Bipolar 2 From Inside and Out

My Guest Spot on a Mental Health Podcast

09 27 26

TW: Self-harm

Recently, mental health educator Ilona Poka asked if I would be interested in appearing on her podcast, Real Human Moments, to have a conversation on a topic that would reveal something about a personal struggle I had and wanted to explore in a way that might be helpful to others, or at least resonate with them.

Instantly, I said I would choose the topic of self-harm if Ilona thought that would fit in with the series. She said it would. The podcast will debut on Friday, Oct. 9, at 9:00 a.m. on YouTube and Spotify.

I’ve written about the subject of self-harm in this blog in the past, a decade or more ago. I figured it was time to revisit the subject and share my experiences with an audience who hadn’t seen those posts. For those people, here are some things I said that don’t duplicate what I said in the podcast:

The name does keep changing. The last I heard, the “approved” psychiatric term was “Non-Suicidal Self-Injury” (NSSI). Self-mutilation, deliberate self-harm, non-fatal self-harm, self-destructive acts, self-inflicted violence, parasuicide, and self-wounding are all names for the dangerous practice performed by desperate people. The subject still isn’t talked about much and carries a huge stigma. As if the mental and physical scars were not enough.

Some facts: Self-harm is not attempted suicide, though with some miscalculation it can lead to serious permanent injury or death. Most people associate it with teenage girls, but I’ve know at least one man in his 50s who cut himself fairly regularly. It is not a matter of attention-seeking, since most cutters hide their physical wounds.

As I understand it, the practice results from one of two phenomena: the build-up of painful pressure such as perfectionism, or a feeling of severe alienation to the point of numbness. Cutting is a coping mechanism, though a dangerous, dysfunctional, and unsuccessful one, to deal with pain.

Cutting isn’t going away if we ignore it. It won’t go away even if we do talk about it. (Or mock it, or gasp in horror.) But understanding self-injury is a big step.

Self-harm is basically a private thing – something we do and hide from the world. Some people are able to hide it even from their most intimate family and loved ones.

As most cutters and other people who self-harm do, I feel shame in recalling the act, and almost never speak of it. The reason I’m sharing the story in such a public forum is to let people know that not all self-harm consists of big dramatic gestures. It can start with a tiny scratch. But it is not something to be ignored. We need to talk about self-harm, educate about it, bring it out in the open, and let others know that it doesn’t have to continue.

And here are some resources for people who self-harm and the people who care about them.

S.A.F.E. alternatives https://selfinjury.com/

Self-Injury Outreach and Support: http://www.sioutreach.org (This does not appear to be active anymore, but there is a resource/FAQ sheet still available, and they recommend the book by Kim Gratz & Alexander Chapman. Freedom from self-harm: Overcoming self-injury with skills from DBT and other treatments. 2009, New Harbinger Publications. It is still available on Amazon.)

988 Crisis Hotline

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What’s Serotonin Syndrome? And How Do I Avoid It?

09 20 26

This week, I sent my husband to the pharmacy to pick up a prescription for me. The pharmacist told him to call me and put us all on the phone together. The prescription was for tramadol, a pain pill that I needed for a foot injury.

What the pharmacist wanted to know was whether I was aware of the possibility of serotonin syndrome. Of course, I said I was. At least I thought I was. After all, I had been on SSRIs for literally decades, and I’d heard the term before.

The pharmacist filled my scrip and included an informational leaflet on serotonin syndrome. I read it over, and that’s when I realized how little I really knew about the condition. But the thought occurred to me that it must be a fairly common thing, since they had leaflets about it on hand. (I found out it’s considered rare to uncommon, but handing out information seems wise nonetheless.)

I guess it shouldn’t have surprised me that a rare illness provokes such concern, given the number of people who take SSRIs—26 to 30 million in the US. There are approximately 4.5 million who take tramadol. I couldn’t find stats on how many people take both. Tramadol is a mild opioid that also affects serotonin receptors, so it is likely to amplify the effects of SSRIs.

