Lisa Loren: Catalysis

Imagine a world where psychiatric medication works 100% of the time, relieves 100% of symptoms, and causes no side effects. In this world, we all agree on the precise differences between mental illness and personality. It’s easy to tell the difference between someone who tires easily and someone who has the flu, right? Why should mental illness be any different? Imagine that drugs work perfectly, and they don’t alter who the “real” person is. In the world I’m describing, there are no rational reasons to refuse treatment - unlike in this one. Do people with mental illnesses still have a right to refuse pills, or inpatient commitment, or whatever we find works well?

In the real world, this world that we live in, there are no absolute cures for mental illness. Up until pretty recently, scientists considered brutal procedures like the lobotomy acceptable treatments for mental illness. Today the lobotomy has been replaced by drugs that can cause permanent facial ticks and neurological symptoms, drugs that cause massive weight gain, diabetes, and heart disease. Electroconvulsive therapy, which can cause permanent memory loss, is coming back into fashion. In addition to whatever personal objections they might muster to treatment, often patients only have the option of treatments that stand to cause them significant, lasting harm.

This confuses the issue of the right to refuse treatment. It makes perfect sense to refuse a treatment that could destroy your memory, right? It seems reasonable that people might rather hallucinate than have a heart attack. Unfortunately, this leads us to focus on medication only as a heath decision, weighting the health benefits versus the health costs. Given that side effects generally don’t show up in the medical community’s consciousness, this leads doctors to feel safe in trying to force newer medications on their patient. But, more than that, it ignores the fact that these kind of decisions ought not to be based on a simple balancing of the possible heath benefits and risks. The right to refuse treatment is a human right, the right to sovereignty over one’s own mind. We cannot deny people their rights simply because we think we know what would benefit them.

It doesn’t matter, then, how close to the ideal our world may be. We don’t abstain from medicating people against their wills because we think that they understand the risks and benefits better than their doctors. While occasionally, as compassionate human beings, it may be necessary to stop the sickest among us from destroying themselves, for the most part we cannot ethically interfere with the way people chose to live their lives and deal with their illnesses. The law allows people to make their own choices about what they do to their bodies and minds because we respect their autonomy as human beings.

In the afterword to her book, The Center Cannot Hold, Elyn Saks mentions that a psychiatrist friend cautioned her to use a pen name, lest she be known publicly as “the schizophrenic with a job.” Her descriptions of psychosis are so lucid that it’s easy to see why friends would want her to hide it. Saks has been crazy in the worst sense possible, paranoid and raving and threatening violence. In this memoir, I feel like I’ve been given a window into what schizophrenia looks like from the outside and feels like from within. If this written had been written by someone who didn’t suffer from schizophrenia, I would call it “compassionate”, but the word doesn’t quite seem to fit in this case. Saks wastes no time in self-pity. This is a brave book, at the heart of it, filled with the hope that one day we all can get the help we need to live.

I admit, I came to the book already in awe of Ms. Saks. Only one out of ten schizophrenics manages to hold a job, let alone win awards or publish books. Forty years ago, Saks would have been confined to an institution for life, without the hope of treatment. Her CV is inspiring. This book is less a motivational speech than a window into another world, where beings from the sky control people’s thoughts and someone can die ten times a day and still be around to worry about it happening again. That she built herself a sane life, however fragile, is a testament to her doctors, her friends, and her own iron will.

Highly recommended.

The issue of individual civil rights for the seriously mentally ill is a major controversy today. Do you feel that schizophrenic patients should ever be institutionalized against their will? If you answer yes, under what conditions should the decision be made and who should have the authority to make this decision?

In our country, schizophrenics tend to be disruptive, scary. In a place where we can, for the most part, cordon ourselves off from the unpleasant realities of human poverty and sickness, schizophrenics stick out as reminders of the frailty and eventual decline of the human psyche. They make us uncomfortable; they make us afraid in a way that bears no relation to to harm they may bear us. I cannot talk about institutionalization, about the involuntary confinement of these people, without acknowledging the degree that it makes us more comfortable to have them locked up and put away where we do not need to see them. These people may benefit hugely from treatment, but any “treatment” that makes them docile and calm and non-disruptive also benefits us. When we consider involuntary confinement, it is important to make sure that we are helping the people in question, not merely removing our own discomfort and guilt.

