Psychiatry-as-usual: beautiful lady or old hag? 06/26/2012Posted by ALT in Mental Health News, Pharmaceuticals.
Tags: bipolar, forced treatment, involuntary commitment, Jeneen Interlandi, medication adherence, New York Times
There is a famous optical illusion called the young lady and the old hag.
The drawing illustrates how one’s perception of an object can suddenly flip, and in a sense, the dueling histories [of psychiatry]… have that same curious quality. There is the “young woman” picture of the psychopharmacology era that most of American society believes in, which tells of a revolutionary advance in the treatment of mental disorders, and then there is the “old hag” picture… which tells of a form of care that has lead to an epidemic of disabling mental illness.
… If you think of the [psychotropic] drugs as “anti-disease” agents and focus on short-term outcomes, the young lady springs into sight. If you think of the drugs as “chemical imbalancers” and focus on long-term outcomes, the old hag appears. You can see either image, depending on where you direct your gaze.
– Robert Whitaker, Anatomy of an Epidemic
It’s my new favorite metaphor for looking at psychiatry (replacing the tried-and-true “Emperor’s New Clothes”). The gulf between what mainstream psychiatry preaches about mental and emotional distress and what alternative and critical thinkers have to say is vast. On one side is an almost completely biological interpretation of mental distress as a chronic disease requiring lifelong chemical intervention, “management,” compliance, and across-the-board lowered expectations – for livelihood, and life. On the other is the idea that extreme emotional states, if not directly iatrogenic, are often the result of environmental, social, and historical factor, are better not pathologized, and in some cases (specifically, a first break into psychosis) may actually be part of a psychic healing process.
The space between being dotted with possibilities as well, though a position located exactly in the middle is about as sturdy as a house built directly over the San Andreas Fault Line.
When I look at the illusion, my strongest inclination is to see the young lady. Only by staring intently for several minutes, carefully searching for the hag, can I find her – it’s the nose that does it, finally.
And though my strongest inclination is to see psychiatry-as-usual as the old hag, I recently had a experience of the beautiful lady, and in this case, it was the appeal to my heart that did it.
A daughter’s story
“When My Crazy Father Actually Lost His Mind,” by Jeneen Interlandi, ran in the New York Times magazine this weekend, and it is moving, heart-wrenching.
It’s a daughter’s retelling of her father’s most recent protracted manic episode, and the devastating costs – financial and otherwise – to her entire nuclear family. During a manic period that lasted from August 2010 until late February 2011, her father endured 5 emergency room visits, 4 arrests and court appearances, numerous police confrontations, 25 days in a psychiatric hospital and 40 in a county jail. Total medical expenses were more than $250,000.
Ms. Interlandi’s story is one of a frightened family desperately seeking a way to stabilize her father – and they felt that forced medication compliance, a stay in a psychiatric facility, or both, were the way to accomplish this.
Here’s what I thought should have happened: My father should have been hospitalized against his protestations until his mania subsided. Once it did, he should have been released under supervision and under the condition that he abstain from drinking, which can exacerbate the symptoms of bipolar syndrome, and adhere to a treatment plan involving some combination of talk therapy and medication. I imagined something like probation, but run by a mental health office instead of a criminal court.
– Jeneen Interlandi, in the New York Times magazine piece “When My Crazy Father Actually Lost His Mind”
And though we do not hear directly from her father about his experience, it seems he had different ideas about what should happen:
We wanted him to go to a state hospital, where he could be cared for until he came around to taking his medication or until his mania subsided … He wanted to go home. But he was unwilling to take any of the steps that we were laying out for him to get there. He insisted that nothing was wrong with him and refused to take mood-stabilizing medication.
– Jeneen Interlandi
Ultimately, Ms. Interlandi’s family got the kind of medication compliance plan they were looking for (complete with probation officer), and the story ends with a scene of domesticity in the Interlandi home.
I asked him what he remembered about the whole ordeal… He [said he] felt like some other being had possessed him for a time. And he hoped that whatever it was, it was gone for good. My mother echoed those sentiments, shouting from the kitchen that it was the only part of their marriage that she wished to forget. Both of them seemed perfectly happy to ignore the fact that bipolar disorder is considered to be a lifelong condition. They would bury this alongside their other shared tragedies until, eventually, it became just another story they told.
– Jeneen Interlandi
Threats of violence from a man who has fiercely loved his wife all the years of their marriage, half-hearted suicide attempts from this gregarious lover of life – one can understand why the author felt as if “an evil alien had invaded his mind and taken over his body.” My heart goes out to a family that managed to stick together through this bipolar nightmare (the author’s mother was told she might want to “get a divorce” by her doctor in the midst of the crisis; she promptly got a new one), and I am happy that, at least for now, they have found the stability they so ardently sought.
The beautiful lady grants them a return to domestic bliss.
The thrust of Ms. Interlandi’s article was that her family’s worst suffering was directly caused by the difficulty they had in getting her father committed and medicated – if only involuntary commitment were easier and there were more places for such people to be committed to, her father could have (her words) “been cared for until he came around to taking his medication.”
One can fairly say that stability via medication compliance was a top priority for this family; Mr. Interlandi’s return to his home was conditional and depended upon it.
Is this the only way to achieve stability?
It’s an important question, because the number of adults (and children, too!) experencing severe mania and being diagnosed with bipolar disorder is soaring. From 1996-2004, the number of adults given the bipolar diagnosis rose by 56%. And I’m sure most readers are familiar with the 4000% increase of childhood bipolar disorder diagnoses between 1998 and 2004.
How to explain this?
We turn again to the old hag, psychiatry-as-usual.
A person treated with an anti-depressant has a significant chance of experiencing mania and receiving a bipolar disorder diagnosis that is, in reality, describing an entirely iatrogenic (drug-induced) phenomenon.
A 2004 study of 87,290 people originally diagnosed with depression or anxiety found that those treated with anti-depressants “converted” to bipolar disorder at the rate of 7.7% per year – ultimately adding up to between 20% and 40% of all people treated with anti-depressants. And this survey found that 60% of people with a bipolar disorder diagnosis said they “had initially fallen ill with major depression and had turned bipolar after exposure to an antidepressant.”
As it turns out, for many with a bipolar diagnosis, medication adherence is the key to instability, to increased mania and ever-more-rapid cycling. This is especially true for people who withdraw abruptly from their medications (as mania is a well-known symptom of rapid withdrawal from both antidepressants and mood stabilizers). And folks who do comply with long-term medication adherence have significantly worse mental and physical health outcomes than those who don’t – the science shows this over and over again.
It becomes clear from reading the New York Times comments section that Ms. Interlandi’s experience is not unlike that of many other families, desperate for a loved one’s return to stability that they believe can only be achieved by lifelong medication compliance, enforced, when necessary.
But how many of these beloved family members would never have experienced mania without previous exposure to a psychotropic drug? How many of these families would’ve been spared the endless cycling through moods, courts, hospitals, and jails, the threats, the attempted suicides if a family doctor had put away the prescription pad?
How many of the new bipolar diagnoses are iatrogenic?
Psychotroipcs as first line treatment, long term medication adherence, psychiatry-as-usual: beautiful lady or old hag?