NAMI Walks for the Mind of America

Saturday, May 8 -- It was COLD!!! and windy.  No upright displays this year.  But there were the usual belly dancers, musicians, dogs, fabulous bagels, cream cheese, fruit, granola bars, cookies...

And volunteers -- serving food, registering walkers, taking photos, cheering us on.  The clown making toy balloons!

And the walkers.  And the strollers.  And the dogs.

Speaking of which:

Here she is, in a rare moment walking the designated path.  Mazie had never been to City Park before.  So many new smells!  So many new trees!  So much marking to do!

After we walked a mile, the short loop, Mazie's back leg began to falter -- the one that has done twice the work of the other two for the last thirteen years.  What with all the zig-zagging between trees, it's likely she did do 5K, and it was just her people who gave out.

Meanwhile, she cooperated magnificently, wearing her own shirt.  As soon as she returned to the start, she got into her therapy dog mode, sitting stock still while little girls with various levels of petting skills mobbed her, countless adults pondered her, and one woman who lives in a group home asked to be photographed with her. -- If her staff person is reading this, we are waiting for your email, so we can send the photo!

There were the requisite speeches from the requisite politicians.  Thank you, Dave Loebsack for doing your part to get mental health parity, more or less, into the health care bill.  Please support the President's interpretation that case management and reimbursement rates for psychiatrists have to match other forms of health care.  -- That issue has cost me thousands, because my care providers won't contract with my stingy health insurance company.

But I had to listen to speeches only from a distance.  They had serious competition.  The Old Capitol City Roller Girls were giving a demonstration in the parking lot.  No, it is not the chaos and brawling that I remember from childhood tv.  It probably wasn't then.  There are rules.  There is a point.  There are fabulous outfits!

This video is a bit long.  But it gives you the idea:

Anyway, as always, a fabulous day.  NAMI Johnson County raised $65,983.99 by walk day, 88% of its goal on the way to $75,000.  Did I mention that it was COLD?!

And Team Prozac Monologues, dressed in layers, but still proudly sporting our t-shirts, has raised $2395 of our $3500 goal so far.

Yes, there still is time to help us reach our goal!  In fact, for a limited time you, too, can receive one of our t-shirts.  They are cotton tagless t's, navy blue, with logos front and back.

The front is a shameless bid to win the t-shirt contest.

while the back says:

-- a shameless bit of self promotion!

Just make a donation of $30 or more or MORE by clicking the link up top on the right.  Then send your size and your address to: wmgoodfe@yahoo.com.  I'll make one up custom for for you!  This offer expires June 25!  So do it today!  Thanks!!

On a more sober note,  Gay and Ciha Funeral and Cremation Service was one of the main sponsors, and got a promo on the official walk t-shirt, while Lensing Funeral & Cremation Service sponsored a kilometer.  Their support reminds me that mental illness is potentially fatal, just like heart disease and breast cancer.  They might sponsor those walks, too.

As a priest I occasionally worked with those who provide funeral services.  I respect these people immensely, as do most clergy I know.  They do things for the bereaved that communities used to do, communities that don't much exist anymore.  Hospice has re-created a way for friends and family to talk with and support one another in the sorrow of many forms of death.  But funeral homes are the ones who step up to the plate for survivors of suicide.  They offer resources and support groups to friends and family.  I appreciate the work that they do.  And I appreciate their support of NAMI, in its work to stomp out the stigma of mental illness.

With them, with you, one step at a time, we shall overcome.

Oh yes, and it was COLD!!?!

NAMI Walks -- We All Win

This is my second year for the NAMI Walk Johnson County, Iowa.  It's how people across the United States raise money for the National Alliance on Mental Illness, an organization whose mission is support, education and advocacy with and on behalf of people with mental illness and their families.

National Alliance On Mental Illness

I became passionate about NAMI when I learned about its origins.  Once upon a time, not so long ago, the holy writ on schizophrenia was that it was caused by overprotective mothers and disinterested fathers.  Wow.  In 1979, a bunch of these mothers started to push back.  They organized and demanded better research, better treatments, better treatment.  Would there ever be any progress in the world if it weren't for uppity women?  A new documentary, When Medicine Got It Wrong tells the story, coming soon to a PBS station near you.

NAMI has grown into a national program, built on local chapters.  It fights stigma.  It advocates for funding of services, research and rights.  It provides information about mental illnesses and medications.  It offers a variety of educational programs and services.

Peer To Peer

Prozac Monologue followers read with some regularity what I have learned from NAMI's Peer to Peer program.  In Peer to Peer, those who have a mental illness and are in recovery help others learn about recovery, living to the fullest while managing a mental illness.  I drove (my wife drove -- my meds won't let me drive anymore) 120 miles round trip every week for nine Iowa winter nights so that I could attend this program.  It was worth every mile.

