But as outrageous as this case is … it turns out that it is not at all uncommon for psychiatric patients to be left for 24 hours — sometimes, for many days on end! — sitting in waiting-room chairs:

The unit [in which Green was left to die] is so routinely backed up with people waiting hours, or even days, for services that patients often spend the night nodding in chairs or sprawled in a corner. …

A survey of hundreds of U.S. hospitals released last month by the American College of Emergency Physicians found that 79 percent reported that they routinely “boarded” psychiatric patients in their waiting rooms for at least some period of time because of the unavailability of immediate services.

One-third reported that those stays averaged at least eight hours, and 6 percent said they had average waits of more than 24 hours for the next step in a patient’s care. …

Emergency physicians at other hospitals describe conditions far less grim, but they uniformly agreed that a hospital waiting room is rarely a comfortable place for someone in a psychological crisis.

“Optimally, you don’t want a patient sitting in the emergency room for any length of time,” said Dr. Bruce Schwartz, the director of clinical psychiatry at Montefiore Medical Center, in the Bronx.

Still, those types of waits can be routine.

In Austin, Texas, hospital officials have complained that a county decision to reduce the number of patients sent to a state psychiatric hospital has clogged their emergency rooms with mentally ill people with no place else to go.

In Massachusetts, some parents have complained about days-long waits in the emergency room for children who need placement in a pediatric psychiatric service.

California health officials have struggled for years with complaints about overcrowding in psychiatric emergency rooms.

I can attest to this phenomenon personally: I was once forced to spend 18 hours in an ER because I happened to arrive a few minutes after the crisis worker left (there are none available in my area, any more, except during “bankers’ hours” on weekdays), and had to get my “PC” (psychiatric consult) once she came in the next morning and only after higher-priority patients had been PC’d (as a depression patient, I didn’t rate very highly). This was in a small community hospital in the suburbs, not a massive, bustling, bursting-at-the-seams urban healthcare center like Kings County.

Note that this rule applies generally only to psychiatric patients. If someone were to arrive in an emergency room due to, say, a car accident or a heart attack, a regular hospital bed would be found relatively soon; no accident or heart-attack victim would be left sitting for days in an ER waiting-room. Yet, this is considered acceptable and even routine, for psychiatric patients. Why is this? We still have not gotten over the fact that mental illnesses are real, they deserve to be treated, and that the mentally ill are human beings entitled to the same dignity and compassion that anyone else with some other malady would be given. This simply cannot be tolerated any longer.

University Police Chief Donald Grady said Friday that Kazmierczak had become erratic in the past two weeks after he stopped taking his medication.

A former employee at a Chicago psychiatric treatment center said Kazmierczak’s parents placed him there after high school. She said he used to cut himself, and had resisted taking his medications. …
“He never wanted to identify with being mentally ill,” she said. “That was part of the problem.”

But the truth is, folks, that none of us lives in a vacuum! We’re all responsible for our part in the lives of others. No one benefits when a mentally-ill person terminates his/her treatment; everyone else in his/her life must pick up the slack and deal with the results of that decision. Denial of the reality of mental illness has repurcussions throughout one’s life. In this case, denial killed (not only the patient, but 5 others, and wounded more). Even in cases nowhere near this extreme, there is nevertheless a price to denying mental illness; interpersonal problems, inability to keep a job or take care of oneself, and so on. A mentally-ill person who refuses treatment for his/her disorder automatically places a burden on others.

The lesson here is a simple one: No one who’s on notice as having a mental illness, can afford the luxury of acting as if that illness doesn’t exist. You have to stick with your treatment, whatever that is, no matter what. If the treatment is not helping or not to your liking, then change it … but don’t decide not to pursue any treatment at all.

Perhaps this isn’t fair … after all, neither I nor anyone else with a mental illness asked for it, so why should any of us be saddled with this responsibility? But we all know that life is not fair. Lots of people have lots of illnesses and problems that they must deal with nevertheless. Looking for fairness in life, is a fool’s errand; you aren’t going to get it. So rather than obsess over fairness, obsess instead with making the best of one’s life. This means taking responsibility for one’s condition and treating it.

My first thought was, “Whew! That’s all we bipolar folks need, to be associated in the public eye with that ridiculous tramp.” This won’t help at all.

My second thought was, “With all of the research going on into bipolar disorder, somehow stories about that tramp — who may or may not even have bipolar disorder — drift to the top of the list?” The mass media have nothing more constructive or meaningful to report, on the topic, than that? That by itself should be enough to depress anyone … !

Unfortunately, I have few answers to offer to all of the many problems I’ve cited above (in my initial series of posts which you can read, in order, at The Heart of the Matter). They’re beyond my expertise, and in most cases, are beyond anyone’s skill, at this point.

