The Trouble With Spikol: Print Edition
This one is especially relevant to this site, so I’m posting it all below, so as to force you to read it. [In hypnotist's voice] YOU MUST READ IT…
Last week the House of Representatives passed the Paul Wellstone Mental Health and Addiction Equity Act, a parity bill that would require insurance companies to cover mental illness and addiction the same way they cover physical conditions.
Sounds good, right? But it’s not all pinwheels and lollipops.
The bill, sponsored by Patrick Kennedy, faces competition from a Senate parity bill passed last fall. That bill—sponsored by Patrick’s dad, Sen. Edward Kennedy—was far less expansive (read: popular with insurance companies and more Republicans). Now there’s going to have to be some compromise, and I’m guessing it won’t come on the part of Eli Lilly or Aetna.
Should a mental health parity bill actually become law, it’ll be a bittersweet victory. By equating mental illnesses with physical illnesses—apparently a necessity in order to get access to healthcare—we run the risk of furthering the so-called “medical model” of psychiatry, which tells us that mental illnesses are biological illnesses whose primary remedy lies in medication.
Don’t misunderstand me. I love my meds. And for many years I used the “chemical imbalance” tag as a sort of talisman to protect me from people who might believe my psychosis and depression were a result of a character weakness.
I didn’t want it to be my fault. I wanted it to be my brain.
But over the years I’ve become frustrated by the system’s reliance on the medical model. Its dominance eliminates so many possibilities—not only for diagnosis but for treatment. For those of us in recovery from mental illness—those of us living fulfilling lives despite the struggle—the primacy of biological psychiatry feels restrictive.
I don’t need to tell you that pharmaceutical companies have a serious investment in the medical model. And they make a persuasive case to the public.
The FDA gave pharmaceutical companies the go-ahead to do TV advertisements in 1997, and since then we’ve become accustomed to the ridiculously self-parodic prime-time ads—those featuring an unshowered person who’s suddenly romping through fields like a Bollywood star after taking a pill that just happens to have an unbelievable list of side effects. Such ads are allowed only here and in New Zealand.
The claims made on these highly influential ads are often misleading or flat-out false. An important study released a couple weeks ago in the journal PLoS Medicine evaluated the effectiveness of four antidepressants—Prozac, Effexor, Serzone and Paxil—in more than 5,000 people. The study’s authors found these drugs were no more effective than placebos for treating mild to moderate depression. Yet antidepressants are the most prescribed drugs in the U.S. There were 118 million prescriptions written for them in 2005.
Studies like this one tell us we must find other ways to feel better. And lucky for us, there are plenty of options, which is perhaps the best reason of all to shift away from the exclusivity of the medical model. In his fascinating new book Comfortably Numb: How Psychiatry Is Medicating a Nation, Yale psychiatry lecturer Charles Barber, who worked for many years as a public health provider, quotes the American Family Physician, the Archives of General Psychiatry and the American Journal of Psychiatry to support his claim that cognitive behavior therapy can be just as effective as antidepressants in treating depression.
Barber also points to progressive approaches in other countries. In 2004 the U.K.’s National Institute for Health and Clinical Excellence (NICE) issued “Clinical Guidelines for Depression,” which Barber cites in his book. They are: 1) sleep and anxiety management, 2) watchful waiting, 3) exercise, 4) guided self-help and 5) cognitive behavioral therapy.
As for antidepressants, NICE suggests them only as a last resort, “not recommended for initial treatment of mild depression because the risk-benefit ratio is poor.”
Those risks are often minimized. Side effects aren’t just irritations to be endured briefly and then surmounted. They can be intense and debilitating, and there can be long-term impact. For severe mental illnesses—like schizophrenia, bipolar disorder and major depression—it’s fair to say medications are generally a necessity. But I’ve only recently come to understand that the greatest tragedy of these illnesses can be their cure.
And meds can’t work alone. I asked Barber about that in an email. He wrote: “What we’ve overlooked, in our simple-minded impatient-for-the-quick-fix fashion, is that recovery—even when it involves medication—occurs over time and in a social context. Relationships matter. Families matter. Doctor-patient relationships matter. Recovering patients will tell you that they get better (and get worse) under the influence of and in connection to other people.”
