Before antidepressants.

After 1 year on antidepressants.

Today, my decision about topics comes down to two choices, both born of recent posts or replies to comments: 1) Bad Thought and Behavior Habits and how hard it is to change them; or 2) Discontinuing Psychiatric Drugs and how it is made difficult by receptor downregulation. The first has to do with why I often ignore the things that have been taught to me about how to be healthy. The second is about why I get so depressed when I try to stop (e.g.) Cymbalta. Then I realized that the two are related. They both have to do with fixed patterns of response in the brain. So this essay deals with both those issues. It is long (despite my resolution to keep posts under 500 words), and involves some physiology. But I think the connection between habits, drugs, and changes in the brain lies at the heart of many difficult emotional problems.

Of course, science understands drugs better than habits. When a negative behavior becomes habitual, so that we repeatedly cave in to it rather than do the harder thing that will make us feel better in the long run, millions (or billions) of cells across the brain may get involved. Many complicated neural centers of thought and action determine such bad habits. On the other hand, when our brains become habituated to the effects of psychiatric medications, the problem largely can be explained by changes in the levels of one or a few proteins. Since I know little about the psychology behind habits and resistance to change, most of this post will focus on receptors. I will try to draw (hopefully not make up) parallels between the brain’s adjustment to pharmaceuticals and its development of habits.

Many people on psychiatric medications have found that a drug may improve ‘symptoms’ after a few weeks, but then gradually works less and less well. This happens, in part, because the body reduces the number of receptor-proteins that respond to that drug, or to one of the natural chemicals the drug increases.

I started my medication odyssey with Prozac (fluoxetine). This drug blocks the removal (reuptake) of serotonin from the synapses in parts of the brain that use serotonin as a signalling molecule. The synapse is the small area that separates the pre-synaptic cell that sends a signal, in this case one carried by serotonin, from the post-synaptic cell that receives it. Removing the released serotonin from the space between the cells–the synapse–attenuates the message, so that it is time-limited, and doesn’t just go on ‘forever’. Since compared to earlier antidepressants Prozac is relatively selective in blocking reuptake of serotonin–but not other transmitters, it is an example of the SSRI class: Selective Serotonin Reuptake Inhibitors.

Under normal circumstances, the pre-synaptic cell releases serotonin, but then sucks it back out of the synapse using ‘reuptake’ proteins. Without the reuptake mechanism, serotonin would persist in the cleft for much longer times, and at higher concentrations, than normal. In fact, Prozac accomplishes exactly that: it blocks the reuptake protein and so causes an increase in synaptic serotonin.

As an aside, only about one-thousandth of one percent of brain nerve cells use serotonin to send signals. Despite their small numbers, serotonin neurons affect many different parts of the brain. That explains, in part, why they have unwanted side effects: areas of the nervous system we’d rather not mess with (like parts mediating sexual response) are modulated by serotonin, just like the parts that alter moods. Another important point is that to date there is no evidence that depression results from an actual deficiency in serotonin levels, even though increasing serotonin activity does elevate moods.

So why does Prozac often quit working over time? In part, it may be because the cells respond to abnormal increases in serotonin by reducing the number of post-synaptic receptors for that transmitter. It’s kind of like what happens with noise. If you want to hear something really faint, like a soft whisper, you cup your hand behind your ear to increase your ability to make out the words. As the person speaks louder, you remove your hand because it’s not so hard to detect their voice anymore. If they start yelling, you might even plug your ears to tone down the volume. The post-synaptic neuron that detects the serotonin signal no longer has to listen so hard. So it reduces the number of proteins in its cell membrane that ‘hear’ the serotonin molecule. And the drug that increases serotonin, and that once had terrific effectiveness, now has less.

Naturally, there are complicating factors. For instance, Prozac may have an immediate stimulating effect, but much of its antidepressant activity is delayed by several weeks. This is thought to be due to changes in receptor numbers on the pre-synaptic cell. I won’t go into this wrinkle, because it does not change the basic fact that eventually serotonin levels increase, and that soon after the system adjusts to the elevated transmitter levels. Regardless of the details, the end result is that the brain settles back toward its natural state. It adapts to the increase in transmitter by reducing its sensitivity.

