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

Colleges and university are cutting back on their involvement with ADHD, primarily due to abuse of the psychiatric medications — stimulants like Ritalin — prescribed to treat the disorder. Students — whether they are malingering the symptoms or actually have it — are prescribed a drug to treat ADHD (sometimes from different providers in different states), then sell a few (or all the) pills on the side. Profit!

Now universities are becoming wise to the epidemic nature of the problem, as some studies have suggested up to a third of college students are illicitly taking ADHD stimulants.

This might help curb the abuse problem, but will it also make it harder for people with actual ADHD to receive treatment?

The short answer is, yes, of course. Students with a pre-existing diagnosis of attention deficit or attention deficit hyperactivity disorder will still often be able to get their prescriptions filled while at school. The university just doesn’t want to do the diagnosing of ADHD any longer.

I’ve long wondered at the wisdom of universities getting into the ADHD business in the first place. University counseling centers generally shrug off long-term treatment of serious mental illness. So it’s never been clear to me why they were comfortable prescribing medications for ADHD.

The New York Times notes — in a well-written take on this issue by Alan Schwarz — that the changes are sweeping campuses throughout the country:

Lisa Beach endured two months of testing and paperwork before the student health office at her college approved a diagnosis of attention deficit hyperactivity disorder. Then, to get a prescription for Vyvanse, a standard treatment for A.D.H.D., she had to sign a formal contract — promising to submit to drug testing, to see a mental health professional every month and to not share the pills. [...]

The University of Alabama and Marist College, like Fresno State, require students to sign contracts promising not to misuse pills or share them with classmates. Some schools, citing the rigor required to make a proper A.D.H.D. diagnosis, forbid their clinicians to make one (George Mason) or prescribe stimulants (William & Mary), and instead refer students to off-campus providers. Marquette requires students to sign releases allowing clinicians to phone their parents for full medical histories and to confirm the truth of the symptoms.

“We get complaints that you’re making it hard to get treatment,” said Dr. Jon Porter, director of medical, counseling and psychiatry services at the University of Vermont, which will not perform diagnostic evaluations for A.D.H.D. “There’s some truth to that. The counterweight is these prescriptions can be abused at a high rate, and we’re not willing to be a part of that and end up with kids sick or dead.”

Not everyone is convinced:

“If a university is very concerned about stimulant abuse, I would think the worst thing they could do is to relinquish this responsibility to unknown community practitioners,” Ms. Hughes [CEO of CHADD, an advocacy organization] said. “Nonprescribed use of stimulant medications on campus is a serious problem that can’t just be punted to someone else outside the school grounds.”

She has a point. The 2010 suicide death of Kyle Craig, who abused Adderall prescribed by his local physician at home and not by the university he attended, suggests the problem is more wide-ranging than perhaps some university officials understand.

However, this sort of effort on the part of Fresno State is amazing and should be applauded:

And in a rare policy among colleges, students receiving prescriptions to treat A.D.H.D. must see a Fresno State therapist regularly — not for a cursory five-minute “med check” but for at least one 50-minute session a month.

Psychotherapy required for ADHD treatment? Nice — finally an institution that listens to the research and understands that medications are, for most, not a life-long answer.

I think that, by and large, this is a measured response to a very serious problem of stimulant abuse among college students. Students have long enjoyed free healthcare on campus, with counseling an additional free service they receive. But student counseling centers mostly refer students with serious, ongoing mental health or mental illness to local providers in the community — they’re simply not well-equipped to treat people with such concerns. I see no reason why ADHD should be an exception.

What this does for the colleges that are mostly getting out of the ADHD business is to limit the overall amount of prescriptions floating around for these stimulant meds. That should drive down supply, drive up prices, and make it less attractive as a “study” option for students without ADHD.

As for the students who actually have attention deficit disorder? I think they will still be able to get the treatment they need. Having seen people at community mental health centers, I know that if there’s a will, people will find a way to pay for mental health services.

Read the full article: Colleges Tackle Illicit Use of A.D.H.D. Pills

There’s something strangely comforting in looking at these lists and hoping that our life problems can be boiled down into five simple steps. I read them hoping for the answers, because I too want the secret to life, the universe, and everything.

However, I think the reality is this: As much as some lists offer interesting ideas, the majority mislead people about change. They offer false hope instead of facts. They generally encourage people to think their lives can be simpler if only they do those five secret things that may have worked for another person.

Come on, really? Life is so complex and the reasons why we feel and do what we do also are complex.

Take depression, for example. The reality is nobody really knows why people feel depressed; and nobody really knows what will cure each individual’s depression. When talking about cause and effect, there are so many factors to take into account: cognitive, environmental, social, biological.

What we do have is good empirical evidence that some therapies can help some people overcome depression. But that doesn’t mean everyone will overcome it through therapy. I’ve worked with many people and, for whatever reason, they remain depressed and sometimes become even more depressed. When that happens, the focus of therapy changes to learning to live with being depressed. No list is going to change that.

We know that medication can help. But it doesn’t help everyone. More often than not, medication is guesswork — an art more than a science. What works for one person can make another person sick. I’ve seen some people recover in a matter of weeks, and others poisoned to the point of hospitalization. Where’s the five-point list on that one?

Advances in neuroscience are helping us understand the brain and how it works. Yet, even super-intelligent scientists with the most sophisticated technology don’t fully understand what is causing depression. So, can a five-point list really tell us how to overcome it?

