Mental Health Association of Portland

Oregon's independent and impartial mental health advocate

Study: Military suicides result not from deployment, but from mental illness, addiction, other factors — same as civilians

Posted by Jenny on 7th August 2013

By James Dao, The New York Times, August 6, 2013

Military funeralIn the largest study of its kind, military medical researchers have concluded that deployments to war zones and exposure to combat were not major factors behind a significant increase in suicides among military personnel from 2001 to 2008, according to a paper published on Tuesday.

The study, published online by The Journal of the American Medical Association, corroborates what many military medical experts have been saying for years: that the forces underlying the spike in military suicides are similar to those in the civilian world. They include mental illness, substance abuse, and financial and relationship problems.

“The findings from this study are not consistent with the assumption that specific deployment-related characteristics, such as length of deployment, number of deployments, or combat experiences, are directly associated with increased suicide risk,” the authors, based at the Naval Health Research Center in San Diego, wrote. “Instead, the risk factors associated with suicide in this military population are consistent with civilian populations, including male sex and mental disorders.”

But even as it points to nondeployment factors as paramount, the study underscores the complex interplay of war and the mental health of troops, even those who never left the United States. It suggests that the stresses of 12 years of war may have worn on all service members, creating work and travel demands far outstripping those borne by peacetime troops.

“Perhaps it’s not being deployed so much as being in a war during a high-stress time period,” Dr. Nancy Crum-Cianflone, the principal investigator for the Millennium Cohort Study, which provided much of the raw data for the study, said in an interview.

Critics of the study said that because its analysis ended with data from 2008, it might underestimate the impact of multiple deployments and traumatic brain injuries caused by roadside bombs.

“Why would the authors repeatedly insist that there is no association between combat and suicide?” asked Dr. Stephen N. Xenakis, a psychiatrist and a retired Army brigadier general. “The careful analysis of bad data generates poor evidence.”

Cynthia LeardMann, the lead author on the study, said the research team planned to update the study to include data through 2012. But she expressed confidence that its bottom line conclusions would remain the same.

“The current study includes information from when we saw a sharp increase in suicides, between 2005 and 2008,” Ms. LeardMann said. “So it’s demonstrating that even in that period, we don’t see association with deployment.”

Yet even providers of mental health care and advocates for veterans who praised the quality of the study cautioned that its findings should not be oversimplified to suggest that deployment has nothing to do with suicide.

Those providers and advocates say that deployment can prompt or intensify problems that are direct causes of suicidal behavior, including post-traumatic stress disorder, depression and substance abuse.

“I’m concerned that some might take this and say: It’s not deployments. We don’t need to worry about this,” said Barbara Van Dahlen, a psychologist who is the founder of Give an Hour, a group that provides mental health counseling to service members and veterans. “This is telling us one important bit of the story. But there are many other factors involved.”

Before the recent wars, the military suicide rate was well below the civilian rate. But the gap began narrowing shortly after 2001, a time when the civilian rate was also climbing. The sharpest increases were in the Army and the Marine Corps, the services most involved in combat operations in Iraq and Afghanistan.

In 2012, suicides among active-duty troops hit a record 350, twice as many as a decade before and more than the number of American troops killed in either combat operations or transportation accidents that year. Today, the military suicide rate is almost the same as the one for civilians, when the civilian rate is adjusted to match the high percentage of young white men in the military.

The study, which was financed by the Defense Department, used surveys conducted for the Millennium Cohort Study, which is tracking the health of thousands of service members over six decades. The researchers studied data for more than 150,000 current and former service members from all the armed services.

Using data from the National Death Index and Defense Department personnel records, the researchers found among the group 83 service members who committed suicide, of whom 58 percent had never deployed.

After correlating those suicides with data from the surveys, the researchers found that suicide rates were highest among men and among people with manic-depressive disorder, depression and alcohol problems.

The authors said their findings could point to more effective approaches to reducing suicide, citing in particular programs that focus on depression and alcohol abuse.

Craig J. Bryan, the associate director of the National Center for Veterans Studies at the University of Utah, said the study’s large sample gave it added significance. “It lines up with what many of us have been finding and talking about for the last several years,” he said. “But they have been able to address the limitations of previous research.”

Several advocacy groups, including Iraq and Afghanistan Veterans of America and Tragedy Assistance Program for Survivors, or TAPS, also said the findings confirmed what they had been seeing on the ground.

“We so often just link military suicide to combat trauma,” said Kim Ruocco, the director of postvention for TAPS. “But there are many others: long hours, separation from supports systems, sleeplessness. All are stressors. All add to increases in mental health issues.”

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‘The Other Side’ – new video shares stories of recovery from mental illness, addiction

Posted by Jenny on 25th July 2013

By Linda Rosenberg, President & CEO, National Council for Behavioral Health, June 21, 2013

Ever wondered what it’s like to live with a mental illness or addiction? Is there hope? Is help available? The Other Side ― an award-winning 5-minute film marking the 50th anniversary of the Community Mental Health Act passed by President Kennedy ― portrays what it’s like to live in the grip of mental illnesses and addictions and how treatments and supports provided in the community make recovery possible — all from the stories of people who’ve inspired me over the years.

  • Dr. Clayton Chau came to America as a refugee from Vietnam, suffered abuse as a child and has lived with depression, anxiety, and PTSD.
  • Larry Fricks lives with bipolar disorder and an addiction.
  • Kevin Hines was diagnosed with bipolar disorder and severe depression at age 17 and is one of only 32 people to survive a Golden Gate Bridge jump.
  • Cheryl Sharp has experienced depression since adolescence and survived 9 suicide attempts.
  • Brandon Staglin had a psychotic break in his freshman year of college and was diagnosed with schizophrenia.
  • Katherine Switz battled severe bipolar disorder while in a demanding program at Harvard Business School.
  • Sharon Wise, a victim of severe childhood trauma, has struggled with bipolar disorder, depression, schizoaffective disorder, and drug abuse.

Today, every one of these individuals has overcome their illnesses to live productive, fulfilling lives in their communities. What made the difference? Watch our short film, The Other Side, to find out. The film — which marks the 50th anniversary of the Community Mental Health Act passed by President Kennedy ― portrays what it’s like to live in the grip of mental illnesses and addictions and how treatments and supports provided in the community make recovery possible.

The film also features Patrick J. Kennedy — who sustains the Kennedy family legacy of championing behavioral health — on his personal struggles and recovery journey.

We hope you’ll share our film to spread the message that there is hope for all those living with mental illness or addiction. That recovery is real. And that community makes a difference.

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Bipolar disorder treatment and the loss of self

Posted by Jenny on 3rd May 2013

By Linda Logan, New York Times Magazine, April 26, 2013

bipolar1-220x165The last time I saw my old self, I was 27 years old and living in Boston. I was doing well in graduate school, had a tight circle of friends and was a prolific creative writer. Married to my high-school sweetheart, I had just had my first child. Back then, my best times were twirling my baby girl under the gloaming sky on a Florida beach and flopping on the bed with my husband — feet propped against the wall — and talking. The future seemed wide open.

I don’t think there is a particular point at which I can say I became depressed. My illness was insidious, gradual and inexorable. I had a preview of depression in high school, when I spent a couple of years wearing all black, rimming my eyes in kohl and sliding against the walls in the hallways, hoping that no one would notice me. But back then I didn’t think it was a very serious problem.

The hormonal chaos of having three children in five years, the pressure of working on a Ph.D. dissertation and a genetic predisposition for a mood disorder took me to a place of darkness I hadn’t experienced before. Of course, I didn’t recognize that right away. Denial is a gauze; willful denial, an opiate. Everyone seemed in league with my delusion. I was just overwhelmed, my family would say. I should get more help with the kids, put off my Ph.D.

When I told other young mothers about my bone-wearying fatigue, they rolled their eyes knowingly and mumbled, “Right.” But what they didn’t realize was that I could scarcely push the stroller to the park, barely summon the breath to ask the store clerk, “Where are the Pampers?” I went from doctor to doctor, looking for the cause. Lab tests for anemia, low blood sugar and hypothyroidism were all negative.

Any joy I derived from my children was now conjoined with grief. I couldn’t breathe the perfume of their freshly shampooed hair without being seized by the realization that they would not always be under my roof. While stroking their backs, I would mentally fast-forward their lives — noses elongating, tongues sharpening — until I came to their leave-taking, until I reached my death and, ultimately, theirs.

I lost my sense of competence. If a colleague remarked on my intelligence, I mentally derided him as being too stupid to know how dumb I was. If someone asked what I did for a living, I would say, “Nothing” — a remarkably effective conversation stopper. I couldn’t bear the thought of socializing; one night I jumped out of the car as my husband and I were driving to a party.

Despite having these feelings in my mid-30s, when my kids were 8, 5 and 3, I was thriving professionally: I had recently completed my Ph.D. in geography, had just finished co-teaching a semester at M.I.T. as a lecturer and was revising my dissertation on spec for a respected university press. Yet several nights a week, I drove to the reservoir near my home, sat under a tree and, as joggers and their dogs ran past, thought about ending it all. There was a gun shop on the way to my poetry group; I knew exactly where to go when the time came.