And there’s the problem. The combination of the two drugs, or SSRIs and other drugs, can have the effect of increasing your serotonin without your realizing it.

In addition to reading the information sheet, which name-dropped tramadol as a particularly dangerous pairing with SSRIs, I decided to look it up online as well. I’m pretty particular about what online sources I use. (I use Wikipedia only to look up people’s bios, and I rely on sites like Mayo Clinic and Harvard Health for medical info.)

Too much serotonin causes serotonin syndrome. The effects of the increased dose include both physical and mental symptoms, from the mild (shivering and mild tremors) to the serious (coma and even death). Body temperature can become dangerously high. Cedars-Sinai lists possible effects as:

Seizures

Tremors

Muscle twitching or jerking

Restlessness or agitation

Sweating, nausea, vomiting, or diarrhea

Dilated pupils

Confusion

Rapid heart rate or blood pressure changes

High fever

I am pleased to report that I haven’t experienced any of the symptoms of serotonin syndrome (though some, like confusion and shivering, might be hard to spot in my case. I get confused easily when I’m trying to write and have to stop to take a phone call, and I always feel cold.) I am also pleased to report that I am weaning off the tramadol, taking one-half twice or three times a day rather than a whole one four times per day.

Still, just because I haven’t suffered much, if any, ill effects from the combination of tramadol and serotonin is no reason to take the chance of serotonin syndrome lightly. Other high-risk combinations with SSRIs include other SSRIs, MAOI inhibitors, some opioids, migraine meds, OTC cough medicine that contains dextromethorphan, St. John’s wort, some antibiotics or anti-nausea meds, and stimulants. A health care professional or pharmacist can explain these interactions in more detail.

Anyway, I’m not bashing SSRIs, as so many people are these days. They have saved my life and done the same for countless others. Are they overprescribed? Almost certainly, but so are antibiotics.

What I’m saying is to know the real dangers, educate yourself about them, and be careful.

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Bipolar Creativity

09 13 26

Does bipolar disorder enhance creativity or hinder it? That’s the question, and it’s one I want the answer to as much as anyone. After all, I am a writer, blogger, and editor. (And if you don’t think being an editor is creative, you’re probably thinking of a proofreader. I’m one of those, too.)

BP Hope magazine recently published a series of articles on the topic. In one, writer Francisco X. Stork wanted to say to a mother who reported that her son refused to take his bipolar meds, fearing that they would stifle his creativity, “If her son truly has bipolar disorder, then whatever he thinks he’s doing while in its grip is not art.”

That’s harsh, but I have an inkling of where he was coming from. Stork says that what he wrote under the influence of mania and even hypomania was “gibberish.” He points to his four published, well-received novels as being products of his creative powers while medicated properly for his bipolar disorder.

I think the operative words there are “medicated properly.” Stork adds, “Does medication affect my work? Yes. But not nearly as much as the unfettered symptoms of bipolar disorder do.”

I’m not saying that medication is necessary in order to be creative. There are no doubt and no doubt have been many creative people who were unmedicated or improperly medicated. Most of them we don’t know about because they lived before bipolar was a diagnosis or proper medication existed.

Stork’s opinions bear out my own experience. I write two blog posts of around 500-800 words each, almost every week since 12 1/2 years ago. I’ve been told by others and seen for myself that when depression or hypomania creeps up and attacks me, I lose not the overall ability to write, but the ability to write well. When I’m depressed, I write depressing things or have a hard time writing at all. I usually force myself to do it, but it’s certainly not my best writing. And when I’m hypomanic, I’ve been told (and believe) that my writing is unfocused, rambling, and/or poorly structured.

BP Hope ran another article by Donna Jackel. The key takeaways included these:

  • Mild hypomanic traits, like extra energy and fast thinking, may boost creativity, while severe symptoms can hurt it.
  • Mania may spark ideas, but mood stability can make it easier to focus and follow through.
  • Treatment doesn’t mean losing creativity, and stopping medication to protect it can carry serious risks.

