Outlook: A Prescription for Fighting Antidepressant Mania
Monday, February 11, 2008; 10:30 AM
"In 2006, an astonishing 227 million prescriptions for antidepressants were dispensed in the United States -- up 30 million from 2002. Altogether the United States accounts for about two-thirds of the global market for antidepressants. Other proven and practical approaches to managing milder forms of depression, such as diet changes, exercise or behavioral therapy, haven't gotten the attention they deserve in our high-tech zeal for the drugs. ... But when you speak to people with severe mental illness who have gotten better, you learn about the reality of the recovery process, which is rarely about a pill. ... As I've learned, both professionally and personally, social context is critical to recovery."
Yale University psychiatry lecturer Charles Barber, author of "Comfortably Numb: How Psychiatry Is Medicating a Nation," was online Monday, Feb. 11 at 10:30 a.m. ET to take questions on his Outlook article about his own struggle with mental illness and what he learned from it about American medicine's methods of treating the ailments.
The transcript follows.
Charles Barber: This is Charlie Barber, read to take questions. I just would like to say that the response to the article has been pretty overwhelming -- I was contacted by more than 100 people after the article came out, and the vast vast majority of the comments were extremely enthusiastic and appreciate of alternative ways of looking at things. I also would like to add, by way of clarity, that I am supportive of the use of psychiatric drugs for legitimate psychiatric conditions. As I say in the book, I many times have seen the life-saving use of drugs for conditions like bipolar disorder and schizophrenia. With this article I merely am opening up a broader discussion to see illness and its resolution more holistically and in a social context.
Warrenton, Va.: Your article hit a nerve with me -- your words sounded like my son was writing it. He too was the person "most likely to succeed" and was unable to complete college because of his OCD. He still is struggling with his "demons," but desperately is trying change though diet, yoga, meditation, etc., etc. He was prescribed Paxil 10 years ago, and has been unable to get off this medicine -- terrible withdrawals, etc. Were you on this medication, and if so, were you able to get off from it, or are you still on this medication?
Charles Barber: I've never taken Paxil myself. Paxil has been associated with more problems getting off it than many other SSRIs, as I understand it.
New York: Thank you for your insightful Outlook article. You were lucky to have been able to work towards functioning at a higher level than your mental illness originally permitted, and sought help through multiple therapeutic modalities. What suggestions do you have for family members of an unhappy, malfunctioning adult who is resistant to both counseling and drug therapy, and seemingly lacks the personal insight/maturity to really want to work for personal change?
Charles Barber: Well, that's a hard question, and any opinion I offer is as a writer and journalist and not as a clinician. But as silly as it may sound, I would start by saying "so, what is that you want to do?" rather than telling them what you want. They may say something rather bizarre or grandiose, like "I want to be a district attorney" (as one of my clients with schizophrenia said to me). Rather than dismissing it, say "okay, what would you need to do to do that?" Often or sometimes you can drill down to a very practical level, like "you might need to see a counselor" or "you might need to get a GED in order to get started on that." Sometimes it works as a way of engaging people in a way that they can commit to. Also, it's always a danger sign when you're doing more work than the person you're trying to help. Look at Bill Miller's "Motivational Interviewing" for more on this. I write about him and interview him in my book.
Washington: Do you have any resources/recommendations for psychiatrists in the D.C. area who take a your holistic approach toward the treatment of schizophrenia and other serious mental illnesses?
Charles Barber: Not familiar with the D.C. area -- sorry.
Crofton, Md.: How does the parent of a 17-year-old, after several years of mediocre success with several therapists and psychiatrists, determine the efficacy of a mental health professional?
Charles Barber: I think the best thing to do is get referrals, where you can questions of people that know them, rather than pulling names from a phone book or something. So ask primary-care physicians, ob-gyns -- anybody you know in the medical community -- who they know and respect. Then, when you see a therapist, be an educated consumer -- you are testing them out, you don't need to commit based on the first session. Visit two or three (if your insurance allows it!) and then decide. Also, the input of your child is important. Treatment alliance (good relations with the therapist) can be a great predictor of treatment outcome.
Rockville, Md.: What are some successful strategies for helping people "get out of their own heads and serve others"? People get tired (feel useless) if they are always on the receiving end of the good deeds of others. How do we avoid setting patients up for failure?
Charles Barber: Well I think it can be exhilarating to help others, and a lot of people I think feel the same way. There can be a great diversity in what helping others means. It doesn't mean doing good deeds necessarily, directly, like at a soup kitchen; it can be doing filing and answering phones at a environmental agency, or something else. I have seen it be very good for patients to switch from being the constant recipient of care to being someone who can provide care. Often they don't know they're capable of it.