My day, once broken by naps, gradually turned into lengthy stretches of sleep, punctuated by moments of wakefulness. My husband and I didn’t explain to the kids that I was depressed. “Mommy’s a little tired today,” we would say. A year or so earlier, a therapist told us to tell the children. “But they’re just kids,” we said. “What do they know?” “They know,” she said. When we eventually spoke to them, my oldest daughter came to me and asked: “Why did you keep it a secret? I thought all mothers were like you.”

After a few weeks of stopping at the reservoir, as suicide eclipsed all other thoughts, I finally told my husband about my worsening psychic pain. The next day I was hospitalized. It was June 1989. Even though we were living in Boston, we decided I should go to Chicago to work with the psychopharmacologist who, 15 years earlier, restored the health of my father, who had also been hospitalized for depression. As the cab pulled away from our house, I turned and saw three children’s hands pressed against the screen of an upstairs window. This is the way the world breaks.

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bipolar-disorder-definition1The moment the psych-unit doors locked behind me, I was stripped of my identity as wife, mother, teacher and writer and transformed into patient, room number and diagnosis. I couldn’t open a refrigerator without permission. If I were on suicide watch, I had to ask before going to the bathroom. I was told when to sleep and when to wake, when to eat and when to go to group. My routine, which at home had cleaved so closely to my children’s, now revolved around the clattering sounds of the food trays being brought three times each day from the service elevators into our unit. With my husband and children nearly 1,000 miles away, I was severed from my fixed stars. I missed my children’s smells, the way they used to wrap their bodies around my legs when I was on the phone. I brought my son’s comforter to the hospital for my bed. I remembered him with one leg thrown across the covers, a small foot peeking out from his pajamas.

When my children visited, I had to resuscitate my maternal self, if only for an hour. I dragged myself to the shower, pulled on a pair of clean sweat pants and a fresh T-shirt and ran a streak of lipstick across my lips, hoping to look like a reasonable facsimile of a mother.

My doctor used my first hospitalization as a so-called washout, a period during which he planned to take me off the medication I was on and introduce several drugs in several different combinations. The prospect of polypharmacy — taking many drugs at once — seemed foreboding. I read about Prozac’s giving some people entirely new personalities: happier, lighter, even buoyant. “Who are you going to turn me into?” I asked my doctor.

“I’m not turning you into anyone,” he said. “You’ll be yourself, only happier.”

“I don’t think I even have a self anymore.”

“We’ll find your self.”

I was wary. “Just don’t turn me into Sandy Duncan.”

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Bipolar-Disorder-SignsHow much insult to the self is done by the symptoms of the disorder and how much by the drugs used to treat it? Paradoxically, psychotropic drugs can induce anxiety, nervousness, impaired judgment, mania, hypomania, hallucinations, feelings of depersonalization, psychosis and suicidal thoughts, while being used to treat the same symptoms. Before getting to the hospital, my daily moods ranged from bad to worse, each state accompanied by a profound depth of feeling. The first drug I was given was amitriptyline (Elavil), which, in the process of reducing my despair, blunted all my other emotions. I no longer felt anything. It was like going from satellite TV to one lousy channel.

While some medications affected my mood, others — especially mood stabilizers — turned my formerly agile mind into mush, leaving me so stupefied that if my brain could have drooled, it would have. Word retrieval was difficult and slow. It was as if the door to whatever part of the brain that housed creativity had locked. Clarity of thought, memory and concentration had all left me. I was slowly fading away.

I would try to talk to my doctors about my vanishing self, but they didn’t have much to say on the subject. Instead they focused on whether I could make eye contact or how much expression I showed in my face. They monitored my lithium and cortisol levels; they took an M.R.I. of my head. I received an EKG, was exposed to full-spectrum lighting and kept awake all night for sleep-deprivation therapy. Nurses jotted down their observations; my scribbled lines in art therapy were inspected. Everything was scrutinized — except the transformation of my self and my experience of its loss.

My current psychiatrist, William Scheftner at Rush University Medical Center, says this is typical when treating patients with acute mental disorders. The primary goal at the height of a mental-health crisis is symptom reduction. That means monitoring patients’ sleep patterns, appetites and responses to medications — not worrying about philosophical questions like who they are and who they will become. “The issue of self just isn’t there,” he told me, “because you’re so preoccupied with whether someone is actually improving or not.”

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Normal_VS_BipolarBy August 1989, I was back in Boston with my husband and kids, having been discharged from the hospital almost three months after I was admitted. My children, like many people, mistook “discharge” for “recovery.” “Why did they let you out if you’re not better?” my daughter asked. I didn’t know how to explain the welter of factors that go into discharge: poses no threat to self or others; is functioning at a high-enough level to participate — however minimally — in the tasks of daily living. Recovery was not an end, I told her, but a process.

The trees were starting to change colors. Acorns dropped and exploded like tiny bombs. My car was in the driveway; my clothes were in my closet. But things felt ill fitting and unfamiliar. “Whose kids are these?” I wondered. “And when is their mother coming to pick them up?” Nowhere was my otherness more keenly experienced than at the driveway at the grammar school. Everyone knew that I had been “away,” and why. I tried to imitate the other mothers, their relaxed camaraderie, their confidence, the way they threw their heads back when they laughed.

Around Halloween, as our neighbors made wild-eyed pumpkins with crooked teeth, my children noticed that there were frightening things in our house, too. I had my first hypomanic episode. This was how my doctors confirmed that my depression wasn’t just depression — I had bipolar II disorder, like my father. With bipolar II, unlike bipolar I, the upward swing from depression stops at hypomania, not mania. Mania is having five grand pianos delivered to your house; trying to buy the Sears company; sleeping with the local baseball team. Hypomania is mania with a tether, and, while it might avert some of the financial and interpersonal disasters that unchecked mania may engender, it can still feel like a runaway train.

By that point my vestigial self had grown used to my depressed self, with her somber mood and tenuous hold on life. Now a newcomer arrived. I seemed to have split into three: my shellshocked self, my depressed self and a brazen hypomanic self. We could practically hear the new girl sizing us up, cackling. Under her reign, we slept two hours a night. We ate half a sandwich and two potato chips a day. We packed the children’s lunchboxes at 3 a.m. We began to study for the MCATs (the fact that we had never taken a biology or chem class seemed irrelevant). We telephoned long-lost friends. The hypomanic self’s activities, from relentless lunch dates and impulsive spending sprees, left my tattered and depressed selves saying, “That’s not us” and “We don’t do that.”

I no longer went to bed with my husband. Instead I stayed awake, scribbling in my notebooks. My wakefulness worried my son. “I had a bad dream,” he said. “You were downstairs working in the middle of the night. And while everyone else in the house was sleeping, the whole house fell down on you.”

“Oh,” I said, pulling him close. “That is a bad dream. Did anybody get hurt?”

“No, but the cats almost died.”

Every few weeks, I needed to buy smaller clothes. “What’s happening to you, Mommy?” my daughter asked. “You’re shrinking.”

Hypomania was consuming me. My doctor, in an effort to quash the hypomania, upped my lithium dose and catapulted me back into depression, back to Chicago, back to a locked psych unit, after New Year’s Day in 1990. A few weeks later, my kids came to visit. I met them in the lobby. The chair I was sitting in felt insubstantial; the walls seemed to bend. My son was excited. “I made a scientific discovery!” he said. “There can’t be a shadow in the darkness.” He understood depression better than my doctors, I thought. “Mommy?” he said a few moments later. He sounded miles away. I leaned back and fell asleep. I didn’t see them again for four months.

My medical records show that by the spring, I thought I was in a Canadian train station and that it was 1976. I lugged a suitcase stuffed with towels around the unit, looking for the departure platform. If my self had been assailed by depression, then psychosis was the final blow. My sense of boundedness — where I stopped and other people or the environment began — was sloppy, like a toddler scribbling outside the lines. I didn’t envision myself as human; I pictured myself as black vermicelli on an asphalt driveway. For a brief time, I could neither write nor speak. My journals show a perseverating pencil — a long string of Ts or entries in hypergraphic writing, alternating between conventional and unconventional language: “They will have a stronstrazzly negative reaction to them. I need held . . . In stortingitoat — plus, the idea of [X] a new set of residential pleomorph — exoskeleton weitropstite jejoined to be betters. blep.”

I hallucinated. The world was suddenly up for grabs; reality, an option. Rectangular rainbows streamed through the day-room windows. Nonexistent organ music pealed through the neighborhood on a Sunday morning. Peasants from a Jean-François Millet poster walked out of the frame and marched across the wall.

Some researchers say that in psychosis, the self persists, however tenuously. Sue Estroff, a professor of social medicine at the University of North Carolina, described it as “more of a foreground, background thing. During psychosis, the self recedes.” But, she told me, “you’re still in there.” I don’t think so. If I had been allowed outside, I would have doubted the reality of my shadow.

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bipolar3By early summer, the psychosis had run its course, and I returned to lucidity. The kids came to visit. They dragged me off the sofa and onto the carpet. We were laughing and crying simultaneously. I felt the surge of something primal.

Later that summer, after I became well enough to be discharged once again, we decided to move to the Chicago area so that I could continue working with my father’s doctor, whom I trusted, and be near our families. But seven months after moving into our new house, I was back in the hospital. I would be readmitted and discharged two more times over the next half-year. When I left the hospital for the last time in August 1991, I was 38, and while no longer intent on self-destruction, I was more accurately rescued, not restored.