My message is simple: Despite the problems, each of us is responsible for making the best of the situation.

Those of us with mood disorders, must stick with treatment, to the best of our ability.

Friends and family of mood-disorder patients, must help them along. And try not complain too much about it, especially in front of the patient. It’s not very nice.

For professionals in the field of mental health, my challenges to you are many: To become focused on cures as opposed to simply keeping a patient functional; listening to your patients rather than deciding, for them, what to do; working within the system as it is, to make that system work for your patients, rather than simply giving up when you reach the boundaries of what the system allows.

Especially for researchers, both physiological and psychological: Instead of identifying “risk factors” or biological markers, focus on causes, and the genesis of mood disorders. That is, precisely what is the process by which people go from being “normal” to having a mood disorder? What is behind this transition?

For people in managed care: Drop the fiction that mental and physical illnesses are somehow “worth” different amounts of money. They aren’t, and saying they are, is patently stupid.

For government: Halt the cost-passing game that’s making healthcare too expensive for too many of us.

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Let’s get down to one of the most contentious aspects of mental health care in the U.S., today. Managed care was invented in the early 1970’s, as a way to hold down spiraling health-insurance costs. It has since become an institution all its own, a true driving force behind how mental illnesses are treated — in addition to driving all other areas of medicine. (Disclosure: I worked for 9 years for a managed-care company, so I know a good deal of this “from the inside” as it were.)

Before the advent of managed care, most people had “health insurance” through their employer. The employee got health care as needed, paid for it, then filed a claim and got reimbursed — between 50 and 80%, usually — for the cost. The need for the care was never questioned, the only question was what the insurance plan’s coverage allowed, usually up to a total amount per year.

As families grew, and lifestyles improved, people naturally became more demanding in their health care. They sought help for things which, previously, they might not have. Costs to employers, for health insurance, went up, as claim amounts rose. Stories such as people going to emergency rooms for hangnails, were swapped among executives concerned that their companies’ insurance premiums were being wasted.

At the very same time, another trend was developing. Medicaid and Medicare covered the indigent, disabled, and the retired, for their medical care. In some cases the reimbursements were quite generous. But budget deficits in the ’70s forced Congress to cut back on how much was paid out, and certain procedures were disallowed completely.

Hospitals, however, were required by law to care for all, without regard to their ability to pay. They lost money on Medicaid and Medicare patients. This deficit had to be made up elsewhere, and inevitably, that was from paying patients, especially patients who were paid by insurance.

Not only were insured patients going to the doctor more often, but their bills for each visit were going up, through no fault of their own. Insurance premiums escalated, sometimes as much as 25% or more a year.

Eventually, insurance companies and large employers developed what became the HMO (health management organization). These were originally closed groups of doctors and hospitals, who were either on payroll for the HMO, or who were paid for healthcare services according to specific, contracted payment amounts. Furthermore, some procedures were subject to review by the HMO for “medical necessity.” Thus was born what know as “managed care.”

The first HMOs were content to limit things such as emergency room visits (which were particularly expensive) and unneeded tests, reduce hospital stays, and deny payment for “experimental” procedures. Over time, however, this was not enough to stem the tide. Cost-passing from Medicaid/Medicare patients continued at an escalating pace, through the ’80s, so more and more, the HMO’s clamped down on what they paid for.

Regular, old-fashioned “health insurance” had by this time became brutally expensive, so more and more employers opted for managed care plans. This trend continues even today. Traditional health insurance takes up only about 2–3% of the total market, while HMOs account for well over 50%.

One arena of healthcare which was incredibly expensive, but which most managed care plans knew little about, was “behavioral health” or psychiatry. Psychiatry is rather unlike conventional medicine, in that diagnoses, condition evaluations, and treatment decisions are far more “iffy” and subject to judgement calls. Many managed care companies set up separate divisions, or even spun off separate companies, devoted solely to behavioral health. This allowed their caseworkers to specialize. Note, this was not done to help patient care, even though most HMOs claim this was the case; it was done so that more ways could be found to control costs.

The upshot, of course, is that managed-care patients often have to traverse a maze of bureaucracy in order to get what they need. Psychiatric hospitalizations and treatment plans are reviewed by a behavioral health company; but prescriptions are obtained through the HMO itself. In many instances the patient is given two or more phone numbers to call, if they have a question, but they don’t always know which one to call, and they still might get referred to someone else, who refers them to someone else, etc.

It’s really a very pathetic picture, especially given that folks with mood disorders often don’t have the wherewithal to handle such bureaucratic gymnastics. Also, it’s counter-productive for these companies to maintain separate bureaucracies, while trying to reduce operating costs.

