Then I was going to relate the story about how, in the summer of 2002, I chose to stop taking my medicine the way my doctor directed me to take it, and then I stopped taking my medicine at all.

This was a bad choice. As a result, my illness became an emergency.

Nine hours in the ICU, four days in a private room, and two more weeks of hospital care brought a bill that topped $95,000.

The cost of nine years of care was eaten up by just a few weeks of my irresponsibility. That was cost that the health care industry, including my insurance company, would not have had to bear if I had only taken my medicine as directed.

It then seemed easy for me to extend this argument to all patients with any chronic disease. Do what your doctor tells you and your condition should improve, or, at least, be far less likely to worsen. By patients only complying with their prescribed treatment regimens the cost of health care in the United States would go down.

How much? A lot. As a matter of fact, a New England Healthcare Institute study of health care costs in the United States pegged the added cost of care due to patient noncompliance at $290 billion. That’s 15 percent of the country’s total annual health care cost. And a Medco study found that only 50 to 65 percent of patients with chronic conditions adhere to the medication therapy prescribed for them.

It seemed clear. I am, for my lost summer, and everyone else who does not take responsibility for their own treatment, everyone who does not comply with their doctor’s orders, are responsible for the high cost of health care in the United States.

When noncompliant, a person does not take his or her medicine as directed. This often leads to their condition worsening and results in higher costs of doctor visits, emergency room visits, and hospitalizations. On the other hand, medication compliance can significantly reduce these costs.

According to Medco, for every dollar spent on diabetes medication medical cost savings are $7.00, for every dollar spent on high cholesterol medication medical cost savings are $5.10, and savings of $3.98 are found for every dollar spent on prescription medication for high blood pressure. Mental illness costs are surely similar.

So if simply taking one’s medicine can lead to lower total health care costs, why are so many patients not taking their medication as prescribed?

Reasons for noncompliance include side effects, lack of continuing symptoms, and, yes, irresponsibility. But cost may loom largest.

I have always had health insurance. The co-payment for my medicine is $49 per month when I’m stable (it was higher, but one drug went generic). It goes up during rough patches. I’m responsible. I pay it. I’m well. I thought, perhaps I adhere to my treatment regimen because I am so heavily invested in it.

Maybe if everyone paid a larger share of his own health care bill, compliance with treatment would increase. Maybe personal responsibility, sacrifice when necessary, and more participation by each individual in the cost of his or her care would improve compliance rates and reduce the overall cost of health care.

But the cost of medication to the individual must be considered. As costs increase, fewer can afford to pay them. A study from the National Bureau of Economic Research finds that an increase in medication co-payments from only $6 to $10 results in a 6.2 percent increase in noncompliance and a 9 percent reduction in the share of fully compliant persons. The same study finds that increases in coinsurance lead to even larger increases in noncompliance. As for the uninsured, the American Public Health Association has found that 89 percent have not filled a prescription due to cost.

What was lost on me was some very simple economics. If each individual pays less for his or her prescriptions, compliance increases and the nation and insurance companies pay less of a total health care bill. Unfortunately, the trend in health insurance is for each individual to pay higher co-pays or coinsurance. As these costs go up out-of-pocket expenses may exceed one’s ability to pay. The choice? Noncompliance or increased debt and possible bankruptcy.

So yes, compliance is a choice. And noncompliance greatly increases the nation’s health care bill. Every proposal on the table that makes an individual pay more for his medicine will increase noncompliance and add even more to the nation’s health care bill. High deductibles and higher co-payments charged by insurance companies against each individual will only make the problem worse. Paradoxically, as cost-driven noncompliance pushes total health care costs higher, these same insurance companies may find themselves less profitable over the long run as they face the higher cost of complications caused by medication noncompliance.

Perhaps if insurance companies lowered prescription co-payments more patients would take their medicine as directed and the insurance companies, with fewer complication-related charges against premiums, could actually increase profits. Pharmaceutical companies would benefit as well as more prescriptions would be filled. We should have no problem with health insurance and pharmaceutical companies making more money if the profits they earn come from lower total health care costs and healthier individuals.

