The initial series of posts are complete. You can view them in order at The Heart of the Matter. From here on, things will work just as any other blog does … I’ll offer occasional insights in the world of mood-disorder treatment, going into the future.

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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So far, you may think I’m in the “anti-psychiatry” camp, but I am not. By no means! For all of the problems with psychiatry I’ve pointed out so far, I think the anti-psychiatry folks are far more dangerous to those with mental illnesses, than even the worst psychiatrists.

When I talk, here, about the “anti-psychiatry movement,” I refer to a number of renegade doctors who’ve dedicated their careers to abolishing psychiatry. I do not presume that they are part of a conspiracy, in that I don’t think they collaborate directly with one another, but I do think that they espouse similar ideas, and behave in ways which make them appear to be an iconic movement. So I’ll speak of them collectively.

The anti-psychiatry movement has, at present, focused its efforts on wiping out the notions of ADD and ADHD (Attention Deficit Disorder and Attention Deficit-Hyperactive Disorder). They do not think these are “disorders” that children need to be treated for. Presumably because there are a lot of ADD/ADHD-diagnosed children, they hope to get more press for their ideas, this way.

But mood disorders are on their hit-lists nonetheless. They consider antidepressant medications to be ineffective and unsafe, and the same goes for mood stabilizers. Further, they consider ECT (electro-convulsive therapy) to be “barbaric” and want it abolished.

But in addition to treatments which they don’t like, the anti-psychiatry movement doesn’t like the way many illnesses are defined. Some, such as ADD and ADHD, they think ought to be eliminated, as they aren’t really disorders, but simply an alternate learning method that the child requires. Others, such as Post-Traumatic Stress Disorder (PTSD) need to be redefined, as too many people (they think) fall under it. Some in the anti-psychiatry movement explicitly claim that there is no such thing as mental illness at all; what we perceive as such, is merely individual eccentricity. There is nothing wrong with them, in this view, and nothing to treat.

If the anti-psychiatry movement has a valid point, it’s that psychiatry as a whole isn’t as responsive as it should be, to those it serves. I cannot argue this, not one iota.

What concerns me, though, is that the anti-psychiatry movement is based on all the worst stereotypes of mental illness, and in many cases, is founded on a desire to get rid of the notion of mental illness altogether. This is what makes this movement so dangerous. If they had their way, clinics all over the country would be emptied, and their residents dumped on the streets, without any treatment or medication, left to fend for themselves. That anyone would actually want to do this, is unconscionable, however, and indeed, is outrageously evil. No other word applies.

I would have more sympathy for the anti-psychiatry movement, if it offered alternative solutions to the problems that people face. But it does not. In some cases, the anti-psychiatry movement simply denies that there’s a problem at all; in others, they admit that something is there to be “fixed,” but they manage to find some fault with all of the known fixes, and have none of their own to offer. (Tom Cruise’s insistence on vitamins is not even worthy of discussion as an “alternative.”)

Perhaps the worst thing about the anti-psychiatry movement, is that it masquerades as an advocate for the truly mentally ill. Really, however, they don’t think that the mentally ill exist. Or if they do, they have no desire to see them get any meaningful help; what they want, rather, is to keep them ill so that they have a “cause” to fight for, and thus continued employment. Or worse yet — those who define all mental illness as non-existent — actually want to propagate misery (now you see why I call them “evil”). Their position is utterly ridiculous, however, and a quick walk through any psych ward will prove it … there truly are some people who are very sick and in pain; defining their illness away will set their suffering in concrete. I can think of few things more despicable than that.

When the anti-psychiatry movement has something compelling to offer those with mental illness, I’ll listen, as should we all. But so long as all they do is weep and wail over treatment methods, or posit that there is no mental illness, offering nothing constructive in their place, they don’t deserve anyone’s ear.

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Depression has been known for well over 2,000 years. The famed ancient Greek physician, Hippocrates, called it melancholia. This name comes from the Greek words μελας χωλη, or “black bile;” the Greeks thought an overabundance of black bile, a fluid formed by the liver, made one melancholy (a word which has come to mean “depressed”). In a similar fashion, the Greeks attributed mania to an overabundance of yellow bile, another liver compound.

The ancients knew mental illness, having many different terms for aspects of mental illness which we now consider to be related. They had many different theories as to why they happened, but quite noteworthy is that the ancient Greek philosophers and physicians — for the most part — looked for physiological causes (at least, as far as their understanding of physiology allowed). It was only in later times-much later, as in, after the Middle Ages — that mental illness was attributed to “demonic infestation” or what-have-you.