This is what I believe about involuntary hospitalization: it’s wrong. Two hundred years ago lunatics were rounded up in asylum and showed off to crowds, the freaks, animals in cages. To imprison some against their will is to deprive them of their humanity, to reduce them to the status of pets and children. Imprisoning the innocent against theirs wills is barbaric.
This I also believe: when you have to tools to help a person, it is wrong to allow them to suffer and die. Schizophrenia undoubtedly causes anguish, and 15% of sufferers kill themselves. This is an illness that strips people of their reason and drives them to suicide. If they are incapable of comprehending, by reason of illness, that treatment may help them, don’t we have an obligation to force them into reason long enough for them to make their own choices?

Two wrongs, they say, don’t make a right. It is no less evil to imprison someone when they are incapable of comprehending what they’re doing, and it is no less moral to turn your back on someone because they can’t understand that you can help them. Treating schizophrenia, then, becomes a question of picking the lesser of two evils. I believe that it should always e a hard choice to make, to commit someone, and that anyone who doesn’t feel anguish at depriving another human being of their rights shouldn’t be in the position to make that judgment.

Anguish, however, can’t easily be proven in a court of law. The decision to imprison or free a person, them, needs to be made someone who at least has nothing to gain from hiding the patient away. I suggest a judge. Family members may care deeply about the person in question, but they often become the primary caretakers, and therefore have a vested interest in letting someone else take care of their schizophrenic relative. I sympathize with them, hugely, but decisions involving involuntary commitment need to be made purely based on the needs of the sick person, and family members simply aren’t capable of that. I believe psychiatrists ought to be involved in the process, but I believe that they shouldn’t have the final call. In clinical practice and in diagnosis, I think, it becomes too easy to address the symptoms rather than the person. Schizophrenia may be better treated in a confined and easily monitored setting, but Joe, the person, might do better with outpatient treatment. In addition, the psychiatrist who commits a patient often end up caring for him, and so it would be a poor business move to turn patients away.

Given that commitment is a form of imprisonment, it makes sense that only a judge ought to be able to do it, and the need to follow pretty stringent guidelines. First, someone must establish that the person is incapable of making rational decisions. That, I suppose, is where the psychiatrist comes in, as we can only rely on his judgment. Beyond that, I propose that one of two conditions must be met. First, if a person can be proved to be a danger to himself or people around him, he can be confined, and likely medicated in an attempt to restore reason. Seeing as schizophrenics are not actually much more violent than the rest of the population, I’d propose that people be considered nonviolent by default unless proven otherwise. If no one could provide evidence (including statements, therapy transcripts, et cetera) a person could only be involuntarily committed if they had, clearly, under no duress, and in writing, provided directions that they wished to be hospitalized during a schizophrenic episode or psychotic break. That way, those who need and might want help can get it, while those who want nothing to do with psychiatry aren’t forced into hospitals purely by virtue of their illness.

by Pete Earley

In reading about mental illness and treatment, you come across crazy people who think that all psychiatric drugs are poison, and crazy people who thing that all mentally ill people should be forcibly medicated. Pete Earley isn’t a another distinct type of personality; one of those family members who believes that everything would be okay, if only they had the power to hospitalize and drug their family members without their consent. It’s kind of touching and a little sad. If only hospitals were that much better than the prison wards, and everyone could get enough time in them. If only we could cure mental illnesses instead of trying to manage them, and picking up the pieces when out loved ones inevitably fall down.

I’ll be honest: this book scares me. Pete Earley takes the sickest of the sick, the most violent and disjointed of the mentally ill, and generalizes out from them. He doesn’t come out and say it, I don’t think, but it’s pretty clear that he thinks all mentally ill people should be forcibly medicated, and possibly hospitalized long-term. Thanks, Pete, but I’ve read about the days when family members could lock people away on word-of-craziness alone. Back when women who didn’t want husbands were considered insane and institutionalized? I don’t deny the existence of mental illness, oh no, but I’ve read my history, and I know that it’s subjective. There are no tests for schizophrenia or bipolar disorder, no way to tell for sure if someone ought to be given medication. Our mental health system is pretty horrific for criminals, but Pete Earley doesn’t have any good solutions for fixing it.

I know this man comes from a fundamentally compassionate place, but I feel like I need to read an anti-Prozac diatribe just to get the feel of it out of my head.

There is evidence that depression is associated with biological changes in the brain, for instance dysregulation of neurochemicals. Do you think that depressed individuals who have committed violent crimes against others (case in point: Andrea Yates, the mother who drowned all five of her children while suffering from depression) should be held morally accountable for their actions?

