Cognitive Behavioral Therapy -- Gingerbread Style

First Cognitive Therapy Technique -- Distraction

My therapist said Think of something you might find enjoyable.  You don't have to do it.  You don't even have to enjoy it.  The goal is not to move your mood from 1 to 10.  Any mood change is a bonus.  The goal is simply to give you something else to think about [-- besides what I had been thinking about.]

Distraction is one of those really irritating CBT techniques.  I am traumatized and can't stop thinking about this.  Okay, so think about something else.  I pay money for this?

But my other therapist, totally different method, said pretty much the same thing.  And I was six weeks from a major project I had promised for the holiday season.  And I am not sure it would have worked except that the wheel was ready to turn from early autumn danger to late autumn hypomania.  But he did and it was.  So...

She said think about it.

I guess I overshot the mark.


Ya think?

To Diagnose Hypomania -- Pay Attention

I used to churn out 10-12 gingerbread houses each season, back in my undiagnosed days.  I used the Joy of Cooking recipe and floor plan.  But each and every one was one of a kind: a log cabin made of pretzel sticks and peanuts for the chimney, another with candy canes on the roof for a chalet effect... No, I wasn't manic.  I was excited...

It could be said I don't know when to quit.  So a simple suggestion, think about something you might enjoy instead of what you are thinking about right now, became a fourteen inch high, furnished gingerbread house.


See what I mean?  Once I decided to tile the kitchen floor with candy corn, I was gone.  Note the faucets for the aluminum kitchen sink.  And the handles on the refrigerator.  There is a fireplace hearth down there, made of a Milano cookie.  Even as I was installing these things, I knew I was out of control.  But I could not stop.

Here is a nine patch quilt, made from fruit rollups.  Plus a teddy bear on the pillows.  Should you decide to start quilting with fruit rollups, here are my methods.  Unroll them a few days in advance to dry a bit.  Don't overreach.  Let the materials tell you what they are willing to do.  Use liberal amounts of vegetable oil on your fingers and cutting utensils.  Keep the knife clean.  I recommend an exacto knife, under supervision if you have a problem with sharp objects.  Place your product between oiled sheets of cling wrap, then between sheets of paper.  Iron at LOW heat for five seconds.  Breathe.

I refer to this as my diagnosable gingerbread house.


By doubling the dimensions, I had introduced engineering issues.  I needed weight bearing walls.The closet was designed for that purpose.  I made a double wall facing the living room.  But I failed to double the wall with the door.  Two by twelve inches, it was the first piece to break.  The pretzel sticks inside the closet hold it together.


Metaphor Alert -- Community

If I were to get philosophical -- and while I bent over this project, holding my breath and waiting for icing to turn to cement, I had plenty of time -- I would reflect that sometimes things or people are created that do not have the structural integrity to withstand the pressures to which they will be submitted.  Nevertheless, they can get by with a little help from their friends, even friends that brittle themselves, like pretzel sticks.  This is the essence of support groups.  Get into one.

Some of us are not particularly unstable, but we collapse under pressures beyond normal experience.  If we don't have to bear the weight by ourselves, we can make still our own creative contribution to the whole.  The fireplace wall fell into three places.  Twice.  It stood, once it received a full back brace.  The brace is not flashy.  It is not even visible, covered by the outside of the fireplace.  But it is essential.

This is the essence of community.  Christians call it the Body of Christ.  If the house were all ribbon candy, how would it stand?  If the house were all support, what would cover the kitchen floor?

Anyway, diagnosable.  The roof also collapsed, the weight bearing walls notwithstanding, because I pushed too hard while attaching it.  Be gentle with yourself, my friends.  The stronger parts can injure the weaker.  Self-restraint is especially important where you are strong.

But we can learn from our mistakes, and turn them into more creative opportunities.  The roof went for snacks to a bible study group.  I replaced it with a lighter version.  And then I broke one side again.  This time I finally listened to my spouse, and put up just half a roof, so people could look in on that nine patch quilt.  None of us has all the answers.  And sometimes irritating advice is good advice.