Make A Difference

So here's the deal.  Every year NAMI raises money through local Walks.  My local chapter will walk on May 8th, rain or shine.  Last year was my maiden voyage into NAMIWalks.  I went with some trepidation, wondering just how bleak and weird a walk for mental illness could be.  Instead, I discovered a registration process that reminded me of summer camp, belly dancers leading the warm up, pep talks from the Hawkeye football team, a balloon arch, kids, dogs, food, t-shirts and more t-shirts, displays that kept falling over in the breeze, and chalk drawings along the trail made by the Girl Scouts.  It was a party!

I did not do a shabby job raising funds my first time out.  I knew I would do well, because I know my friends.  This year I decided to co-chair a team called, wouldn't you know, Team Prozac Monologues!  And right there, on the name, is where you can go to support my team.  Giving online is safe, easy, fast and tax deductible.

Team Prozac Monologues is about halfway to our goal so far.  Any amount you can give is important.

And as Hoops and Yoyo say,

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.

Calling All Mood Charts

A comment on yesterday's post inspired this quicky.  Based on a my narrow experience, I have a rigidly held opinion on the topic of mood charts.  Well, like a lot of things.

But I have a readership that might have a broader experience.  And while I am not above blathering away on my own opinions, I do have the wit to listen and learn from others, even to ask.  So...

What are YOUR experiences with mood charts?  (Mental health professionals can answer based on your clients' experiences, if you are sure they aren't bullshitting you.)

What kind of charts have you used?  Are you still using one?  Why or why not?

What have you learned by using a mood chart?  Or not?

Make liberal use of the comment section below.  When I get to that post, maybe I will have a slightly larger experience base from which to draw!

Thanks --

The Mood Chart Video

I call this video Mood Chart for UltraRapid, Ultradian Cycling Bipolar, with a Touch of PTSD.

To the Therapy Theme Song.

Much more fun than some old DSM code, doncha think?

A family member said, "If you can relate to that song and video, now I know your mind works on a completely different level."  To which I responded, "Then we are making progress."

Yes, this is the inside of my head today.  Someday when it's not, I'll write about mood charts.  Very useful things, mood charts.  A basic tool for recovery.  My favorite is here, also listed among the Resources on Mental Illness over there on the left.

But that's all for this week.  See ya.

One Year Later -- A New Look for Prozac Monologues

What do you think of the new look?

I talk about how my brain turned into Swiss cheese.  Lately, I spend most of my time in the holes.  So if you are waiting for the second PTSD post -- keep checking back.  The good news about cycling is that it comes back round again.  (That's also the bad news, depending on what part of the cycle you are talking about.)

Anyway, as an alternative to thinking, and to celebrate my first year online, I decided to renovate the site.  So, what do you think?

Okay, I stayed with the dark blue motif, this being a blog about depression.  I rejected many new options that blogspot.com, my host, now offers.  Just think, I could have spread the page with barbed wire -- really!  I gave it a lot of thought, but in the end, I am just not that Goth.  I could have used rain as a backdrop -- no, too cliche.  Another option was this flock of birds flying over head.  I live by a pond, so I know -- way too messy!

So, same color, a little texture in the banner.  I was at the therapist's this morning, and noticed how nice it is that her carpet has some vague design to it.  I can look here, and then for a change, I can look there.  That's the idea.

It has long been my desire to do three columns.  But I didn't know how to pull it off.  The new template made it possible.  And now the tour:

To the left is the resource column, a work in progress.  I started with great ambitions to become a port of entry to mental health resources.  Those ambitions languished for a while.  But this is a new year.  So I need a little help from my friends!

Resources on Mental Illness and Resources on Medications: Where do you find the most useful information and tools on mental illness and medications?  Add a comment below, or send a message to the email address at the top of the blog.

About the Brain and About the Mind: At first I was putting research reports that intrigued me under these headings.  They became a slush pile for posts I wanted to write some day.  Then I figured out I don't need to leave my pile of unfinished homework out in public -- I can store them offstage in a draft pile.  So now you find here comprehensive works, reviews of literature, big swipes at their topics -- generally educational, that sort of thing.  Some bent stuff might sneak into the list, too, just to keep you on your toes.  Again, I am delighted to receive suggestions for content.

Books I Like: Here you find links to previous posts that review book titles.  The unfinished homework is preserved in this section, when I want to recommend a book, but haven't gotten around to writing the review.  When you move your curser over the title and it turns dark red -- ding, ding, ding! There is a review.  Click it and read more.  If the title remains black -- buzz!  I'll get to it...

All of the stuff that relates to the blog itself is on the right, the description, the labels, the archives, etc.  I might update the blog description and About Me one of these days, give you my latest diagnoses, that sort of thing...

Labels: It took me a while to figure out tag clouds (labels) on other blogs I read.  I thought they were Word Art.  Well, yes, but created automatically and with a function.  When I write each post, I "tag" it with a few key topics, like antidepressants, hope, OMG...  If you click on one of those words in the tag cloud, all the posts that have been tagged by that word will come up.  The more posts that I tag with a certain word, the bigger that word appears in the cloud.