Also, in many ways, the ancients were (oddly enough) more tolerant of mental illness, than we are. (So much for our having become “enlightened” over the centuries!) Quite simply, they accepted that some people appeared to have some eccentricities or even moments of madness. Ancient and medieval literature is full of characters who, when confronted with some terrible situation, fall into episodes of absolute madness, from which they (usually) recovered, and moved on. Socrates and Plato advocated setting up colonies for the mentally ill, complete with scribes to take down their utterances, which they thought might be divinely-inspired. Ancient and medieval history has many figures who had odd habits, and who now would probably have been diagnosed with some mental illness.

The first-century Roman philosopher Seneca once said, “There’s no great spirit which is not somehow touched by madness.” Others echoed this sentiment, down through the centuries. That some very learned or creative people were affected by mental illness, was accepted as a “given,” and in fact, it was even expected!

Recently, experts have gone over the biographies of historical people, and generated lists of those who’re suspected of having had a mood disorder. These lists are extensive, numbering in the thousands; but even if some of the individuals are debatable, the fact remains, that many of the most influential people of the last 2,000 years or more, must have had mood disorders.

I cannot help but wonder, though, why mood disorders were accepted, among the ancients and even in medieval times, whereas more recently, these disorders (and the folks with them) are shunned? How can this be? Around the same time that slavery was abolished in the western world, the western world suddenly decided that the mentally ill were “dangerous” and needed to be secluded, shut out, forgotten. Along with this came a presumption of “guilt” on the part of the mentally ill … e.g. that mental illness is of the patient’s own making, the result of laziness, eccentricity, personal weakness, etc.

This leads us to a great deal of current thinking about mood disorders (held of course by those who’ve never experienced them!) that patients need to “pick themselves up by their own bootstraps,” just eat better, “get right with God,” or whatever. The ancient Greeks certainly had a much healthier view of mental illness, even if they did not really have the means to treat it effectively.

Why is that, do you think?

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For a lot of people, mental illness is something they know only in the headlines, usually when a mentally-ill person commits a crime. The case of Andrea Yates leaps to mind, but many others have graced the pages of our newspapers or the screens of our television sets.

When mental illness is something one hears about only as a courtroom tactic used by defense attorneys, it’s easy to assume that mental illness doesn’t really exist. Heck, if I knew it only from defense attorneys, I’d agree! But mental illness, and mood disorders, do exist, independently of criminal courts.

In fact, what is called “insanity” in court, doesn’t correlate to mental illness, in the rest of the world. The legal meaning of insanity is rather specific, and focused solely on one issue: Was the person aware of the consequences of their actions? Mental illness, on the other hand, goes far beyond this. Most mentally ill people, including almost all folks with mood disorders, do not qualify as “legally insane” and probably never will. The number of people who are actually “legally insane” in the United States at this very moment, probably number no more than a couple dozen.

The fact is, the mentally ill are no more, or less, likely to act out violently, than anyone else. This has been borne out by statistical surveys that probably stack up higher than I am tall. In addition, in many cases, it’s possible for caretakers or family to anticipate when a mentally-ill person may act out — since mental illness often manifests in predictable patterns of behavior — thus actually reducing the danger, in many cases.

Of course, this depends on the willingness of those around the ill person to acknowledge such possibilities and plan for just such contingencies. Too often, though, especially family members are unwilling to admit that something of this sort might happen. These, sadly, are the folks who end up grabbing headlines.

Another point to be made is that violent acts such as these, which make headlines, do not really represent the mentally ill. Some folks may qualify as “legally insane” yet not be clinically mentally ill. This may sound unbelievable, but it’s true, because as I pointed out, being legally insane and clinically mentally ill, are not the same thing.

I can only admonish you not to form your opinion about mental illness, especially of mood disorders, based on media headlines and lawyers’ sound bites. Neither of these is a good way to learn about anything, much less mental illness!

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Rather than having three levels of treatment (routine periodic treatment in one’s doctor’s or therapist’s office, attendance at a day treatment or partial hospitalization program, and inpatient psychiatric wards), I propose that several more such levels be created. Among them:

1. A level of outpatient clinical care, similar to partial hospitals, but perhaps a couple of hours a day, one or more days a week;
2. Another level of outpatient clinical care, this one being only one or two hours a day, every day, early in the morning or in the evening so that patients can work;
3. Visiting-nurse or in-home counseling care, in which a qualified psychiatric nurse checks in on the patient in his or her home, either daily, or a few days a week;
4. And for those times when inpatient care is unavoidable, wards devoted to mood-disorder patients are in order. These are places where their particular needs are addressed, and which have a population of similar patients for them to relate to, along with outdoor activities (where practicable), since exercise is important to recovery.