Even if it is irritating.

Another Cognitive Therapy Technique -- Dialectical Thinking

Even in the midst of this craziness, I kept aiming at sanity.  My mantra was Prototype, prototype.  The point of a prototype is to make as many mistakes as possible, in order to learn, and not make the same mistakes while doing the real thing.

I was making a lot of mistakes.  Boy, was I learning.

Dialectical thinking means that life is not divided into black and white.  One can hold a painful thought and a positive one in the same brain at the same time.  That and valium got me through.

I learned not to use a double barrel aged single malt scotch as a brace to hold up a wall while assembling, like the soup cans above.  The bottle was missing only as much as is pictured here before I made that particular mistake.  Sigh.

After mopping up the nearly full bottle of scotch and as much shattered glass as I could find, it was time, it was time to stop working on the prototype.  Well, after I built the fire in the fireplace.


Two hot tamales, cut on the bias, a couple little pretzel sticks and a sprinkling of ribbon candy crumbs.  The back of the fireplace is the inside of a mint Milano with the white frosting scraped off.

Like I said, diagnosable.

It wasn't finished.  It still isn't finished.  But the time for prototype was at an end.  The time for the real deal had begun.

To be continued...



all photos of gingerbread houses by Helen Keefe 
photo of scotch by Suat Eman

Hope and the Play of the Week

I am up to my earlobes in ribbon candy, pretzels and gingerbread right now, a holiday project gone diagnosable.  I have been working for several weeks now on the prototype of a gingerbread house that is yet to come.  If this one stands.

I hope I can post pictures of the finished product.  They could go in my file.

Meanwhile, I have scavenged a video from a Facebook friend.  It reminds me of my very favorite poem in the whole wide world.  My congregations know it by heart, they have heard me preach it so often.

Listen to the mustn'ts, child.  Listen to the don'ts.
Listen to the shouldn'ts, the impossibles, the won'ts.
Listen to the never haves then listen close to me...
Anything can happen, child.
Anything can be.


Come to think of it, the gingerbread house, the poem and the play of the week all have this is common.  They are matches, held up against the darkness.



Here's hoping you some light.

Weighing Costs and Benefits Part V -- Down and Dirty Algorithm

SE + NE + $$$ + STG + TR = STC.

E#PT X NSR = STB.

STB TO STC = ODDS OF SUCCESS


There it is, the Prozac Monologues Down And Dirty Algorithm, to weigh your costs and benefits for medication or any other treatment for any mental illness, or any other medical condition, for that matter.  Click on the first and second lines.  They will take you to the posts that develop the formula.

Can you believe we finally made it?

We started with the:

Manifesto of a Lab Rat. 


I am a Lab Rat.  Yes, I am.

The Manifesto begins there.


It continues: 
 
If I am a lab rat, I will be a free-range lab rat.

What I mean by free-range lab rat is this: 

I insist that I contribute more to this enterprise than my body.

Your doctor tells you to weigh your costs and benefits, but gives you no way to do so, other than insufficient information + gut + desperation = noncompliance, if you don't come up with the same answer as your doctor.

What we need is an algorithm: logical rules that we can apply to objective data to solve a problem.

This algorithm does not exist.

So as an interested party, a very interested party, given that my body is the test tube, I decided that my contribution to this chemistry experiment would be the algorithm.

The problem we want to solve is this:

Do I Want To Put These Chemicals Inside My Body?

This task has continued over several posts this fall, interspersed with a few sick leaves and vacation days.  Click on costs and benefits to follow the whole development.  (The first post is at the bottom, dated August 19, 2010).

What To Do With The Algorithm

The resulting algorithm can be applied not only to the chemicals you put in your body, but any other form of treatment as well, talk therapy, aerobic exercise, yoga, Chinese medicine, acupuncture, even aroma therapy, should you choose.