If that’s so—and I believe it is—the notion of what mental illness is must not be hogtied by an equation with biology.
Just a few days before the parity bill passed the House, another decision was made in the halls of power: The FDA gave Wyeth approval to make a new antidepressant that’s a variant of Effexor. Wyeth loses its patent on Effexor in two years, so it created a chemical mix, Pristiq, that’s almost indistinguishable from the original product. The New York Times quoted psychiatrist Daniel Carlat as saying, “Is there a compelling public health reason for Wyeth to be releasing another antidepressant into the market, with no clear advantages over others? Not that I can see.”
By the time Pristiq hits the shelves, we may have a parity bill to pay for it. I’m just not sure we’ll want to buy it.
[illustration by the awesome Alex Fine]
liz | 10:04 AM | Uncategorized
Wow, Liz, this entry was worth waiting for. Let’s just hope it’s not too late for those of us diagnosed with mental illness to avoid forcible intoxication with drugs that will make us dangerous.
Liz,
Here is a link regarding a petition for drug ads to place a 1-800 number in there ad to report side effects of medications to the FDA.
They need 50,000 signatures by the end of the month!
https://secure.consumersunion.org/site/SPageServer?pagename=Rx_Drug_Ads_Petition&JServSessionIdr005=bpc74k92e1.app46a
Link?
Mental health care is about a lot more than the few antidepressants from that antipsych meta-analysis that were turned into a straw man. The medical model does include CBT, supported housing, and more holistic care – at least in other countries.
Great post.
But it occurs to me that you may be on to yet another way that parity makes sense.
Because the drug companies aren’t just overselling us on antidepresseants — they’re overselling us on just about everything, from drugs that lower our cholesterol without necessarily having any effect on our actual heart risks to drugs that treat symptoms the ads are there to help us recognize.
Those clinical guidelines for depression — especially exercise and watchful waiting — probably work just as well for things like irritable bowel and a host of other physical ailments Americans spend millions trying to cure.
No, talking and listening probably won’t cure cancer, any more than therapy alone will cure schizophrenia.
But what could they hurt?
Dearest Liz:
I just love these good news/bad news stories {laughing}. You start to think things will get better, and then next thing you know you’re grabbing your ankles and wondering why you’re being spanked so hard and hearing the snap of the latex gloves in the background. Then after some extensive mind recovery time, some calming conversation from the CIA genetically altered Penguins, and the all mighty Mother Ship; you realize it’s the same old story! Just follow the money aka the real political influence {is that my face turning green and grey/orange brain matter/substance leaking out my ears; or is it the latest treatment for Bipolar that the FDA fast tracked. What the heck might as well to the Lobbyist pharmacological Limbo dance across the Congressional floor anywise WOO HOO}.
I love the medical Model {pulls the barf bucket close just in case I have a legitimacy moment, or need to hug from inanimate object that cares* snicker*}. Especially since they have no idea what they are treating in reality with mood disorders {always the same old perfect deflection statement “chemical imbalance of brain chemistry” I believe this one came up just after dunking and them blaming it on demon possession}. They just treat symptoms, not the actual disorder per say. Let’s not give those avid script writers with a Big MD by their God like names more credit than they deserve now{ Hope My PDoc reads this one *laughing and humility are good things* checking to see if I didn’t blow a kidney out on that one*}.
As I speak/write about medical parity/equality for mental health issues within the whole of the health care debauchcal. I always refer to a much needed change/overhaul in mental health care system.
I’m envisioning a more all inclusive/ holistic model that includes social support systems, therapy, job and educational support, some recreational outlets, Basics like housing and food, and if appropriate medication that proves effective in allowing functionality without creating a walking zombie state emotionally and physically! I call it “ONE STOP MENTAL HEATH SHOPPING” { wonders in paranoia if Wal-Mart will steal that one?* snicker*} Unfortunately the model used today basically ignores the psychosocial component; which may be the most important factor in creating wellness for those that wrestle with mood disorders. As I have written before here! We need to stop a wasteful money train rolling down the tracks in the wrong direct, and empower those with mental health issues to have viable and realistic options available to them. When is either party going to stop taking the dirty/partiality money train to fund zillion dollar re-election campaigns; and actually serve the people they have taken a solemn pledge to do as our representatives? I always try to stay hopeful and look for the bright positive light at the end of the tunnel. But in this case that light is just another speeding train coming down the tracks straight at me with horns blowing and I’m standing here frozen in my tracks {I guess you would call this one of those perilous and capacious moments when you should either check for clean underwear as mom warned you, or be wearing Super Spiderman decorated “Depends” for active adults (Chuckling)}.