Those points, I feel, are important. Jackel reports that “A review pooling 13 studies and nearly 1,900 people found a real, but very small, connection between bipolar disorder and creative-thinking scores — one that showed up mainly when people were feeling stable or had mild symptoms, and disappeared during depressive episodes. Mood state, in other words, may matter just as much as the diagnosis itself.”

Kay Redfield Jamison has also addressed the question in her many books. One question she has asked is “Does hypomania cause creativity, or do the two simply run in parallel?” And one answer may come from Sheri L. Johnson, PhD, a psychology professor at UC Berkeley, who studied people who self-identified as highly creative and living with bipolar disorder, and found that “More than half the participants described unique states of creative thinking that benefitted their work.” More than half also “considered creativity central to their identity.” She hopes that these findings will help reduce the stigma surrounding bipolar disorder and other mental illnesses.

The links between bipolar and creativity are complex. Other research has shown that “People with stronger hypomanic traits came up with more ideas overall, but when judges rated how good those ideas actually were, they scored lower on average….A flood of ideas during hypomania, in other words, isn’t the same as a flood of good ones.”

Painter Missy Douglas recommends performing other creativity-related tasks while manic or hypomanic, such as running errands and preparing her materials. “I come up with a lot of complex, involved ideas for new projects in the studio during these times, but bringing them to fruition doesn’t normally happen until I’ve calmed down, if ever,” she adds.

Creative activities can help mitigate bipolar symptoms, however. Art therapy that includes sketching, painting, and even ceramics and making collages is a way to experience emotional release. Writing and journaling are good for mood management. Other people find music and movement good as coping tools, or use expressive dance for emotional regulation.

All in all, bipolar disorder may not be good for creating art, but creating art can be good for bipolar disorder.

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Receiving Help

09 06 26

Sometimes it’s harder to receive help than it is to give help or to ask for it.

I’ve needed lots of help with my bipolar disorder over the years, and my husband has consistently been there to give it. His help has been the embodiment of the wedding vow “In sickness and in health.”

He’s held me when I’ve been depressed and tells me when it seems like I’m shifting into hypomania. He’s my “emotional support animal.” And he helps me with tasks of daily life like meals and showers.

Recently, though—well, really, throughout the past year—I’ve needed physical help as much as or more than emotional support. I’ve been through a series of physical challenges that started when I had a knee replacement and have progressed to the point where I am in pain every day and very nearly housebound. The kinds of help I’ve needed have been complicated and sometimes embarrassing.

I’ve been feeling guilty, needy, and insecure because my care requirements have increased so much. I know Dan is feeling insecure too, because he keeps asking me whether he’s taking care of me well enough. We’re both finding the situation stressful. I reassure him that he is doing a great job, and I try to make sure it’s not a thankless task.

Tonight we watched a movie on video together and had a pizza. It was a good break for both of us. But afterward, my bandages needed changing so I could get ready for bed. And so it goes.

Dan is about to experience his own set of physical needs as he needs a medical procedure, too. I hope I can repay a little of his care and kindness by giving some back to him. And I hope he’ll ask for help when he needs it. Like he does, I’ll do the best I can to give help while balancing both our needs.

Is all that confusing? Well, it’s no wonder. It’s a confusing topic, and I’m confused by it. Here’s what I know about help in a nutshell, though.

  • Asking for help. If you can do it, this is the first step. Ask for what you need. Ask as clearly and specifically as you can: “I’m feeling lonely/distressed/in pain. I need to talk to someone.” “My dressing needs to be changed.” “I need to eat something.” (Sometimes it’s easier if you phrase them as needs rather than wants. Asking for what you need makes it clearer that it’s not just a whim or something you could easily do without.) But if it’s all you can do at the moment, at least say, “I need help.” It improves the odds that you’ll actually get help. Then you can figure out the details later.
  • Giving help. If at all possible, give the person what they ask for. They know their own needs better than anyone else. Don’t guess. Sometimes the helper will need to ask questions to clarify. “Do you need to take your meds right now or with a meal?” “Which size bandage does this wound need?” If you can’t give the help right away, explain why not. “I’ll go to the store and pick up your other prescription. Then I’ll pick up lunch on the way back. Is that okay?” “I’ll be there in 20 minutes. Can you wait that long?”
  • Receiving help. This is the part no one tells you about, and it can be tricky. Say thank you, even if you didn’t get exactly what you asked for, and even if you’re in pain. Your helper is doing the best they can. Sometimes all they can do is part of what you need. Later, they may be able to do the rest of it.