You can compare the results of the cost/benefit analysis of different treatments, and do the same with various combinations, when you can find the numbers.  Which admittedly, you cannot for any of these that do not get Blue Cross Blue Shield reimbursement.

There are numbers out there for talk therapy and aerobic exercise.  But doctors do not usually use the word therapy for anything other than chemicals or electro-convulsive therapy (ECT) or any of those new-fangled electrical interventions.  That is the context in which you are told to weigh your costs and benefits.

For the most part, I have used antidepressants as examples.  One out of every ten people in the United States is taking them right now.  So this would be the most common application, among psychotropic medications.

It was helpful to look at chemicals as I developed this algorithm, because they are the form of treatment with the greatest costs and greatest variety of costs:





dizziness and confusion,





insomnia and fatigue,



weight gain, irritability, sexual dysfunction,  irritability.




So this is what you do when you use the algorithm to weigh your costs and benefits -- you compare two numbers, STC (Short Term Costs) and STB (Short Term Benefits).

And how do we get those numbers?

Remember,

SE + NE + $$$ + STG + TR = STC.
E#PT X NSR = STB.

The abbreviations increase the confusion quotient, and thus make it look scientific.  Here is a translation:

Side Effects (SE) plus Not Effective (NE) plus Money ($$$) plus Stigma (STG) plus [lack of] Trust (TR) are your costs (STC).  These costs are based on the reasons people give for discontinuing their medication.

Efficacy Given The Number of Present Trial (E#PT) times How Many Would Not Experience Spontaneous Remission Unless They Took the Medication (NSR) are your benefits (STB).

Did you like my illustrated tour of the previous posts?

And Where Are We Supposed To Get Our Data?

They ought to be provided to you by your doctor, who has told you to weigh your costs and benefits.  Except for money, stigma and trust -- you have to come up with your own odds that you will quit taking your medication because you can't afford it, you are afraid for your reputation, or you do not trust your doctor.

They ought to be provided to your doctor by the drug reps.

But they are not.

So you have to do your own research.

I think the algorithm would make a fabulous app.  The numbers could be regularly updated, from the latest research by scientists not funded by the companies that sell these chemicals.

I claim copyright, by the way. 

Long Term Costs And Benefits Are Missing

Notice that I refer to short term costs and benefits.  Some will object that I left out good reasons to take meds: the difference that meds make to how quickly another episode occurs (relapse rate), how long various approaches take to work (time to remission), how medications affect things like brain mass, suicide risk.

Others will object that I left out good reasons not to take them: the possibility that medication might accelerate the natural progression of the disease, the possibility that the diagnosis is off and you will flip into mania or hypomania, liver damage, the consequences of weight gain, such as heart disease and diabetes, suicide risk.

Someday I will do a post or two on that suicide risk issue.  There is a lot to say about that.

Well, this algorithm is complicated enough and took five posts already.  This one has that i-Pod potential.  The one that includes all those other issues will take more gigabytes.

STC versus STB give you the odds.

Once more I repeat, they do not give you your decision.  There are additional personal factors that influence or even override logical rules, objective data, and problem solving.

Personal Factors:

You have used up your sick leave, your vacation time and your family leave for this year and next, and your boss will fire you if you don't start taking meds.

Your wife has issued a similar ultimatum.

You can't get out of the loony bin any other way.

You are desperate.

You have the knife to the wrist.

Like I said, it is your decision.  I am merely your humble servant.  Who does occasionally buy a Powerball ticket.

How Does The Algorithm Work?

Let me give you a personal example.

When I first took Prozac, Eli Lilly's website said that it had helped 70% of the 55,000,000 who had already taken it.  I didn't know anything about spontaneous remission or the effect of which trial this was.  So STB = 70.

Meanwhile, none of the side effects (SE) reported went above the 15% range; the odds that it would not be effective (NE) were 30 out of 100; it was already generic, and I could afford it ($$$); stigma (STG) was not an issue for me; and I had total trust (TR) in my doctor.  So STC was 15 + 30 + 0 + 0 + 0 = 45.