In ending this trivial comment! I do believe you wrote an excellent article Liz, and I agree with you on the overwhelming and vast majority of the content.
I also got that new Radiohead CD and like it very much {I hope your getting royalties from them to help with your ice cream fund *laughing*}. Of course I’m more of a jazz type person. But I’m also pretty eclectic in musically taste and have been listening to Radiohead for years. I think they may very well be one of the most influential and talented groups out there today.
Yours truly:
Stan
A very thoughtful article, and one that I find accords well with my own experience.
I was diagnosed with a range of issues two years ago; major depression, attention deficit disorder, and non-respiratory sleep apnea. I still suffer severe insomnia. For the last 18 months I’ve been taking Wellbutrin XL, Adderall XR, and different formulations of Zolpidem as needed.
While I have no doubt the medications have helped me, I have also found that the addition of marriage counseling and individual psychotherapy has made a significant difference in my life. I do not believe the medication alone would have resulted in the improvements in my mood and mental state. Psychotherapy has definitely been an important part of my improvement as well.
I teach in the University of California system, and one of my courses is an introductory physiological psychology class; I am keenly aware of the power of our biology on our behavior. Yet, as Konrad Lorenz most cleverly showed, we are not simply products of our physiology. The environment we live in also has powerful effects on us, and as we are by definition social animals, I don’t see how those in the mental health profession can deny the effect that social relationships and support have on our mental well-being.
Paul D. Thiem, PhD
Yes, the seemingly humane notion of parity has a dark side. If all we are doing is allowing more access to a broken system, we are not really fixing the problem. Liz, I want to ask you to please be careful with statements such as: “For severe mental illnesses—like schizophrenia, bipolar disorder and major depression—it’s fair to say medications are generally a necessity.” I see that you used the word “generally” probably to allow for exceptions to this rule, but the word “necessity” is somewhat dangerous. As a society, we have to get over the myth that people diagnosed with schizophrenia and bipolar disorder cannot live meaningful lives without medication. There is plenty of rock-hard science to support otherwise, plus countless ex-patients – myself included – who are demonstrating that it is possible. However, as long as the public believes that medications are a “necessity,” they are less likely to react to and advocate against the mistreatment and oppression of people with major diagnoses who receive services. And heaven knows we need to start creating various options as opposed to simply offering powerful antipsychotics and so-called mood-stabilizers. Thanks for reading this!
As usual Liz makes excellent points. Unfortunately, I doubt they will receive the consideration they deserve. While parity will afford more persons the opportunity to access treatment, will anyone consider the nature, timing, and extent of that treatment or the outcomes it is likely to engender? Perhaps, in a few years some scholar will study the impact of parity on America’s mental health, perhaps not. There is little institutional memory in the mental health system and sans accountability systems rarely improve.
At one of our community mental health centers of the approximately 2,500 patients receiving outpatient treatment 2,000 (80%) find treatment in its entirety is only medication. This is a far cry from the comprehensive, recovery & wellness based care so frequently represented. Where medication is but one tool and increasingly a tool whose long claimed benefits are increasingly suspect and detriments were only recently disclosed, we have every reason to be concerned about how this potential mental health “victory” will play out.
It will be interesting to see if the number of individuals on SSI and/or SSD by virtue of a mental illness continues its rapid increase. After all, parity by reducing economic barriers allows for early identification and treatment. This is supposed to result in better outcomes. If it doesn’t we should remember that this parity legislation doesn’t apply to those on Medicare and/or Medicaid.
Dysfunctional systems repeatedly look to the promise rather then the reality which follows.
Liz -
Joe’s comments about 80% of patients at community mental health centers getting medication only are a sad commentary. It would be a disaster if cut-and-dry pill prescriptions became the only recourse for mental illness – I had one health plan where medication management was the only function allowed for psychiatrists. We can’t allow that.