Taking care of children and running a household seemed like a herculean task. My husband and I realized we needed a full-time housekeeper. We found a wonderful woman who knew just what needed to be done: cook, clean and be a surrogate mother. While appreciative of her help, I felt as if my role had been usurped.

I continued to see my doctor every week as an outpatient. But I was demoralized and failed to see much of a change. I asked him how he healed my father, maintaining him on only three lithium tablets a day, whereas I had experimented with about 100 different combinations and dosages of medications (including antidepressants like monoamine oxidase inhibitors, tricyclics and, later, S.S.R.I.’s). “Because,” he said, “your dad was a Ford. You are a Ferrari.” I didn’t know if this was a compliment or an insult.

The first few years after my last hospitalization, I spent a lot of time on the shore of Lake Michigan, near my home. I collected hundreds of beach stones and organized them by size, color, shape and heft. Soon I had dozens of shoe boxes full of them. Sometimes I talked to the Russian fishermen looking for smelt on the pier; other times I walked alongside older women and helped them look for sea glass. I took three-hour naps every afternoon, trying to remember to set the alarm clock, so I would be awake when the kids came home from school. Many times they met a closed bedroom door.

By 1995, I started to feel small changes. The medications were the same. I was still seeing my father’s doctor. I had the same support from my family and from my husband, who once, when I came home on a day pass, had pansies — my favorite flowers — planted along the path from the driveway to the house. The protective cocoon he made for me, along with time, allowed my self to regrow. I could feel my self filling in.

Gradually, I was able to fulfill more of my maternal role: helping with homework, driving to piano lessons, making the worst Rice Krispies Treats in the school. Our housekeeper, while still a tremendous support, was becoming more of a safety net than a primary caregiver. One of my favorite things was driving in the car with the kids, singing along to oldies, trying to answer their questions: “Is the sun going to fall on the earth?” “Where is the first car?” “Why are some books called a ‘turn-pager’?” I had lunch with family members and the occasional friend. With confidence easing its way back to my self, I volunteered at an anorexia foundation near my house. I lined the edges of my desk with stones. Writing was getting easier, words were unlocking. One day I was on the porch with the two younger kids, who were doodling with crayons, when I wrote down the word “pain.” Without thinking, I picked up a crayon and added the letter T to the end of the word. A half-hour later, we were at an art-supply store, buying brushes, tubes of paint and a canvas. We converted the unused third floor of our house into a cavernous studio. Passion had returned and, along with it, creativity.

One day, about eight years ago, it struck me that bipolar disorder was the hand I was dealt. I remembered what my father said to me when I moved from Boston: “Don’t look at what your disorder has taken away from you, try to find what it has given you.” I began speaking to family-education classes of the local chapter of a mental-health organization. I presented a paper at a conference. The more often I spoke, the less traumatic my experience seemed, the less sad, the less painful and, somehow, the less personal.

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Over the years, I’ve talked to clinicians about why the self is rarely mentioned in treating patients who suffer from mental illnesses that damage their sense of who they are. If anything, it seems that psychiatry is moving away from a model in which the self could be discussed. For many psychiatrists, mental disorders are medical problems to be treated with medications, and a patient’s crisis of self is not very likely to come up in a 15-minute session with a psychopharmacologist.

Philip Yanos, an associate professor of psychology at John Jay College of Criminal Justice, in New York, studies the ways that a sense of self is affected by mental illness. He told me that when his work was under grant review, it was initially met with skepticism. Some thought that what he calls “illness identity,” which manifests in some patients as overidentifying with their mental disorder, was a topic of lesser importance in the face of other serious symptoms that patients experience, like cognitive impairment and thoughts of suicide.

Yanos told me that reshaping your identity from “patient” to “person” takes time. For me, going from patient to person wasn’t so arduous. Once I understood I was not vermicelli, part of my personhood was restored. But reconstructing my self took longer.

One reason that may have been the case, as Amy Barnhorst, a psychiatrist at the University of California, Davis, told me, is the unique set of challenges facing people who have experienced mania and hypomania. “The parts of the selves that may come out” in mania and hypomania, which can be horrifying, “are very real,” she said, making it difficult for patients “to reconcile those behaviors with their self as they have come to know it.” In mania and hypomania, the sick self has no accountability; the improved self has a lot of explaining, and often apologizing, to do.

For many people with mental disorders, the transformation of the self is one of the most disturbing things about being ill. And their despair is heightened when doctors don’t engage with the issue, don’t ask about what parts of the self have vanished and don’t help figure out strategies to deal with that loss.

Some in the mental-health field are beginning to recognize this need. Janina Fisher, a psychologist and the assistant director of the Sensorimotor Psychotherapy Institute in Broomfield, Colo., told me that there has been a “sea change” in the role the self plays in the therapeutic dialogue since the decades when I was sick. New therapies and treatment philosophies, founded mostly by clinical psychologists and other practitioners who are not medical doctors, recognize the role of the self in people with mental illness. Patients tell her, “I just want to be that person I used to be.” Fisher encourages her patients to recognize that their mental trauma is a part of their life, but shouldn’t dominate it.

In my own experience with Scheftner, whom I began seeing after my father’s doctor moved away, we talk about the self but only when I bring it up. That’s why I have enjoyed helping to run a support group for people with mental disorders, something I’ve been doing for the last three years. There are usually 8 of us, sometimes 12. We sit in the basement of a local library every Wednesday afternoon. Though we know one another’s innermost thoughts, we are intimate strangers, not friends. Like A.A. and other self-help groups, we’re peer-led: run by and for people with mental disorders. We talk one by one about the past week — small achievements, setbacks, doctor appointments, family conflicts. While the self is not always an explicit topic, the loss of self — or for those doing better, the reconstruction of the self — is a hovering presence in the group.

One day, not long ago, a middle-aged man came to our group. He told us that he spent the past year attending different grief groups, but none of them were right. “Why not?” someone asked. The man said: “Because everyone there was grieving over the loss of another person. I was grieving for myself. For who I used to be before I got sick and who I am now.”

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imagesDuring the 20-odd years since my hospitalizations, many parts of my old self have been straggling home. But not everything made the return trip. While I no longer jump from moving cars on the way to parties, I still find social events uncomfortable. And, although I don’t have to battle to stay awake during the day, I still don’t have full days — I’m only functional mornings to midafternoons. I haven’t been able to return to teaching. How many employers would welcome a request for a cot, a soft pillow and half the day off?

One morning, about five years ago, my husband and I were talking on the family-room sofa. I was still wearing my pajamas and had wool hiking socks on. As he rubbed my feet, he told me he was leaving. It was, at once, a scene of tenderness and savagery. A little later, he threw some clothes into a suitcase and moved out. But my self — devastated, grieving, angry — remained intact.

Today, my mind is nimble. Creative writing has crept back into my life. I’ve made a couple of close friends in Chicago. My greatest pleasure is still my children — they’re starting careers, marrying, on the brinks of their lives. I’m looking forward to grandchildren, to singing the 1950s favorite “Life Is but a Dream” while spinning those babies under the stars of a falling night on a Florida beach. This June, I’m turning 60. I’m having a small party to celebrate my ingathering of selves. My old self was first to R.S.V.P.

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Get schooled! Classes and online learning opportunities starting soon

Posted by Jenny on 3rd May 2013

flowersBy Jenny Westberg, Portland Mental Health Examiner, May 3, 2013

Along with spring blossoms, this May is bright with learning opportunities for those interested in mental health. With classes ranging from dream interpretation to cinema to living well with bipolar disorder, it’s a great time to learn something new and broaden your understanding of yourself, your friends, and your world.

The list below is in order by starting date, with the exception of the last entry, which is an online course structured according to the learner’s schedule.

Note that the first class listed is scheduled for this Sunday, May 5; other classes may have limited openings, and some offer discounts for early registration, so if something interests you, reserve a place now – and let the enrichment begin!

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Take Charge of Bipolar Disorder: A 4-Step Plan for You and Your Loved Ones to
Manage the Illness and Create a Life of Wellness

  • Instructor: Julie Fast
  • When: Sunday, May 5, 2013, 2-4 p.m.
  • Where: Cedar Mill Community Library, 12505 NW Cornell Rd, Portland, OR
  • Cost: Free
  • To reserve a seat, RSVP to Gayathri Ramprasad at gayathri@myasha.org or call the Cedar Mill Library at 503-644-0043 ext. 114.

ASHA International and the Cedar Mill Community Library present a free two-hour workshop with author, speaker, and family coach Julie Fast. It is ideal for individuals affected by bipolar disorder, their family members, healthcare providers and the general public. Topics include:

  • Understanding the Incidence & Impact of Bipolar Disorder
  • Different types of bipolar disorder and their symptoms
  • A 4-Step Plan to Manage the Illness and Create a Life of Wellness
  • Wellness Resources

For more information: see http://archive.constantcontact.com/fs165/1102343272915/archive/1113080551647.html

Julie A. Fast is a leading mental health expert on the topics of bipolar disorder, depression, seasonal affective disorder and mood management. She is the bestselling author of Loving Someone with Bipolar Disorder and other books on mental health.