What happens when you stop the Prozac? At this point, your neurons are accustomed to increased serotonin levels. What was once abnormally high is now, according to your brain, the right amount. When you take the (reuptake inhibiting) drug away, reuptake goes back up, which (probably along with other changes) reduces synaptic serotonin. Since the brain has adapted to high serotonin, this reduction (back to levels that once were normal) feels like a deficiency. The serotonin system is under-stimulated, and you feel depressed. And because serotonin neurons are so widespread, other withdrawal symptoms are not uncommon. You might even be more depressed than when you first started Prozac. If you can weather the depression without killing yourself, there is a pretty good chance that your neurons will return to their original condition. Or maybe not. There is also a risk that not all of the changes are reversible. One line of evidence that suggests receptor downregulation may sometimes be irreversible comes from the fact that some people have long-term sexual dysfunction that continues after SSRI agents have been discontinued.

Either way, the habituation of your brain to the presence of Prozac (and other SSRIs) makes it a difficult drug to stop. The same thing happens with heroin users: the number of opiate receptors drops, and the addict feels horrible if her or she can’t get enough heroin. (In the brain, ‘opiate’ receptors normally detect peptides called endorphins; heroin and related drugs stimulate those receptors and thereby promote analgesia and euphoria.) Hence they have trouble springing back from ‘receptor downregulation’ just like Prozac users. A common name for this is ‘addiction’. For obvious reasons, drug companies and psychiatrists resist applying this term to the withdrawal symptoms people have when psychiatric drugs like SSRIs are stopped.

Now, back to habits. Could it be that similar adaptations to signal strength, protein levels, and other features in various parts of the brain account for why habits are so hard to break? When we try to alter our behavior away from the established pattern, do we experience a seeming deficit in some chemical important to feelings of well-being? This mechanism must be operative in bad habits involving substance abuse, like cigarette addiction. But would it be extending the analogy too far to suggest it explains my habit of retreating into depression after minor setbacks? Or how I avoid doing the things that I know will gradually lead to less depression (e.g., distraction, exercise, positive self-talk), and instead curl up in a darkened room because it somehow feels better at that moment?

To answer that, one confronts the question of whether all of our decisions result from neuronal activity. Surprisingly (to me) not all scientists agree with that notion, or at least not entirely. Jeffrey Schwartz, MD, published a book in 2002 with reporter Sharon Begley called, The Mind and Brain: Neuroplasticity and the Power of Mental Force. In it, he uses obsessive-compulsive disorder (OCD) as a model for how the mind and brain interact. On the one hand, he reports that PET imaging data imply that OCD results from faulty action patterns in the frontal lobe. he goes on to show how entraining OCD patients (via CBT techniques) with new behaviors changes those circuits, and that the better the patients become, the ‘better’ the circuits look. This supports the idea that bad habits can result from changes in neuronal circuitry (note that OCD behaviors are particularly bad and pernicious; I want to reassure OCD sufferers that I am not saying their condition is something you can just ‘quit’ like cigarette smoking–hard as that is).

(Note: these images taken from the site linked by clicking on them. They were not obtained via CC license. Since they are promotional pictures on an OCD clinic’s website, and this is a mental health blog, I assume the developers would not mind. I do not have any affiliation with that organization, by the way.)

Schwartz also conveys the optimistic message that with training and intention we can change cellular connections. In other words, we can physically alter our brains to improve our lives (which brings up the giant topic of neuroplasticity, a subject for another blog). So Schwartz agrees that structural and functional elements in the brain determine habits, and that changing those elements is the key to improvement.

On the other hand, however, he argues that the intention to change behavior (and hence the brain), originates from something outside the physical structure of the nervous system: a so-called ‘mental force’. He is doing nothing less than postulating a new physical entity to add to the nuclear strong, nuclear weak, electromagnetic and gravitational forces already known by physicists. His argument is well-constructed, though it fails to convince me. (That does not mean I don’t believe in forces outside of matter, only that his reasoning and supporting data are insufficient to establish non-material forces acting in this instance.)

Whether intention originates in neuronal tissue or outside of it, it is nevertheless clear that behavior is grounded in the brain, that we can and often do change our behavior, and that doing so probably involves changing the structure and/or function of neural circuits. My whole reason for this long discussion is to make the point that while drugs quickly and efficiently change synapses and brain circuits, we can do the same thing (more slowly) with willpower, training, and practice. Breaking the habits that promote depression is then not all that different from recovering from long-term use of psychiatric drugs, although it is probably easier. In both instances we need to readjust synaptic activity.