Silver Spring, Md.: Do you think a young adult, say age 19, can self-direct their own recovery?
Charles Barber: It all depends. Lack of insight (lack of awareness) about the illness can be a hallmark of many psychiatric illnesses -- schizophrenia for example. Part of what I was saying in the piece was that getting better, which involves that gaining of insight, can take a very long time.
New York: I have been in the mental health profession for 20 years and could not agree more, Thank you for articulating the need for community, connection, meaning and soul with such passion.
Charles Barber: Thanks very much. It's an overlooked area in psychiatry and mental health these days.
Springfield, Va.: I appreciate your point of view, and you obviously have much more experience with severe mental illness than I do, but I have to say that antidepressants changed my life for the better and continue to do so, as long as I take them. It has been 13 years, and they are not a cure-all, but they allow me to think clearly enough and have the motivation to do other things for myself that allow me to live a normal life. For some people on the right medication and the right dose, pills can make all the difference.
Charles Barber: As I say in the book, I have seen the life-saving effects of psych drugs on legitimate psychiatric conditions over and over again. If they work, take them! I'm trying to bring a broader discussion into the picture -- that recovery, and even medication, takes place in a social context.
Also, I didn't realize (not for your question, but for others) I'd be asked for so much advice. I would just like to repeat that although I've worked in the mental health field for a long time and written and researched a lot, I am not a psychiatrist or psychologist and my thoughts should not be taken as professional advice -- they should be taken as those from a hopefully thoughtful person with lots of kinds of experience in the field.
Fairfax Station, Va.: Your article states that you were able to mollify the debilitating effects of OCD to become a successful researcher-writer. As an aspiring researcher-writer I can spend hours searching for the most effective verb to carry my message! Can you be more specific about the techniques you used during the writing process to overcome the "stranglehold" of OCD?
Charles Barber: Part of becoming a writer is letting things go. It's more important that things be "good enough" than perfect. Similarly, you have to deal with lots and lots of rejection, even attacks. But finding that way to let it go -- to send things out when they are ready and learning how to complete projects -- is essential.
Silver Spring, Md.: How can patients keep from being stigmatized or discriminated against -- how can the rest of us who care about the patient work on this?
Charles Barber: The brain research shows that severe mental illnesses are physical illnesses, diseases of the brain -- there is a broader and broader understanding of that. So I think very gradually stigma is being reduced, and I've been the beneficiary of that personally. The main thing is, it's not your fault.
Savannah, Ga.: Do you think some of the over-prescribing is because of general practitioners with limited background in mental health? Is this an area that needs more oversight?
Charles Barber: Yes. There has been a huge shift in the prescribing of psychiatric drugs, particularly of antidepressants, by primary-care physicians. Now the majority of antidepression prescriptions are written by them. And antipsychotics, which rarely were prescribed by doctors other than psychiatrists, are becoming more commonly prescribed by generalists. I think this can be a big problem. The most pointed aspect of it is the lack of follow-up. Primary-care physicians, busy as they are, are hard-pressed to schedule regular follow-up appointments to see how the drug is going.
Silver Spring, Md.: In your article, you said that "most major psychiatric illnesses are episodic but chronic" -- I didn't understand what that meant.
Charles Barber: Major depression, schizophrenia, bipolar disorder -- for the most part -- are lifetime illnesses, or large parts of lifetimes. The diseases wax and wane, there are bad periods and then periods of abatements, but the illnesses do not disappear -- or do so pretty rarely, in my experience. There are no cures. And that is why I argue that recovery often involves a measure of acceptance of the illness.
Rockville, Md.: I have a 9-year-old son recently diagnosed as bipolar. Do you have any insights, resources or recommendations for a child? I like your model, but I'm not sure how a child can find a purpose to pull him through.
Charles Barber: I know that rates of bipolar diagnoses for kids have gone up a lot in recent years. I would make sure he's being diagnosed by a very experienced psychiatrist, someone experienced with illnesses in children. I hadn't really thought about it, but I'm not sure the aspects of my model of self-direction, etc. necessarily apply to a child. It was an adult experience for me.
Washington: I think you are missing an important point, which is that in order to do the things you recommend, such as helping others, people may need medication and counseling just to reach a certain level of emotional stability. I speak from my own experience: When I became depressed, I had to quit a rewarding volunteer commitment because I didn't have the emotional or physical energy to devote to it. Now that I have been in therapy for a year and on medication for six months, I look forward to returning.