Archives: for the historical record of Prozac Monologues.  You can go back to April 5, 2009, should you be so inclined.

Search: You can search my entire blog for a specific word that may not be a label or tag, like Zoloft or Conroy.  This feature will even find words that are in the comments.  The search engine at the top of the blog does the same thing, search my blog.  Redundant or convenient -- you make the call.

I like these blogs: may or may not bear any relationship to the matter at hand.

Followers: Would some follower tell me what happens when you become a follower?  Do you get a message when I put something new up or what?  I have always wondered...

Ads: The contract says I am not supposed to click on them myself.  So when I am interested in one of them myself, I have to copy and paste the address.  So if it's objectionable , I won't know about it unless you tell me.  I can block an advertiser, and did block Scientology.  It's always fun to go to one particular post from the archive list, and find out what ads will pop up.  Okay, Goodfellow, get a life...

Oh, yes -- the center.  One of these days I will pay attention to topics again.

I like to put lots of links to other sites in my posts.  The regular text is black.  Links appear in a dark blue or may purple, depending on your browser.  Do they show up?  When you move your curser over them, they turn deep red, more visible.  Click, and you find my source or my inspiration.  If you find a dead link, let me know.

Coming later: Videos?

Anyway, time to go clean my paintbrushes and pour a drink.

Good Friday Reflection

American Tune by Paul Simon, sung by Art Gunfunkel and Paul Simon 

These all died in faith, not having received what was promised, but having seen it and greeted it from afar, and having acknowledged that they were strangers and exiles on the earth.  For people who speak thus make it clear that they are seeking a homeland.  If they had been thinking of that land from which they had gone out, they would have had opportunity to return.  But as it is, they desire a better country, that is, a heavenly one.  Therefore God is not ashamed to be called their God, for he has prepared for them a city.

Hebrews 11:13-16

The Bible, Revised Standard Version

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.

Agoraphobia Day

It's taking a while to get the next post written -- PTSD and DSM: Science and Politics -- Again.  It has turned into a two-parter, i.e., I got long-winded.  Meanwhile, as long as we're on the topic of anxiety disorcers...  This one comes from one of the blogs I like -- a link is on the sidebar and also in the credit.

 Permission granted for non-profit use by artist: Chato B. Stewart.

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 II -- How Did We Get Here?

 

Lost Creek Wilderness

Starting point -- Okay, the only way we get anywhere is if we understand very clearly who owns this map.  The pharmaceutical companies do.  It's their map.  Get over it.  This knowledge will help us steer a course, or maybe give them a nudge, or at least anticipate where they are taking us.

For the longest time, depression got no respect.  When they started using medication for schizophrenia, depression was still lost in the la-la-land of Freud's neurosis.  You could either talk it out over years on the couch, or you could snap out of it.   Medical advances in the treatment of depression came about by accident.

So back in the 1950's, Smith Kline and French (today GlaxoSmithKline) were making a killing on thorazine, the first med to treat schizophrenia.  It worked, but thorazine has so many side effects they list them alphabetically.  Other drug companies wanted a piece of the action.  Seeking to improve the side effect profile, they came up with the first tricyclics.  Tricyclics (Elavil, et al.) were a bust, as far as psychosis goes.  But they had an interesting new side effect -- mania.  Happy psychotics.  

Same time frame, different illness, MAOIs were developed to treat tuberculosis.  Again, not so effective against tuberculosis.  But suddenly sullen patients were skipping down the hallways and creating "discipline problems." Happy coughers.

Mile Marker #1 -- We have a whole new market for psychotropic medications -- depression.

These accidental discoveries drove research into the neurological mechanisms of depression, posing not the question, "What causes depression," but rather, "How come antidepressants work?"  Well, one of the consequences of taking these medications is an increase in the presence of neurotransmitters, serotonin et. al.

Mile marker #2 -- We have a simple, catchy sales pitch.  Depression isn't a rich lady's neurosis, after all.  It's a "chemical imbalance in the brain" -- just as diabetes is an imbalance of insulin.  Well, that's not an issue of character, as depression was thought to be.  (And still is, you will find out if you don't get better.)  It can happen to anybody.  And it can be fixed, too.  Take a pill, just as diabetics take insulin, and you fix the imbalance.

At this point, the neurotransmitter hypothesis takes us deep into our map.  Prozac and other SSRIs (Celexa, Zoloft...) were developed by tinkering with the basic concept behind tricyclics, again as attempts to improve market share by improving the side effect profile.  But SSRIs didn't really work as well as the sales pitch did.  The market share threatened to drop as "treatment refractory" patients ran out of new meds to try.  Meanwhile, pharmaceutical companies were running out of patent protections.  Along came SNRIs (Cymbalta, Effexor...), more tinkering.