WATCH – ASHA International

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Dreamwork Fundamentals: Practical Tools to Enhance Life and Work

  • Instructors: Will Hall, MA, Dipl. PW and Suzette Payne MA, Dipl. PW
  • When: Saturday, May 11, 2013, 10 a.m.-5 p.m.
  • Where: Process Work Institute, 2049 NW Hoyt St., Portland, OR
  • Cost: $120 (PWI members $108)
  • To register, email pwi@processwork.org or call 503-223-8188

How do you figure out what a dream means? Using Jungian and Process Work methods, this class will equip you with essential tools of curiosity, symbolic association, body awareness, amplification, and creative expression. Dreamwork can be fun, inspiring, and easy, and will open you up to a whole new creative resource you can draw on for living. Anyone new to understanding dreams or wanting to deepen their skills will find Process Work a practical and effective approach.

Download flier here

Will Hall MA, Dipl.PW, is an internationally recognized therapist and mental diversity trainer who has himself recovered from a diagnosis of schizophrenia. Host of Madness Radio and founder of Portland Hearing Voices, Will’s writing has appeared in the Journal of Best Practices in Mental Health and Modern Community Mental Health Work: An Interdisciplinary Approach (Oxford Press). For more information, visit www.willhall.net.

Suzette Payne MA, Dipl.PW is a Process Work Diplomate, practicing therapist, and teacher. Both Will and Suzette have a longtime passion for teaching and learning about the power of dreams. As therapists and teachers, they’ve used night dreams and daytime dream-like experiences as an active and ongoing part of their professional and personal lives for many years, and are inspired to share what they have learned about the power and usefulness of dreams.

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Dreaming the Movies: How We Live Inside the Films We Love

  • Instructor: Will Hall, MA, Dipl. PW (see bio above)
  • When: Two days, Tuesday May 28 and Tuesday June 4, 2013, 6:30-9 p.m.
  • Where: Process Work Institute, 2049 NW Hoyt St., Portland, OR
  • Cost: $100 (PWI members $90)
  • Early Registration (by May 14): $90 (PWI members $80)
  • To register, email pwi@processwork.org or call 503-223-8188

Download flier here

George Lucas acknowledged Carl Jung’s vital influence on “Star Wars,” but what light can Process Work shine on film storytelling? How do the emotional power and aesthetic fascination of films resonate with our spirits? Why do we love films so much?

In this two-night cinematic extravaganza, explore three great films by masters of the form: Howard Hawks’ “Bringing Up Baby,” Martin Scorsese’s “Hugo,” and Byambasuren Davaa’s “Story of the Weeping Camel.” Come study amazing scenes, learn basic film concepts, and try out imaginative tools that blur the boundary between audience and screen. Discover how we are already living the movies we love – and add new depth to your film watching enjoyment. (View these great films online first!)

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Living With Suicidal Feelings: From Powerlessness To Engagement

  • Instructor: Will Hall, MA, Dipl. PW (see bio above)
  • When: Saturday, June 8, 2013, 10 a.m.-5 p.m.
  • Where: Process Work Institute, 2049 NW Hoyt St., Portland, OR
  • Cost: $120 (PWI members $108)
  • Early Registration (by May 24): $108 (PWI members $96)
  • CEU’s available for this class through the NASW
  • To register, email pwi@processwork.org or call 503-223-8188

Download flier here.

Shrouded in taboo and judgment, suicidal feelings are much more common than we realize. How can we support others – and respond to these feelings in ourselves? Discover latest research about responding to suicidal feelings, hear about innovative practices, and learn practical tools for engaging with these often frightening and overwhelming emotional states. Clinicians, students, people who have struggled with suicidal feelings, family, and others welcome. Co-sponsored by Portland Hearing Voices.

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ONLINE LEARNING

Transforming Our Suffering – An Online Family Recovery Course

  • Instructor: Krista Mackinnon
  • When: Online, asynchronous, flexible times
  • Cost: $150
  • For more information, or to register, visit PracticeRecovery.com.

Through a dynamic online learning community, this 8-week course will support and educate families and friends of people who have received a psychiatric diagnosis and/or are struggling with mental health problems. Using latest research and practical tools for recovery, Transforming Our Suffering addresses: Stories of Your Experience; the Continuum of Mental Health, Distress, and Psychosis; Fundamentals of Recovery; the Power of Hope + Resilience; Strengths Based Perspective; Relationship Building Amidst Psychosis; Boundaries, Limits and Barriers; and Celebrating Recovery Stories.

You can participate during the hours that fit your schedule in this asynchronous class. Course content will be delivered to your email inbox twice a week and will also include access to a password-protected online learning community where you can find additional resources, videos, homework challenges and facilitated community discussions.  Pre-registration is strongly reccommended. Enrollment is limited to 50 participants.  If you have any questions or wish to join waiting list, please email Krista at practicerecovery.com.WATCH – Online Family Mental Health Recovery Course, with Krista Mackinnon

Krista Mackinnon is mental health recovery consultant/trainer/counselor. She is the CEO and co-founder (with Will Hall) of PracticeRecovery.com, an innovative online therapeutic education and support community for families that works in partnership with Family Outreach & Response Program (Toronto) and MotherBear CAN (North Carolina).

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The limits of lithium, and the hunt for a better alternative

Posted by Jenny on 28th March 2013

By Bethany Halford, Chemical & Engineering News, March 25, 2013

Bipolar-DisorderWhen something goes wrong with the inner workings of the body, we call it a disease. When things go awry in the mind’s fine machinery, we call it madness. Risdon Slate knows all about that. It has been more than 25 years since the events that led to his diagnosis of bipolar disorder. But he has no trouble recalling them.

In 1986, he was a 26-year-old U.S. probation officer visiting Miami for training. At one point, he remembers sitting in his hotel bar and getting into an argument with a man whom he perceived was playing the role of his father. “I actually believed that I was on the set of ‘Miami Vice’ and that I was going to be in an episode of the TV show,” Slate says. The police got involved, and Slate told officers that he would not answer any questions unless they were posed to him by Sonny Crockett, the fictional undercover police officer and central character of “Miami Vice.”

The retelling is almost comical, but the consequences for Slate were anything but. As a result of his bipolar disorder, Slate lost his job as a U.S. probation officer. His wife left him. A few years later, after a doctor took him off medication, Slate experienced a second manic episode, which led to an arrest (which has since been expunged) and a brutal physical assault while he was in jail. A bipolar patient swings between bouts of mania—when a patient can feel irrationally euphoric—and depression.

For the past 20 years though, Slate has managed to keep his disorder in check thanks to the drug lithium. “Taking the medication has been the key,” says Slate, now a professor of criminology at Florida Southern College. “It is essentially saving my life.”

Like Slate, 9 million people in the U.S. struggle with the disease at some point in their lives, according to the National Institute of Mental Health. Although roughly a dozen drugs are approved to treat bipolar mania and prevent or delay the onset of manic or depressive episodes, in many ways, lithium stands alone. Psychiatrists often turn to lithium—usually given as the salt lithium carbonate—as a first-line drug for patients. Its ability to calm the highs of mania and lift the lows of depression has been known for more than 60 years. It’s the only medication that demonstrably reduces the risk of suicide in bipolar patients. And it’s inexpensive.

Bipolar treatmentsBut lithium is not a panacea. The drug’s therapeutic window is very narrow—that is, its toxic dose is only about two to three times higher than its therapeutic dose. Patients who take lithium also need to have the ion monitored in their blood to make sure it’s below toxic levels. And there are the side effects: tremors, frequent urination, thyroid problems, weight gain, and, in some cases, kidney failure.

In the hope of skirting lithium’s limitations, scientists are trying to figure out exactly how the drug works and, in particular, hunt down its targets. The idea is this: Because lithium is an ion, it hits several different cellular targets, which is why it has so many side effects. If scientists can figure out which of those targets are responsible for its mood-stabilizing properties, they might be able to hit them specifically, using a small molecule that doesn’t have lithium’s downsides.

“For some percentage of patients, lithium really does have a lot of the characteristics of an ideal treatment,” says psychiatrist Gary S. Sachs, founding director of the Bipolar Clinic & Research Program at Massachusetts General Hospital. “However, that is a relatively small percentage of patients.”

Other drugs approved to treat bipolar disorder were originally developed as anticonvulsants to treat epilepsy or as antipsychotics to treat schizophrenia. Thanks to their ability to level out certain moods, the drugs have been used to treat bipolar patients. It’s not clear how these drugs work either, and they often have more adverse side effects than lithium. All bipolar medications carry the U.S. Food & Drug Administration’s “black box” warning, Sachs points out, indicating they carry the risk of death. “Patients aren’t in a hurry to take those drugs,” he says.

Molecules“People find the side effects aversive, so they find ways to go off their medicine,” adds psychiatrist Kenneth Duckworth, medical director of the National Alliance on Mental Illness.

Scientists don’t really know what causes bipolar disorder, which was once known as manic depressive illness. It can strike at any age.

The disorder is unique among psychiatric illnesses, Duckworth points out, because people experience one phase of it, hypomania, positively. “People feel funnier, sexier, and more energetic,” he explains. They don’t want to take their medication, but they may be on their way to mania and psychosis.