Cognitive research has shown that to some extent persistent depression is about bad habits of thought and action. If we can break those habits, we can reduce depression. It may even be that improving thought and behavior increases brain serotonin activity, just like Prozac. However, unlike using a synthetic drug, in this case the neurotransmitter gets increased in just the right locations, not the whole brain. There is no problem with, for instance, anorgasmia or weight gain. We can accomplish the same thing as drugs, but without the side effects. It just takes the desire to change, and enough motivation to step off the easy and well-worn path. One needs to muster the courage to forge new trails and conquer new horizons. But drugs are not required.

Medications all-too-often only provide temporary relief. In some cases, a period of drug-mediated improvement in depression can give one the solid ground needed to step in a new direction. After that, the ideal decision would be to withdraw the drug in short order. I believe medications can play a useful, even vital role. But pharmaceutical agents can not, and should not be the only compass used to find a new way to live. Lifelong treatment with psychiatric medications is questionable, and despite what we are led to believe, most pharmaceutical agents lack scientific evidence of usefulness over long term treatment. So if drugs are used at all, they should be used in the lowest number, at the lowest doses, and for the shortest time possible. It takes much effort and time to change neural pathways without drugs, but the improvement is longer lasting, without side effects, and far more natural.

Since I started this blog at the end of May (and ramped it up in July), most of my posts took on a rhetorical style. In college (UC Berkeley) I took a year of Rhetoric rather than Freshman English, for reasons I no longer remember. Ever since then, it has been hard for me to write without composing an argument. My guess is that readership will not be attracted to an endless column of that stuff, as much as I enjoy logical analysis of issues.

While I cannot change into someone new, as much as I sometimes wish it, it is important for me to also be ‘real’ in this project. So what follows gives a brief sketch of my current lifestyle, at least as I lead it when in the Bay Area.

After waking up early, I sit at my computer for an hour or more looking at any comments that might have come in, writing responses, and visiting blogs. Then my wife and I walk our two little dogs: Emily, a chihuahua-dachshund mix, and Ralphy, who is some version of a poodle. Both weigh 10-11 pounds, and are the cutest dogs in the world (but it’s possible I’m a little biased). Some days I also go to an AA meeting a few miles from home; it’s a daily meeting, and it is one of the few places I’ve made friends as an adult.

After the dog walk, Mandy and I usually go to the gym. This takes us to noon, or a little later. The afternoon I often spend running errands, though I prefer to have time to write. That is one of the reasons I prefer living in the foothills (where we spend 1/4 to 1/2 of our time); it presents fewer distractions to my writing.

Mandy usually cooks dinner, and I either do the clean up alone, or with Mandy’s help. I actually prefer to do it by myself because, truth be told, Mandy does 90% of the housework; I have never been one to assist much. I feel guilty about it, but evidently not enough to pitch in on a regular basis. That’s another reason I like being up at our mountain place: there is a great deal of work to do outside, around the land. That way I can contribute to the function of the household, since I am poorly motivated toward cleaning and doing the indoor work.

In the evening we typically watch a rented movie. Then I do one of two things. If I am feeling OK, I spend more time at the computer. Unfortunately, very often I get depressed as the day ends, and I retreat to a dark room, curl up in a ball, and try not to think. I focus on my body and its sensations in order to escape the torment of my thoughts. Not a pretty picture, and obviously not one I am proud of, but there it is.

When I am writing, my guilt about not helping around the house gets alleviated slightly. Since my surgical career ended in 2000, I have spent six months in graduate school, three months teaching high school, and eighteen months doing public speaking for the California Department of Public Health (about childhood lead poisoning). I’ve also done some volunteer computer programming and other unpaid work (including a little recent work as a mental health patient advocate). But you can see how I do not have any earning capacity. For now we are coasting along OK, but someday an income will be needed. Since I have crashed at every endeavor since my surgical career ended (due to neck problems), the only thing I have left is writing. Although it may never pay actual money, at least it feels like work rather than mere laziness.

Writing as a living is obviously a very, very uncertain thing. Especially for someone with so little background in the field. I have what I think is an interesting story to tell, but whether I can tell it in a compelling way is an open question.

Believe it or not, those eight (rather short) paragraphs sum up the better part of my current life. It is simple, uncluttered, and sometimes boring. The difference between what I do now and what things were like back when I had a clinical practice is impossible to overstate. Back then I worked fifty hours a week (half of those in the operating room), fixed up our vintage house in San Francisco on the weekends, and spent the rest of my free time either sculpting or reading about sculpture. I was busy as hell. I felt productive and proud of myself. I was probably a little arrogant.