By now marketing drove/drives the research.  The pharmaceutical companies were not interested in figuring out what is happening inside the depressed brain -- they thought they already knew.  Instead, they funded research into a jillion examinations of the same "chemical imbalance" and what their own medications do for it.

Mile Marker #3 -- The pharmaceutical companies, with their already developed products to market, take over research departments of universities and medical schools.  Research departments fund their way having their top scientists sign on to reports that they have not written.  A scientist will sign more reports than he or she has time to read, much less write.  The practice is called "guest authorship."  (In other academic departments, this is called "plagarism.")  Often the pharmaceutical companies contract out the writing or do it themselves, called "ghost authorship."  They write slightly altered reports of the same clinical studies, and flood the medical journals, who publish the seemingly different reports, neglecting their own publishing standards that call for disclosure of these practices and conflicts of interest.  

No, really. The ethics of medical journal publishing has become so problematic that the AMA (American Medical Association) convened a special forum five months ago to examine the issue.  The results of study after study on various practices in authorship and publishing demonstrate that this problem has not improved since it was raised in the mid-1990's and standards were developed.

What are the prospects for improvement in publishing?  I find particularly amusing/astounding/discouraging the report on Background, Training, and Familiarity With Ethical Standards of Editors of Major Medical Journals. "Although 86% of respondents were “confident” or “very confident” in their knowledge of scientific publication ethics when they began the survey, this number dropped to 71% by the end."  Indeed.  Because: "Performance on the editorial scenarios was poor; correct answers were given by 18% to the question on plagiarism, 30% to authorship, 15% to conflicts of interest, and 16% to peer review."

These are failing grades received by the editors of medical journals.  These are the people who decide which studies get published, what information is available to my doctor and yours.  Why does this matter?  Because reading journals is how my doctor and yours keep up to date, their continuing education after medical school.

So the science has gotten pretty bad.

And in the field of mental health, the pharmaceutical companies own it.  There is one sales representative for every five doctors.  This is the United States of America.

(You get better science, and different results, if you read the journals from Europe.)

Okay, getting us into this map has made for a long enough blog post.  Next week -- Mile Marker #4, and onward.

map of Lost Creek Wilderness made by David Benbennick

in public domain

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.

Shadows

Thom is a long-time fellow traveler and now both a Facebook friend and Prozac Monologues reader.  He regularly posts on Facebook the latest segment of the ABCs of Spiritual Literacy.  Last week's entry was on Shadow.  Well, that hits me where I live.  My thanks to Thom for leading me to this post. 


This website presents one spiritual practice at a time, each in a similar format.  First it names what the practice enhances (in this case, wholeness) and what it balances (Pollyannaism/projections).  Then it moves to the Basic Practice and Why This Practice May Be for You, with links to books, films, art, prayer, imagery, discussion questions...


So here is the story on Shadow:


The Basic Practice:
The spiritual practice of shadow encourages us to make peace with those parts of ourselves that we find to be despicable, unworthy, and embarrassing — our anger, jealousy, pride, selfishness, violence, and other "evil deeds."


Kinda reminds ya of a therapy session, doesn't it?


University professor, author and fellow depressive, Parker Palmer is my favorite resource on shadow.  His book Let Your Life Speak has vocation as its central focus.  By "vocation" he means the call to be one's true self, not the self that one finds virtuous.  Ah, but the journey to the true self is treacherous.  He got there himself by traveling the road of depression.  He quotes Annie Dillard:


In the deeps are the violence and terror of which psychology has warned us. But if you ride these monsters down, if you drop with them farther over the world’s rim, you find what our sciences can not locate or name, the substrate, the ocean or matrix or ether which buoys the rest, which gives goodness its power for good, and evil its power for evil, the unified field: our complex and inexplicable caring for each other, and for our life together here. This is given. It is not learned.

(from Teaching a Stone to Talk)

Palmer continues: Why must we go in and down? Because as we do so, we will meet the darkness that we carry within ourselves—the ultimate source of the shadows that we project onto other people. If we do not understand that the enemy is within, we will find a thousand ways of making someone “out there” into the enemy, becoming leaders who oppress rather than liberate others. 


In his chapter on Leading From Within, Palmer writes of what makes people leaders, five virtues or strengths of leaders, and the shadows associated with each of these forms of light.  This is how I encountered Palmer, when I was creating a formation process for spiritual leaders in congregations.  We examined five virtues, things we all wished/hoped we brought to our leadership, their shadows and what we might find if we ride the monster down. 


The first shadow-casting monster is insecurity about identity and worth.  This monster is hidden by an extroverted or outgoing personality that hides its insecurity by creating settings where others are in the disadvantaged or less powerful position.  If we ride the monster down, we find that we are loved and valued simply because we are children of God.  We do not need to make others feel less so that we can feel worthy.