It’s clearly frustrating not knowing the secret to being well. As a therapist and coach, it’s my job to help somebody get well, so it’s easy to hope a list will provide me with the secrets that’ll help me and the person I’m working with.

But many lists just don’t cut it. I was reading a list on procrastination the other week and the first thing on the list was something like ‘just do it.’ I can imagine all the people who procrastinate reading that and thinking, “Wow, that’s amazing. Why didn’t I think of that?”

OK, I’m knocking these lists, so I must know all the answers, right? Nope. I wish I did but unfortunately I don’t (please don’t tell my wife I said that). With that being said, I will now counter everything I’ve just written and offer you my own secret five-point list to life, the universe and everything.

1. You are personally responsible for all that you think, do, and (mostly) feel.
2. Accept reality: Life doesn’t owe you a thing.
3. You are you. Nobody can ever know what it means to be you, so be kind to yourself and others.
4. Life is meaningless, except for the meaning that you give it — so use that power wisely.
5. Nobody has all the answers. We’re all just making stuff up as we go along, hoping for the best.

One of those things was eat ice cream. A lot. So I gained a few pounds. It was time to buy new pants anyway. The only important thing was that my medicine was working and I was feeling good. I felt like participating in my life again. Feeling good and eating ice cream were natural.

But then I broke the couch.

Maybe it was a coincidence that I was the one whose bottom touched the couch and made it go POP and collapse. But it had occurred to me, in that moment I felt the couch break underneath me, that I had gained a lot of weight. And that was enough to tell me that all this weight gain was starting to bother me.

I finally realized that as my mood had gone up, so had my weight; maybe my medicine came with a trade-off. I’d never had a medicine that made me gain weight before or gave me cravings that led to weight gain. But here I was.

I’d always told people in the same situation that it didn’t matter if they gained weight. Obviously mental health is more important than gaining a few pounds.

But is there a line that can get crossed, where weight gain can make the scales tip in favor of switching meds? What’s the number? 15 pounds? 25 pounds? 30 pounds? 50 pounds? In what span of time? One month, three months, a year? What is OK and not OK?

Mental health is most important, but at what point does weight gain also affect health? It affects physical health, like blood pressure and risk factors that come with obesity (I am now technically obese), but I’m not even talking about the physical drawbacks of weight gain. What I’m irrationally worried about is the emotional toll that weight gain can cause.

I’m not satisfied with what the medicine is doing with my body. I don’t feel like myself. I feel like myself when I was pregnant, only without a baby, meaning I feel too big and tired and slow. That is affecting my mental health. Not in a serious, clinical way. But in a way that is still real.

Still, I would never stop a drug that’s working in favor of nothing, or one that didn’t work, to be able to lose weight. I’ve been in the dark hole that depression is, and there’s no way I would jeopardize my own quality of life or my family’s with my vanity. But it’s a little tempting, when I’m still on my meds and they’re working well, but there’s just this one side effect…. And I think, maybe I could stop. But I wouldn’t just stop; I would switch to something else, after talking with my doctor like I should. I’m more vain than I realized, but I’m also even more terrified of falling into depression again.

One of the most disconcerting things is the feeling that I don’t have power over my body. Even when I eat well, and exercise, and sweat off what feels like pounds of water, it turns out I have actually gained weight. I haven’t lost a single pound since I started my medicine several months ago. That unsettles me and makes me feel a tiny bit like I do in a depressed state: I am not in control of my body.

This doesn’t cause me to lose hope in general, to think that there won’t be a better time. But it does cause me to lose confidence in myself. I’m already on shaky ground, living with mental illness. Will I feel good today or bad? How am I feeling? But now, I add, How do I look? How much have I gained? to the daily evaluations. I can’t always depend on my mind; now I can’t depend on my body.

Having a mental illness throws new challenges at me at every turn. Even when I feel well, it still reminds me of its presence, in this case, through these extra pounds clinging to me. I believe that there might be side effects and trade-offs to medication, but I also believe they saved my life, or at least saved the quality of my life, and that it’s worth it. And I believe the perfect medication might be out there, waiting to still be discovered for me.

Maybe I’ll always have to make the decision between effective medicine and side effects like weight gain. But I have hope that someday I won’t have to.

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.

Ya have to admire psychologists who endlessly lobby state legislatures for the right to extend prescription privileges to their profession (with a little additional training). They won’t take repeated defeat as a sign that perhaps their efforts are… insane?

Illinois is the latest state to hand psychologists seeking prescription privileges a defeat, with NAMI Illinois siding on the side of not supporting the bills in front of the Illinois legislature. After intense lobbying by both sides of this issue, they concluded, “NAMI Illinois opposes SB 2187 and HB 3074 in its current form to expand prescriptions privileges to psychologists.”

When will psychologists learn?

The movement that is supported by some psychologists to gain prescription privileges is called RxP. The rationale behind the movement is that, in some communities in the U.S., psychiatrists are few and far between. With too few psychiatrists, patients often have little choice but to wait weeks or months for an appointment, or travel long distances to see another psychiatrist. Psychologists argue that their existing training prepares them to take an additional set of courses (which can be taken exclusively online) and training (supervision under a physician) that results in them being high-quality prescribers — equivalent to a medical doctor.