All this is true, even if you have a paid caregiver. But if it’s a partner or family member, it’s even more essential.

Here are things to keep in mind:

You need help. Everyone does at one time or another. Everyone. No one is truly self-sufficient.

You deserve help. Help isn’t something you have to earn. Your needs are important.

You can get help. But in many cases, you have to ask for it. And you may have to keep asking. Don’t give up.

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Causes of Depression: The Debate Continues

08 30 26

Earlier this month, I wrote about inflammation and a possible cause of mental illness and, in the process, mentioned some of the theories about what causes depression. Now I want to revisit the debate and the pros and cons of the various possible explanations.

The leading suggested causes are emotions (anger turned inward), genetics, trauma, brain chemistry, and now bodily causes such as cell disruptions and inflammation.

Anger turned inward and other emotional mechanisms never made a lot of sense to me, though in the course of my depression (later revealed to be the depressive phase of bipolar disorder), I certainly experienced a lot of anger that I wasn’t able to express. In fact, I denied that it even existed. The emotions most associated with depression for me at that time were guilt, shame, and hopelessness. There was a veritable stew of emotions I had turned inward, including anger, but it was far from the only one. Everyone who’s depressed has their own stew of emotions, which may also include fear, self-hatred, blame, and/or resignation. Any of those could turn inward as well, punishing their sufferers with depression.

Genetics makes more sense when you consider that depression and other mental disorders can run in families. But it also arises in families with no history of depression. Statistics say that if one family member experiences major depression, other family members—parents, children, and siblings—are 30% to 50% more likely to have it too. It’s even higher in twins.

Depression’s heritability is complicated, however. There’s not a specific depression gene, but some combination of elusive genes that combine to foster that tendency. What genes they are and how they interact with each other are among the problems still to be solved. And if genetics cause depression, what to do about it is still a mystery.

Trauma, PTSD, and C-PTSD have also been implicated in depression. That really rings true. Experiencing personal trauma or witnessing it again creates a stew of emotions, many long-lasting, which could easily cause depression. If you’re living with the after-effects. potentially for years, it’s easy to see how depression might result. The science of epigenetics may explain how the genes themselves change or how they are passed on to family members. The answers may involve several different mechanisms.

Brain chemistry is the most controversial of the hypotheses for the cause of depression. The theory is that certain neurotransmitters, such as serotonin, are deficient or not properly taken up by their receptors. However, Harvard Health Publishing has noted that “It’s often said that depression results from a chemical imbalance, but that figure of speech doesn’t capture how complex the disease is. Research suggests that depression doesn’t spring from simply having too much or too little of certain brain chemicals.” The major treatment has been to try to restore the balance with medication.

Part of the problem with this theory, however, is that no one is quite sure how these drugs work, only that they do—but not for every person with depression and not reliably. The most popular antidepressants are thought to work by improving the uptake of these brain chemicals. Until recently, improving these chemical “imbalances” was the primary treatment for depression, and it did a lot of good for a lot of people. But if the receptors are flooded with neurotransmitters right away, why do they take six weeks or more to take effect? Why do the results lessen over time to the point where antidepressants quit working for some patients? Why do they have no effect on others (treatment-resistant depression)?

Neurons/Cellular Interactions and Immune Disruptions are the latest avenues being explored. Research has focused on specific areas of the brain, such as the hippocampus, which is associated with both emotion and memory. Excitatory neurons, which change gene functions, and microglia, which microglia, the brain’s immune cells, become dysregulated and cause ongoing inflammation, which can affect the brain..