Well, let me pause right here and notice my own projection.  I can name half a dozen people to whom this applies, without pausing for breath.  It is harder to stay with it long enough to find this shadow in me.  I invite you, as I name the other shadows, to take the step deeper, to look within rather than without. 


A second shadow inside many of us is the belief that the universe is a battleground, hostile to human interests.  The strong competitor turns others into enemies that weren't there before the competitor's fear of losing created them.  Palmer asserts that death and loss are part of a circle of life, that harmony is the deeper reality, and that this spiritual truth could transform our lives and our institutions.


A third shadow common among leaders is “functional atheism,” the belief that ultimate responsibility for everything rests with us.   Those who take on the responsibility for making every good thing happen ourselves often end up with burnout, depression, and despair, when we learn that the world will not bend to our will and we become embittered about that fact.  When the load becomes so heavy that we have to drop it, then we can receive the gift of community, in which we trust that each will give and each receive. 


Palmer's fourth shadow within and among us is fear of the natural chaos of life.  Those who are organized can become rigid, imprisoning the organizations we lead, rather than liberating them.  Following the monster down, we learn that chaos is the precondition to creativity: as every creation myth has it, life itself emerged from the void. Even that which has been created needs to be returned to chaos from time to time so it can be regenerated in more vital form. 


The last shadow is the fear of failure or death itself that keeps the successful leader from letting go.  The best leaders in every setting reward people for taking worthwhile risks even if they are likely to fail. These leaders know that the death of an initiative—if it was tested for good reasons—is always a source of new learning.  The monster takes us down to the place where we can learn that death does not have the final word.  It is the source from which new life can spring.


So many of these shadows participate in depression.  Before we get to Annie Dillard's matrix... which buoys the rest, the monster takes us through the darkness that depressives know too well.  Here we touch a question both quietly pondered and hotly debated.  Is there anything good about depression?


Palmer's point seems to be that going through the darkness is how we get to the light.  His personal story is one of finding his true vocation after depression deprived him of what he thought he should be doing.


Depression, like pain, can be good, if it is used for what it is good for -- telling us that something is wrong -- that we are hiding our insecurities at the expense of others, that our combative attitudes deprive us of peace, that we have false expectations of ourselves and others, that excessive control has stifled our creativity, that our fear of death is preventing us from being born again.

Those who ride the monster down have stories to tell to the rest.  We believe there is a link between our depressive personalities and our depth of thought, understanding and feeling.  We can rattle off the names of authors, poets, musicians and artists who have struggled with mental illness and sometimes lost, Hemingway, Scott Fitzgerald, Woolf, Mary Shelley, Plath, Whitman, Handel, Cobain, van Gogh, Ansel Adams, O'Keefe...


I have a friend who responds to this question with anger -- there is nothing romantic about this terrible disease that destroys minds and sometimes those who suffer from it.


It is time to distinguish between depression and Depression, one the feeling common to all thinking and feeling people, the other an out of control extreme that is caused by and causes further brain damage.  The Shadow is not the latter.  It is part of the human experience.  Everybody benefits by becoming mindful of its place in their lives.  While the disease is overrepresented among artists, perhaps every true artist rides the same monster down to find the truth expressed in his/her art.


I wonder, how often does the disease interfere with artists' creativity?  According to Ernest Hemingway who was there, when T.S. Eliot and F. Scott Fitzgerald were being wrestled to the ground by their personal demons, they were not writing.


I was going to say, "putting to one side the works that were not created because their creators were dead..."  But I can't say that.  We can't put suicide to one side.  That is the romantic garbage of which my friend speaks.  It calculates the value of artists for what they give us, their utilitarian purpose, not for their own sacred selves.


In my own experience -- my books lie unfinished, out of reach of this brain that the Grim has gone through with a paper punch for the last five years.  It takes me a week's effort to write a blog post, two sentences at a time.  The Shadow is something else.  It calls me to my self.  It shows me that I am of value, even with a brain that has holes in it, even if I have to lay down my work in formation of spiritual leaders, even if my books remain unpublished.  It brings me to the place where I am held in the hands of a tender God.


Even if I am still fighting it all the way down.
 

Photo by Victor van Werkhooven

Permission is granted to copy, distribute and/or modify this

document under the terms of the GNU Free Documentation License

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.

The Miracle of Gheel -- Humane Treatment for Mental Illness

It was seventh century Ireland.  The Queen died.  King Damon's grief was so deep that it moved into depression and then psychosis.  He thought his daughter Dymphna was his queen.  Rather than submit to his advances, Dymphna fled to Belgium, to the town of Gheel.  But her father followed.  When she again rebuffed him, he killed her, cut off her head.  Dymphna was buried in the local church.

Six centuries later, her coffin was found during renovations.  Signs on the coffin demonstrated her holiness.  She began to be venerated.  Cures of the sick were attributed to her.  She was canonized in 1247 as the patron saint of the mentally ill.