This will have the added benefit of allowing attending physicians and other staff, to treat mood disorder patients as they need to be treated, without being distracted by the varying demands of a much larger population.

There are other possibilities. Oddly enough, some of them are being tried, in various places, but they aren’t always accepted by the rest of the system. In fact, many renowned facilities are now doing some or all of these things. Why aren’t the rest? What are they waiting for?

That must change. But will it?

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While psychiatric-ward stays have saved many lives (including mine), overall, they aren’t always the best way to deal with a depressive. Since psychiatry has become crisis-oriented, however, they’re a necessary evil. They will continue to be, until psychiatry becomes less crisis-oriented.

One of the main problems with putting depressed patients into psychiatric wards, is that they’re often thrown in with a hodgepodge of other patients, who have other sorts of mental illnesses. Now, I don’t mean to put those other patients down, but people with mood disorders are quite different from people with, say, psychotic disorders. The comparison is not always a favorable one, and the message conveyed to a patient who already feels rather poorly about themselves, is that this is “their place.”

Most psych wards are restrictive, in that one cannot just walk around the hospital grounds. Again, this is for safety reasons, however, a patient can feel as if he or she is in jail — which again isn’t conducive to improving his or her state of mind.

As I said, the real problem is a crisis-orientation. Patients are allowed to get worse and worse, but remain on their own, and when they get bad enough — that is, when they’re suicidal — we stuff them into a “mental illness warehouse” to keep them safe. Then, for too many, cycle resumes all over again.

Again, I have to say that I am not impugning the caring or dedication of the people who work in psychiatric wards. I’m simply suggesting that psych-ward visits be eliminated in the first place, by not allowing depression patients to degrade to the point where they need to be “locked up” for their own safety.

In simpler terms, we need more intermediate treatment options than are usually available. We also need inpatient facilities which are devoted specifically to those with mood disorders, in which the environment isn’t so restrictive and, well, depressing.

A very good intermediate treatment option which currently exists, is known variously as “partial hospitalization” or “day treatment.” My best hospitalization experiences have been in such venues, and I cannot recommend them highly enough. Unfortunately, they are usually used (as in my case) as follow-up after an inpatient hospitalization, and not proactively to prevent an inpatient stay.

The reasons for this are varied, but they come down mainly to two: Staffing, and insurance. A hospital’s priorities are naturally going to be in its inpatient units, where “the worst of the worst” are. Outpatient treatment is secondary, and often suffers from budget cuts or consolidations. Insurance companies are generally unwilling to pay for outpatient programs unless they’re convinced it’s necessary in order to keep a patient out of an inpatient unit — but by the time that point has been reached, an inpatient stay is sometimes already required!

In any event, very few inpatient facilities cater specifically to mood-disorder patients, even though they comprise the majority of the mentally ill. This makes no sense, but it remains a fact. A facility for those with mood disorders could be constructed so as to offer some freedom of movement for patients, but with little compromise on their safety.

Most inpatient wards have a schedule of activities for each day; they don’t want patients sitting in bed feeling sorry for themselves. Obviously, keeping them active is a good idea, but unfortunately, more and more inpatient units are not maintaining sufficient staff to run all of these activities. Hence, while “on the books” they can claim to keep people busy, in practice, they don’t.

Most units offer one or more sessions of group psychotherapy a day. While these are probably useful to people who’ve been “through the system” and know what to expect, for most patients, who are in rough shape (otherwise, they wouldn’t be there!) and new to such environments, it’s utterly useless and sometimes frightening. Something much better would be a simple check-in followed by exercises or some other form of activity.

Another problem that many inpatient wards have, is that attending psychiatrists are usually treating several people at a time. Even the best of them can get mixed up, or drained, or inattentive to those who don’t make their presence felt. Unfortunately, most people suffering a severe depressive episode, are (by definition) unable to make their presence felt and demand the psychiatrist’s time. Hence, they get only minimal, assembly-line treatment.

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This is my term for when a mood-disorder patient is put on a medication, the dosage is raised, then another is tried, the dosage of that one raised, etc., in a fast-and-furious effort to find something — anything — that works. While providers often have good intentions behind putting a patient on the “medication mill,” ultimately, they’re more likely to do harm, than good.