Doctors split bipolar patients into two subgroups. Those with bipolar disorder type I, like Slate, have had at least one full-blown manic episode. Patients with bipolar disorder type II experience hypomania but not mania. Both type I and type II patients wrestle with depression, usually for far longer periods than they experience hypomania or mania.

“My depression feels like hell,” says Rebecca Gatlin, a 30-year-old nursing student who was diagnosed with bipolar disorder at age 19. “You have to push yourself to do every little thing,” Gatlin says. “You put so much effort into getting out of bed and brushing your teeth. Everything takes so much effort that you’re so exhausted and you walk around listless. You’re so exhausted from the littlest thing.

“You know that there are only two ways to get through it—to hang on until it lets up and things get better or the medicine kicks in, or you make a plan to end your life, and that’s not really a viable option,” Gatlin says. “You’re stuck holding on for life.”

“When you call depression mild, it’s sort of like saying you’ve had a mild heart attack,” Sachs says. The depressive phase of bipolar disorder can be extremely disabling, he says, and doctors don’t have many pharmaceutical options for treatment.

In 2007, Sachs and coworkers released the results of the Systematic Treatment Enhancement Program for Bipolar Disorder, or STEP-BD, the largest federally funded treatment trial ever conducted for bipolar disorder. They learned that antidepressants are no better at treating bipolar disorder than a placebo.

“So far, the track record of the so-called standard antidepressants has been terrible in terms of their ability to treat bipolar depression,” Sachs says. “None of them have proven to be effective, even though they are the most commonly prescribed drugs. So there is an area of great need to find novel compounds that would either treat or prevent depression in bipolar people.”

Lithium has a reputation for being moderately effective at treating or preventing bipolar depression. Scientists know that lithium displaces magnesium ions and inhibits at least 10 cellular targets. They have been able to narrow that range on the basis of what lithium inhibits at therapeutically relevant concentrations, roughly 0.6 to 1 mM.

One putative lithium target researchers have been pursuing for decades is inositol monophosphatase, or IMPase. The enzyme is part of the phosphatidylinositol signaling pathway. It strips the phosphate off of inositol phosphate to produce inositol, a key substance in the biosynthesis of compounds that trigger cellular responses.

There is some evidence that in bipolar patients the phosphatidylinositol signaling pathway becomes hyperactive. Inhibiting IMPase halts the pathway and depletes inositol. Adding credence to this theory, researchers have fingered inositol depletion in the mechanisms of two other bipolar medications—carbamazepine (Tegretol) and divalproex (Depakote), also called valproic acid.

“How can we really be sure that lithium works to treat bipolar disorder by inhibiting IMPase?” asks John R. Atack, director of translational drug discovery at En­gland’s University of Sussex. “You make a good inhibitor of IMPase and see if it works in treating people with bipolar disorder.”

In the 1990s, Atack was part of a team at Merck & Co. trying to do just that. Reckoning they couldn’t do any medicinal chemistry on an elemental ion, because they couldn’t adjust its structure, Atack and coworkers developed IMPase inhibitors based on the enzyme’s substrate—inositol monophosphate.

Eventually they came up with an antagonist capable of inhibiting the enzyme at nanomolar concentrations. Polar phosphonate groups proved to be crucial to the compound’s ability to bind in IMPase’s active site, but the phosphonates kept the molecule from being bioavailable. “To get enzyme inhibition you need polar molecules,” Atack explains, “but those polar molecules don’t stand a very good chance of getting into the brain at high levels.”

The group tried to circumvent the problem by turning the molecule into an ester prodrug that could cross the membrane of the cell. It didn’t help. “If you inject that compound into an animal, it just sits there in a greasy lump,” Atack says.

Finally, the team used X-ray crystallography to study IMPase’s active site. “It confirmed what we already knew. The active site is very polar and therefore you need polar molecules to bind in it,” he says. Furthermore, the enzyme has no convenient greasy pockets where something less polar might do the job. “At that point, we didn’t really know where to go next,” Atack says, and the project was shelved. Talking about his work with IMPase is “like talking about an old girlfriend,” he adds. “She took a big chunk of my life, and I still have affection for her.

“It’s an unanswered question whether IMPase would be a good therapeutic target or not,” Atack adds. “Merck put a heroic effort into this and got nothing out of it. Perhaps it is an attractive but intractable target.”

Since then, scientists have largely been silent about any efforts to come up with IMPase inhibitors. Late last year, however, a team led by Grant C. Churchill and Sridhar R. Vasudevan, of the University of Oxford, in England, reported that the compound ebselen can inhibit IMPase (Nat. Commun., DOI: 10.1038/ncomms2320).

Ebselen, an anti-inflammatory antioxidant, was originally developed by Daiichi Sankyo, in Japan, to treat patients who had suffered a stroke. But the compound was never marketed and has since come off patent. It’s also part of the National Institutes of Health Clinical Collection—several hundred small molecules that have, to some extent, gone through the gamut of human clinical trials and have been found to be safe, but never reached final FDA approval.

In addition to inhibiting IMPase in vitro, the Oxford researchers found ebselen has lithium-like effects in a mouse model of mania. The compound calms mice that have taken amphetamine. Subsequent administration of inositol reverses the behavior, Churchill says, which is a clue that ebselen affects inositol recycling.

Since the report came out, Churchill says, a few psychiatrists have started to apply for funds to study ebselen’s effects in bipolar patients. At Oxford, doctors are giving the compound to a small group of healthy adults to see how it affects inositol processing in the brain. Ebselen has gone from identification as a potential bipolar treatment to human trials in about two years, Churchill points out. “That is incredibly fast for any drug discovery effort.”

Some, however, are skeptical that IMPase is a viable target for making lithium mimics. The target was discredited years ago, says Edward M. Scolnick, who served as president of Merck & Co. from 1982 through 2002. Rather, he believes the key to finding better treatments for bipolar disorder lies in unraveling the disease’s genetics. Currently chief scientist at Broad Institute’s Stanley Center for Psychiatric Research, Scolnick is part of an effort trying to do just that.

“The single largest risk factor for a person becoming bipolar is genetic,” Scolnick explains. Scientists can’t study the biochemistry of the living human brain, he points out, and imaging methods lack the sensitivity to pick up molecular causes. So, Scolnick says, the only way to get a handle of the underlying pathophysiology and biochemistry of bipolar disorder is to find the genes related to illness and see what biochemical pathways they point to. “Unless one understands the underlying biochemistry of the human disease—not some animal model that has no clear relationship to the human disease—one will never be able to make important new therapeutics,” he says.

Scolnick is not the only one to voice concerns about animal models for bipolar disorder. Psychiatrist Carlos A. Zarate, chief of the National Institute of Mental Health’s (NIMH) Section on the Neurobiology & Treatment of Mood Disorders, also notes that these models of the disease leave something to be desired.

Typically, the complex mental state of mania is modeled by giving mice amphetamines. Scientists test antidepressants on animals by forcing rodents to swim or suspending them by their tails. The length of time the creature swims or struggles is supposed to be indicative of the antidepressant’s efficacy.

Correlating animal tests that take only a few minutes with a patient who’s suffered from a disease for decades is problematic, Zarate says. With such imprecise animal models and uncertainty about a disease’s pathophysiology, he adds, it’s no wonder that companies are hesitant to get into psychiatric diseases.

Until the genetics become clear enough to show what pathways to pursue, Scolnick says, he and his colleagues at the Stanley Center are working on developing inhibitors of another putative therapeutic target of lithium: glycogen synthase kinase-3, or GSK-3.

GSK-3 appends phosphate groups to serine and threonine amino acid residues. It functions in many pathways and has been implicated in diseases such as Alzheimer’s, type 2 diabetes, and cancer. “What it does in the human brain is very hard to tell,” says Peter S. Klein, the University of Pennsylvania professor of medicine who discovered that lithium inhibits GSK-3. One possibility is that lithium’s inhibition of GSK-3 turns on the Wnt signaling pathway, which stimulates the generation of neurons.

Inhibitors of GSK-3 are currently in clinical trials to treat progressive supranuclear palsy and certain cancers. But there are few reports of GSK-3 inhibitors being developed for bipolar disorder.

In 2007, researchers led by Alan P. Kozikowski, a chemistry professor at the University of Illinois, Chicago, reported that 3-benzofuranyl-4-indolylmaleimides are potent and selective inhibitors of GSK-3 (J. Am. Chem. Soc., DOI:10.1021/ja068969w). The most promising of the compounds Kozikowski’s team made calmed hyperactive behavior in mice that took amphetamine—the same model system of mania the ebselen researchers used. But Kozikowski says funding for the project dried up and his group hasn’t worked on GSK-3 inhibitors for years.

Scolnick says his group at the Stanley Center has come up with some selective GSK-3 inhibitors, but he declined to comment on their structures. Now, he says, they’re doing classical medicinal chemistry to boost the molecules’ pharmaceutical profiles.

Some people are concerned about using GSK-3 inhibitors, Klein says. Inhibiting GSK-3 potently activates the Wnt pathway, he says, and activation of the Wnt pathway is a key step in roughly 90% of colorectal carcinoma. “The worry is that you’re going to cause cancer,” he says. “In the many years that lithium has been studied, there has been no increased incidence of leukemia or cancers in people taking lithium,” Klein is quick to add, “but a more potent GSK-3 inhibitor could be oncogenic.”