Okay, here the one last bit of unrecovered Catholic in me demands to be heard, to note Rome's fascination with girls who prefer death to rape.  Even as a nine year old, that made me uncomfortable.

Moving on.  People came to Gheel for healing.  Many brought family members who were mentally ill.  Sometimes they left them there.  The priest housed these abandoned ones next to the church.  When the job of caring for them became too much for him, townspeople started bringing in food.  They built a hospital in the 14th century.  When it was full, the real miracle of St. Dymphna occurred, or rather, began.  Townspeople took some of the patients into their own homes, reserving the hospital only for those most ill.

All across Europe, people with mental illness were thought to be possessed.  They were exorcised, tortured and burned at the stake.  But not in Gheel.

Imagine it!  A psychotic foreigner commits a terrible deed.  But the townspeople do not close the borders.  No, they open their homes.

And they still do.  Through plagues, wars, revolutions, recessions, depressions, during the Napoleonic "Reform," when all the mentally ill people in the country were ordered into one big hospital, during the Nazi occupation, with their "final solution" for mental illness, during the latest reform when the U.S. of A. was/is dumping all our mentally ill people out of the hospitals, onto our streets and into our jails, the people of Gheel developed and continue genuine community-based mental health care.

Today, there are 700 foster homes for 1000 people with mental illness.  A person will enter the hospital for evaluation and stabilization.  S/he meets the psychiatrist, psychologist, nurse, social worker and family practitioner who staff one of the five neighborhood community mental health centers.  Each of these staff people spends half a day each week in the hospital, so everybody gets to know everybody.  The potential foster family and patient meet at the hospital, then over tea at home, then over a meal, then over a weekend before placement.  Outpatient care, medication monitoring and therapy continue at the neighborhood center.  If possible, the biological family participates in the treatment plan.

Once part of the family, the person shares in family activities, chores and church.  The church doesn't have special bible studies, services or programs for the mentally ill.  They are fully integrated, regular readers, members of the choir, ushers, etc.

What if the person's symptoms flair?  "We say s/he is having a bad day."  Because the person lives in a family, not on the streets or alone in an apartment, problems are caught and addressed early, not after getting fired or evicted or arrested or in a bloody mess.  If needed, s/he can go back to the hospital for a while.  In fact, the hospital is not the place of last resort.  When the foster family has to go out of town, say, for a funeral, the person can stay at the hospital.  There is continuity of care.  There is care.

Three years ago I wrote a chapter for Deep Calling called, "If This Were Cancer."  I detailed all the ways that hospice patients receive the support of others, and that people who have suicidal depression do not.  "If this were cancer, there would be casseroles..."  I imagined the total collapse of care for the mentally ill, under the weight of our crazy health care system.  In fact, it's happening as I write.  I imagined that the Church would step in to meet a desperate need, to create hospice for the mentally ill, as the Church originally created hospice and hospitals.  I claimed that the Church has the resources to organize for such care on a local basis.  It has the faith to imagine such a thing, the love to cast out fear, and the values to demand it.  I will have to rewrite that chapter.  I didn't know it had already been/is already being done.

I am ever so grateful to Janet, whose last name I don't remember, who gave me Souls in the Hands of a Tender God: Stories of the Search for Healing and Home on the Streets by Craig Rennebohm, the source of this story.

Lord God, Who has graciously chosen Saint Dymphna to be the patroness of those afflicted with mental and nervous disorders, and has caused her to be an inspiration and a symbol of charity to the thousands who invoke her intercession, grant through the prayers of this pure, youthful martyr, relief and consolation to all who suffer from these disturbances, and especially to those for whom we now pray. (Here mention those for whom you wish to pray.)

We beg You to accept and grant the prayers of Saint Dymphna on our behalf. Grant to those we have particularly recommended patience in their sufferings and resignation to Your Divine Will. Fill them with hope and, if it is according to Your Divine Plan, bestow upon them the cure they so earnestly desire. Grant this through Christ Our Lord. Amen. 

Dymphna's feast day is May 15.

The Best Health Care in the World

Rush Limbaugh says that he experienced the world's best health care in the United States of America, and it does not need fixing.  I am glad for Rush that he was staying at a resort near a world class hospital for coronary care last month.  I imagine he has insurance to pay for the hotel-like accommodations, the angiogram and several other tests that failed to find the cause of his chest pains.

Given his public platform and his wide influence on American opinion and public policy, I wish Rush would expand his experience of health care in the United States of America.  He could shadow Craig Rennebohm for a few days to find out how health care works for other people.  Craig is the pastor of Pilgrim Church (UCC) in Seattle and, as part of their ministry, "companions" persons who are homeless and mentally ill.  With David Paul, Craig describes their quite different experiences in Souls in the Hands of a Tender God: Stories of the Search for Home and Healing on the Streets.