NAMI Illinois’ statement is worth a read, so we’ve posted a copy of it here. But here’s a highlight:

If we don’t fully address integrated health care needs, mental health needs become moot if people continue to die so early from physical causes. NAMI Illinois cannot advocate for the creation of more silos that hinder full integration of physical and mental health care needs.

Exactly. Instead of working with the profession of psychiatry to help address the shortage of psychiatrists, psychologists seek to circumvent that profession entirely by pushing for professionals with little medical background or knowledge to become medical prescribers.

This is a misguided, failure-ridden effort that has been going on now for more than three decades — with very little success to show for it. The bills are introduced into a number of state legislatures each and every year. Each and every year, they get defeated or never get voted out of committee.

And Illinois is not alone. Ohio’s legislators appear disinclined to keep reintroducing the same bills that keep failing, year after year, according to an update sent out by Janet Shaw, MBA, the executive director of the Ohio Psychiatric Physicians Association:

It appears Senators Burke and Seitz are no longer inclined to reintroduce last year’s bill in its current form.

Instead, Senator Burke suggested, and Senator Seitz agreed, that psychologists in Ohio who want to prescribe medications go the route of becoming a physician assistant since the training is similar and duration the same (approximately two years), to the psychopharmacology programs for psychologists, and since the scope of practice for a physician assistant already allows them to prescribe in Ohio.

I agree. Psychologists — like all mental health professionals who don’t hold a medical degree — already have a path to gaining prescription privileges. It’s called “go to medical school” and become a medical doctor, a registered nurse practitioner, or physician’s assistant. There is virtually nothing unique or special about a doctoral degree in philosophy (the Ph.D., which most psychologists hold) that gives them a leg up on the medical training necessary to prescribe.

Psychologists should be working with psychiatrists to understand how best to address the dearth of psychiatrists in certain geographical areas in the U.S., instead of trying to steal their profession away from them.

Psych Central remains steadfastly against psychologists gaining prescription privileges. It is a waste of psychologists’ time and efforts, and minimizes their specialized expertise and training in being uniquely qualified in the understanding of human behavior.

The mental health charity Mind UK recently highlighted their concern that there is a serious need for a range of therapies to be made available to depression sufferers.

According to the best psychological working practices, medication is now considered to be only one option for effectively treating the illness.

Talk therapies — otherwise known as psychotherapy — such as cognitive behavioral therapy (CBT) have proven effective at alleviating melancholic symptoms in hundreds of research studies conducted around the world. In Australia, the Australian Psychological Society has identified a serious need for psychotherapeutic interventions in the lives of people with depression.

Cognitive behavioral therapy (CBT) is a form of psychotherapy. Participants work with a specially trained psychologist to make positive steps in changing their thoughts and feelings. Committing to CBT means accepting that your actions affect your emotions and reasoning. Therapists help you to learn skills and strategies for changing negative thinking. This helps many people to learn to cope with depressive illness.

A recent study in the UK, carried out over a period of 12 months, looked at the benefits of CBT for managing depression. Participants were allocated a one-hour CBT session each week for the period of the trial.

After six months, 46 percent of the group who had been previously resistant to medication reported a reduction in depressive symptoms. The study concluded that CBT can improve quality of life by reducing depression’s severity.

A 2012 study published in the Australian and New Zealand Journal of Psychiatry involved a review of Australian National Health data. Researchers became interested in the period between 2001 and 2006, when better access to psychological treatment was made available in Australia.

The study showed from 2001 to 2008, following health care reform, there was a drop in the use of antidepressant and anti-anxiety medications. CBT is currently recognized in Australia as being a viable and effective way of treating mental illnesses like depression.

It is important to note that CBT is not intended to be a substitute for medication. In many cases it will serve to complement any medicine from the family doctor or psychiatrist. However, in those for whom medication has failed, CBT offers an alternative while new medicines are being developed. Of course, not everything — whether medication or talk therapy — will work for everyone.

In Australia, there is still a shortage of psychiatrists. The right of psychologists to prescribe medication is now a subject for debate. If this becomes reality, the therapist will then be able to evaluate each patient’s needs, and only prescribe drugs when necessary.

In the meantime, although it may not be the best option, family physicians are able to prescribe psychiatric medications if they believe it warranted.

If it were actually effective, I would wholeheartedly join you in your strike against shame, holding signs to keep it out of the psyche and saying, “Shame on you, shame.” But from my experience, it usually just grows into an angry beast. It haunts us day and night until we do something about it.

Pushing away the shame isn’t the answer. So what is?

Sharing the shame with a trusted person is what will heal us.

Think of a time when you have felt shame. Maybe the shame is associated with a word, a fantasy or thought, or an action. Here are some:

• “I put on a good facade, as if I have everything together. But I break down and cry when no one is around.”
• “I am broke.”
• “I think about cheating on my husband.”
• “I have cheated on my husband.”
• “I am married to a woman but I am more attracted to men.”
• “I have a mental illness.”
• “I was abused as a child.”
• “I am a battered woman.”
• “I hate the way I look.”
• “I hate my kids sometimes.”
• “I cheat to get good grades in school.”
• “I got fired.”
• “I lied about my age.”
• “I dropped out of school.”
• “My family was on welfare.”
• “I have STDs.”
• “I have AIDS.”
• “I prostituted for money.”
• “I used to steal when I was a kid. I still do.”
• “I have an addiction.”
• “I take medication for my depression.”
• “I dream big but I am lazy.”