That meant (with the information I had) that the odds for Prozac were 70 to 45 in favor.  And I could put off therapy.  No brainer.

Next up -- actually, five keep trying's later, we had moved on to a psychiatrist who prescribed Effexor.  Crazy Meds says: for deep, despairing clinical depression that needs to respond to the standard tweaking of the three most popular neurotransmitters, Effexor XR (venlafaxine hydrochloride) often pulls people out of the abyss.  By then, the deep, despairing abyss -- that would be me.

My doc said I get good results from Effexor.  She didn't say how good results translated to a number,.  (That's case studies, by the way -- not research.)  But she did tell me to weigh my costs and benefits.  By then I knew that most antidepressants have about the same effectiveness level, which I took to be around 40%.  I didn't know it mattered that I was on my sixth go round.  Odds for benefit, STB = 40%

She also gave me the usual side effects, because I asked.  Since insomnia was a major issue for me, and we had run through a number of sleep aids, she said that the insomnia risk (SE) was 15%.  Not effective odds (NE) would come in at 60 out of 100.  Since she didn't ever answer phone calls, and I knew I couldn't stop this med without help tapering off, and I was wary of her by now, I grilled her on how to discontinue without her help.  Trust, lack thereof, (TR) was in the 40% range.  STC was 15 + 60 + 40 = 115.

With Effexor, my odds were 115 to 40 against.  Not so good this time.  However, desperation overcame gut instinct.  So I kept trying.

The rules of the algorithm work, but the results are only as good as the objective data.  What if I knew then what I know now?  Without going into the whole story, and by tweaking numbers actually available: 

Prozac -- 

STB = 40 (E#PT) X .8 (NSR) = 32.
STC = 30 (SE) + 60 (NE) + 0 ($$$) + 0 (STG) + 20 (TR) = 110. 

110 to 32 against.  I still had issues with therapy (nothing to do with any therapist I have ever known, by the way).  And being over-educated, I am on the compliant side.  So I would have given it a shot. 

Effexor --

STB = 10 (E#PT) X .8 = 8.
STC = 34 (SE) + 92 (NE) + 0 ($$$) + 0 (STG) + 95 (TR) = 221.

221 to 8 against.

The numbers for Effexor come from the STAR*D study, and were available at the time I started taking it.  But I didn't know that.  STAR*D's original conclusion was that after two antidepressants have been tried, subsequent results are dismal, and more research for better medications should be a priority.

Since then, a jillion articles have been written about how STAR*D was a lousy research design that cooked the books in way favor of the chemicals at every step, starting with the selection of subjects.  Click here for my posts that reference STAR*D.  But Google it for for what the scientists say.

Anyway, 221 to 8 against -- I would have given it a pass.  Even I could tell the books were cooked.  And I got so much better after I went off it.

And So The Manifesto Of A Lab Rat Concludes

Of course, your results may vary.  Just remember, it's your test tube.




flair from Facebook
Photo "Tired Man" by graur codrin
Photo "Angry Father" by Akapl616.  Permission is granted to copy
under the terms of the GNU Free Documentation License
i-Pod family photo by Matthieu Riegler, licensed under
the Creative Commons Attribution 3.0 Unported license.png
photo of Warren G. Harding in public domain
photo of woman pointing taken by David Shankbone,
used by permission under the Creative Commons 
Attribution-Share Alike 3.0 Unported licence and modified
photo of prozac by Tom Vasco and is licensed under
photo of effexor by Parhamr who has placed it in the public domain
photo of John LeCompte of Evanescence by Samuel Lang,
permission to copy and modify granted under GNU Free Documentation License

Mental Illness -- Stigma or Sexy?


Full confession time.  You may have noticed that I respect copyright.  I use images in the public domain or with permission, and don't use pictures where permission has been denied.  Which sometimes is a real bite.  The Des Moines Register...