The emergency personnel got Rush to the emergency room like that [snap!]  That's not what happened to Sterling.  Over months Craig built the trust of this man who camped in the church courtyard, surrounding himself with trash to protect himself from the evil spirits.  Finally, when the trash included highly combustible materials, Craig convinced him to go to the hospital.  Winter was coming.  The mental health professionals (MHPs) who showed up said they couldn't take Sterling in, because he was a voluntary patient.  They only picked up involuntary patients.  Sterling accused Craig of betraying him and fled the scene.  Craig couldn't find him until a month later, when he read of a homeless John Doe who died of exposure.

Rush was examined for days after they already knew he was not having a heart attack.  That's not what happened to Shelly, seven months pregnant, with bronchitis and in a state of euphoria and grandiosity.  Craig brought her to the ER.  But she wasn't a "good faith" voluntary patient.  They believed she would check herself out so she could go "accomplish her mission."  She didn't qualify for involuntary admission, because she wasn't a danger to herself or others.  What about her baby?  What about her bronchitis?  "Bring her back when she develops pneumonia."

Karl's story is the clearest example of how health care in the United States of America is not working just fine.  Karl is a vet.  He was arrested for resisting arrest for vagrancy.  He just remembers being attacked, and later that the people in prison were poisoning him.  He was transferred to the hospital for two years, then back to jail to be released, no money, no meds, nothing but the clothes on his back.

Craig had been alerted.  He was a total stranger when he met Karl at the jail that morning and took him to breakfast.  Karl was stymied by the question, "White or whole wheat?"  They continued to a clinic, where Karl couldn't understand or fill out the two-page form.  Since he wasn't in immediate danger, they sent him to the Department of Social and Health Services to apply for SSI.  Craig helped him with the six-page form there.  The social worker discovered he once received benefits.  So he had to get a statement from Social Security.  Social Security noticed he was receiving veterans benefits.  Next stop, the Veteran's Administration.  But the counselor there said they were a PTSD program and didn't take walk-ins.  He sent them a mile away to the Federal Building.  His file was in another state, so they had to get it transferred.  Meanwhile, the file was on computer, and said he was getting 50 cents a month, which was going to the hospital. (They could look up the information, but couldn't give him a copy until the file was received in a few days.)  Craig said, "He's homeless and needs medication right now."  So he was sent to the VA hospital, then to the outpatient clinic in the bowels of the hospital.  Several kind strangers helped Craig find the way.  To get help at the outpatient clinic, Karl had to be admitted through ER, where they determined his illness was not service-related.  The waiting list for outpatient treatment was six months, and he might not get in, because he had been hospitalized only once.  The social worker suggested they try the clinic where they had started the day.  By now it was 6:30 and the clinic was closed.  They covered miles that day.  Karl spent the night in a homeless shelter, still not able to remember Craig's name.

That's where I will end the saga, though it is still several days from completion.  Small wonder that 83% of psychiatrists want a national health insurance plan, a higher proportion than any other specialty.  So many of their patients are homeless.

And I thought I was having a hard time.  I have boatloads of people to help, support and advocate for me.  My salary is continued while I fill out applications.  I have a roof over my head and continued health insurance.  Most of all I have Helen, who asked me all the repetitive questions over several days, monitored my capacity, and terminated the work each day, usually after twenty minutes when I was getting overwhelmed.  My phone has been set to mute the disability company whose questions put me over the edge.  She screens my messages.  This process turned me into a pill-popping wreck last fall, and though my memory is not what it used to be, I do know my helper's name.

Rush, the system works well for you.  But not for the rest of us who live in the United States of America.

I commend to your reading Souls in the Hands of a Tender God by Craig Rennebohm with David Paul.  Craig uses his stories to help us see the face of Christ in these abandoned ones, and to frame his theology of God and what it means to be a human being in the sight of God.  We cannot make the journey alone.  None of us.  We are made for life together, made for community.  Those of us blessed with health and wealth may be tempted to forget that.  We may want to believe that we are self-made and assume that we have succeeded through our individual merits alone...  Illness - and especially mental illness - confronts us with the unavoidable truth of our frailty and finitude.  Illness underscores our fundamental dependence on the love and help of others...

Craig describes the work that his community is doing, "companioning" people who are mentally ill.  Companionship can be described in terms of four practices: offering hospitality, walking side by side, listening, and accompaniment.  Let's consider these in detail...

And he tells the astounding story of a very different kind of system in Geel, Belgium.  I will tell you about the miracle of Geel next week.  There is a different way to do this.

The image is from http://mentalhealthchaplain.org

Spiritual Practices for the Dark Night -- Forgiveness

Okay -- one more in the spiritual practices series.

But I don't put forgiveness in the same category as thanksgiving and tithing, practices I keep and commend to my readers. I can't say that I practice forgiveness. When forgiveness happens, it comes as unbidden as a gracious gift in a time of desperation.

I can't tell you how to forgive. I never learned.

What I mean by forgiveness goes something like this: This person has a relationship with me, in which I can expect this person to treat me well, AND this person did me some harm, AND I forgive this person and will carry the burden of not forgiving no longer.