In those days I had minimal spiritual sensibility. I tended to see things from a materialist perspective and gave almost no attention to the murmurings of my heart. Stress consumed me.

Which is better? For all the loss, grief, depression, and defeat, I am now a more enlightened, understanding, and humble person. Admittedly, I sometimes take the humility thing too far until it borders on humiliation. But most of the time I see myself as a better person than before. (I admit my wife might have a different take on things.)

So that’s my story. I don’t know if anyone will care, or even read this far into my post. But I want this site to include some of my real day-to-day experience, rather than just arguments. Besides, I see now that my opinions about mental health topics sound naive compared to what I read on other blogs, where similar topics have been kicked around for a long time.

Lately, I’ve been battling a low-grade conviction that life is s**t. My grip on living has been slipping, and I find myself dreaming of the long fall off the Golden Gate Bridge, just like the old days. (When I was in the hospital, the therapists grilled me about why I was fixated on the bridge, when as a doctor I could–they thought–easily get my hands on some pills to die painlessly. My answer came down to what I mentioned in another post: my mother loved the bridge before she died. It seemed to represent something to her, even as she faded into the mists of depression back in Michigan.) That’s why I gave in and boosted the Cymbalta again.

Since the dose increase, my mood is perking up. Of course, I pay the price of diminished sexual responsiveness and the discouragement of losing ground in my project of breaking free of pharmaceuticals. But at least the nagging feeling that life just isn’t worth the trouble has lifted–sort of.

I’d like to end on a better note, but that would not be true to my current condition. When I started this blog my hope had been to show everyone a path to freedom out of depression: I actually believed my progress exemplary enough that I could begin to teach others. Rather predictably, however, I’ve slipped back into the pit, though fortunately not too terribly far. I have every expectation that things will look bright again before too long. I even have hope of feeling connected, once more, with the cosmic resonance that I feel at my calmest times, especially when surrounded by arrow-straight pine trees and dozens of birds, whose clicking, chirping and trills remind me of God’s voice.

This is another addition to the ongoing conversation between me and Marian at Different Thoughts.

Believe me when I say that it pleases me to the core to know that you have attained a place of peace and connection with the central currents of creation. I am very happy that you have found your suffering to be a path to such a healthy and profound axis. I do know of St. John of the Cross and believe wholeheartedly in the concept of suffering leading to wisdom. At my best, I have found myself in such a state of grace.

Unfortunately, I am not there right now. It has been an impossible condition to maintain, as you said. Right now, the suffering just feels tiresome. I experience the world as a place that doesn’t fit my psyche, like I should have been born on a different planet. I’ve been trying meditation, retreats, groups, reading spiritual books, attending mystical services, hanging around people with values I respect, finding those who believe in deeper realities. Yet that state of grace is outside my reach, for now. I don’t mind that, because I don’t expect life to always be bliss. But I do get very exhausted having no energy and no enjoyment. That is the feeling the pills reduce.

I don’t like the medications. I think they are my enemy. But one way or the other, my brain is now adapted to them, and the pain (withdrawal symptoms?) I feel when I cut back too quickly gets to be too much if it goes on for more than a month or so. That’s when I raise the dose again, in order to catch my breath before the next attempt at reduction.

But for my part the drugs do not feel deadening. The antipsychotics did, but not the antidepressants or the mood stabilizers. They just don’t have an effect on my sense of reality that I can detect, except that they take away the experience of my days as exercises in pointless pain. I am not talking here about existential suffering, awareness of the aching heart of human tragedy, or connection with the streams of sorrow that run like lifeblood through the history of humanity. I am talking about dull, meaningless pain that I get sick of and can reduce with a chemical. Am I happy about needing to do that? NO. Do I feel weak for resorting to the pills? Sometimes. But I do what seems like the right thing for me, for now.

At the same time, I don’t believe the medications block me from spiritual awakening, or connection with divine consciousness. Our brains are biological. I suspect there is a non-material spirit too, but the organic matrices of our brain play at least a large role in our experience. If you add a foreign chemical you alter the biology, but you do not change the brain into something entirely new. I don’t think every chemical has the effect of blocking spiritual growth, though some might. I have not found the drugs to be a barrier to spiritual connection. In fact, my peak spiritual experience in life, which far transcended anything else that’s ever happened to me, and was very similar to what the saints describe, actually occurred while I was on Effexor and Depakote. I don’t think those drugs did anything to cause my epiphany, of course, but they did not prevent it either.