I don't have permission for this one yet.  I ripped it from a site where you can purchase bracelets to support nkm2.org.  So I urge you to help me atone for my sins, while I write for permission.  Go to this link and buy one.  They have those cute little loony birds on them.  And you know how I love loony!

nmk2.org is Joey (Pants) Pantaliano's bid to make mental illness as cool and as sexy as erectile dysfunction.

Really.



Okay, it hasn't gone viral yet.   But Harrison Ford with one earring is kinda sexy.  It's a start.

It Gets Better

I was going to get funny this week.  But this won't wait.

The message below took place at a city council meeting in the center of Iowa.  It means all the more to me, because I live in Iowa, and because I know this small city in a rural and conservative part of the middle of America -- a fly-over state.

Oops -- a reader corrected my confusion.  Joel Burns is a councilman in Fort Worth, Texas.  Maybe that makes the story even more significant.

Joel Burns, elected to that city council, has lived long enough for it to get better.



Educators who want to respond to his challenge can find resources at the Teaching Tolerance arm of the Southern Poverty Law Center.


Their new documentary and classroom resource, Bullied includes lesson plans and is available for free to any school that requests it.


I also want to plug their quarterly magazine, Teaching Tolerance.  It gives teachers specific ideas and lesson plans for K-12 on many diversity issues.  Subscriptions are available for free to any teacher who requests it, any donor, and also online.

Bullying Has To Become A Crime

I have never understood why schools are law-free zones, why students who beat up other students are not prosecuted for assault, why teachers and administrators who do nothing are not prosecuted for accessory after the fact.

It Is Time To Prevent Bullying

I also have never understood why society places the burden of violence on its victims.  We know the names of recent victims who could no longer bear that burden.  We develop therapies to repair damage that is done to other victims.  But as with PTSD, we treat after the fact.  We do not prevent.

All the bullied teenagers who died recently have been "outed."  But we do not know the names of the bullies.  We do not work on fixing them.

Children who are cruel grow up to be adults who are cruel and raise children who are cruel.  I repeat Joel Burns' challenge to stop the violence.  That is when we will stop the suicides.

We also do not know the names of the witnesses, those who remain silent.  All that it takes for evil to triumph is for good men to do nothing -- Edmund Burke.  These students, too, must find their voices.  We all must.

Meanwhile, If You Need Help Now:

In the U. S., call 1-800-273-TALK (8255)
Press 1 for English, 2 for Spanish.
Click here to find a hotline outside the United States.



Use of the SPLC and Teaching Tolerance logos does not imply
that they have endorsed the views expressed in this post. 

Weighing Costs and Benefits Part IV: Costs

Some people quit taking meds that their doctors believe will relieve their symptoms of mental illness.  Why?

Because the meds don't work, because they can't afford them, because the meds make them sick.

Manifesto:

For any of these reasons, people who quit are making intelligent decisions in their own best interests.

On The Other Hand 

Sometimes the meds do work.  Sometimes people have decent health insurance with good drug coverage.  Sometimes the side effects are not as bad as the disease.  In that case, those who quit their meds are stupid.

Let's just get that right out front.

Moving On To The Costs

Today my series on weighing costs and benefits turns to the costs.  The costs do not tell you whether you should try a medication.  They simply give you the odds.  It is up to you to decide how you want to play the odds.  I calculate the odds based on the numbers of those who quit.  Those who consume have the best information about costs, what actually happens when they put these chemicals in their own particular test tubes.

How Many Of Us Are Noncompliant?

Out of 100 prescriptions that providers write, 10 consumers never consume.  They don't show up at the pharmacy at all.

28 consumers quit within the first month.  That includes those first 10.

50 quit within 60 days.

72 are outta there at six months, 78 within the year.

That leaves 22 compliant consumers.

How Do Noncompliant Consumers Explain Their Decision?