As for my, and others’, idea that if people pay a larger percentage of their health care costs they will live healthier, more compliant, lives, the truth is that health and compliance can be expensive. Low-cost prescription benefits must be considered as we approach ideas to lower total healthcare costs. Higher costs to individuals for medication lead to higher rates of noncompliance, which lead to a higher national health care bill that, one way or another, we all must share.

References

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3326767/

http://www.hreonline.com/HRE/view/story.jhtml?id=5059249

http://www.nber.org/digest/apr05/w10738.html

http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2010/Jun/1408_Morgan_Prescription_drug_accessibility_US_intl_ib.pdf

Mindfulness meditation is currently all the rage, and it works. But I am wary of its proponents who claim it can treat (or even cure) mental illness by itself.

Meditation is a powerful tool when used to decrease stress and increase well-being. But if we are to maintain that mental illnesses are biochemical malfunctions of the brain and nervous system, then we must allow room in treatment for medicine. Therapy also has a long history of positive impact on the lives of those challenged by psychiatric disease. Meditation, when added to more traditional and well-tested methods of treatment, can help a patient successfully manage a challenging life. I, and so many others like me, am proof of that.

I am sure that there are people who face serious mental illness well using only meditation. Dan Siegel writes of one teenager who manages bipolar disorder with meditation alone in his excellent book Mindsight.

But the popularization of such case studies may lead people to stop taking medication and pick up meditation in a hope to finally be done with meds. Anyone who hopes for this and changes his own medication regimen without proper medical oversight is asking for relapse and worse.

Another book on the benefits of meditation, Transcendence, by Norman E. Rosenthal, clearly states that meditation for mental illnesses such as bipolar disorder and schizophrenia should only be administered in conjunction with medication and therapy and should be monitored by a physician. I believe this more balanced view will help more people manage the symptoms of mental illness successfully.

Since I have become a disciplined meditator I have had little difficulty with my bipolar disorder. It is only natural to wonder if I could manage as well if I continued to meditate and came off the drugs. In fact, it is very tempting.

But my doctor advises me not to and, after much reflection and concern for my family, I agree. Just as I couldn’t manage this well without the meditation, much research evidence supports the idea that I couldn’t manage without the medication either. I’m not willing to take the chance.

Every person with mental illness to whom I have taught meditation has asked me if I think serious mental illness can be cured. At this point, with what science has discovered, I don’t. But it can be managed, and managed well, if meditation is added to the medical model of drugs and therapy.

Just as the person with diabetes will take insulin indefinitely, I must continue to take my medicine. And just as one with diabetes must adopt a healthy lifestyle to best complement her medication, the person with mental illness must as well. What I am sure of is that meditation is one of the best complements available.

It’s been hard to sit at all, let alone for the 30 minutes I meditate each day. I find myself agitated and fidgety. My thoughts are all over the place.

This is not unusual during meditation, but in taking note of the subjects of my thoughts, I can see hypomania creeping in. I’m thinking of buying stuff. I’m thinking of trading stocks. I’m thinking of another career change, discarding good ideas for more exciting, if undoable, ones.

All of my thoughts are about getting and doing. Anything. Right now I feel smarter, more creative, and more energetic than I usually do. That might be dangerous, but that’s what I’m feeling, and that’s what I encounter during meditation.

And here’s where mindfulness meditation really helps.

I’ve picked up these early signs of hypomania, so I can work to avoid myself going full-blown manic. During meditation, which I now have to force myself to do, I become calm for a time and clearly see the maelstrom I’ve entered. I give my wife my credit cards. I walk past the corner pub without going inside.

I also implement the two-week rule for purchases, investments, changing my LinkedIn profile, and publicly flouting new ideas. The two-week rule allows me to note what I want, or want to do, and set it aside. If, two weeks later, it still seems like a good idea, I can act on it. Meditation sessions keep me honest. I note if I’m breaking the rules, or planning anything big and stupid.