To blame neurochemicals for our actions is, at once, entirely reasonable and horribly misguided. Our minds, our brains, are all neurochemicals and electricity: saying that someone’s neurotransmitters make him want to kill people is essentially the same as saying that his mind makes him want to kill people. Mentally ill people are, in fact, sick, and studying the dysfunction of the brain can help find ways to treat their very real illnesses, but that doesn’t make them separate and uninvolved from their brains. The in mental illness, the brain doesn’t step in and take control; the brain is always the controller. Mental illness may affect the way that people are help responsible for their actions, but mere pathology of the brain does not.

This may sound cruel, but I believe that in a moral sense people are always responsible for for their actions. Always. Regardless of our insanity, or intoxication, or anger, we always have to live with our pasts, and what we’ve done. It’s not fair to blame our illnesses for our crimes, as if we could so cleanly and easily cut our diseased minds of from the rest of us. I’m not saying that people with mentally illnesses don’t deserve more slack and more forgiveness than sane people who kill others, but if a woman kills her children in a fit of psychosis, shouldn’t she be overcome with grief and remorse? Could we call her human if she isn’t?I believe that mentally ill people have an obligation to seek treatment. I believe that if any of us wake up in the morning with a flicker of my children would be better off if I drowned them, we have an obligation to go to an emergency room and check ourselves in for psych evaluation immediately, before letting things get worse. People don’t control or create their mental illnesses, but it is up to us to decide how we deal with our problems. There are always warning signs when psychosis strikes, and there’s usually some way or some place to put yourself where you can’t hurt yourself. If you are foolish to think that, in the face of mental illness, you can carry the lives of other people with your will alone, you deserve to feel responsible when you break. It’s a different kind of responsibility than rationally going out and shooting someone, but it exists nonetheless.

I feel a lot of compassion for people with mental illnesses. I feel that, by saying this, I’m condemning people who are essentially not in control of themselves to suffering. I want to be very clear that I don’t think mentally ill people ought to be shunned for things the do while not in their right minds, and they certainly shouldn’t be held legally responsible for these things. When I talk about moral responsibility, I mean something highly internal and personal. People prone to delusions ought to, even need to doubt themselves when they start thinking things that other people would find crazy. They need to take responsibility for those thoughts, take responsibility for dealing with them in a way that won’t end with anyone dying.

I guess I’m being a little idealistic here, because I’m assuming that anyone who tries will be able to get the help they need, or at least enough help to prevent them from hurting anyone else. I know that isn’t true. If a trip to the emergency room means thousands of dollars that you don’t have, I can see that it would be hard to check yourself in somewhere. If you can’t get someone to take you to the hospital, or if they give you antipsychotics and kick you out the door, that’s a different story than simply believing you could handle it. If that happens? I can’t blame a person who’s tried the best they could to get help, and been rejected by the world.

People who want to treat illnesses as complicated as depression, bipolar, and schizophrenia with predetermined algorithms make me a little nervous.  I’m not saying that there shouldn’t be treatment guidelines for these diseases.  I’d love to see every psychiatrist in America with a cheat sheet detailing what meds and doses have been proven to work for which conditions.  I worry, though, that the logical next step is to take psychiatrists out of the prescription process altogether, and pass the burden of psychiatric care onto primary care providers and nurse practitioners.  Both are capable, no doubt, but they don’t really have the expertise to manage the symptoms and side effects of psychiatric medications.

However, that requires highly competent and knowledgeable psychiatrists.  Not always a given.

Take this study of the Texas Medication Algorithm Project.  The study was set up to work in concert with psychiatrists, not without them, but the across-the-board success of the algorithm still worries me.

Compared with patients in usual care, patients in algorithm-based care incurred higher medication costs and had more frequent physician visits, although these differences often became smaller with time. For major depression, algorithm-based care achieved better outcomes sustainable with time but at higher agency and nonagency costs (mixed cost-effective). For bipolar disorder, patients in algorithm-based management achieved better outcomes at lower agency costs (cost-effective). For schizophrenia, patients in algorithm-based care achieved better outcomes that diminished with time, with no detectable difference in health care costs (cost-effective).

When an algorithm can do a better job of picking medications than a trained psychiatrist, that says some terrible things about the state of psychiatry today.  It’s bad enough to be taking “donations” from pharmaceutical companies when properly treating patients, but if that could be delaying the recovery of patients, it’s criminal.