Government programs don’t work the same way as commercial managed care does. Either patients are contracted out to commercial health insurers or HMOs, or their care is reimbursed according to delineated standards, such as their diagnosis, severity level, etc. In other words, government agencies pay for hospital stays only for certain diagnoses, and so long as the person is in poor enough condition to remain there; and it’s all decided by rote, not by careful analysis.

Either way, managed care companies and government agencies all too often save money in the short term, but lose money, long term. A patient who is discharged from the hospital too early, may wind up back in it all over again. An extra couple of days in the first stay, could have saved many, from the second, or eliminated that second stay entirely. Yet the companies and agencies are not learning this lesson. If anything, they’ve become increasingly parsimonious and even more short-sighted. In the end, they’re doing the patient no favors, and they aren’t really saving premium-payers or taxpayers anything.

One particular problem for those with mood disorders, is that insurance doesn’t always cover mental illness in the same way that other diseases are covered. Some plans have very low annual caps on total behavioral health payouts, which can be particular harmful if the patient needs, say, frequent therapy sessions.

Fortunately, though, over the last decade, an effort has been made to correct this situation. Many states, such as my own state of Connecticut, have passed “parity” laws, which require insurers to grant mental illnesses “parity” with others.

That it comes down to passing laws of this kind, though, is a travesty. What makes anyone think that mental illnesses are worth less than others? By what standard does one make such a determination? It’s all right for a depressive to go broke paying for Prozac, while a diabetic need not pay anything for insulin? Does this make any sense?

Of course it doesn’t! Nothing about mental illness makes any sense … not the illnesses themselves, not the way in which they’re treated, and not the way in which they’re paid for.

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I’ve referred to depression as a perception disorder, several times. I’d like to explore this in greater depth, as it affects how depressives relate to life. Note that I will be making some gross generalizations here — but even if these assertions don’t apply to everyone, experience has shown me that they’re valid observations nonetheless.

Depressives tend to take everything more seriously, than average folks. They also tend to take things personally.

This much is well-known. It lies at the heart of a school of therapy which is thought to be very effective for depression, known as “cognitive therapy.” “Very effective,” however, is a relative term; it’s successful for only about 60% of patients, and in the case of bipolar disorder, it’s much lower than that.

This compares favorably to antidepressant medications, which are anywhere from 60-70% effective. So I guess folks in the field of psychiatry are satisfied with these statistics.

But I’m not. I think it’s disgraceful.

Would you hire a mechanic who only repaired 60% of the cars he tried to fix? Would you believe a weatherman who was right only 60% of the time? Would you settle for 60% reliability, in any other area of life?

The fundamental problem with cognitive therapy, however, as with so many other treatments for depression, is that, while we know that it can help somewhat, we don’t precisely know how, and in the cases when it doesn’t help, we have no way to know why it failed.

Really, though, it comes down to what I said already: Depressives tend to take everything more seriously, than “average” folks. They also tend to take things personally. These are not things can easily be changed, if they can be changed at all.

What happens in patients treated with cognitive therapy, is that they are taught how to argue with themselves; they must constantly tell themselves that their own spontaneous thoughts are somehow “wrong” and that things are not always as they seem. This sets them up for failures when they discover that their original thinking was correct.

Here’s an example: Let’s say I’m going on a date, but she stands me up. I wonder why; being a depressive, perhaps my instinct tells me she didn’t really want to go on the date at all. Using cognitive therapy, I then tell myself that there are any number of reasons why she didn’t show up: traffic, car trouble, losing track of time, whatever. Perhaps this is good enough, for the moment. But later, I find out — perhaps from a third party — that my instinctive thinking had been true, all along. My date really did back out merely because she did not want to go out with me. It was personal, after all.

It only takes a few of these “failures” to make someone realize that cognitive therapy simply amounts to lying to oneself. That, of course, is precisely what it is! Only no one in “the business” will admit to it.

Ultimately, it’s not one’s thinking that needs to be changed. Rather, what needs to be changed is one’s basic, initial perceptions. It’s not enough to be able to wrestle intellectually with one’s automatic thinking; that can only go so far, and often can fall apart.

What really needs to happen, then, is to remove the sunglasses from one’s eyes. But cognitive therapy cannot do that — in spite of proponents’ claims that it can. Cognitive therapy is inherently flawed, and there’s no way to repair the flaw.

In any event, the manner in which one perceives things, is both deeply personal, and penetrates to all aspects of one’s life. Each and every waking moment, we view life through our own individual “perception filters.” It is not possible to go without one, as to do without it would require one to absorb each and every impulse that hits our senses, and analyze it. This is impossible to do. Instead, we selectively choose what we pay attention to, and we selectively choose what to heed, and what to dismiss.