Charles Barber: No argument here -- meds are part of the solution for many, many people. Again, I'm trying to broaden the dialogue to include the social context of recovery.
Washington state: We live in a time that is polluted like none other in history. We eat drink and breathe more chemicals than ever before. Could our demand for antidepressants stem from damage caused by poor nutrition and environmental toxins like mercury, lead, toxic mold, arsenic, PCBs, etc.?
Charles Barber: I'm not an expert on environmental toxins, but the research is strong that fish oil can be very helpful to depression; it supplies chemicals helpful to brain functioning. There is an argument that in countries where people eat a lot of fish, like Japan, there is less depression (though there are cultural reasons for that probably as well).
Washington: So glad to see someone raising this issue. I get a lot of Viagra spam and figure there must be huge demand for it. Could the massive number of selective serotonin reuptake inhibitors prescriptions explain things? (SSRIs are known to deflate sex drive).
Charles Barber: Makes sense!
What we've seen is a concentration on drugs as lifestyle-enhancers, like Viagra and sometimes the SSRIs, which have been discussed by many as ways to enhance one's personality. It's a pulling away from what it seems like medicine should be focusing on -- the most severe cases and the most severe illnesses. In psychiatry, the rates of treatment among the homeless mentally ill are pretty low (about half in treatment), whereas the worried well in the upper-middle class are taking antidepressants in huge numbers.
Silver Spring Md.: Why do you think bipolar illness in particular seems to be on the rise, especially in children?
Charles Barber: It's a combination of it not being recognized before because it was poorly understood, and it being overdiagnosed. I think you have to be very careful with kids' diagnoses and medication. Certainly there are severe conditions that merit the diagnosis and the medication, but you have to be cautious. There's a new book coming out soon about this by David Healy, published by Johns Hopkins University Press.
Reston, Va.: I have seen two "therapists" to date and have not had much success in dealing with my depression. I call the insurance company and they read off names of covered therapists in my area, but this "pick one out of a hat" method seems absurd. Your earlier comment about "test driving" a therapist is okay, but when do you stop?
Charles Barber: If they are referred by knowledgeable people (you're not picking blindly and people are thinking of therapists who match your needs and style), you should be able to find someone helpful in two or three visits with practitioners. Think about what sex of therapist might be most helpful and why -- and what treatment modality -- so that you are getting educated referrals.
Chevy Chase, Md.: I agree that the use of medication alone is not helpful and I have seen in an underdeveloped country how the mentally ill are not cut off. However, it can be very difficult for some to survive in our high-pressure, competitive society. Do you see any alternatives in living arrangements for those for whom life on their own is difficult or impossible?
Charles Barber: Family support is critical. There are so-called "psychosocial clubhouses" for people with mental illness, which do not provide treatment but provide a place for people to hang out and socialize and get jobs. The most well-known and original one is Fountain House in New York City -- but there are more and more of them, and they largely have been endorsed and funded by public mental health systems. The Internet also has been a way for people with disabilities to communicate with, advocate for and support one another.
Washington: I was excited about your article and the principles you set forth. I run a national nonprofit called the Center for Neighborhood Enterprise. The principles that you set forth have demonstrated that an inside-out, bottom-up approach has been effective in dramatically reducing antisocial behavior in violent young people in our seven demonstration cities. I very much would like to share some of this with you and at some point and meet with you. Please visit our Web site.
Charles Barber: Sure. Send me an e-mail at my Web site.
Social inclusion has a lot of benefits. I was very influenced -- and cite it in my book -- by "Bowling Alone," by Robert Putman. There's a lot of evidence that social inclusion (which has disintegrated a lot in the past 30 years in our culture) is good for health -- good for lower crime, good for a lot of things. There's a brilliant study along those lines by Sampson and Laub, a long-term study (50 or 60 years) of juvenile delinquents and what helped them get out of that life. Their conclusions: relationships and work (not so much work itself, but the social connectedness implicit in a meaningful job). For many of their guys, it was the military.
Washington: Orthomolecular Psychiatry was Linus Pauling's term for using nutrition to manage depression. There are some famous cases where this worked, and it has worked for me. Are there any professionals who practice this approach, or did they all sell out to big pharma and the fear of malpractice if they don't prescribe something?
Charles Barber: I believe it's Andrew Stoll at Harvard who has written specifically about fish oil, which I mentioned before, but no, there are a lot of people who write about diet (and exercise) and depression.