If you keep shame inside, it will produce a heavy sensation in your body. But notice what happens when you share it with someone you trust, someone who will not judge you. Most likely, it will be embarrassing at first. But once you share that same story over and over again, the shame will be able to go through transformation.

Ultimately, the shame will no longer have the same power over you. Eventually, you will be able to look back and say to yourself, “I can’t believe that I was so ashamed about that.”

Try using imagery to help you. Imagine shame to be a baby who just looks terrified on the outside but frightened on the inside, sucking on her thumb. Be curious about what this baby is so terrified about. Move toward it and ask it what it needs. Hold it in your arms with great care, curiosity and empathy.

When you give shame attention, you free yourself from being held in captivity. You will be able to feel joy again and walk with confidence. It is the act of letting yourself be who you are that frees you from the pain associated with shame. It is also an ingredient for healthy self-esteem. You will eventually learn that you aren’t such a bad person after all.

Now imagine that out of nowhere, a repulsive creature has stepped into your path. He’s got a grotesque body, horns on his head and a menacing smile. You freeze in terror as this hideous face stares into yours!

Though you desperately wish to flee, you find yourself helplessly frozen. Your heart is racing. Your chest is pounding. You can’t catch your breath. You feel lightheaded. You feel faint. You think you might die right there on the spot.

Now imagine feeling this very same terror when there’s no creature in your path. What would your experience be? Would you feel mystified? Bewildered? Embarrassed? Wonder if you’re going crazy?

This is the experience of those who endure panic attacks. Many keep their experiences secret, for they are embarrassed and at a loss for words to describe what happens to them. Nobody else has ever had such a reaction, or so they believe. Panic attacks, however, are more common than you may think.

The word “panic” emanates from the ancient Greeks, who were said to experience overwhelming terror when they encountered Pan, their god of nature. Half man, half beast, Pan had a scream so intense that terrified travelers who happened upon him in the forest died from fear.

In our modern world, we don’t believe in Pan. But we do have plenty of fears that paralyze us. Those who have had panic attacks are fearful of having another one. So they avoid being in places or situations in which they feel vulnerable or where there’s no quick and easy escape. For some, this means they can’t be alone. For others, it means they can’t be with new people or in crowds of people. In their attempt to create a safe life, they inadvertently create a small life.

Some panic attacks are not so omnipresent, occurring only when zero hour draws near. Students panic before an exam. Hosts panic before their guests arrive. Actors panic before the curtain rises. Working folks panic before their annual evaluations. Patients panic before their medical test.

When family and friends witness the panic, they typically offer well-meaning advice. “Just relax.” “Chill out.” “Take it easy.” “Roll with the punches.” Easy to say. Hard to do.

If the panic doesn’t subside, many people confide in their physicians. They are then prescribed anti-anxiety medication. At first, these meds may take the edge off. Over time, however, nothing changes. So, the medication is increased or another drug, usually an anti-depressant, is added to the mix. Fogginess, sleepiness and lethargy now become additional issues that the panicky person needs to deal with.

There’s a better way to treat panic attacks. It involves a combination of:

• Cognitive therapy (changing your thought patterns and internal dialogue)
• Behavioral therapy (gradually exposing yourself to scarier situations)
• Body therapy (controlling your breathing and muscle relaxation)
• Adjunct medication, if needed, to calm your body down.

If you or a loved one are sweating bullets over an upcoming event, feeling frenzied about the future, restricting your life to cope with your fears or shuddering at the thought of another panic attack, don’t shrug your shoulders and assume that nothing can be done. Actively seek appropriate treatment that can help you master your fears and get on with your life.

For more information about strategies and skills that can help you move forward, read my book, “Master Your Fears: How to Triumph over Your Worries and Get on with Your Life,” available at Amazon or at www.PsychWisdom.com

Panicked woman photo available from Shutterstock

When a person hears the word “bipolar,” his or her mind usually immediately jumps to the depiction of roller-coaster mood swings and lashing out.

Yet, this is not always the case with bipolar disorder. Bipolar can also affect your thoughts. Some people — like myself — experience a different version of the mental illness where many of your symptoms are internalized.

My illness varies from depressive apathy to euphoric mania which can be accompanied by a delusion or hallucination. I have not had the more severe experiences in about five years, thanks to therapy and medication. Though my journey to recovery was a difficult one, it is not an impossible feat.

It was two days after my fifteenth birthday that I had a full-on episode. I can remember it as clear as day.

First there was the fever, then a slow numbing to the core with sounds around me heightening, and nonexistent pain causing me such unbearable agony. Light burned, sounds screamed, and the depression was unbearable — it left me nearly incapacitated. My mood was so flat that people who hadn’t seen me prior had quickly judged it as something more severe.

Prior to this episode I was living at a boarding school for high school students. My behavior was erratic for several weeks prior to my episode, and had also instigated feelings of neglect from other students, who either felt sympathy or who bullied and harassed me.

I could not be talked down from the mania. Eventually I had climbed so high that I crashed into a severe depressive episode. My dad consulted a doctor, who immediately jumped the gun by telling me I might be smelling things that weren’t there or tasting or sensing things that weren’t real. That didn’t happen, though.

What did happen was I listened to Sarah McLaughlin on repeat for hours on end, trying to divine any emotional contact from her words. Nothing I did was bringing me back to myself. I was trying, in my own way, but it was painful.