This is when meditation becomes a little different. In quieter times, while focusing on the breath I note thoughts and release them, always returning to the present moment.

But when I recognize the signs of creeping mania (or depression), I incrementally change my relationship to my thoughts. As they arise, I pay a little more attention to them as I note them. I investigate what my thoughts are about.

Are they fantasies? Is there anger? Am I subconsciously planning? What thoughts keep returning? Are there consistencies, or even deep inconsistencies? As I note repeating and defeating thoughts, I can see how they are affecting my behavior when I’m not meditating. Then I can make what changes I need to make in my day, my plans, and my expectations, and avoid trouble.

So here’s hypomania. Although it can lead to very bad things, it has its benefits. As I stated, I think it does make me more creative and energetic. By meditating, staying present and responsible, and noting my thoughts, I can both stay focused and harness some of that energy and creativity. Meditation helps me hold on to the good ideas and keeps me away from acting out the bad ones.

Anyone who’s experienced hypomania and felt the energy, charisma, and flush of ideas it often brings, knows that if we could bottle this stuff we’d make millions. But we can’t bottle it. If left to ramble it often becomes grandiosity, poor judgment, and hurtfulness.

Through the focused attention of mindfulness meditation, I can harness the positive and avoid the negative. This episode will pass, and I hope to leave it with my life intact — and a few good ideas.

Yes, I have been scattered, unkempt, flighty, undependable, and absent. But I have also, at times, been able to carry out with incredible focus to minute detail tasks that I could never stick with if not at least mildly manic.

While the energy to work and the attention to detail did not always congeal on a reasonable or desirable task, the results were often impressive.

But then, I’ve also spent an awful amount of time lying around doing nothing. Not contemplating, not planning, not even daydreaming. Just depressed. Could there be a way to predict moods? A way to harness and apply a disciplined approach to managing symptoms?

Too often we equate discipline with punishment or control. But The American Heritage Dictionary offers the first definition of discipline as training expected to produce a specific character or pattern of behavior, especially training that produces moral or mental improvement.

Viewed in this way, discipline can be very positive. Self-discipline can lead to self-improvement. A regular meditation practice is a tremendous exercise in self-discipline. And this self-discipline can help one to manage and even predict difficult times with mental illness.

Mindfulness meditation, for most practitioners, is about cultivating an ability to stay aware of the present moment in order to manage stress. But for those suffering from a chronic illness, it can also be diagnostic.

Prior to becoming a meditator, I all too often found myself in the midst of a hypomanic or manic episode, unaware how things had gotten so carried away. While meditating, however, I can sense the very small changes in mood that signal an oncoming episode.

Thoughts, emotions, and behavior patterns often become clear during meditation sessions. Fleeting, disorganized thoughts, looming grandiosity, and kinks in self-control can all pass unnoticed in a busy schedule. Soon, the negative symptoms have grown so large that positive behavior is buried by irresponsibility and self-destruction.

But if I take time to stay present each day, and to remove myself for a time from the onslaught of distractions in life, early clues of changing behavior become apparent.

Once a pending episode is revealed, adapting to and preventing further behavior changes can be handled by avoiding stressful situations, getting enough sleep, rallying friends and family, and calling the doctor (if necessary). A plan previously put in place to best handle oncoming episodes can be carried out, and a major episode can be avoided.

Used this way, meditation not only affords a way to manage stress, but it provides a tool to manage changes in mood and breaks in rational thinking. Meditation can help both diagnose and manage the symptoms of chronic illness.

I have hurt those who love me, squandered my savings, lost jobs, behaved very poorly, and even attempted suicide.

As episodes ended, the knowledge of what I had done made me feel so alone, so separate from those close to me. Isolated even from strangers. The worse I felt I behaved, the more I felt undesirable. Immoral acts left me feeling as if I had no one.