I never learned that kind of forgiveness. I learned BUT forgiveness: This person did me some harm, BUT it wasn't that big a deal. Or: This person did me harm BUT there were extenuating circumstances. Or: BUT I just haven't figured out the bigger picture yet. Or: BUT he/she couldn't help it. Or: BUT I am the better person, and will let it go.

But the BUTs don't work. They hide a wound that does not heal. They disrespect me and how I deserve to be treated. And they cover with a fig leaf my disrespect for the one who hurt me.

The "I just haven't figured it out yet" thing is especially problematic. There are certain statements that simply can't be reconciled unless something gives. In my case, my brain. Rehearsing and rehearsing the same event, trying to comprehend the incomprehensible, experiencing that pain over and over -- this is called rumination, the bad kind of rumination, perseveration even, my therapist would call it when she was trying to scare me out of it.

Spiritual Practices for the Dark Night -- Tithing

Yes, I'm serious.  Tithing.

I knew about tithing because I am a Christian.  The concept comes from the Old Testament. I used to think it was interesting -- from a distance. Like fasting. Of course nobody except the legalists actually did it. Still, I suspected I was missing something.

Then two things happened within two months. I left the person to whom I had turned over all decisions that mattered. And I attended a conference about what was called the "Alabama Plan." We did bible studies about money, about tithing, about abundance and God's promises. And then we were asked, What is preventing you from claiming God's promises? I realized my answer was -- nothing. Nothing prevented me.

So I became a tither.

Now remember the context. Having just moved out on the chief money maker of the family, my household income had plummeted to 40% of what it had been. It occurred to me -- this was the perfect time to begin tithing. Instead of 10% of what I was used to living on, now it would cost me just 4%. The difference between living on 40% and living on 36% didn't seem like that bit a deal.

I was so excited by my new resolution that I decided to tithe for the previous two months as well. So I sat down with my checkbook. That's when the magic happened.

Suddenly, I had $300 to give to whatever cause I wanted.

I had never had $300 to give to whatever cause I wanted.  I was rich!

And I have never looked back. In the years since, I have purchased honey bees, rabbits, trees, a pig, a llama, a sheep, and this year a goat from the Heifer Project. I have purchased mosquito nets from UNICEF. I have fought hate crimes and taught tolerance through the Southern Poverty Law Project. I am helping secure marriage equality through the Lambda Legal Defense Fund.

My most satisfying sense of wealth was the opportunity to purchase four chlorinators for $300 a pop. They provide four villages in Swaziland with clean drinking water. The last time our diocese sent a team to partner with the Anglican Church there, they sent back word, "One elder welcomed us with great thanks. He said, 'Ever since you came, we have not buried a child.' It's a much bigger project than my contribution. Now the Swazis are making the chlorinators themselves.

And I have given lots of money to old churches in small towns. I make no apologies for paying heating bills of drafty old buildings. Hearts starve as well as bodies; Give us bread, but give us roses. In out of the way places, stained glass windows are the only art most people see. So I am glad to support the furnace repairs of my church home. We are family. Paying the bills is part of belonging.

I couldn't do all this if I hadn't made a commitment -- 10% on the first line item of my budget. If I had to decide each month whether I could afford it, well, of course there are other things I "need." But with that money already allotted, my only decision is where I get to spend it. Frankly, it's almost the only discretionary money I have. That there is so much of it makes me feel rich.

And what on earth does this have to do with Prozac Monologues: reflections and research on the mind, the brain, depression and society?  This:

Regarding depression: those of us with mental illness experience loss piled on loss, often including financial loss. We live in a world so programmed for consumption that it consumes us. We are surrounded by images of things we don't have. It hurts to feel poor.

Regarding society: the "Crazy Delusion" consumes all the rest of us, as well. Do you realize that of the almost 7,000,000,000 people on the planet, most of them do not have cable?

Regarding the mind: think of tithing as Cognitive Behavioral Therapy. First, pay attention to your feelings about money. Money is the quickest way into what we value. Examine the assumptions behind your feelings. Challenge your assumptions. Do they have a basis in reality? Explore and test options.

Nothing has ever matched the rush I got when I wrote those first checks. If you have to be careful about mania triggers, you might start slower. Figure out what you gave away last year. Calculate the percentage. Double it this year, and double it again next year, until you reach your goal. The trick is to make it a line item in your budget, as intentional as your light bill.

Tithing is a spiritual practice for the dark night, a way to push back your feelings of loss and your anxiety about the future. I am not going to promise that you will be rewarded by an unexpected windfall. Rather, it will occur to you that you already have enough.

So like thankfulness, tithing is a form of mindfulness, paying attention. The Torah has given us this great gift. Claim it. As Moses said, Choose life.

P.S.  I seem to have given a lot of advice lately. Too much.  There will be no third spiritual practice; the series ends here.