People on the “medication mill” usually get there by being hospitalized, frequently due to a suicide attempt. The worry is that the person needs to have some improvement — soon — if they’re to be allowed to return home. There’s a very real sense, on the part of providers, as well as the patient’s family and friends, that something must be done quick, or all may be lost.

Generally there’s merit to this urgency; but the problem is that, even under the best conditions, it can take weeks for a medication to begin lifting or controlling someone’s mood. Not giving a medication ample time to “do its thing” and begin working, may end up putting off an improvement, as one after another is tried, none of them having been given long enough to do any good.

Look at it this way: Let’s say you are started on a medication. After 1 week, it appears not to work, so the dosage is raised. After another week, it’s still not working, so another medication is tried, repeating the same pattern. This might go on for 8 weeks or even more; but for all anyone knows, the first medication might have worked, had it been tried for a solid 4 weeks.

In psychiatry, giving a medication sufficient time to work is called a “fair trial.” Medical journals decry that providers aren’t allowing for a fair trial for any given drug a patient tries. So in this instance, I’m not the only one pointing out the problems with the “medication mill.”

One factor encouraging the medication mill, is managed care and government-insured medicine. Patients who are covered by managed care or government insurance (Medicare, Medicaid) are often pushed out the hospital doors as soon as possible. These companies and agencies pressure providers into taking chances, in order to get a patient just barely good enough to get out of the hospital. After that, they couldn’t give a damn what happens. All they know is that they aren’t paying a thousand dollars a day for the patient to be in the hospital.

What they fail to figure, however, is the long-term cost. Sure, getting someone improved enough to go home, quickly, is all well and good … but if, after that, they don’t improve much more, they stand a greater chance of relapsing into another depressive episode, and another, and so on.

What’s much better, in the long run, both emotionally for the patient and financially for the bill-payer, is to ensure that patients get “fair trials,” in a safe environment; this way they’ll be less likely to return to the hospital.

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Perhaps no single development has had more of an impact on the treatment of mood disorders, than the discovery of antidepressant medications, and for bipolar folks, mood stabilizers. Medications are the best-known treatments for mood disorders, and they are what most doctors will want to try first, when someone is initially diagnosed.

While medications are often a tremendous help for a patient, they cannot usually “cure” anyone. They are a step in the right direction, but only one step of many that need to be taken.

That antidepressants and mood stabilizers work is not in doubt — we know that statistically from clinical studies — but we still don’t know how they work. Researchers have made guesses, but that’s all they are — guesses. Too many things about them are uncertain or unknown.

Psychiatry commonly calls mood disorders “imbalances of brain chemicals.” But not only is this not very helpful, it doesn’t actually mean anything! Precisely what is being “balanced” against what? And how does depression represent an “imbalance?” Which chemicals are in question? Is there any way to test someone’s brain chemistry?

There are no answers to these questions, aside from some educated guesses.

Don’t get me wrong. I’m convinced that there is some sort of electrochemical brain malfunction at the heart of mood disorders-that’s not in doubt — I just dislike the phrase “chemical imbalance,” because ultimately, it’s gibberish. We need our terminology to have meaning, not lack it, if we’re to advance the cause of mood-disorder treatment.

Even when researchers thought they were onto something — it often turned out that they weren’t. For example, the inventors of buspirone thought they had devised an antidepressant of the class known as SSRIs (selective serotonin reuptake inhibitors) along the lines of Prozac. But during clinical trials, they discovered that buspirone isn’t effective against depression — but it is effective against anxiety. Ultimately, it was approved by the FDA as Buspar, an anxiolytic (anti-anxiety agent). It’s sometimes given to depression patients, but usually to alleviate associated anxiety, not the depression. Yet, every early indication had been that buspirone would work similarly to other SSRIs, which are effective for depression.

What went wrong with buspirone? No one knows. Chemically, it should work on depression … but it doesn’t.

In the case of bipolar disorder, it was discovered that anticonvulsants, long used to treat epilepsy, were effective in quelling mood fluctuations. Carbamazapine, gabapentin, lamotrigine, and several more, all help in this way — but no one knows what the connection is between convulsions and mania. Furthermore, another mood stabilizer, lithium, is unrelated to these — or anything kind of medication — and its workings are even more of a mystery.

So while we do have some effective medications for mood disorders, we have few answers as to how or why they work, and are at a loss to devise new ones, since even those that appear chemically-promising, can end up not helping.

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