Vienna, Va.: Your essay seems to a more articulate and sophisticated version of the statement often heard in the past that depressed people should "just snap out of it." You seem to be rejecting the idea that people can suffer from depression because of a chemical imbalance, or if they do, then they can cure that imbalance by force of will. My own experience (years of pointless analysis) makes me skeptical of this conclusion. However, I think you probably are correct that these drugs are overprescribed, and that people should make some effort to understand and deal with their problems. For many, drugs will be part of that effort.
Charles Barber: You make a good criticism. Parts of me are very puritanical (work ethic, fight the good fight, and all that) and I could see that in my article, and in my book.
No, it's not a matter of will. And it is not a person's fault if they get sick! It's a matter of treatment, hope, getting acceptance and finding meaning.
Washington: You state "In psychiatry, the rates of treatment among the homeless mentally ill are pretty low (about half in treatment), whereas the worried well upper-middle class are taking antidepressants in huge numbers." I don't think this is a fair statement to make at all. I am not convinced one can compare the mental health of homeless versus upper-middle-class people based on the number of homeless seeking therapy/medication. How many homeless even register on the census? How many can afford health care? How many even know they have a mental illness? I am upset that you wrote this, it is extremely misleading of you.
Charles Barber: I am citing research studies about the proportion of the homeless mentally ill not being in treatment, which is in the area of half. Also, the rates of people with severe mental illness who are receiving truly quality therapy has been estimated in large epidemiological studies at about 15 percent. This is what the research says.
Kensington, Md.: Charles: Your article was refreshing and quite positive. I have dealt with an affective disorder for decades. I soon realized that taking responsibility for one's mental and physical health is very positive. I had met personally with Dr. Anthony from Boston University, the man you mentioned in your article about psychiatric rehabilitation. He is fantastic. Thanks for your terrific comments! I'll read your book.
Charles Barber: Thank you. I love that quotation by Dr. Anthony. Their center at Boston University appears to a great place.
Columbia, S.C.: I recently read "Artificial Happiness" by Ronald Dworkin. In it, he claims that the percentage of patients who are medicated and seeing a mental health professional has remained the same. However, the number of people getting prescriptions from their general practitioner has increased, as they are allowed to write prescriptions for such drugs. What's the source of the increase?
Also, isn't unhappiness a good emotion? Maybe if you are unhappy there is a reason, and you should look to that to change your life. If one takes drugs or self-medicates (yes, exercise and dieting also are forms of self-medication) to rid themselves of unhappiness, rather than dealing with the underlying cause, I think this could lead to bigger problems.
Charles Barber: Indeed, general practitioner prescribing has increased greatly. I would say the biggest factor is the TV advertising of drugs, which only started happening in the mid- to late-1990s. TV advertising of drugs is illegal everywhere in the world but in the U.S. and New Zealand. What happens is people see the drugs advertised on TV (and a lot of the ads are for psych drugs), they go to their doctor -- and the doctor, feeling harried, often will prescribe it, even if they feel ambivalent about it. A study was done out of University of California-Davis in which people were hired to act depressed (some of them were trained actors) and ask for drugs from doctors. Three-fourths of the time when they made a medication request, they got the drug. They were not depressed, they were acting depressed.
Unhappiness can be a good emotion within reason. We shouldn't be so quick to dismiss it.
Bel Alton, Md.: I'm having a hard time getting my spouse to understand that meds are not the cure-all. I've given him tons of material to read on the bipolar I've been diagnosed with; he seems to think he should see a difference in my emotions and actions. How do I help him understand that it's a slow process?
Charles Barber: Part of what I say in the book is that there are no cure-alls. That's part of what got us into the bind in the first place, with all this overmedication. It's a very American thing to think that right around the corner, some day, some way, everything will be perfect. The reality is that life is hard, these conditions are protracted and difficult to resolve, and very rarely are they expunged or cured. Some of the alternative approaches I write about --, cognitive behavioral therapy, for example -- have good outcomes but the are not panaceas, and any given approach will not work for a pretty good portion of people. That's why I suggest exposing patients to an array of treatment choices.
Silver Spring, Md.: I wanted to say thank you so much for the thoughtful article -- especially your point about how thinking of your own mental health disorder in terms of not being a passive recipient of treatment, but rather the author of your recovery, helped you so much. Very helpful and encouraging.
Charles Barber: Thanks. We like to think a pill will rescue us from oblivion -- and sometimes they do. Usually though, we actually have to do something as well, and it's hard work.
Arlington, Va.: I valued your Post article for may reasons. One of the biggest being that your personal story/situation seemed extremely similar to mine. The article was helpful to me largely because I identified so strongly with you as a person with mental health problems. Does your book come from the same perspective, or is more clinical/journalistic in nature?