Then came the hospitalization — I had been betrayed by my parents. I was put on Risperdal, and thus began the catatonia and shortly thereafter a suicide attempt after missing a dose: I walked into a field of icy water and nearly froze to death.

The second hospital, which my dad had to fight the insurance to pay for, was a disaster. After the psychiatrist there finally told my parents that they could not keep me any longer for fear of making me worse — and several abuses which I reported in writing — I had post-traumatic stress disorder. At age 16, I left a meeting with my psychiatrist to find “paranoid schizophrenia” circled on a sheet of yellow paper.

This label continued to define me for several years, and caused me a very confusing internal dilemma. I began to mimic the behaviors of schizophrenics on forums, and applied the label to myself to understand what was wrong. My dad was utterly convinced of it, as it was something to explain the catastrophe.

But, I really do have bipolar disorder, which my doctor realized when I was 17. Trauma caused my condition to worsen. This was clear only after fighting with doctors who too quickly labeled my behavior as erratic, not eccentric. I actually began to hear voices for the first time when I was 17, inside a hospital before they sent me home.

So does it matter what you call it? Yeah, it does. If I had actually had someone to talk to those times in the hospital, instead of being ridiculed for my behavior from staff more than patients, I would have recovered more quickly. I’d not been so plagued if they hadn’t tried to diagnose what they saw, not the actual chemistry behind it.

At 24, I am still the same as ever, but there is definitely a wound. I endured severe trauma in an understaffed hospital. I wonder exactly what was going through their minds when they verbally harassed me. Did they not understand that I had just attempted suicide and was traumatized?

If it weren’t for my voice — the same one which spoke out against treatment in the beginning — I wouldn’t have recovered. The same stubbornness that told me to say I didn’t want a certain medication was the same stubbornness that said I wanted to heal and recover. You don’t break someone to get them to comply, you try to put yourself in their shoes and understand where they’re coming from. If you’re trying to break people who are sick, you are coercing them, not helping them. I feel that this point needs to be heard.

I am on medication now, and have been on just one for about six or seven years. It works to help with depression and mania. I would not be better had it not been for my family, though stubborn themselves, who have loved me unconditionally and were always there for me when they could be. We have all learned from this mental illness, so implore people everywhere to learn what they can about bipolar and other disorders. If people were more open to reaching out to those who need help, more people will recover. Insight is the key.

“Most psychiatric drugs in use today originated in serendipitous discoveries made many decades ago,” according to a recent article on Science News by Laura Sanders. And it’s true — we can trace back today’s most popular psychiatric drugs to discoveries made over 30 — and in some cases, 40! — years ago.

Because of the heady cost of drug development — costing hundreds of millions of dollars to bring a new drug to market — most pharmaceutical companies have been playing it safe these past few decades. They’ve been working on developing “me too” drugs — subtle molecular changes to existing compounds.

Which means the pipeline is darned near empty of truly new drugs likely to come out in the next 5 to 10 years for the most common types of mental illness.

This provides the drug company with two things. The first is a new medicine they can patent and sell at a significant markup over the old, generic drug it’s based off of. The second is the illusion of progress, of releasing something that is “new and better” than the old thing — but which additional research almost always demonstrates is simply as good — not better — than the old thing (and usually with a different — not better — side effect profile).

So the “new” SSRIs of the 1990s did away with tricyclics’ side effects, but brought on a whole host of their own, new side effects (chief among these, sexual dysfunction… as though nobody cared much about the quality of their sex lives).

The one thing these “me too” drugs don’t provide is any additional, substantial relief to patients.

So it should come as no surprise that most pharmaceutical companies’ psychiatric drug pipelines are… how shall we say?… empty.

Not a single drug designed to treat a psychiatric illness in a novel way has reached patients in more than 30 years, argues psychiatrist Christian Fibiger of the University of British Columbia in Kelowna, who described the problem in a 2012 Schizophrenia Bulletin editorial. “For me, the data are in,” says Fibiger, who has developed drugs at several major pharmaceutical companies.

“We’ve got to change. This isn’t working.”

The biggest problem, from mine and other researchers’ perspective, is the simple lack of understanding of the organ we’re trying to impact with these drugs — the brain.

Perhaps the largest impediment to the development of new psychiatric drugs is the brain itself. A complex web of interconnected systems constantly altered by the environment, the brain is difficult to study.

Even though it’s nestled right in our heads, the brain is hard to reach. A blood pressure cuff can be slapped on for an instant and objective measure of what’s happening with the heart. A needle biopsy can physically pull out suspected breast cancer cells for further tests. But when it comes to the brain, there is no easy way to identify and measure the thing that isn’t working.

As neuroscientist Steven Hyman of the Broad Institute of MIT and Harvard says in the article, “You can’t just open up the hood, take out a chunk and see what’s happening.”

Thomas Insel, director of the National Institute of Mental Health, believes there is hope by pursuing a new path in research — understanding the very basics of the brain’s functioning. Combined with Obama’s announcement of the Brain Activity Map project to be undertaken by the U.S. later this year, there is hope that we can greatly increase our understanding of the body’s most vital organ.

The situation is grim, but not hopeless, says Insel. At a time when major pharmaceutical companies are abandoning psychiatric drug development, Insel says he is doubling down, investing federal grant money in places where investors fear to tread.

“There are a whole series of pretty amazing developments that I think are worth investing in,” he says.

That’s the good news… But it’s going to take years — and more likely, decades — before we will see the benefit of such research efforts.