On the other hand, the medical model is getting abuse it doesn’t deserve. It’s not only about drugs and brain chemistry. It encourages – and health insurance often pays for – therapy and a wide range of treatments besides medication – when it’s properly incorporated into a comprehensive health plan. While the drug companies do promote the neurotransmitter- amine myth, as Peter Kramer calls it, as if it were truth, the research on brain chemistry is much more complicated and offers the best evidence for looking beyond the commercial nonsense of pills curing mood disorders.
We can’t get to be anti-science because the drug companies are corrupting both the forms of treatment and research itself. We need to fight for reforms to control the influence of money in health the way we fight for reforms (OK, usually in vain!) to control the influence of money on the electoral process. And we need to fight for parity in the way health insurance pays for treatment of mental illness, provided parity doesn’t mean pills only. Liz, I think you’ve got the right balance of caution and commitment to action in your piece. Thanks for highlighting this issue.
John D
I was thrust into the mental health system due to my daughter’s suffering that started about 4 years ago. My previously stable, non-moody, dependable daughter fell into a deep depression around age 13. She started out as a caring & loving sister and daughter who was pretty amazing! She is now a shell of her former self….I do not say that easily. It was as if the child I had known was taken and this new child was left in her place. My daughter’s illness came on quickly and I almost don’t recognize the child that is left here in our home. The issues that she deals with are due to the fallout of whatever is happening inside my daughter’s brain/body. Thankfully she was responded to Lithium and it has helped her to regain some of her self. She also goes to weekly therapy sessions. I cannot believe that what my daughter is going through is NOT medical. This is something that I am so confused about when I read blogs about mental health issues. Do people think that bipolar disorder is something that should be treated only with therapy? I am confused when people talk about forced medication. What is this really about? Please help me to understand as I see the medications as helpful, almost like a life raft during the dark storm. Why am I the in the minority on this issue?
As for parity, I for one, would be able to swallow that terrible taste in my mouth after I learn that my daughter’s therapy sessions AND her med managment appointments would be covered after 30 visits. It sickens me that the insurance companies can legislate my familiy’s health care. It is hard enough to deal with the hardships of mental illness but the entire insurance system is broke and I feel so angry about the struggle to get the insurance to cover her medical appointments. I wouldn’t feel so badly about the therapy capitation, but they limit visits with her psychiatrist for her medication checks! They would never legislate that for diabetes, AIDS or cancer.
This is such a thoughtful and well-balanced article that I think it should be of interest to almost anyone who cares very much about mental health care in the United States, or elsewhere. One of the worst things about the current dominant treatment model is that it offers so little choice and so few options for people seeking help, especially if they don’t have a lot of money or fairly good insurance. I know that many people benefit from the medications they take, and depend on them, but I think it should always be the choice of the person taking them, and they should have more alternatives available.
The example that Joe cites of 80% of the patients at one particular community mental health center being offered nothing but medication is probably fairly representative of public mental health treatment throughout the entire United States. Alternative treatments that have worked well in years gone by have been defunded because of the belief in the halls of power that only biologically based treatment can work.
I think there is an inherent hypocrisy in the medical model as it is applied to mental health treatment in that diagnoses of non-infectious diseases almost never are considered as justification for forcing treatment on someone in any other field of medicine. Even in regards to life-threatening diseases, like cancer for example, people aren’t forced to have treatment if they don’t want it. I believe that many of the people suffering from mental health-related problems who refuse treatment do so not because they are unaware that they have problems, but just because the treatment options available to them are so limited and bad – there is probably no other area of modern medicine where the treatment is so likely to be worse than the malady.
That online petition linked to in a previous comment is asking only that drug company TV ads be required to include a toll-free phone number and web address where people can report side effects or other problems with the drugs they take. It is not to stop anyone from taking drugs that might help them, but just so that more information can be gathered on what side effects can occur. If it doesn’t get the needed 50,000 signatures by the deadline, I guess that idea will probably just die.
Personally I can relate a lot to the statements by Charles Barber about relationships making a difference – in ways that are both good and bad. I see a lot of relevance in his statement: “Recovering patients will tell you that they get better (and get worse) under the influence of and in connection to other people” – particularly in regards to family relationships. I have found that the influence of some family members can be so consistently negative that the best thing to do is to just avoid as much as possible having anything to do with them, while the influence of other family members can be very positive and a great aid to mental health.