Charles Barber: I've published two books. My first, "Songs from the Black Chair," is a highly personal memoir about the suicide of a friend, my OCD, and my work in shelters. It's a feel-good book! Ha, ha. Actually, like in the article, there's a lot of hope in it, I think. The new book, "Comfortably Numb," is not at all personal -- it's a social critique, particular of "cosmetic psychopharmacology" (the prescription of psychological drugs for reasons other than genuine psychiatric conditions), and an exploration of alternative approaches and alternative ways of looking at illness and symptoms.
Reston, Va.: I'm sure you're aware of Viktor Frankl's book, "Man's Search for Meaning." Do you advocate his type of therapy, logotherapy?
Charles Barber: I read it a long time ago and really like it. Don't know much about the therapy he specifically proposes.
Haymarket, Va.: I agree that you should read up on your illness when you are diagnosed. My comment is that when your condition is severe to begin with, it's impossible to read up on it. You're at the mercy of the prescribing doctor's (or doctors') care if and until you can think clearly enough to educate yourself on your illness so that you can make informed decisions and get the most out of your doctor visits.
Charles Barber: True enough -- it's a tough spot, in the throes of illness, to be educated and rational. Family members who truly can advocate are helpful when available. Also there is a thing called advance directives, where people with mental illness can make advance choices about how they want to be cared for in case they lose rational choice during a psychotic episode, for example. There are people at Duke University I believe who have done a lot of work on Advance Directives.
Baltimore: You mentioned fish oil as beneficial to mental stability -- what about other natural products, especially St. John's wort? Is there any real benefit to taking these dietary supplements?
Charles Barber: My sense of St. John's wort is that the research is very mixed, but I'm no expert on that. The great thing about the Internet is that you can look at the studies in academic journals yourself, or at least the summaries of them.
U.S.: On a related topic, I teach at the college level, and it seems to me that many colleges and universities have become awfully free about making accommodations (e.g. extra time on tests, etc.) for students with assorted disabilities. Especially ADHD and related issues. I realize that I'm not a mental health professional, and it's not up to me to make these diagnoses. But in some cases (not all, certainly), I really do have my doubts. Are my doubts justified? Do you see this as a problem?
Charles Barber: Yes, it's a real concern. There are legitimate disabilities and disorders and then there are people who latch onto them. I write in "Comfortably Numb" a bit about entitlement, a huge theme in American society. All the more reason to have experts do the assessments, for ADHD, for example.
Alexandria, Va.: I really hope you post this, as I am quite worried about the effect of your book. While you have very good points, I can say that Wellbutrin has saved my life, and as I suffer from a chemical imbalance, I am going to have to take it forever. I am terrified that some doctor will say I am cured and cut me off, because I cannot go back to that very dark hole I was in and survive it this time.
I take the meds every day, and I exercise every time I feel a bit of black creeping in, and that helps. I also see my therapist every year or so, or as needed, to check in, but I am one of those who simply needs this medicine like diabetics need insulin. It is an annoyance to take every day, and I sincerely wish I did not need to, but it is a fact I life.
I hope that you do not think all of us out here just want to pop a pill to make things better. In fact, I rarely take medicine, and am a big fan of meditation, yoga, stretching and integrative medicine rather than popping pills, so please don't lump us all together or cause a backlash that further stigmatizes those of us who have to take antidepressants to keep the blackness at bay. As it is, I don't admit it to anyone, as there is a real shame to it (and I know I would be judged). We don't need to make that worse and make those of us who sincerely need the treatment to be seen as weak or dependent on the easy answer.
Charles Barber: I am responding because you asked me to!
As I say, I am very clear in the book that psychological drugs are absolutely essential and life-saving to people with severe psychiatric conditions. I am trying to introduce other factors into the discussion. To date, and in our culture, it overwhelmingly has been about the drugs.
Charles Barber: I am going to sign off now -- thanks for all your interest. The response to the article has been rather overwhelming. A full discussion -- or at least observations about these issues can be found -- in quite different ways, in both books, "Songs from the Black Chair," and "Comfortably Numb." I'll be on a book tour in parts of the country and will be on NPR's Fresh Air soon, in the next couple of weeks.
In closing I'd just like to say: This stuff is complicated. That's why it engenders such extremes. My take-home message would be that mental illness is complicated and hard, and easy solutions should be looked at with skepticism. As Tanya Luhrmann, who wrote a great book about psychiatry, says people cling to easy solutions for mental illness like swimmers to a raft (or something like that).
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