It is also important to remember that some spiritual traditions actually employ chemicals to foster spiritual enlightenment. Even the Roman Catholic church incorporates wine in its services. I know, at present the little sip of wine at communion is purely symbolic. I strongly suspect, however, that the early church founders did some actual drinking as part of their rites.

My point is still the same: each person is unique, and every path is different. I am relying on chemicals right now because I am trying to make my transition off the drugs without killing myself or making my wife miserable. And yet, I have had many days (not very recently, but not all that long ago, either) when my spiritual state was such that everything made sense and suffering became irrelevant: I was on a higher plane. I know that condition exists, but I can’t be there all the time, and as long as I’m living an ordinary existence I want to try to enjoy it.

I am glad that you have found your way to union with the grand consciousness. I fully respect that for you that has meant clearing your brain of pharmaceuticals.

Not everyone can reach union, whether they take medications or stop them. And for those that do, not everyone will do so the same way. There are many paths to God. For some, drugs may slam the door. For others, they may open it. For me, they do neither. My path to the heart of creation is open sometimes, and closed others, without regard to how much medication I’m on. It may have to do with lunar cycles, or simply with some variable rhythms in my body. Or perhaps I just try harder sometimes than others. But I am absolutely convinced that it is possible to get there now, or at least sometime not too long from now, and I don’t need to wait until every last psychiatric medication is out of my system.

Please understand that my ultimate goal is to be drug-free. So I embrace your philosophy on its basic level. However, I am not sure if I will ever achieve total freedom from psychoactive agents. It would be very discouraging if I thought that I would never experience God as a result. Fortunately, I know that to be false. I have before and will again experience the divine touch; I will feel in my innermost self the purpose, beauty, and power of suffering. In the meantime, I choose to live my life with a little less of the dreary kind of pain that is about as enlightening as pounding my thumb with a hammer.

Since I already carried a burden of hostility toward the system for how medications damaged my life and my body, the rejection propelled me into a belief that I should be an activist from without, rather than a clinician on the inside trying to do a better job. Problem is, I’ve never been an activist before, having mostly done safe (though long and tedious things) like go to medical school and become a surgeon. But at least I like to write, and apparently one can accomplish a lot just by putting ideas on paper. ‘Activism’ doesn’t only mean I have to get out and hit the streets.

What is happening, however, is that I am being pushed into a more extreme position than that from which I started. I’d like to think medications are not all bad. I do believe they have a role in acute situations. It’s just that as chronic treatments, they suck. Side effects and destruction to health build up, and efficacy diminishes. In the end one gets stuck in my position, having a really hard time getting off the drugs because my brain has gotten habituated (read: addicted) to them. Yet, the more I read, the more I wonder how much the benefits outweigh the hazards. While some small number of acutely psychotic people will perhaps always need some medication, most likely the majority of  ’patients’ could be treated better with kindness, cognitive techniques, and comprehensive attention to their spiritual and physical health. This is the kind of approach I believe Tom Wootton’s Bipolar Advantage is advocating. Maybe we have enough medications for now. Maybe the whole endeavor (and highly profitable industry) of looking for and marketing new drugs needs to be shelved. These are questions that I can’t answer right now. Not for myself and certainly not for others. But I do see my attitudes becoming more and more opposed to the medical model and psychiatric drugs. This wouldn’t be occurring if I was on my way to becoming a psychiatrist.

My biggest question is: would I have been able to make more difference as a clinician? Would helping dozens, or hundreds, of patients get (what I consider) appropriate treatment be more valuable than writing? The point is mostly moot, of course, since I don’t have a door into the field. On the other hand, I could reapply (to programs that don’t already know me) without being so revealing about my psychiatric history. Yet, all I’ve read since I entered the (badly named) blogosphere convinces me I’m better off not going into the field. Marian makes a persuasive argument about the compromises that one inevitably makes in the course of entering any kind of organization. Plus, if I could bring myself to get my whole story out (I’m still hesitant to reveal the worst of it), it might attract some attention and really increase awareness. It would require a lot of work, and that much effort might be beyond me (not to mention the requisite compelling writing style). It is an idea for the future. For now I am just exploring options, writing my blog, and commenting on the blogs of others.

I never wanted any of this. Although I once had dreams of glory, more recently my ambition has just been to settle down as a happy worker bee, productive and comfortable. Unfortunately for those modest dreams, however, my past has caught up with me. My only choice seems to be to tell my stories and comment on the messed-up systems of psychiatric care. That puts me out in public view, where the way to be successful is to try to be as visible as possible. So now the question becomes, once again, how successful do I want to be? Especially knowing that the price of success is exiting my comfort zone and losing my anonymity?