Also, Columbia University has shown for the first time that neurogenesis stalls in the brains of adults with major depressive disorder. They have identified the molecular programs that control neurogenesis, which may help researchers develop new therapies.

These new theories, while they present hope for understanding depression and the brain, are still a long way from reaching a consensus, or even agreement on the causative factors. That means they’re also a long way from developing new treatments for depression. Until they do, selective serotonin reuptake inhibitors (SSRIs) will likely continue to be the front line of therapy for major depression.

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Is TMS Right for You?

08 23 26

On Tuesday, when I went to my psychiatrist’s office, I noticed a large display of brochures for Transcranial Magnetic Stimulation (TMS). My husband, who was with me, asked about it, so I told him what little I knew about what it is and what it’s supposed to do. But I realized that I’ve never investigated it thoroughly. When I was considering ECT, TMS was rather new and not an option offered to me. Then a change in medication alleviated my treatment-resistant depression at last. When we got home from my appointment, I thought I’d look into TMS further.

What Is TMS?

TMS, sometimes called rTMS (for repetitive TMS), is a non-invasive treatment for long-term depression (and perhaps a few other conditions such as OCD, PTSD, migraines, epilepsy, and even nicotine addiction). It differs from vagus nerve stimulation and deep brain stimulation because it doesn’t require surgery or cutting the skin.

TMS involves placing electromagnetic coils on the patient’s scalp and moving them around until they have the desired effect. The procedure targets areas of the brain that show decreased activity in patients with depression and is thought to activate those areas.

Calibrating the magnetic coils and determining their placement happens at the initial appointment. For subsequent appointments, the coils are simply placed at the effective points already determined. TMS only affects areas of the brain that are close to the surface. Sessions are required five days per week for several weeks. Each session lasts approximately 20 minutes or sometimes less.

TMS doesn’t require anesthesia and can be performed as an outpatient procedure in a provider’s office or a clinic. You don’t have to have someone to drive you home afterward, though you may want to for your first session until you know how TMS will affect you. Symptom relief can occur after several weeks of treatment.

TMS is FDA-approved, and most insurance plans cover it if you meet certain criteria, like having no effect from several antidepressant medications. Many also cover repeated treatments if the effects wear off. Deep TMS, in which the electromagnetic pulse reaches deeper into the brain, is FDA-approved for OCD and nicotine addiction when standard treatments have failed, but is off-label for other conditions.

Outcomes

Approximately one-third of people who undergo TMS experience full remission of their depression. Fifty to sixty percent report improvement of their symptoms. Most patients, however, experience remission lasting for months after the treatment, with positive outcomes averaging somewhat more than a year. But the results are not permanent; there is a high rate of recurrence. Patients can engage in multiple rounds of treatment after the effects wear off. For patients who don’t respond to TMS, ECT is often considered.

Side Effects

One of the first things I learned about TMS was that I wouldn’t have been a good candidate for it. My illness is bipolar disorder, which has a mania component, and one of the possible side effects of TMS is mania. And I might not qualify for it now, as I have metal implants in my body, which is sometimes a contraindication. Although TMS is sometimes recommended for bipolar depression, I’m not sure I would like to risk it. I would have talked it over with my psychiatrist.

TMS has other potential side effects as well, though not the memory loss that can accompany ECT. In addition to possible mania, TMS carries the risk of seizures, as well as hearing loss if the ears aren’t properly protected. More common side effects include headaches, scalp pain, lightheadedness, and twitching facial muscles.

Pros and Cons

The relatively high success rate is certainly a selling point. Even better outcomes are expected for TMS guided by fMRI for more precise placement of the magnetic coils. Although seizures can occur, the rate is approximately 1 in 10,000 sessions. In addition to alleviating depression, TMS may also reduce suicidal ideation. If you’re taking medications for depression, they will not interact negatively with TMS. Many clinics offer the procedure.