But it Hasn’t Stopped Drug Sales…

But that hasn’t stopped the sales of all of these me-too psychiatric drugs:

Which only goes to show you that pharmaceutical company marketing works better than perhaps some would give it credit for.

Read the full Science News article (lengthy, but gives many examples and further details about this issue): No New Meds

Plummeting into darkness on occasion made me a burden. When insomnia attacks, I get frustrated and the anxiety builds up — that deep gut feeling where everything is my fault. It’s 3 A.M. and I think about all the times people have promised me that things will get better. But they don’t.

I’m in the office with the psychiatrist and he diagnoses me with the “bad medicine.” He tells me it works for manic-depressive symptoms in children. It was the dark purple kind. In other words — bipolar. But my mood disorder is not that heavily diagnosed yet.

I turn to my laptop in my room. I take a sip of coffee or tea and close my eyes. I look at the blue capsules that hold my pills. I can’t forget to take my medicine or dangerous things happen. Terrible things. It’s never simple to live with but it keeps me stable most of the time.

I keep a list of the times I’ve changed myself. It’s located in the back of my closet, concealed beneath old sweatshirts that I don’t wear anymore. The pushpin binds itself to the wall from the cracking plaster; it reveals the times I’ve become a different person.

I track the months and color-code for whenever my mood changes, I switch crowds, or flip my attitude around. Sometimes, I think it’s getting better since I don’t let it interfere with my life or change who I really am.

It’s strange. I delved into emptiness because I focused on the absence of living. If I were really better off alone, I would not feel the need to connect with others. I would isolate myself and never need anyone. I had my illness to overcome.

With neglected makeup and last night’s eyeliner smeared over my face, it looks as if they’re tire marks. The sky is obnoxiously blue. If it rains it would match my mood.

It’s different with friendships. If I can’t fix problems between my parents, or my inner voice, at least I can talk to Linda. I grab the phone off the bedside table and talk to my middle-school best friend before she moved to California.

She listens while I turn on my crying-and-talking fast mixture. At the end of our conversation, she sings me a song (vanilla twilight), which makes everything okay again.

In a mid-second of a blink, I found out things get much worse later in life. If you are blessed enough that God doesn’t give you a crippling illness and anxiety to count the days until your life ends, consider yourself lucky.

I remember my psychiatrist telling me to be myself. That’s the only way.

It was a long struggle back to reality. After, I decided to keep a journal. I began getting my poems published by various magazines and journals. I also worked for The Student Review. Things started to change again.

Being diagnosed at an early age has helped my recovery since then. There was a time where all my social interactions were unethical because I couldn’t find stability. It’s like a virus, it takes all of my strength to fight it.

And the memories. My inspiration has always reached out to show me a different path. I believe there is faith in even the littlest parts of life.

Much harder than most physicians and many psychiatrists are willing to admit.

That’s because most physicians — including psychiatrists — have not had first-hand experience in withdrawing from a psychiatric drug. All they know is what the research says, and what they hear from their other patients.

While the research literature is full of studies looking at the withdrawal effects of tobacco, caffeine, stimulants, and illicit drugs, there are comparatively fewer studies that examine the withdrawal effects of psychiatric drugs. Here’s what we know…

Benzodiazepine withdrawal has a bigger research base than most classes of medications — SSRI withdrawal has much less research. So what’s that research say? Some patients are going to have an extremely difficult and lengthy time trying to get off of the psychiatric drug prescribed to them. Which ones? We don’t know.

One study nicely summarizes the problem experienced in many such patients:

Various reports and controlled studies show that, in some patients interrupting treatment with selective serotonin reuptake inhibitors or serotonin and noradrenaline re-uptake inhibitors, symptoms develop which cannot be attributed to rebound of their underlying condition. These symptoms are variable and patient-specific, rather than drug specific, but occur more with some drugs than others. [...]

There is no specific treatment other than reintroduction of the drug or substitution with a similar drug. The syndrome usually resolves in days or weeks, even if untreated. Current practice is to gradually withdraw drugs like paroxetine and venlafaxine, but even with extremely slow tapering, some patients will develop some symptoms or will be unable to completely discontinue the drug.

Psychiatrists and other mental health professionals have known ever since the introduction of Prozac that getting off of benzodiazepines or the “modern” antidepressants (and now add the atypical antipsychotics too) can be harder than getting symptom relief from them. Yet some psychiatrists — and many primary care physicians — appear to be in denial (or are simply ignorant) about this problem.

Back in 1997, a review of the literature on SSRIs (selective serotonin receptor inhibitors) outlined the problem (Therrien, & Markowitz, 1997):

Presents a review of 1985–96 literature on withdrawal symptoms emerging following the discontinuation of selective serotonin reuptake inhibitor (SSRIs) antidepressants. 46 case reports and 2 drug discontinuation studies were retrieved from a MEDLINE search.

All of the selective serotonin reuptake inhibitors were implicated in withdrawal reactions, with paroxetine most often cited in case reports. Withdrawal reactions were characterized most commonly by dizziness, fatigue/weakness, nausea, headache, myalgias and paresthesias.

The occurrence of withdrawal did not appear to be related to dose or treatment duration. Symptoms generally appeared 1–4 days after drug discontinuation, and persisted for up to 25 days. [...]

It is concluded that all of the SSRIs can produce withdrawal symptoms and if discontinued, they should be tapered over 1–2 weeks to minimize this possibility.