Which brings up the whole question of obligation. Having learned medicine formally, a lot of psychiatry informally, and possessing a pretty good understanding of cellular neurophysiology, I certainly can speak with an authoritative voice about the medical implications of modern mental health care. Add to that how I’ve suffered really horrible side effects and lost a decade of my life  to mental illness-related disability (which might not have happened if I’d not been given so many medications), can I justifiably stand by and not speak out? Can I actually, in good conscience, let this go on without trying to make a difference? Painful questions for someone who just wanted life to get easy.

Forgive me for using this website as a chalkboard for sketching out a future strategy and a guiding philosophy. I am learning a lot from your blogs and your comments, and look forward to a lively and productive conversation.

On the other hand, I believe starting medication for my mood issues was a mistake. I would never have begun psychiatric drugs if without unshakable faith in my therapist at the time. Yet my life now seems to revolve around pills. I take six different medications for various aspects of my mental health. A year ago I was on seven. Currently I am in a pitched battle aimed at trying to reduce my medication load. The war is not going well.

Case in point: I have been on SSRIs (selective serotonin reuptake inhibitors) for almost fifteen years. Currently I take duloxetine (Cymbalta) which increases synaptic norepinephrine in addition to serotonin. I have been working hard to reduce my dose of this drug. A year ago I took 120 mg each day. About six weeks ago I took my latest step down, and limited myself to 20 mg per day.

It has been a rough six weeks. I find myself saying things like, “if someone told me I only had five minutes to live, I’d be upset: I wouldn’t be able to say goodbye to my wife and dogs. But if they gave me an hour, I’d be fine with it.” Or words to that effect. Not a very positive outlook, is it? For the most part, I haven’t been bothered by the melancholy, since one of my projects this year has been to learn to tolerate adverse moods more. After six weeks of feeling like life is nothing but a chore, however, I broke down and went back up to 40 mg. I just got tired of the dreariness, and it did not seem to be going away. So today I increased the dose. No doubt my mood will improve, but I hate to retreat in this way. I feel trapped by my body’s habituation (addiction?) to these medications.

My psychiatrist says she could switch me to fluoxetine (Prozac); it has a longer half-life and comes in smaller dosage forms. So it would make for an easier taper. The problem is, I’d be left anorgasmic. Ever since I started SSRIs my sexual sensations have been diminished. Cymbalta at least wears off quickly, so I can stop it 48 hours before sex and things feel mostly normal. If I go back to Prozac, I won’t have that option. So I hesitate to travel that route. I don’t want to give up something that brings me joy, at least not when I my life already feels so ‘blah’.

Like I said, a well-meaning therapist convinced me to start psychiatric medications back in 1995, after I had spent the previous 20 years refusing them on the grounds that they had not helped my mother. (She died in a mental hospital in 1964, after years of psychiatric medication and shock therapy.) Since I had benefitted a lot from this therapist’s help, I took her advice. I did well on Prozac (and lithium) for several months, but then became depressed again. So the dosage was increased. Later, more drugs were added. Then yet more again to deal with side effects. That has been the story of my life ever since: transient improvement, followed by increased need for drugs. It is hard not to conclude I’d be better off without any of it. Not to mention that I’d have a more normal sex life.

So even though I extend apologies to all the hard-working therapists out there, I still end on the same note as last time: I wish I had exercised more caution, kept my own counsel, and pursued less therapy.

Insomnia? Depression? Anxiety? Soon, you will be able to turn on your computer and learn how to work with these problems.

Widely recognized as effective, Cognitive Behavioral Therapy (CBT) has been demonstrated experimentally to improve emotional health. The theory behind CBT, as most people involved in mental health care (whether clients or providers) understand, is that you can change how you feel by changing how you think. Leaving aside the question of whether you should change how you feel (I’ll deal with that in a later post), if you learn the techniques, they seem to work. At least they did for me. I learned to cut my depression and anxiety in half, easily. I also started sleeping better, just by not driving myself nuts with worry. Good stuff!

It’s called ‘therapy’, but is it? In truth, it is a set of methods for working with thought to keep it from wrecking your life. Person-to-person ‘therapy’ is not absolutely necessary. I got most of what I needed from a book or two, and you can search Amazon to find any number of texts on the subject. (They all look about the same to me.)