Mental illness and its associated behaviors can make one feel wrong without equal. A sense that only a very sick person would commit such transgressions can drive one inward and away from those who can help. We often push those who want to help away. Fear of hurting or disappointing others leads to strained and severed relationships.

But who hasn’t hurt someone? Who hasn’t lost money, stayed in bed, embarrassed himself in public or acted cruelly? No one is infallible — we all have flaws.

Could it be possible that our egregious behavior actually joins us to others? Love, grace, and honesty support humanity. But humanity screws up. Why should our failures leave us feeling so apart when everyone has failed?

Perhaps the very things that make us feel alone are the things we have most in common with others. Perhaps the acknowledgement that we share failure can make us more able to share success.

This does not give us license to continue to hurt others and ourselves. But it does allow us to forgive ourselves.

Just as we can forgive others for transgressions against us, we must forgive ourselves for our failings, rejoin humanity, and move on. We must see the behavior that most embarrasses us as an opportunity to practice self-compassion. We should hold ourselves gently and let guilt and regret go. Then, and only then, can we seek forgiveness from others. For how can we ask to be forgiven if we haven’t first forgiven ourselves?

Everyone who hurts, and everyone who has hurt someone else, has something very deep in common. This hurt is independent of any diagnosis. Hurt is not a symptom. It’s part of being human, something we all share.

With something so profound in common with everyone, why should we feel so alone?

An anxious person will report an unreasonable exaggeration of threats, repetitive negative thinking, hyper-arousal, and a strong identification with fear. The fight-or-flight response kicks into overdrive.

Anxiety is also known for producing noticeable physical symptoms, such as rapid heartbeat, high blood pressure, and digestive problems. In General Anxiety Disorder (GAD) and Social Anxiety Disorder (SAD) the symptoms become so severe that normal daily functioning becomes impossible.

Cognitive-behavioral therapy (CBT) is a common treatment for anxiety disorders. Cognitive-behavioral therapy theorizes that in anxiety disorders, the patient overestimates the danger of disruptive events in his life, and underestimates his ability to cope. CBT attempts to replace maladaptive thinking by examining the patient’s distorted thinking and resetting the fight-or-flight response with more reasonable, accurate ones. The anxious person and the therapist work to actively change thought patterns.

In contrast, instead of changing thoughts, mindfulness-based therapies (MBTs) seek to change the relationship between the anxious person and his or her thoughts.

In mindfulness-based therapy, the person focuses on the bodily sensations that arise when he or she is anxious. Instead of avoiding or withdrawing from these feelings, he or she remains present and fully experiences the symptoms of anxiety. Instead of avoiding distressing thoughts, he or she opens up to them in an effort to realize and acknowledge that they are not literally true.

Although it may seem counter-intuitive, fully realizing the experience of anxiety enables anxious people to release their over identification with negative thoughts. The person practices responding to disruptive thoughts, and letting these thoughts go.

By remaining present in the body, they learn that the anxiety they experience is merely a reaction to perceived threats. By positively responding to threatening events instead of being reactive they can overcome an erroneous fight-or-flight response.

At the University of Bergen in Norway, Vollestad, Nielsen, and Nielsen surveyed 19 studies of the effectiveness of MBTs on anxiety. They found that MBTs are associated with robust and substantial reductions of anxiety symptoms. MBTs proved as effective as CBT, and are generally less expensive.

The researchers also found that MBTs are successful in reducing symptoms of depression. This is especially important since major depressive disorder affects 20 to 40 percent of people with GAD and SAD.

The study finds the success of MBTs notable “given that these approaches put less emphasis on the removal of symptoms as such, and more emphasis on cultivating a different relationship to distressing thoughts, feelings, and behavioral impulses. It seems that this strategy paradoxically could lead to less distress.”

In other words, a way to reduce the symptoms of anxiety is to be fully, mindfully, anxious. As anxiety reveals itself to be a misperception, symptoms will dissipate.

Reference

Vollestad, Nielsen, and Nielsen (2011). Mindfulness and acceptance-based interventions for anxiety disorders: A systematic review and meta-analysis.