Liz,
You’re a good writer. Every so often you hit one out of the park and I always take great delight in reminding you that you’ve done it again. This entry is at least a triple, probably a homer. Good work.
Sandy,
I’m so sorry to hear what you’re going through. And glad to hear your daughter is responding well to the lithium. I think part of the confusion you’re experiencing is that meds are oversold. For the few people for whom they work well, they are a godsend. But the fact is, they really only seem (to many of us) to work well for only a few. And many of the newer drugs, especially, work well for a while and then poop out.
But the ads and mainstream press, combined with remarks I hear in general conversation, would have me believe that psych drugs are mental health penicillin. Not so. And, just as some people are allergic to penicillin, some people find the side effects of psych drugs (about which we are typically NOT informed by our doctors) intolerable or simply too dangerous.
So we go off them. And yes, we often feel betrayed, which tends to make a body angry and no doubt lends a sharp edge to our conversation.
When someone cannot take penicillin, no one blames them. But if you refuse psych meds, anything that happens after that is your fault. It’s a blame game and many of us who are actually getting better outside the system know it well. Part of the problem is that, unlike people allergic to penicillin, we’re not sporting rashes; our risk-benefit analysis often involves factors invisible to others. Part of the problem is the *massive* amounts of money at stake. And a large part of the problem is the continuing stigma of mental illness–once you have that label slapped on you, you lose your voice, you lose all credibility. That makes me angry and definitely lends a sharp edge to *my* conversation at times.
In the end, my feeling is if the drugs were all that helpful and benign, people wouldn’t be going off them wholesale. And I’m tired of people being blamed for everything that happens to them because “he/she went off his/her meds”–as if the meds are a Big Cure. If they were nearly as big a cure as they’re oversold to be, we’d have wiped out mental illness.
Sandy, you know your daughter best. Listen to her, listen to your guts. Do your best to tease out what’s her depression and what’s the normal insanity of adolescence in a basically crazy culture. I hope she continues to respond to treatment, no matter what that is. Keep reading, keep thinking.
Best wishes,
Sherry
PS: Forgot to mention that Alex Fine, whoever he/she is, is indeed awesome. Great illustration!
Liz:
Congratulations on the New York Times article!!!
I cannot possibly, possibly disagree more with your commenter Mr. Morgan about the lack of need for medication for serious mental illness.
He says we can live “meaningful” lives without lithium or other similar drugs for bipolar disorder, or anti-psychotics for schizophrenia. All these drugs have profound side effects, yes — I’ve experienced many of them personally.
But his definition of “meaningful” without drugs seems, by his own literature, to indicate some sort of assisted living facility, with the help of health aides and family. And as Kent (no fan of medication) pointed out, the influence of family, so critical to a patient’s recovery, is often profoundly negative due to stigma and past relationship difficulties.
Lithium (and Lamictal) are what allow me to live independently, period. And a non-independent life — when the treatments to assure otherwise exist — hardly seems “meaningful” to me. In fact, Dr. Kevorkian would seem an appealing option. (And I refer to the infamous death doctor from Michigan in full knowledge I am a consumer myself and am in an audience of consumers.)
I am also deeply disturbed that worry many of your posters, not just Mr. Morgan, unthinkingly accept Charles Barber’s “medication is bad” line, primarily based on his own personal life. Barber’s diagnosis was OCD, a profoundly different disease from unipolar depression, let alone bipolar disorder and schizophrenia. And it strikes me he has unfairly projected his OCD experience, harrowing though it was, onto a spectrum of diseases he has no knowledge of.
His tossed-off, profoundly insincere in tone, “Well, I guess you need medicine for serious mental health conditions” goes begging to be ignored. And if that in fact is his intention, how does that make Barber different from, say, Tom Cruise?
PS — If we no longer, like Tom Cruise, stipulate that depression is a medical condition (as if our docs don’t prescribe therapy, exercise and diet, just like heart doctors don’t just prescribe blood pressure and cholesterol medicine and be done with it), doesn’t that just make us plain old “crazy” (or Liz, as you would say, “mad”) again? And put us right back at square one in the stigma battle — with a self-inflicted wound, no less?
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