In addition to being psychologically indispensible, our perceptive filters are also not sharable. We cannot explain ours to others, nor can they explain theirs, to us. As the physician and philosopher Karl Jaspers said, each human being is, indeed, a universe to his or her own, and can only share glimpses of that universe to others, not the universes themselves.

Thus, anyone pretending that he or she can show you how to alter your own perceptive filter, is at best tilting at windmills, and at worst, lying. No one can tell you what to do with your perceptive filter. You can change it on your own, however, without some outside information to go on, this is exceedingly hard. Unfortunately, no such information appears to exist.

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One of the problems with discussing clinical depression, is the word “depression” itself. Many people confuse a state of clinical depression — i.e. the mental illness that manifests as (sometimes periodic) states of sadness — with the normal depressed emotions that people experience from time to time. They are not the same, however. In fact, they’re often very different.

Someone can be “depressed” over a divorce, or the death of a loved one, yet not have clinical depression. The differences between these are stated rather clearly in psychiatry’s chief reference manual, the Diagnostic and Statistical Manual, 4th edition, better known as “DSM-IV.” The criteria for clinical depression are rather specific, and the majority of the population thankfully will never meet them.

Even so, there are a lot of misconceptions out there. I can only tackle a few of them meaningfully.

Misconception 1: Depression is just a “phase” that everyone goes through. Why turn it into a mental illness? As noted, there’s a pretty specific difference between normal bouts of “depression” caused by the emotional fluctuations of everyday life, and the illnesses of clinical depression. No one is saying that a normal period of mourning a loss (for example) is a mental illness. Mental illness is when it lasts too long, or becomes so deep that a person is disabled by it.

Misconception 2: Depression was invented by the psychiatrists and the pharmaceutical companies, in order to sell chemicals and drug the public. If you think this, then perhaps a Web site on paranoid conspiracy theories would be of more interest to you, than my blog. I admit that psychiatry has many faults (in fact, I plan to address many of them here!), but there is no evidence whatever that it’s conspiring against anyone. Psychiatrists are often at odds with the pharmaceutical companies! In any case, depression has been known as an illness, long before there were psychiatrists or pharmaceutical companies. Hippocrates and other ancient Greek physicians mention melancholia in their texts, and it corresponds to what we call “clinical depression.”

Misconception 3: Depression is just an excuse for laziness. No way! All of the depressives I know, would give anything to be able to conduct productive, normal lives! In fact, many (including yours truly) manage to keep full-time jobs, and participate in other social activities. The last thing most of them want is to sit home doing nothing — but sometimes, their illness keeps them housebound, nonetheless.

Misconception 4: If you just watched your diet and took some St. John’s Wort, you’d never get depressed. The idea that clinical depression is “caused” by a bad diet, is as insupportable as any other theory of its causes that are going around. Furthermore, the jury is out on St. John’s Wort; studies have come up with conflicting information about whether it helps alleviate depression, and there have been none which even suggest that it can prevent depression.

I agree with William Styron, the famous writer and fellow depressive, who once said that the term “depression” is a poor one, and doesn’t convey how terrible it is. He prefers the ancient-Greek-derived term melancholia, and I admit to some partiality for it as well (having studied ancient Greek!).

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Depression. Or, “clinical depression.” Whatever you call it, it seems to be everywhere, these days.

Go into any bookstore, and you see dozens of volumes on depression, in the self-help or psychology sections. Ditto for many libraries. Watch television or listen to radio, and you’ll hear commercials for antidepressant medications. Read the newspaper and listen to the news, and you’ll hear about new depression treatments, or alternative forms of treatment which aren’t so new.

Depression is all around us. Why is that? Are we as a society more depressed now than ever before? Or have we simply learned to recognize depression more often, when it happens? Or is depression just something that the pharmaceutical companies and the psychotherapy industry have cooked up, in order to make money?

Unfortunately, I can’t answer any of these questions. While I am sure there’s no corporate conspiracy involved, the other questions are all beyond my expertise. What’s worse, they’re beyond anyone’s expertise!

For all that we know about clinical depression, and as prevalent as depression seems to be, no one really knows where it comes from, or how to cure it. All anyone can do — even professionals in psychiatry — is flail away at it, and hope by sheer luck to hit some formula for success, for each individual patient.

As for depression and society … if we don’t have a handle on what causes it, and how it works, individually, we’ll never know what its relationship to society at large is.

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Please note that while I am a facilitator for the DBSA of NW CT, and their webmaster, I do not speak for the support group or any of its members. The meanderings in “Notes From The Ward” are purely my own, individual opinion.

An initial series of essays started this blog; an index of these, in their original order, is called The Heart of the Matter.