Diagnosis du jour

Like changing hemlines, there are fashions in mental health. In the 1980s, taking Prozac was hip and, on the cocktail circuit, you were embarrassed if you weren’t taking the little blue and white capsule. A decade later, attention deficit hyperactivity disorder (ADHD) was the ‘in’ condition, not just among children and adolescents, but also among driven adults. And now, in the new millennium, the diagnosis of the moment is bipolar disorder.

A new study conducted by researchers at Columbia University http://www.nimh.nih.gov/press/rates_bipolar_diagnosis.cfm?OututPrint) finds that 1 in every 100 youth aged 19 or younger has bipolar disorder (and 2 in every 100 adults). That may not sound so bad – just 1 percent – but taken in the context of trends, it is disturbing: the rate of bipolar diagnosis has increased forty-fold in ten years among adolescents.

Forty-fold.

What the hell’s in the water?

Probably nothing. Historically, bipolar disorder has been under-recognized, under-diagnosed, and under-treated, especially in pediatric populations. The mood swings, excess energy, and restlessness associated with bipolar parallel the signs and symptoms seen in other conditions, including ADHD, oppositional defiant disorder, psychotic disorders, and garden-variety depression. Not to mention the normal angst and sturm of adolescence.

But now it appears we may be swinging to the other side of the pendulum: over-diagnosis. And a consequence of any diagnosis is usually a treatment. The medications used to treat bipolar disorder – lithium and other mood stabilizers, anxiolytics, antidepressants, and antipsychotics – are not innocuous. They are powerful, mind-altering drugs which, when used appropriately, confer tremendous medical benefit. But they also have potent and dangerous side effects, ranging from the inconvenient and uncomfortable (loss of libido, dry mouth, shaking) to the downright dangerous (blood dyscrasias, weight gain, diabetes).

In BRIGHTER THAN BRIGHT, Ben is bipolar. Diagnosed at age 16, he’s a model patient, compliant with his lithium and psychotherapy for the past four years. But a series of events cascade and lead him to ‘forget’ his happy pills and he starts the upward spiral into mania…

My very atoms vibrate: from caffeine, from sleep deprivation, from the constant moving forward. From erratic consumption of my mood regulators. But my mind is sharp, focused; my dreams, Technicolor wonders. Everything I touch explodes from this magical, sub-cellular energy surging within me. When I press the closed hollow-wood door to Bruce’s office, it flies open with a bang. The knob gouges the plaster wall. He sits at his desk, the room dim but for the green glow of a single lamp, head down, not noticing my tumult.

The Mind - Au Naturale

For decades, psychiatrists, surgeons, family physicians, and quacks have resorted to a myriad of methods to still the sadness and quell the voices echoing in our heads. Lobotomies, insulin treatment, electroconvulsive (shock) therapy were once standards of care for mental illness, along with all sorts of medicaments and solutions. Now, we're more humane – we manage most of our mental ailments by ingesting pills. And what a variety: olanzapine, lamotrigine, sertraline, paroxetine, quetiapine, aripiprazole, ziprasidone, duloxetine, venlafaxine. The syllables drip off my tongue, almost a lilting poem.

But folks who have the blues or other mental and emotional maladies are starting to tell their prescribing psychiatrists and family docs: no thanks. Why? The growing evidence that some medications are as effective as placebo, their prohibitive expense and increasing hassles imposed by insurers, and side effects that sometimes seem worse than the disease: weight gain, diabetes, lack of libido, and changes in cognitive and emotional capacities. And, of course, some people just don’t want anything screwing with their head.

Which I find fascinating. Why wouldn’t someone in the throes of severe emotional distress not gobble a small, white sphere to feel better? to become functional? To return to ‘normal’?

This dilemma underlies both my research and my fiction. During the day, I ponder how to improve patient ‘adherence’ to antidepressants and antipsychotics. My hypothesis: take your meds, and you'll experience improved clinical outcomes and save money. Crass, perhaps, but these are endpoints I can measure by crunching very large datasets comprised of millions of medical and pharmacy claims using fancy statistics and large hard-drives.

But the numbers only go so far: Why don’t people take their meds? Why do they resist medically-accepted treatments? Why aren’t people adherent to experts' proscriptions?

A pivotal section of BRIGHTER THAN BRIGHT finds Ben, my protagonist, wallowing in a mixed manic-depressive state and grappling with the decision of whether to take an antipsychotic. After days of fear and indecision, he succumbs and experiences a miracle - the reinstatement of his mind…

I waken and hear the whir of highway traffic and, more distant, the lonesome wail of a train. The night workers rustle, talk softly, prepare for the next group of caretakers. Someone moans from another room. These are the only sounds; my mind is quiet; there is no noise, no morbid, florid thoughts, no whooshing or thrumming or humming, no lingering nightmares or images or memories. Normal? Is this what normal feels like? I don’t remember.

There are many ways to attain and maintain mental health. Whatever it takes - pills, gamma rays, sun, running, talk therapy, magnets applied to your temples, Emotional Freedom Techniques, or hey, dirt - stay healthy and happy. Peace, Linda

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For an excellent article on the pitfalls and pros of medications – and their 'natural' alternatives - turn to The Unmedicated Mind http://online.wsj.com/article/SB118428285736265304.html?mod=googlenews_wsj