Whether in the center of a city or deep in a forest, the cacophony of sounds around us makes it apparent that true silence is impossible. Composer John Cage wrote music that included long periods of silence. When the musicians stopped playing, concertgoers were quickly confronted with the shuffling, shifting, and coughing sounds in the concert hall.

So what is silence?

Silence is the absence of intentional sound. Intentional sounds are the things we turn on, such as TVs and iPods; words spoken or heard in a conversation; music such as humming or tapping; and the noise of tools, keyboards, or other objects. Sounds that remain are unavoidable. So silence is purposeful quiet. Some find it unsettling.

A study of 580 undergraduate students undertaken over six years, reported by Bruce Fell on The Conversation, shows that the constant accessibility and exposure to background media has created a mass of people who fear silence.

This study, along with research by Drs. Michael Bittman of the University of New England and Mark Sipthorp of the Australian Institute of Family Studies argues that “their need for noise and their struggle with silence is a learnt behavior.”

This cannot be blamed on the relatively recent rise of social media and 24-hour availability. For many of these students’ lives the TV was always on, even when no one was watching. That often was the case throughout their parents’ childhoods as well. If background noise has always been with us, it’s no wonder we can become so uncomfortable when it’s taken away.

Lest I try to pass myself off as a contemplative or a meditation master, I confess that I have my own difficulty with silence.

My wife and I, city dwellers, were staying in a house far from the city. It was rustic, with no TV, radio, or Internet. When we went to bed it was so dark and quiet it was unsettling. We couldn’t sleep! If I miss a few days meditating in a row, as I did in the busyness of the recent holidays, I find it very challenging to break away and begin my practice again. And when I am in a difficult episode, riddled with self-doubt, nervousness or anxiety, the last thing I want to do is turn off all of the media that distracts me from my insecurity. But I soon realize that distractions can exacerbate the difficulty. I get back to fixed periods of silence, return to the discipline of my practice, and heal.

If the fear of silence is a learned behavior, it can be unlearned. This can be undertaken through mindfulness meditation and focused attention.

To develop focused attention, you may want to begin by confronting the experience of silence. Turn everything off, go to as quiet a place as you can find, and sit for a few minutes. Take in the environment. Just experience the present moment and allow what is around you to exert itself.

If you find yourself agitated or ill at ease, start with very short periods of quiet. Turn off the TV when washing the dishes. Drive without the radio on. Walk the dog without the iPod or phone. You will reap benefits. And slowly, as silence is embraced, you will find comfort there.

Silent man photo available from Shutterstock

With a psychiatric diagnosis comes an excuse for everything. Any bad behavior, lack of motivation, or failure can be passed off as a symptom or the result of an episode. The excuse is always available. Don’t take it.

No one’s asking you to take responsibility for having a mental illness. That’s not your fault.

But you have to take responsibility for your actions and for your recovery. Sure, unexpected things happen as a result of serious mental illness, but most of our behavior is within our control, or at least our influence. And the behavior that most influences our wellness is treatment compliance.

If you have a treatment regimen that works, stick with it. If you had one and left it, get back on it.

While many of us bemoan the fact that we’ll never be well, treatment success rates for mental illness are very high. The National Institute of Mental Health has shown success rate of treatment for schizophrenia of 60 percent, depression, 70 to 80 percent, and panic disorder, 70 to 90 percent.

Compare this to treatment success rates for heart disease of only 45 to 50 percent. But treatment only works if the patient complies with the doctor’s orders. So take your medicine as directed, stay away from non-prescribed drugs and alcohol, exercise, sleep, and eat well. Manage stress. Chances are you will get better. But you’ll lose your excuse. Then you’ll have to start taking responsibility for your actions.

Responsibility brings a sense of control. This is important because one who feels he has control over key aspects of his life is most destined for success and well-being. If all things that happen to me, or if my very own behavior, is beyond my control, why should I bother?