On the other hand, TMS is not for everyone. The treatments can be time-consuming. And some practitioners don’t treat patients under the age of 18 or over 65. If you’re not insured, the procedure can cost $6,000 to $15,000. Advanced equipment and the costs of added therapies can boost the total to $30,000.

Only you and your doctor can determine whether TMS is worth trying. But if you have longstanding, treatment-resistant depression, you may want to explore the possibility.

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Mood Music

08 16 26

Last week, I got to go out and hear live music—the Stray Cats, one of my favorite bands, were having a reunion tour with some new music, and I had tickets for it. I looked forward to it with great excitement (and a little anxiety, which proved warranted when a violent thunderstorm started as we were driving home on the highway). Aside from the thunderstorm, however, the evening was magical.

And I needed it. I’ve felt myself sliding toward the depressive end of the scale lately.

My Music

When I’m depressed, I always forget the power that music has to restore me. I have plenty of music accessible to me, on my Mac, Pandora, Spotify, and other sources. I even have Pandora on my iPad and my phone, so I can have music with me at all times. But I don’t remember, and I don’t make use of this inestimable resource that is always at my fingertips.

Of course, there’s nothing to compare with live music when it comes to restorative power, and I’ve been sorely short on that. I remember times in years past when I went out to hear live music as often as several times a week. Later in life, it became a lot less common, only happening every month or so. Now, it’s so uncommon that it doesn’t happen even once a year.

Listening to music—and singing along, loudly, enthusiastically, and totally off-key—clears the cobwebs out of my brain. I return to the same music over and over, favorite singers and songwriters, bands that no longer exist, artists who are now dead. I don’t object to new music, but it doesn’t hold all the memories, the weight and history, of music that I already love.

Bibliotherapy and Music Therapy

The idea of bibliotherapy is pretty well known. Self-help books abound (for all the good they do), and therapists sometimes recommend books and articles to their clients. Music as a part of formal therapy might be much more difficult to make work, however. One person’s soul-touching music is simply background music even to others who know that person well.

No one but me can prescribe what music “works” best for me on any given day. Are what I need raucous tunes to lift me up or calm ones to settle me down? Do I crave hearing a particular artist or band? Should I search out songs by a favorite songwriter that have been covered by others? Or do I simply click shuffle and let my vast playlist decide for itself?

There’s some science behind the idea that music can be good for people with depression. Listening to music has been associated with increases in neurotransmitters like dopamine, and the lessening of the levels of the stress hormone cortisol. Emotional release is another way that music works, allowing you to access feelings that you can’t actively name. “Active engagement,” such as playing an instrument, writing lyrics, or “intentional listening,” is also said to be good for grounding. It certainly activates more areas of the brain.

Still, we’re talking about some awfully subjective findings. A study-of-studies found that TAU (Treatment As Usual) with added music therapy “was superior to TAU alone for anxiety and functioning,” but that the combination “was not more effective than TAU alone for improved quality of life.” Maybe it’s just me, but I’d think that an improvement in anxiety and functioning is an improvement in quality of life.

Formal Music Therapy

That meta-study was looking at formal music therapy, however. What does that entail? One site I visited described individual and group music therapy like this:

“In individual music therapy sessions, a therapist works one-on-one with a client to address their specific needs. This personalized approach allows the therapist to tailor interventions to the client’s preferences, whether it involves playing instruments, songwriting or listening to music. Group music therapy sessions provide a supportive environment where people can engage with others through music. These sessions may involve collaborative music-making, improvisation or group discussions about the music’s impact. Group sessions foster a sense of belonging and provide opportunities for social interaction.”

I’ve never had that kind of music therapy. I’ve had to create my own with Pandora listening sessions and tickets to the Stray Cats. But I hope that if I’m ever in need of the formal variety, there will be some place where it’s available to me. For now, I’ll enjoy the subjective improvement in anxiety and functioning that I can build on my own.

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New Science: Inflammation and Mental Health

08 09 26

Over the years, I’ve heard all kinds of definitions and supposed causes for depression, from anger turned inward to double-jointedness. Many of these turned out, like these two, to be either questionable or outright bogus.

