -- First, sleep deprivation is not as convenient as taking a pill.  Actually that's debatable.  No doctor's appointment, no worries about in or out of network, no copay, no trip to the pharmacy, no need to check the formulary...  If that were the only downside, it would have much to commend it.

Second, prolonged sleep deprivation is not exactly a desirable state; it leads to cognitive defects, such as reduced working memory and impaired decision making.  Translation: NOT relatively safe.  I remember when my son was three months old and I had just gone back to work.  I stopped at the stop sign, looked both ways, and then pulled out in front of oncoming traffic.

Finally, depression recurs after the mother, inevitably, succumbs to sleep, even for a short nap.

Oops.

Wait a minute -- this is the New York Times here.  Read that again.

Sleep deprivation is wonderful cure for depression.  It's quick, cheap and safe.  That's the good news.

The bad news?  A relapse rate of 100% after 15 minutes.

Yes, that would be a difficulty.

There are a few other difficulties with this stupid science report, as well.

Actually, Sleep Deprivation Is Linked To Postpartum Depression

Lori Ross, et al did a review of the literature on this subject.  Against Sejnowski's 75 studies are piles and piles of studies that assert quite the opposite, that sleep deprivation is a significant risk factor for postpartum depression, almost every woman who has postpartum depression is sleep-deprived, and improving mothers' sleep improves their mood.

Sleep Deprivation And Psychosis

The most serious risk of postpartum sleep deprivation would be psychosis.  Studies back over a hundred years, noting that the almost universal early symptom of puerperal [first six weeks after childbirth] cases is loss of sleep (R. Jones, Puerperal Insanity from the British Medical Journal, 1902).

One or two women out of a thousand experience psychosis after giving birth, putting them at risk for suicide and infanticide.  Depending on the study, 42-100% of women with postpartum psychosis also experience insomnia.  Now that is a robust finding.  Furthermore, there is evidence that sleep loss is the last straw that tips women into development of continued bipolar disorder.

Mood is a continuum item.  Depression would be on one end.  Lifting of depression moves in the other direction.  Then comes euphoria, then mania, then psychosis.

Sleep Deprivation And Mania

And speaking of mania, the experience of people with bipolar and college students is well supported in the literature, that sleeplessness can trigger mania.

Sleep For Prevention Of Postpartum Depression

All this stuff is so well known, the Women's Health Concerns Clinic at St. Joseph's Healthcare has developed a preventive intervention that is routinely offered to patients who present with high risk for postpartum depression. Can you imagine a five-day stay in a private room after childbirth?  These and other strategies aimed at improving the sleep of new moms decreased mood disorders and even psychiatric hospitalizations months after childbirth.

Sleep.  That is the REAL cure for postpartum depression.  Forget baby showers.  The kindest gift you can give a new mom is to take care of the kid while mom takes a nap.

Speaking of which,

Aimee -- get off the computer and go to bed!

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