One drug that’s recently grabbed the spotlight for treating bipolar depression is the anesthetic agent ketamine. In the past few years, trials in people have shown that a subanesthetic infusion of the drug can relieve the symptoms of depression and suicidal urges in a matter of hours, says NIMH’s Zarate, who conducted some of the studies. The effect lasts about a week, whereas commonly prescribed antidepressants usually take weeks to work.

Ketamine is a derivative of phencyclidine, or PCP, and acts as an antagonist of N-methyl-d-aspartate glutamate receptors. There’s some evidence that its antidepressant effects may be modulated by GSK-3, although scientists aren’t sure how.

“It’s really ignited interest in drug discovery and development,” Zarate says. His group and others are looking into compounds that act like ketamine but last longer and don’t have ketamine’s psychotropic side effects.

Although interest may be picking up, efforts from the pharmaceutical industry to develop new drugs specifically to treat bipolar disorder remain rare. Last year PhRMA, the Pharmaceutical Research & Manufacturers of America, put out a report on medicines in clinical trials to treat mental illness. Most of the 12 compounds listed for bipolar disorder fall into the category of anticonvulsant or antipsychotic. Even the few that don’t fit into those categories were originally developed for other uses.

New drugs come at a price, though. “The expense of our medication is a problem,” says Leah Nakamura, who has bipolar disorder type I and coordinates several support groups for people with the illness. She points out that having bipolar disorder can make it tough to keep a job, so people lose their health insurance and can’t afford their medication.

Although lithium costs less than a dollar a day, drugs still under patent protection, such as aripiprazole (Abilify), can cost hundreds of dollars each month. “At some point you just can’t afford it,” Nakamura says, “and these are lifesaving drugs.”

Nakamura wishes she had better medications to choose from. She’s currently on her fifth drug to keep her bipolar symptoms at bay. If this one doesn’t work, she says, she doesn’t have many options, but she is still hopeful for the future. Nakamura says, “I tell our young adult support group, ‘Hang in there. Hope is on the way. They’re working on treatments for us.’ ”

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Off-Label Use Of Risky Antipsychotic Drugs Raises Concerns

Posted by admin2 on 19th March 2012

By Sandra G. Boodman, for Kaiser Health News, March 12, 2012

This story was produced in collaboration with The Washington Post.

Adriane Fugh-Berman was stunned by the question: Two graduate students who had no symptoms of mental illness wondered if she thought they should take a powerful schizophrenia drug each had been prescribed to treat insomnia.

(Illustration by Richard Borge)

(Illustration by Richard Borge)

“It’s a total outrage,” said Fugh-Berman, a physician who is an associate professor of pharmacology at Georgetown University. “These kids needed some basic sleep [advice], like reducing their intake of caffeine and alcohol, not a highly sedating drug.”

Those Georgetown students exemplify a trend that alarms medical experts, policymakers and patient advocates: the skyrocketing increase in the off-label use of an expensive class of drugs called atypical antipsychotics. Until the past decade these 11 drugs, most approved in the 1990s, had been reserved for the approximately 3 percent of Americans with the most disabling mental illnesses, chiefly schizophrenia and bipolar disorder; more recently a few have been approved to treat severe depression.

But these days atypical antipsychotics — the most popular are Seroquel, Zyprexa and Abilify — are being prescribed by psychiatrists and primary-care doctors to treat a panoply of conditions for which they have not been approved, including anxiety, attention-deficit disorder, sleep difficulties, behavioral problems in toddlers and dementia. These new drugs account for more than 90 percent of the market and have eclipsed an older generation of antipsychotics. Two recent reports found that children and adolescents in foster care, some less than a year old, are taking more psychotropic drugs than other children, including those with the severest forms of mental illness.

In 2010 antipsychotic drugs racked up more than $16 billion in sales, according to IMS Health, a firm that tracks drug trends for the health-care industry. For the past three years they have ranked near or at the top of the best-selling classes of drugs, outstripping antidepressants and sometimes cholesterol medicines. A study published last year found that off-label antipsychotic prescriptions doubled between 1995 and 2008, from 4.4 million to 9 million. And a recent report by pharmacy benefits manager Medco estimated that the prevalence of the drugs’ use among adults ballooned more than 169 percent between 2001 and 2010.

Critics say the popularity of atypical antipsychotics reflects a combination of hype that the expensive medicines, which can cost $500 per month, are safer than the earlier generation of drugs; hope that they will work for a variety of ailments when other treatments have not; and aggressive marketing by drug companies to doctors and patients.

“Antipsychotics are overused, overpriced and oversold,” said Allen Frances, former chair of psychiatry at Duke University School of Medicine, who headed the task force that wrote the DSM-IV, psychiatry’s diagnostic bible. While judicious off-label use may be appropriate for those who have not responded to other treatments for, say, severe obsessive-compulsive disorder, Frances said the drugs, which are designed to calm patients and to moderate the hallucinations and delusions of psychosis, are being used “promiscuously, recklessly,” often to control behavior and with little regard for their serious side effects. These include major, rapid weight gain — 40 pounds is not uncommon — Type 2 diabetes, breast development in boys, irreversible facial tics and, among the elderly, an increased risk of death.

The Latest Fad?

Doctors are allowed to prescribe drugs for unapproved uses, but companies are forbidden to promote them for such purposes. In the past few years major drugmakers have paid more than $2 billion to settle lawsuits brought by states and the federal government alleging illegal marketing; some cases are still being litigated, as are thousands of claims by patients. In 2009 Eli Lilly and Co. paid the federal government a record $1.4 billion to settle charges that it illegally marketed Zyprexa through, among other things, a “5 at 5 campaign” that urged nursing homes to administer 5 milligrams of the drug at 5 p.m. to induce sleep.

Wayne Blackmon, a psychiatrist and lawyer who teaches at George Washington University Law School, said he commonly sees patients taking more than one antipsychotic, which raises the risk of side effects. Blackmon regards them as the “drugs du jour,” too often prescribed for “problems of living. Somehow doctors have gotten it into their heads that this is an acceptable use.” Physicians, he said, have a financial incentive to prescribe drugs, widely regarded as a much quicker fix than a time-intensive evaluation and nondrug treatments such as behavior therapy, which might not be covered by insurance.

In a series in the New York Review of Books last year, Marcia Angell, former editor in chief of the New England Journal of Medicine, argued that the apparent “raging epidemic of mental illness” partly reflects diagnosis creep: the expansion of the elastic boundaries that define mental illnesses to include more people, which enlarges the market for psychiatric drugs.

“You can’t push a drug if people don’t think they have a disease,” said Fugh-Berman, who directs PharmedOut, a Georgetown program that educates doctors about drug marketing and promotion. “How do you normalize the use of antipsychotics? By using key opinion leaders to emphasize their use and through CMEs (continuing medical education) and ghost-written articles in medical journals,” which, she said “affect the whole information stream.”

James H. Scully Jr., medical director of the American Psychiatric Association, sees the situation differently. He agrees that misuse of the drugs is a problem and says that off-label prescribing should be based on some evidence of effectiveness. But Scully suggests that a key factor driving use of the drugs, in addition to “intense marketing and some effectiveness,” is the growing number of non-psychiatrists prescribing them. Many lack the expertise and experience necessary to properly diagnose and treat mental health problems, he said.

Among psychiatrists, use of antipsychotics is rooted in a desire to heal, according to Scully. “All of the meds we use have their limits. If you’re trying to help somebody, you think, ‘What else might I be able to do for them?’”

Since 2005, antipsychotics have carried a black-box warning, the strongest possible, cautioning against their use in elderly patients with dementia, because the drugs increase the risk of death. In 2008 the Food and Drug Administration reiterated its earlier warning, noting that “antipsychotics are not indicated for the treatment of dementia-related psychosis.” But experts say such use remains widespread.

In one Northern California nursing home in 2006 and 2007, 22 residents, many suffering from dementia, were given antipsychotics for the convenience of the staff or because the residents refused to go to the dining room. In some cases the drugs were forcibly injected, state officials said. Three residents died.

A 2011 report by the Inspector General of the Department of Health and Human Services found that in a six-month period in 2007, 14 percent of nursing home residents were given antipsychotics. In one case a patient with an undetected urinary-tract infection was given the drugs to control agitation.

“The primary reason is that there’s not enough staff,” said Toby S. Edelman, senior policy attorney for the Center for Medicare Advocacy, a Washington-based nonprofit group, who recently testified about the problem before the Senate Special Committee on Aging. “If you can’t tie people up, you give ‘em a drug” she said, referring to restrictions on the use of physical restraints in nursing homes.

Drugs At 18 Months

Nursing home residents aren’t the only ones gobbling antipsychotics.

Mark E. Helm, a Little Rock pediatrician who was a medical director of Arkansas’s Medicaid evidence-based prescription drug program from 2004 to 2010, said he had seen 18-month-olds being given potent antipsychotic drugs for bipolar disorder, an illness he said rarely develops before adolescence. Antipsychotics, which he characterized as the fastest-growing and most expensive class of drugs covered by the state’s Medicaid program, were typically prescribed to children to control disruptive behavior, which often stemmed from their impoverished, chaotic or dysfunctional families, Helm said. “Sedation is the key reason these meds get used,” he observed.