Now there is new information about what may be a factor in causing depression, bipolar disorder, schizophrenia, and indeed any diagnosed psychiatric disorder: inflammation. And there’s some science behind this theory.

Some have called the link between inflammation and mental illnesses “undeniable.” Others aren’t willing to go quite that far, saying rather that it “seems to be” a factor. Statistics seem to back this up. Roughly a quarter of people with major depression show increases in immune molecules that are associated with chronic inflammation. That’s far from saying that all people with depression also experience inflammation, or vice versa, however.

Even more intriguing, though, is that researchers have found that inflammation occurs before the depression sets in. Even childhood trauma, chronic low-level stress, and infections that are associated with inflammation are also implicated in treatment-resistant depression. Of course, they’re also associated with depression in general.

Brain chemicals aren’t entirely out of the picture either. Inflammatory proteins can reduce the levels of serotonin and dopamine in the brain and disrupt activity in areas of the brain associated with reward mechanisms. There’s also the possibility that inflammation and depression form a “loop” in which depression may increase inflammation and inflammation may have some causal effect in depression and other mental disorders.

So, what should you do if you think that inflammation might be a factor in your depression, bipolar, or schizophrenia? One option is to see a medical professional who can run tests to see if a connection between the two conditions is likely. It won’t be cheap. It involves specialized tests and assessments, as well as a doctor who knows something about the subject.

On the other hand, you can treat the inflammation with remedies that are known to have some effect. These include a change in diet, eliminating sugary drinks and ultra-processed foods; reducing the stress in your life, which is known to be associated with both inflammation and mental health issues; lessening indoor smoke inhalation, such as that produced by air freshener dispersers, incense, and candles; limiting alcohol consumption; increasing physical activity; and getting enough good sleep, including dealing with problems such as sleep apnea.

There are still many unknowns on the subject of inflammation and mental disorders. The reporting on the topic includes words like “may,” “might,” “associated with,” and “implicated,” which indicate that the link is not entirely solid so far. One article got the headline right (“How Inflammation Can Threaten Your Mental Health”), but then had a subhead that went the other way (Important breakthroughs promise new understandings and treatments”). Others asked questions that at least had some ambiguity (“which came first?,” “is there a connection?,” and “Could lowering inflammation treat depression?”).

I hate to end this post with a wishy-washy “Time will tell,” but honestly, that’s about the most I’m willing to say. That and “Follow the science.”

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“Why Don’t They Just Take Their Meds?”

08 02 26

That’s maybe the most common reaction to hearing about the unhoused mentally ill. After all, there are medications that lessen the effects of schizophrenia, mania, and bipolar delusions. Why wouldn’t a person take advantage of them? Don’t they want to be mentally healthy? Why wouldn’t they do something that can alter their lives so dramatically?

Anosognosia is frequently the answer.

What Is Anosognosia?

If you look in the DSM-5, you won’t find anosognosia listed as a separate illness. Instead, it’s a symptom of another illness, often called “lack of insight.”

But anosognosia is so much more than that. It’s the reason that a sufferer doesn’t even realize that they have a disorder. They aren’t able to comprehend that there is anything wrong with them, that they have a serious mental illness that affects the choices they make and the way their brains work.

This is not mere denial. Someone in denial realizes on some level that they have a problem. They just keep pushing it away. A person with anosognosia does not understand that they have a disorder, that their mind is affected by it, and that their behavior is shaped by their condition. It might instead be called “brain-blindness.” The schizophrenia or other condition itself prevents the person from perceiving that there might be something wrong with their thinking, emotions, and behavior. As far as they’re concerned, they have no illness.

The Medication Question

Schizophrenia was once considered an untreatable illness. All that could be done with a person suffering from the disorder was to put them away—lock them up so they couldn’t harm anyone. After all, the diagnosis of schizophrenia at the time was synonymous with violence. In the minds of many people, it still is.

So, if their disease is so severe and there is a medication that will help, why don’t they just take it?