So how about learning the techniques from a computer?

I was not surprised to find out this is already possible. I came across one article about an internet-based protocol for teaching CBT techniques to manage insomnia.

I am not a big fan of therapy, even though (or because) I have undergone more than 20 years of weekly sessions. In truth, I have found it almost as often harmful as helpful. Maybe someone with a good, strong sense of identity and purpose could visit a well-skilled and careful therapist and do really well. At my best, and with the best therapists, that has been my experience. The problem has been that usually by the time I’ve stumbled into therapy I’ve been pretty well crushed emotionally. Desperate for guidance and support, I have given my counselors far too much control over my decisions. Later on, when I’ve felt better, too often the choices made under a therapist’s influence look like his or her choices, not mine. His or her values shine through, and mine get obscured.

Maybe a computer therapist would have been safer. I would not have leaned on a computer for support in the same way. I could have just learned the techniques, and relied on my own personality for courage and strategy. Given the never-ending effort by insurance companies to reduce mental health expenses, it is safe to assume that this method of delivery will become widespread. As much as I think psychiatry services should be covered by health plans, perhaps it would not be a terrible thing if some of the care came from silicon circuitry rather than the neuronal networks of a (fallible and corruptible) human brain.

I like people. There is no substitute for the warmth and support of another human being. But paying a therapist to guide me through life has not always worked well. I would not have become a doctor and a surgeon had it not been for a therapist who vehemently encouraged me to look for the highest paying job within my reach. Without those choices, I might not have damaged my neck by leaning over an operating table four days a week. I might not have lost my career at age 42, and might not have had a nervous breakdown. Who knows how my life would have gone? There’s little benefit to thinking about ‘what if..,’ but obviously therapists with poor boundaries can push vulnerable clients in directions that may prove disastrous.

The crucial decision about my career direction should have been made by me under the influence of family and friends. A person paid to help me (especially one who later admitted he was a cocaine addict and alcoholic) should not have been the one to choose. I was too young and emotionally weakened to understand how vital it was to make my own choices, and I allowed myself to be swayed away from my heart’s native desire (to study nature and ecology).

So I applaud the development of computer systems to teach mental health techniques. Psychotherapy can be helpful, but sometimes it is better to let people find strength and solutions on their own. Therapy should be a tool, not a crutch.

Amanda (my wife) and I spend part of our time in the mountains, and part in the city. We go back and forth regularly. This morning we head back to town.

I hate going back. It would be easy to live up here full-time. I’d like to. Ultimately, and not long from now, we’ll need to choose one or the other. I choose here.

Amanda worries about me, however, and my occasional need to be close to doctors. She had a dream last night that showed that: we were about to jump a car across a ravine. She did not think it could make it. I ‘floated’ ahead to show her it was OK. Halfway across I plummeted to the floor of the canyon, and all she could hear was faint whimpering. A pretty clear message?

It’s tough having an illness of any kind. Between my bipolar disorder and my neck issues, I used to need doctors a lot. Right now I don’t, and I’d love nothing more than to get away from them for good. I see no advantage in living near ‘advanced’ medical care. My body has been badly damaged by medications. My father probably died as a result of a medical error. My mother had severe depression in the early 1960′s, and they treated here with valium, barbiturates, and shock therapy. Probably she had tricyclic antidepressants, too, but all she did was get worse and worse and die anyway. As a six-year-old, I was convinced that the treatments were bad for her. I still hold that view.

But what if my neck worsens, and I need intensive care just for daily life? Or if I get so depressed I need partial or full hospitalization? (As much as I am skeptical such a thing would help, sometimes it is reassuring to loved ones.) When here in the mountains, we are an hour from the nearest hospital, and almost two from the HMO of our choice. As people who have lived our whole lives in urban areas, we find it hard to imagine living so far from services. Yet I see people dwelling all around us up here in the mountains, and some of them are quite elderly. If they can do it, why can’t we?

You have to listen to your spouse’s dreams, however; both the dreams for the future she or he has by day, and the terrors by night. I hate feeling like my fate is in the hands of illnesses I can’t control. I’m not giving up on the move, but there probably needs to be a compromise here. Right now, the answer is not clear. I have made some catastrophic decisions in the past, and I don’t want to repeat the mistake of acting on poorly conceived impulse. On the other hand, my heart yearns to live in the forest.