More than any other factor, experts agree, the explosive growth in the diagnosis of pediatric bipolar disorder has fueled antipsychotic use among children. Between 1994 and 2003, reported diagnoses increased 40-fold, from about 20,000 to approximately 800,000, according to Columbia University researchers.

That diagnosis, popularized by several prominent child psychiatrists in Boston who claimed that extreme irritability, inattention and mood swings were actually pediatric bipolar disorder that can occur before age 2, has undergone a reevaluation in recent years. The reasons include the highly publicized death of a 4-year-old girl in Massachusetts, who along with her two young siblings had been taking a cocktail of powerful drugs for several years to treat bipolar disorder; the revelation of more than $1 million in unreported drug company payments to the leading proponent of the diagnosis; and growing doubts about its validity.

Helm said that antipsychotics, which he believes have become more socially acceptable, serve another purpose: as a gateway to mental health services. “To get a child qualified for SSI disability, it is helpful to have a child on a medicine,” he said, referring to the federal program that assists families of children who are disabled by illness.

Ask Your Doctor

Psychiatrist David J. Muzina, a national practice leader at pharmacy benefits manager Medco, said he believes direct-to-consumer advertising has helped fuel rising use of the drugs. As former director of the mood disorders center at the Cleveland Clinic, he encountered patients who asked for antipsychotics by name, citing a TV commercial or print ad.

Some states are attempting to rein in their use and cut escalating costs. Texas has announced it will not allow a child younger than 3 to receive antipsychotics without authorization from the state. Arkansas now requires parents to give informed consent before a child receives an anti-psychotic drug. The federal Centers for Medicare and Medicaid Services announced it is summoning state officials to a meeting this summer to address the use of antipsychotics in foster care. And Sens. Herb Kohl (D-Wis.) and Charles E. Grassley (R-Iowa) introduced legislation that would require doctors who prescribe antipsychotics off-label to nursing home patients to complete forms certifying that they are appropriate.

Medco is asking doctors to document that they have performed diabetes tests in patients taking the drugs. “Our intention here is to get doctors to reexamine prescriptions,” Muzina said.

“In the short term, I don’t see a change in this trend unless external forces intervene.”


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Armed to the teeth: The Craig Belknap Story

Posted by admin2 on 22nd October 1993

From The Oregonian, October 21, 1993 – not available online.

Ten years ago, Craig M. Belknap had one enduring obsession: a college student he stalked for years in and around Spokane.

Today, people who know him say Belknap’s obsession is fascism, Nazism and guns.

He has amassed a notable arsenal of weapons and ammunition in Portland even though he doesn’t hold a job and is a former Washington state mental patient with a history of harassment.

Belknap also has been linked to Aryan Nations, a militaristic white supremacist group based in Idaho.

“He’s said the only person he really admired was Hitler,” said his mother, Nita Belknap, “It just made me cringe to hear it. I tried to talk him out of it but there is no talking him out when he makes his mind up. At least I can’t do it.”

Belknap, 35, is awaiting trial in Clackamas County Jail on misdemeanor weapons and trespassing charges. He came to local police attention Sept. 23 in a Clackamas Town Center parking lot, where he had just bought a bulletproof vest from an unidentified man.

Deputies found several weapons on Belknap, including a loaded and cocked .22 caliber Magnum derringer and other handguns.

His case raises several questions:

    *How did he obtain the guns? Authorities won’t say. There are, however, state and federal laws aimed at preventing someone with a history of mental problems from buying firearms from legitimate dealers.

    *What was he planning to do with the weapons? There is little indication of his plans, although an apparent suicide note was found in a search of his apartment.

    *Why did Clackamas County authorities release Belknap after initially arresting him and seizing several weapons? The district attorney’s office says it is standard procedure to cite someone, release him and take the case to a grand jury for indictment. They did keep the seized weapons.

They also say they did not know until later about his mental history and did not know until he was indicted and rearrested that he had numerous other firearms in his apartment. They apparently also did not know that Belknap had reportedly made threats against Portland Mayor Vera Katz.

Belknap left the Clackamas County Jail the day after his arrest and returned to his downtown Portland apartment, just blocks from City Hall.

Belknap’s bail was raised from $100,000 to $500,000 because officials felt he posed a potential threat to the community. His case also has pricked the interest of Alcohol, Tobacco and Firearms agents, the Portland Police Bureau, the FBI and the U.S. Attorney’s office.

Belknap did not reply to requests for interviews, and his attorney, Charles Moore, declined comment.

After Belknap’s second arrest, authorities found more weapons, ammunition and some anti-Semitic literature in his Portland apartment, along with a letter of warning to a local television station and the suicide note.

Authorities believe Belknap may have more weapons in a downtown storage locker. They say they have not sought a search warrant because neither the locker nor its contents were linked to any crimes.

That was before Clackamas County deputy district attorney Jerry Seeberger asked for a court order to have the state of Washington turn over Belknap’s mental records.

State and federal laws restrict people diagnosed with mental disorders from buying or possessing firearms. It is also against the law to sell or give firearms to a person diagnosed with mental disorders.

Alcohol, Tobacco and Firearms agents are tracing the weapons. “At this point,” said ATF unit supervisor John McMahon, “We don’t know how he came to obtain those weapons.”

Authorities won’t discuss Belknap’s mental records, but Belknap’s mother remembers vividly the times her son was in and out of Washington state mental hospitals.

“Initially, it was this girl that he fell in love with,” she recalled. “He went on her wagon for a couple of years. He was in love with her, but she wouldn’t have anything to do with him. She was scared.”

In fact, the college student was terrified. In 1982, Belknap was sent to Eastern State Hospital after four years of stalking the student.

He had spotted her when they were both students at Gonzaga University in Spokane. He followed her everywhere. He wrote hundreds of letters and called the student’s family home more than 27 times a day. The young woman had never even spoken to him.

Many of the letters Belknap sent to the young woman were intimidating and obscene. In one letter, he wrote about having her in the back seat of his car, her face covered with razor slits.

When he finally landed in jail for refusing to leave her house, he told a newspaper reporter that he was inflicting “noble terror” on his victim.

At one point, authorities moved Belknap from Eastern State Hospital to Western State Hospital to put more distance between him and the student, whom his mother said he continued to harass.

Nita Belknap, who still lives in Tacoma where she raised her son, said that the obsession lasted until 1990.

In 1986, Belknap was committed again to Western State Hospital in Washington. Doctors diagnosed Craig Belknap as suffering from bipolar manic depression and paranoid schizophrenia, his mother said.

In 1987, Belknap applied for a concealed weapons permit but authorities turned him down because he had a history of mental instability.

He was living in Tacoma in 1988 but made frequent trips to Seattle. Seattle police reported they had contact with Belknap five times that year, all harassment complaints.

The complaints involved claims of harassment at a bank, a university, two television stations and a government office, Seattle police reported.

That same year, according to Tacoma Police spokesman Wally Mason, Belknap was spotted recruiting enrollment for the Aryan Nations at Seattle’s Bumbershoot festival.

Mason said that Tacoma police considered Belknap an affiliate of the Aryan Nations. Police also considered him mentally unstable and dangerous, Mason said.

For the past 1 1/2 years, Belknap rented a studio apartment in downtown Portland. The apartment complex is federally subsidized housing for low-income elderly, handicapped and disabled residents.

Even though his mother says he has never held a job, Belknap was able to afford occasional tickets to the Performing Arts Center. One day, employees said, Belknap demanded a refund for a production of Romeo and Juliet when he learned that Juliet was played by a black woman.

He was always polite and placid and never appeared threatening.

“He usually spouted pretty standard white supremacist stuff,” said Jan Powell, art director for the Tygres Heart Shakespeare Company.

Employees of the theater company and the Performing Arts Center said racist and anti-Semitic literature would sometimes appear stuffed under doors and in brochure boxes.

Belknap is facing four counts of unlawful possession of a weapon, two counts of carrying a concealed weapon, one count of carrying a concealed weapon and one count of trespass with a firearm. His jury trial in Clackamas County District Court starts Thursday.

No other state charges have been filed against Belknap. Seeberger, the prosecutor, says Oregon’s statute is flawed because it restricts only people committed to Oregon mental institutions from owning guns. It does not deal with people committed in other states.

Belknap was born in Tacoma in 1958. He was educated in Tacoma Catholic schools and was considered very bright. He graduated with honors from Gonzaga University in 1981 with a degree in English.

His father, Chet Belknap, was found dead in a Tacoma hotel in 1982 from alcohol and prescription drug overdoses. He was physically abusive to his family, but as Craig Belnap grew to adulthood, Chet Belknap began to fear his son, Nita Belknap said.

Nita Belknap, who watched her son grow up, watched him lose perspective, watched him turn against Jews, doesn’t want to see him as a danger to anyone.

“I don’t think he is, personally,” she said. “I can’t believe, in knowing my son, that he could be that kind of person… I may be all wrong, but that’s my gut instinct.”

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Beyond our reach

Posted by admin2 on 23rd October 1992

From The Oregonian, October 21, 1992 – not available online

Jane Hoyt’s sense of reality left her in the days before she died.

She told people she was married to Jim Morrison, the late singer for The Doors. That the air smelled bad all over Portland because witches were burning. That somebody was trying to steal all her assets.