10 out of the 78 don't.  Providers failed to close the sale.  Providers would be interested to know why these 10 are pharmacy no shows, because it might help them improve their pitch.  Their assumptions are that it was because the consumers didn't understand, or the providers didn't establish trust, or that good old back up -- stigma.  But often, consumers don't report their decision.

We could invent reasons, which might be fun, top ten list, that sort of thing.  The drinking buddy said, Buck it up.  Real men don't get depressed.  The transmission fell out of the car on the way to the drug store.  My favorite -- the primary care physician said, Are you kidding?  With your blood glucose and lipid levels?  Does this so-called doctor even own a blood pressure cuff?  However, all this speculation is just that.  These 10 do not give us information about the costs of taking the medication, because they never take it.

So now we have 68 consumers who quit after they tried the meds.  AK Ashton et. al. actually asked them why.

30 (out of the 90 who actually filled the prescription) say they quit because they could not tolerate the side effects.

30 say the medication was not effective.

That already adds up to 70 nonconsumers, counting the nonstarters and leaving eight who quit for other reasons.  I will suggest some of these other reasons, and you will have to come up with the odds yourself that any of them might put you among these 8.  (They may have reasons similar to the 10 who never started.)

And by the way, these numbers vary by how many different medications the consumer has already consumed, which primarily affects the efficacy number.  They also vary by which medication is currently being considered, primarily effecting the side effect number.

We don't have all the numbers we need.  Somebody needs to be collecting this data.  A consumer group, looking at real world data over the course of a year, not the guys with 6-8 weeks of information, seeking FDA permission and doctors' cooperation to sell pills.  But the algorithm itself will work for whatever the numbers turn out to be. 

Let's Start With Side Effects

30 of the 68 who consumed and quit say they quit because of side effects.  The clinical trials, lasting eight weeks or so, report much lower numbers.  The numbers the providers give you are from the clinical trials.

The common belief among providers is that they could improve compliance by giving consumers more information up front about side effects.  Small isolated studies sometimes confirm this over the short haul.  But this belief does not stand up to more research and more time.

Up front discussion of side effects can give the consumer strategies for dealing with insomnia, reducing nausea, preventing falls when they get out of bed.  These are the side effects we notice immediately.  Maybe they are tolerable if you have social supports to get you through the roughest first weeks.  Sometimes your body does  acclimate, and the immediate side effects become less bothersome.

But sometimes these strategies don't work.  Social supports wear out.  Mom has to go home and stop helping you with the kids.  You run out of sick leave.  The body does not adjust.  And sometimes these side effects are indications that you are taking the wrong medication!

But the major side effects appear later.  Which are the most bothersome?  The results: weight gain (31%), erectile dysfunction (25%), failure to reach orgasm (24%) and fatigue (21%).

Weight gain -- a few pounds in the first few months are not a problem.  You hardly notice.  But over the months, when you are moving from overweight to obese, you get a reality check on what this medication really costs.  Morbid obesity takes 8-10 years off your life.

Tell that to your psychiatrist when you complain and he/she says you have to weigh your costs and benefits.  Your doctor may not even know about how serious the health risks of obesity are.  Obesity even increases the risk of dementia.  But psychiatrists treat psychological problems with pharmacology.  They do not treat your heart, pancreas or liver.

Then there are the sexual side effects.  When you started the medication, you weren't getting much anyway.  That was one of the symptoms -- loss of interest in formerly pleasurable activities.  But six months later when you're not getting any, you (and your partner) recalculate your costs and benefits.

Hence, these noncompliance numbers go up over time.

Side Effects In The Algorithm

The major competition between makers of psychotropic medications has always been on this side effect issue.  It turns out, we just won't keep taking stuff that makes us feel worse.  So sometimes you can find studies that pit one against the other and get real numbers about side effects.

STAR*D found that in just 8 weeks, a combo of lithium/sertraline (Zoloft) got an intolerable rate of 45%, 2-5 times any other treatment.  Effectiveness rate -- 9%.  I wonder how many of the 91% who didn't get better would have been better off if they had taken nothing at all.