But if prescribed treatment brings me a measure of control over events and my behavior, then I can positively influence what happens to me and those I love. I’ll have to get out of bed, get off the disability insurance, go to work, and suffer the challenges that everyone faces. Life may even be a bit more boring. But I can contribute, connect with others, and work toward dreams I may have long ago abandoned. Yes, this can be very hard. I may have to deal with side effects and limitations. I may have to say no when I want to say yes. And compliance can be costly. But wellness is possible.

Unfortunately, access to treatment is not available to everyone. Finding a correct diagnosis and a successful treatment regimen can take years.

But if you have access to treatment, you have a responsibility to work with doctors, counselors, social workers, and any family and friends available to help you to find a successful treatment regimen. And then you have a responsibility to stick with it. Health can be more challenging than illness, but the life that results is always more satisfying.

Running shoe photo available from Shutterstock

My heart bleeds for the victims lost and the loved ones remaining. Nothing written can take away the pain of the survivors. But a call to action may help to prevent such crimes from continuing.

The offenders in these incidents are often troubled and plagued by recurrent mental illness. The tragedy begins when our mental health system fails these individuals and their families as they seek help that is sometimes unavailable.

It layers as so many people who do not have direct experience with mental illness find their only exposure to people with serious mental illness in these stories. This adds to an already daunting stigma against those with psychiatric disease, and too many of those who need help avoid it for fear of being labeled or ostracized.

Every incidence of violence leaves me heartbroken, and waiting for the inevitable story about someone with mental illness gone wrong.

The result of a broken mental health system and the stigma that drives people with serious mental illness into the shadows is fewer people getting treated than need treatment. Some people (a very small percentage of the population with mental illness, but a disturbingly real number) with untreated mental illness act out and sometimes violence occurs. In addition to the senseless tragedy that results, this adds to the stigma placed on those with psychiatric challenges as the general population hears the stories of mentally ill offenders who were “off their meds,” refusing treatment, or being refused treatment.

In truth, even though sensationalized in the media, very few people know anyone with mental illness and violent tendencies. However, almost everyone knows someone with mental illness who is managing life well. Yet because of the stigma, more often than not few know that those managing well have a mental illness at all. There is so much to risk in stepping from the shadows and saying “I have bipolar disorder, or schizophrenia, or anxiety disorder, or major depression or…” Jobs and relationships could become tenuous.

Still, until those of us who have a mental illness and do cope well stand up and act as role models for those who are not currently able to deal with disease, the stigma will hold, people will avoid treatment, and society will view the mentally ill as disturbed, demented, or violent. Those of us who do well owe it to those who are suffering to light a path toward recovery. Only we can testify that treatment often works, and only we can tell our stories and reveal to the larger population that those with mental illness are not miscreants, vagrants, and criminals. We are your teachers, your accountants, your child’s playdate’s parents, your boss, your mechanic, your kid’s soccer coach, your favorite musician, actor, or writer, your doctor, your councilperson.

Treatment is difficult and access is often limited. But there is no denying that even when treatment is readily available, many refuse it for fear of the stigma. These same people often get worse. Some do stupid or reprehensible things. This can be avoided if we can chip away at the stigma. And we can chip away at the stigma by taking a stand and showing our neighbors that mental illness does not mean maladaptation. There is much pain in knowing that in all of these incidents of violence we could not be there to intervene or help.

But we can help avoid the next one by testifying to the very ill that: “I did it. I overcame this. You can, too, and I can help show you how.”

If more of us act as responsible role models the stigma will erode. As the stigma falls away, more people will seek help. Examples of people who have been successfully treated may open up access to treatment for others, as policymakers see that dollars spent on psychiatric care are well spent. As more people seek and receive care, fewer incidences of mindless violence will occur.

It’s our responsibility to let society know that those with mental illness can lead peaceful, productive, creative, and meaningful lives. We are examples of this. The stigma against people with mental illness is one factor that leads to so many bad outcomes. We owe it to those who have lost loved ones, and to those suffering from illness as we surely once did, to stand up and be seen as examples of how things can turn out well.