So, maybe standing there on the edge of the Hawthorne Bridge on Aug. 18, she believed she could fly. Or maybe, looking at the Willamette River below, she saw something besides choppy blue-gray water. Awash in delusions, maybe the 40-year-old Hoyt couldn’t understand that plunging from the bridge would mean death.

No one will ever know.

Wandering the streets of Portland, her mind racing from one bizarre thought to the next, it didn’t matter that Jane Hoyt, a former TV reporter and promotions manager, had money and friends and a family who desperately wanted to help her.

In the middle of a manic episode — one phase of bipolar disorder, the disease that afflicted her for several years — Hoyt was utterly incapable of helping herself. Yet, when she brushed with police on at least three occasions in the days before her death, they did nothing to help her, either. To intervene, say police, would have violated her civil rights.

Lay people call Jane Hoyt’s illness manic-depression. It affects about 1.5 percent of the population and generally doesn’t show up until early adulthood. Hoyt was diagnosed in her mid-30s, well after she was into a big-time television career. Her disease eventually got in the way of work. Perhaps worst of all, though, the disease embarrassed her, says her family.

Throughout history, a number of creative people are believed to have been afflicted with bipolar disorder. Composer George Frederick Handel wrote the “Messiah” in five weeks during a manic episode. Poets Edgar Allan Poe, Ezra Pound and William Blake supposedly were manic-depressive. More recently, actress Patty Duke said she has lived with the illness since her teens.

For Hoyt, though, her illness always carried a stigma.

“She lost her confidence with this damned disease,” says her sister, Anna Lyon. “She couldn’t accept it. She never looked at it like having diabetes or some other medical problem.”

When the illness was under control, Hoyt would look back on her manic episodes with shame, her sister says. “What if you were running around doing crazy things? It was terribly hard for her to face,” says Lyon.

Hoyt arrived in Portland Aug. 12 on an airplane from Maine, where she had lived for two years. She was to be a bridesmaid in a friend’s wedding. From the way she acted in Portland, though, Hoyt clearly was having a manic episode.

At a bridal shower, her behavior was peculiar, says another sister, Margaret Guinasso. And in the middle of a formal dinner, Hoyt ripped off her clothes and went for a swim.

Her friend told Hoyt that although she wanted her to attend the wedding, she didn’t think Hoyt was up to being a bridesmaid.

Enraged, Hoyt sent her luggage to the Hotel Vintage Plaza in downtown Portland and left her friend’s home. No one close to her ever saw her alive again.

While her family searched for her — checking homeless shelters, distributing homemade missing-person fliers — Hoyt’s corpse lay in the morgue for a month. It was the final indignity of many suffered by a talented, creative woman whose disease — when untreated — robbed her of her rational mind.

Manic-depression is a mood disorder characterized by episodes of mania, during which a person feels on top of the world, and deep depression. No one knows exactly what causes the illness, but genetic links are strong.

In the beginning of a manic phase, people with bipolar disorder frequently are very productive. They feel euphoric. They are a whirlwind of activity. They hardly sleep.

Eventually, though, the mania and lack of sleep combine to make them irritable. Then the irritability can give way to psychosis. As the manic phase progresses, people with bipolar disorder lose touch with reality. They think things that aren’t true. They make irrational decisions.

After such an episode — which, untreated, may last as long as three months — a debilitating depression always follows.

Unlike an acute depression, which affects as many as 5 percent of the population at least once in their lives, bipolar disorder is a chronic illness with no cure.

That said, though, the disease frequently can be controlled with lithium, a naturally occurring metal that, as a medicine, works to level out a manic-depressive’s extreme moods. Sometimes, anti-epileptic drugs are prescribed for bipolar disorder, but psychiatrists say lithium is widely accepted as the first course of treatment.

When Hoyt took her medicine, it was impossible to tell she had a mental illness. When she didn’t, or when the level of lithium in her bloodstream fell too low, a manic episode would ensue.

Even though lithium is effective, patients often don’t like it because it makes them emotionally flat.

“It’s hard for some people to feel any feelings when they’re taking it,” says Christine McCartney, a senior clinical psychologist at Oregon State Hospital in Wilsonville.

In addition, the drug’s side effects include tremors and mild memory impairment. Some patients gain 40 to 60 pounds in a year. It also can contribute to diarrhea and a need to urinate frequently.

McCartney says up to 30 percent of all people with manic-depression stop taking lithium against their doctors’ advice.

Bipolar disorder, in a way, is more insidious than other forms of mental illness because the manic episodes can produce such great highs, say medical professionals. It’s a rush that some patients find irresistible.

Mick Schafbuch, Hoyt’s former boss at KOIN, chanced to meet her in the KOIN Tower lobby on Aug. 17, the day before police believe she died.

It’s an encounter he recalls in detail because the unkempt woman he spoke with was so unlike the Jane Hoyt he remembered.

For one thing, Hoyt’s looks had always caused heads to swivel. At 20, she worked as a movie double for Raquel Welch. Just a few years ago, during a marital separation that eventually ended in divorce, word was she was dating a famous TV game-show host. No one was surprised. Not only did she have the looks — slim but shapely, pouty lips and a mane of light brown hair always tousled just so — she was smart, to boot.

Hoyt left KOIN in 1986 bound for Los Angeles and a management job with King World, syndicator of such programs as “Jeopardy!” and “The Oprah Winfrey Show.”

So when Schafbuch spied Hoyt in skintight purple shorts, peekaboo sweatshirt and sandals, it took him a moment to realize that this was the same woman who had cut such a striking, stylish figure during her days with Channel 6.

“I walked up to her and said, `Jane, how are you? What are you doing here?’ “ says Schafbuch.

They chatted for a few minutes. Hoyt told Schafbuch she had come to Portland for a friend’s wedding. But the friend, said Hoyt, took Hoyt’s Jaguar from her. Now, she told him, somebody was trying to steal all her assets.

“I asked her if there was someone I could call for her,” says Schafbuch. “She said no.”

Schafbuch couldn’t have known it, but Hoyt’s sister, Margaret Guinasso, was frantically trying to find her.

On Aug. 16, Guinasso, the only member of Hoyt’s immediate family who now lives in Portland, filed a missing person’s report with the Portland Police.

She asked the management at Hoyt’s hotel to telephone her if her sister showed up. And the hotel did call once, with the message that Hoyt was in the lobby, involved in a fracas.

“I called the police and asked them to hold her until I could get help and get there,” says Guinasso.

They didn’t.

Police say detaining Hoyt or carting her off to an emergency room for a mental evaluation would have violated her rights; no officer who encountered her believed she was a threat to herself or others.

On the final occasion, police escorted Hoyt from the Marriott Hotel lobby, where she had fallen asleep, says Guinasso. The hotel is across the street from the Willamette River, a short walk from the Hawthrone Bridge.

“My feeling is that Jane went straight from the Marriott to the bridge,” says Guinasso.

The family believes that police could have detained Hoyt, even if they failed to connect her as a missing person.

“She was clearly out of it. She was kicking and scratching people,” her sister says.

That Hoyt crossed with police so many times and was never taken to a hospital emergency room disturbs Dr. Joseph Bloom, chairman of the psychiatry department at Oregon Health Sciences University.

“I don’t want to be a police basher, but I think this case really needs to be looked at,” he says.

Police spokesman Derrick Foxworth says there must be evidence of a threat to safety before police can hold someone. Acting goofy isn’t enough.

Several times dating to 1986, Hoyt was hospitalized because of bipolar disorder. She moved from Los Angeles back to Portland about 1988. Then in 1990, she moved to Edgecomb, Maine, renting a cottage by the sea. Her brother, Billy, lives in Edgecomb, and sister, Anna Lyon, lives nearby. The Hoyt family has a summer house in Bristol, Maine, which has been passed down from generation to generation for the better part of two centuries, so her parents were frequently around, too.

Mostly, Hoyt lived quietly and unremarkably in Maine. She was writing a screenplay. She frequently visited her sister and brother.

Then, early this year, Hoyt’s father, Bill Hoyt Jr., a newsman at KGW and KOIN during the 1960s and ’70s, was diagnosed with lung cancer. Hoyt helped care for him at her parents’ home in Dover, Del. He died July 7.

“Jane took it very hard,” says her mother, Muriel Hoyt. “She thought the world of her dad.”

Her family believes that the stress of her father’s death was part of what triggered Jane Hoyt’s final manic episode.

With this illness, says Oregon State Hospital’s Christine McCartney, self-esteem problems also are common. So much so that about 15 percent of all people with this disorder commit suicide .

Muriel Hoyt says after her daughter was diagnosed, she never would get too close to anyone. “I think she was afraid people would not accept it or understand it.”

Hoyt’s world grew smaller and smaller.

Sometime this year, Jane Hoyt wrote a letter — never mailed — to Ted Turner, the broadcasting magnate who acknowledged in a Time magazine article that he requires lithium to stay calm.

This is what she said:

“Maybe someday I’ll come to terms with my illness. The stigma and consequent embarrassment is weighty. But perhaps I’ll reach a point when I can look back without bitterness and resentment.

“If I thought my story would help others,” wrote Hoyt, “I’d share it in an instant.”

A memorial service for Jane Hoyt will be held at 7:30 p.m. Friday in Lake Oswego’s Our Lady of the Lake church.

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