Or to put a finer point on it, did lithium/sertraline make matters worse?  They didn't test against placebo, so we don't know.

If the odds of harm are five times the odds of help, I will give it a pass.  That is like rolling the dice, looking for one particular number.  Only it's not dice; it is my body.  That is my personal decision, made after my eighth trial.  It is up to you how you play the odds.

For the sake of the algorithm, SE means the odds that you will quit taking this medication within a year because of side effects.

Efficacy -- What If It Just Doesn't Work?

We already discussed effectiveness in detail on September 2, Weighing Costs and Benefits Part II: Benefits.  Go back there for the details.  It makes more sense if you know the back story.  In summary:

Efficacy for Number of Present Trial (E#PT) means how many people got better with this med after they tried a number of others that didn't work.  Non-Spontaneous Recovery Rate (NSR) means how many people would not have gotten better if they had simply waited for the depression to go away on its own.  Efficacy for Number of Present Trial times Non-Spontaneous Recovery Rate equals Short Term Benefit (STB).  Those are the odds that it will work.

Or, E#PT X NSR = STB.

The abbreviations are there to make me look smart.  Which, as a matter of fact, I am.  Some days, I can make the smart parts of my brain connect  again and actually work smart.

Another way of looking at it: STB is a number between 1 and 100.  That many times out of a 100 are the odds that you have come up a winner.

So then the odds that the medication will not work are 100 minus Short Term Benefit.  We will call that Not Effective (NE)100 - STB = NE.  You have wasted your time, and are more discouraged than ever.  Bummer.

Now you may have noticed, the algorithm calculates the Short Term Benefit for eight to twelve weeks.  And the Short Term Cost refers to one year.  Why the difference?  Because you will likely be one of the early quitters (50%) if you don't get relief by twelve weeks.  And if you do get relief by then, you are likely to keep taking the medication for a year.  It may quit working for you eventually.  But you are probably good to go for a year.  Hence, twelve weeks for STB and twelve months for STC are probably equivalent measures.

Efficacy -- What About Those Who Quit Before They Gave The Medication An Adequate Trial?

I did not consider how many reported that they discontinued because the medication was ineffective, the 30 out of 90 that Ashton, et al, discovered in their survey.  This number is not helpful, because some of these 30 quit before the full 60 days needed to determine efficacy.

Instead, I used the efficacy numbers reported from the clinical trials.  As a result, those 8% discussed below is a larger group.  It would include the early quitters, because some of them might have gotten better if they had been more patient.

But these numbers are for illustration purposes only.  The algorithm is designed to be general, so that you can insert whatever the numbers turn out to be.

If you quit simply because the medication does not work faster than it works, and for no other reason, then you go into the stupid category.  Just to get that right out front.

Other Costs

8% (plus) quit taking the medication primarily for other reasons.  I expect that money, stigma and trust are the the big ones, with stupid in there, too, as stated above.

Money

Let's face it.  These medications cost money.  There are two costs to consider.  The first is the pills themselves.  The provider may provide you with samples, if yours is the newest wonder drug being promoted this week.  The samples likely last for two or three weeks.  This is good, if it helps you determine early on that there is no way you can tolerate the medication, even long enough for some of the side effects to become less troublesome.

On the other hand, it does not help you determine whether the medication will be effective.  That takes more time and your own money, a lot of it, if yours is the newest wonder drug being promoted this week, which you can count on, if you have failed to prove your provider a genius by getting better with his/her first or second choice.

If you have a good drug benefit, cost of medication may not be a major issue.  I now get my generics for free.  I represent a very, very small portion of the U.S. population.

I used to have insurance with a high deductible and mediocre drug benefits.  After the samples ran out, I paid $120 for a two month supply from a company that required I buy from them by mail order.  By the time the pills arrived, I had already discovered I couldn't tolerate the med.  I never even opened their bottle.  Meanwhile, I had to pay through the nose at my local pharmacy for the two weeks it took me to taper off.