Some patients may require a more extended tapering period. No specific treatment for severe withdrawal symptoms is recommended beyond reinstitution of the antidepressant with subsequent gradual tapering as tolerated.

The conclusion is quite clear — some patients are going to suffer from more severe withdrawal effects than others. And, just like psychiatry has no idea which drug is going to work with which patient and at what dose (unless there’s a prior medication history), psychiatry also can’t tell you a damned thing about whether a patient is going to have difficulty getting off of the drug when treatment is completed.

It’s simple trial and error — every patient that enters a psychiatrist’s office is their own personal guinea pig. That is to say, you are your own personal experiment in finding out what drug is going to work for you (assuming you’ve never been on a psychiatric drug in the past). Our scientific knowledge hasn’t yet advanced to be able to tell what drug is going to work best for you, with the least amount of side or withdrawal effects.

The U.S. Food and Drug Administration (FDA) doesn’t require pharmaceutical companies to conduct withdrawal studies in order to analyze a drug’s impact when it’s time to discontinue it. It only requires a broader safety evaluation, and a measure of the drug’s efficacy. The FDA is concerned about adverse events while a patient is taking the drug — not adverse events when the drug is removed. In recent years, some have been calling on the FDA to require pharmaceutical companies to conduct more analysis on a drug’s discontinuation profile, so that the public and researchers can get a clearer picture.

While all SSRIs have these problems, two drugs in particular appear to stand out in what little research is out there — Paxil (paroxetine) and Effexor (venlafaxine). The Internet is littered with horror stories of people trying to discontinue one of these two drugs.

And they’re not alone — benzodiazepines can also be extremely difficult to stop. “Withdrawal reactions to selective serotonin re‐uptake inhibitors appear to be similar to those for benzodiazepines,” says researchers Nielsen et al. (2012).¹

What Do You Do About Withdrawal?

Most people are prescribed a psychiatric medication because it’s needed to help alleviate the symptoms of a mental illness. Not taking the medication is often simply not an option — at least until the symptoms are relieved (which often can take months, or even years). Psychotherapy, too, can often help not only with the primary symptoms of mental illness, but also as a coping mechanism during medication withdrawal.²

The important thing is to go into the process with your eyes wide open, understanding the potential that discontinuing the medication may be difficult and painful. A very slow titration schedule — over a period of multiple months — can sometimes help, but may not always be enough. In some extreme cases, a specialist who focuses on helping people discontinue psychiatric drugs might prove helpful.

I wouldn’t let the problems with withdrawing from some of these medications prevent me from taking the drug in the first place.

But I would want to know about it beforehand. And I’d want to be working with a caring, thoughtful psychiatrist who not only acknowledged the potential problem, but was proactive in helping his or her patients deal with it. I would run — not walk — away from a psychiatrist or physician who claimed the problem didn’t exist, or that I shouldn’t worry about it.

This article was edited to clarify a few sentences on Feb. 14, 2013.

References

Kotzalidis, G.D. et al. (2007). The adult SSRI/SNRI withdrawal syndrome: A clinically heterogeneous entity. Clinical Neuropsychiatry: Journal of Treatment Evaluation, 4, 61-75.

Nielsen, M., Hansen, E.H., & Gøtzsche, P.C. (2012). What is the difference between dependence and withdrawal reactions? A comparison of benzodiazepines and selective serotonin re-uptake inhibitors. Addiction, 107, 900-908.

Therrien, F. & Markowitz, J.S. (1997). Selective serotonin reuptake inhibitors and withdrawal symptoms: A review of the literature. Human Psychopharmacology: Clinical and Experimental, 12, 309-323.

1. Thanks to Beyond Meds for the suggestion of this blog topic.
2. Tellingly, I could find no similar withdrawal syndrome associated with leaving psychotherapy, although certainly some people have difficulty with ending psychotherapy.

But electroconvulsive therapy (ECT) treatment has developed considerably since the days depicted in “One Flew Over the Cuckoo’s Nest.”  A current study at JAMA Psychiatry examines a treatment called transcranial Direct Current Stimulation (tDCS).

Could this fairly new form of electrical treatment for depression really be effective — and without the negative side effects of ECT?

This new treatment, which involves stimulating the brain with a weak electrical current, is starting to be considered as an alternative — and potentially effective — treatment for depression.  tDCS, unlike traditional ECT, passes only a weak electrical current into the front of the brain through electrodes on the scalp.

Patients receive the treatment once a day for 30 minutes and remain awake and alert during the entire procedure.

Why is New Treatment for Depression So Essential?

Depression in adulthood remains a common and often under-treated condition.

Depression can occur at any age, but it typically emerges in the mid-20s. Women experience depression twice as frequently as men, and symptoms can vary from mild to severe. Major depressive disorder, which may be diagnosed when depressive symptoms last for 2 weeks or more, is understood to occur in 15 to 17 percent of the population.

Symptoms of major depressive disorder can include a depressed mood, loss of interest and enjoyment, reduced energy, increased fatigue, diminished activity and reduced concentration and attention.

These and other symptoms, particularly when prolonged, impair a person’s ability to function in day-to-day life, making effective treatment essential.

Research continues to improve our knowledge about the impact of depression on our ability to process information and the underlying processes in the brain that are associated with depressive symptoms.