Years later, we now know that the SSRIs do not exceed the older drugs in effectiveness. Compared with ‘tricyclics’ (the older antidepressants), drugs like Prozac have different side effects, but not fewer. Perhaps the only real advantage of SSRIs in treating depression is that they don’t kill you if you take too many. Tricyclics are notoriously lethal in overdose.

So the dust has settled, and SSRIs no longer look like wonder drugs. Worse (from the standpoint of the drug companies) most of the patents of the original SSRIs have expired (long acting preparations and other alterations may still be available only in branded forms). So the pharmaceutical industry needed to move on to something new.

Enter the ‘atypical antipsychotics.’ They are ‘atypical’ because they work differently from the old antipsychotics. The old drugs were essentially dopamine blockers. The class had been discovered because of an herbal folk remedy for insanity, from which a very effective anti psychosis drug was isolated. It turned out that it worked by blocking the effects of dopamine in the body. This led to the ‘dopamine hypothesis,’ which postulated that schizophrenia results from excess dopamine. That idea was eventually proven too simplistic, though there is little doubt that dopamine is one of the neurotransmitters that goes awry in psychotic illnesses.

Atypicals, however, are less specific for dopamine than the older drugs, having widespread effects on serotonin and other neurotransmitters. (They also may be more discriminating in which of the body’s several types of dopamine receptors they target.) The prototype was clozapine (Clozaril), which had tremendous antipsychotic activity, but life-threatening side effects. Working from the structure of clozapine, researchers created the other atypical agents. These include: olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), and risperidone (Risperdal).

Unfortunately, I have taken all of them (except clozapine) at one time or another. I have had only one episode of so-called psychosis, which was relatively short-lived, but the psychiatrist who followed me during that period continued the atypical antipsychotics long after my spiritual euphoria had resolved (religious ‘delusions’ and ‘hallucinations’ were my only psychotic symptoms). She continued the atypicals because the drug companies started promoting these agents for mood disorders. The pharmaceutical manufacturers first succeeded in expanding the scope of the agents for non-psychotic mania. Eventually, they began touting them as helpful augments in intractable depression. These potent ant highly toxic agents are being used more and more for such reasons (Abilify, in particular, gets promoted for this purpose).

When I took them, they mainly felt like strong sedatives. Sure, they helped with agitation. They made me feel like I’d been hit with a hammer.

Problem was, they had terrible side effects. Well-known problems include incredible weight gain, increased cholesterol, and diabetes. I got the first two, and was well on my way to the third by the time I finally quit the drugs. There are other side effects, it turns out, when these drugs are used in combination with different classes of psychiatric medications. I won’t go into detail right now, because I am still getting up the nerve to talk about how these drugs have harmed me: it is a very sensitive subject for me.

My point right now, however, is that these are hazardous drugs. Their side effects are far more dangerous than, say, those of the SSRIs. Given the escalating epidemic of obesity and ‘metabolic syndrome’ in this country, we really should question whether these drugs are good choices when so many people already have trouble controlling their weight. Especially since the evidence for the effectiveness of atypicals for mood disorders is not all that convincing.

Addendum:
Here is a link to a good site to check out if you want to know more about the controversies surrounding atypical antipsychotics. I also just came across an article about the problems with big Pharma and atypicals (with reference to a recent major legal settlement involving Zyprexa) on HuffPost by Dr. LLoyd I. Sederer. My thanks to Liz Spikol for her The Trouble With Spikol blog post summarizing the article.

What really matters to me is mental health, and especially how professional services attempt to get us there. I’ve had both positive and negative experiences with medication and therapy. Both have helped me, but both have also caused some grievous harm. I’m interested in hearing what others have experienced. I’d like to know your horror story, and/or how a therapist or medication has changed your life for the better. As time goes on, I will share my own tales of disaster and delight.

Please join me as I explore the treatments meted out by the mental health system. I am tired of being treated as a ‘patient,’ or even a ‘client’ or ‘consumer.’ I don’t like being put in a separate category from those who are supposed to be helping me, but often that seems to be exactly what happens. I am a person like any other, and capable of solving my own problems with a little assistance.

Too often ‘the system’ wants to take over and dictate what is wrong with us and what we are capable of. But the fact is that psychiatric science remains primitive, with little if any predictive power. If any one of us wants, we can exceed the expectations the system tries to hand us. I just wish we heard that truth more often from those who are supposed to be guiding us. I wish they more often had the humility to let us know they lack answers.

That’s just a small taste of my frustration. I’d really like to hear yours.