In addition to the medications, you will pay for medical management, trips to the provider who will monitor your condition and tweak the chemistry experiment.

Again, these costs will vary by insurance plans and whether you have insurance at all.  With my current insurance, I pay $5/visit.  In my previous plan, I paid $40.  If I had no insurance at all, the cost would be $135.  And I see my doc every six weeks on average.

I cannot assign a number to the odds that you will quit a medication because of how much money it will cost you.  That is your call. Out of 100, what are the odds that you will quit because you cannot afford it?  We will call that $$$ in the algorithm.

Stigma

Okay, if you have made it this far through the Costs and Benefits series, you ought to be motivated enough to resist those who shame you (including yourself) for relying on a pill, for being weak, for being sick... whatever garbage they throw at you and you throw at yourself.  Please let's get over it.  I hope your stigma number is low.  But again, that is your call.  Out of 100, what are the odds you will quit for reasons of stigma? -- STG.

Trust

Next, out of 100, what are the odds that you will quit because you cannot find a provider you trust with your body, or because you think the pharmaceutical industry is corrupt? -- TR.

Stupid

Stupid is a side note.  Providers prescribe the medication because they already believe that the benefits outweigh the costs.  So they expect the stupid category is a large proportion of the noncompliers.   Only they call it confused.

Stupid is irrelevant to the algorithm, which is designed to weigh costs and benefits.  So stupid (or confused) is not in there.  Like stigma, stupid can be fixed.  But it is not a cost.  It is a prior condition.

Down And Dirty Costs

So now we simply add the odds of each of these costs together:

Side Effects plus Not Effective plus Money plus Stigma plus Trust (lack thereof) equals Short Term Costs.

SE + NE + $$$ + STG + TR = STC.

So How Do You Decide?

STC versus STB give you the odds.  Once more I repeat, they do not give you your decision.

We will look at a couple other issues and pull this all together in our next installment.  Whew.  My brain is about to explode.

Flair from Facebook
Clipart from Microsoft
Photo of die by Roland Scheichder, in the  public domain
Photo "Solution" by Salvatore Vuono
Photo "Angry Father" by Akapl616.  Permission is granted to copy
under the terms of the GNU Free Documentation License
Photo of "Tired Man" by graur codrin
Photo "Aces" by Felixco, Inc.
Photo "Loneliness" by graur razvan ionut 
Photo of Pristiq by Tom Varco.  Permission is granted to copy
under the terms of the GNU Free Documentation License
Mademoiselle Zizi Feints at Fainting, by John Sloan

Mental Illness Awareness Week -- One Year Later

A year ago, Prozac Monologues was just crawling, six months old.  I was new to this disability experience.  And NAMI Johnson County was new to me.

I am not sure how Della McGrath decided I was literate.  Maybe I had given her my card, and she read some of the blog.  But she asked me to speak at a candlelight vigil, to remember those who have died from mental illness, give courage to those who hope to survive it, and support to those whose loved ones did not.

The great thing about NAMI -- if able is always part of the contract.  So I could say yes, even when we were using sedation in place of hospitalization.  And hope for the best.

As it turns out, God gave me a window, and I was able to say what is written below.  It is reposted from October 3, 2009.  It is a bit out of date.  Once I was on disability, I could explore and admit to a better diagnosis, bipolar II, in place of major depressive disorder.  Bipolar is a disease with more stigma than vanilla depression.  And hardly anybody has ever heard about bipolar II, so they think the worst.  But now that I wasn't working, stigma didn't matter so much.  And I could let myself take the best bipolar II medication.  I knew its side effects would make my job impossible.  But that didn't matter anymore, either.

The year since has not been an easy one.  But I am still here.  And so, amazingly enough, is Prozac Monologues.  You, dear readers, give me a life that begins to replace the life I lost to this illness. 

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