With increased information, psychologists and mental health professionals have made significant progress in identifying effective treatments.  A combination of cognitive behavioral therapy and medication has evolved the most effective treatment to date.

However, it is not fully understood exactly how and why antidepressants work. And despite significant advancements in medications, treating major depressive disorder remains a challenge. Although medication helps, it can be costly and produce troublesome side effects.

Recent Advances in Electrical Treatments

Noninvasive brain stimulation, such as tDCS, has been increasingly investigated for the treatment of major depression.

In previous research out of the University of New South Wales (UNSW) and the Black Dog Institute, 64 depressed participants who had not benefited from at least two other depression treatments received active or sham tDCS for 20 minutes every day for up to six weeks.

The study found up to half of depressed participants experienced substantial improvements after receiving the treatment.

In a recent clinical trial, Andre R. Brunoni, M.D., Ph.D., of the University of Sao Paulo, Brazil, and colleagues examined the safety and efficacy of electrical current therapy compared to treatment with sertraline hydrochloride for major depressive disorder (JAMA Psychiatry).

Participants included 120 patients with moderate to severe nonpsychotic unipolar major depressive disorder who were not taking antidepressant medications. A three-point change in a depressive rating scale at the six-week mark was considered clinically significant.

Participants were divided into groups to compare sertraline to tDCS or a combination of both.

In major depressive disorder “the combination of tDCS and sertraline increases the efficacy of each treatment. The efficacy and safety of tDCS and sertraline did not differ,” the study concludes.

According to the study reports as noted in JAMA Psychiatry, there was a significant difference in the depression rating scale score when comparing the combined treatment group (sertraline/active tDCS) vs. sertraline only (mean difference 8.5 points); tDCS only (mean difference, 5.9 points); and placebo/sham tDCS (mean difference 11.5 points).

Side effects of participants who received active tDCS treatment were fairly minimal, with skin redness at the treatment site and an increased potential for hypomania or mania episodes being the primary adverse effects.

More research is needed to confirm the results of this latest study. But increasingly, it looks like tDCS may offer people with depression another alternative to more traditional forms of treatment.

Reference

Andre R. Brunoni MD, PhD, Leandro Valiengo MD, Alessandra Baccaro BA, Tamires A. Zanão BS, Janaina F. de Oliveira BS, Alessandra Goulart MD, PhD, Paulo S. Boggio PhD, Paulo A. Lotufo MD, PhD, Isabela M. Benseñor MD, PhD, Felipe Fregni MD, PhD. The Sertraline vs Electrical Current Therapy for Treating Depression Clinical Study: Results From a Factorial, Randomized, Controlled Trial. (2013). Arch Gen Psychiatry, 70, 1-9. doi:10.1001/2013.jamapsychiatry.32

Once diagnosed, treatment often consists of nothing more than pill prescribing.

Sometimes responses to ordinary life events can be incorrectly diagnosed as mental disorders. Let’s look at a few examples…

“My husband passed away almost a year ago and I still miss him so much. There are times I feel like there’s not much purpose to my life anymore. We were married for 42 years. It’s tough to fall asleep without him at my side. And it’s tough for me to feel like cooking when I have to eat alone.”

This is a normal bereavement reaction. The proposed new Diagnostic and Statistical Manual code, however, states that these may be signs of a major depressive episode. Why? It’s as though our standard for bereavement is now quick, like everything else in our lives. Nothing to it! A piece of cake! Okay, mourn. But return to your old life in a week, a month, three months. You need more time than that? Well, perhaps you should take anti-depressants. Good for the drug companies. Not good for the bereaved individual.

“I tend to be nervous in some social situations. While my friends are up for any new venture, I become anxious when I don’t know where I’m going or who I’m going with. Last week I was feeling keyed up and irritable when my friends pressured me into meeting them at a bar after work. Though I acquiesced to their pressure, I really just wanted to go home and curl up with a good book.”

Everyone is not a party animal or an extrovert. No one should feel stigmatized for disliking group gatherings. No one should be diagnosed with an anxiety disorder for preferring reading to partying. No one should be prescribed anti-anxiety meds because they feel uncomfortable in a social situation.

Let’s stop pathologizing those who don’t fit into the dominant lifestyle.

“When my neighbor committed suicide, I was the one who found his body. What a horrible experience! The first thing I needed to do was to shield my young children from seeing him. Then I had to notify his parents. Then I had to deal with my own feelings — disbelief that he had killed himself, anger that he did himself in, grief that such a young life was over and regret that I couldn’t have prevented it. It took me about a year to deal with these emotions and move beyond all that was stirred up for me.”

Has life ever thrown you a curveball? How did you react? Not always seamlessly, I suspect. Does that mean you have a mental disorder? Absolutely not. Intense emotional reactions to unforeseen, unanticipated events are normal. It should not be diagnosed as a stress reaction disorder. Over time, most people adjust to traumatic events. Masking important emotions with sedatives is rarely a good idea.

According to the National Institute of Mental Health, approximately 25 percent of Americans suffer from some sort of mental illness. The vast majority of those are taking psychotropic drugs. That’s a lot of disturbed Americans.

Or is it? Perhaps that high statistic is nothing more than normal emotional reactions being over-diagnosed and over-medicated.

Are there ways to help without harming? Yes! Consider educationally-based psychotherapy. This consists of teaching people how to cope with difficult situations, become more resilient, and manage their emotions — all without diagnoses and medication.