Let’s think about this. If you didn’t have a serious heart condition, would you agree to take Inderal or Plavix? Would you just mind your doctor and take it anyway? Or would you decide you didn’t need it and stop taking it?

What if you took the Inderal and you experienced unpleasant side effects? You should tell your doctor that it’s having side effects that you can’t tolerate, such as dizziness, stomach pain, sexual problems, or vivid nightmares, and ask for something else. But you might be tempted simply to stop taking it without your doctor’s knowledge or input.

It’s the same with medications for schizophrenia. Many of them have very troubling side effects, including uncontrollable muscle movements (tardive dyskinesia), which may not go away if you take the medication for a long time. Weight gain, sexual dysfunction, sedation, or dizziness are other possible side effects. Stopping the meds might seem very attractive, especially if you don’t believe you are ill.

The Blame Game

It used to be that when the public saw the unhoused, the sick and suffering, they might think “But for the grace of God, that could be me.” At some level, they recognized the people they saw as human beings and knew that they, too, might someday fall prey to illness, financial reverses, or other disasters. There was empathy, or at least sympathy.

Now, that reaction has turned to “othering”—denying their common humanity. The “unfortunate” are to blame for their circumstances. They “choose” to live on the streets. They make bad decisions that lead to their problems. And they don’t take their meds. It’s all their own fault. They’re not like us.

Empathy only comes when a problem touches a person directly. Unless they have a schizophrenic or unhoused family member, they don’t think about how people get into dire circumstances. They separate themselves and continue to believe “it will never happen to me.”

But as the population ages, many people must deal with older relatives who have dementia, who sometimes become combative or violent, who may resist taking their medication, and who don’t realize that they have a condition that makes them confused, less capable, and in need of specialized kinds of care.

Unfortunately, that understanding seldom reaches the schizophrenic people who experience many of the same difficulties. And anosognosia is a big reason. If you’re not aware you need help, you’re not likely to get it.

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mental health

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Living With a Bipolar Family Member

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Let’s start with this: A bipolar family is like any other family. They have good times and bad. They live with each other; they fight with each other; they care about one another. They deal with each other’s differences and problems. But they have the added stressor that one or more members of the family have bipolar disorder.

What does this mean for a family? It does mean that there are likely to be difficulties that other families don’t face. Depending on how severe the disorder is, whether the family supports their relative in getting treatment, and the resources available to them, their lives will look quite different.

My Family

My family was unprepared for me to develop bipolar disorder. They knew that I was different, and often didn’t know what to do with me, particularly when I went into depressive episodes and retreated from the world, crying hopelessly. I remember this happening in seventh grade in particular. I had been publicly humiliated at a birthday party and spent days curled up in a bean bag chair, sobbing uncontrollably. My parents knew that something was very wrong.

Nothing happened for quite a while. When I was in high school, my behavior had gotten so off-kilter that it was recommended I go see the district psychologist. My parents left the choice up to me, and I didn’t go, for reasons that now seem completely ridiculous. I should have taken the opportunity.

Later still, when I was diagnosed and medicated with Prozac, my family was encouraging, but had some issues. My mother, who got a lot of her information from TV talk shows, said she had heard that Prozac was a “ticking time bomb.” My father had no objection to my therapy as long as he didn’t have to go (which no one had ever mentioned). But they continued to give me love and emotional support throughout, though they never really understood my condition or what I was going through. I don’t think they ever did, but they never gave up on me.

Other Families

I think it’s vitally important for family members of someone with bipolar disorder to learn all they can about the disorder. This will require bravery and openness on their part. But learning all you can about bipolar disorder will help you help your family member in the best possible way.

Of course, the kind of support a person with bipolar needs will differ greatly depending on how severe their symptoms and their disorder are. If they are subject to mild to moderate depressive phases, don’t try to “cheer them up.” It won’t work. Instead, talk therapy and/or medication, or, if they’re in a more severe depressive phase, an alternative therapy like TMS or ECT may be called for. Hospitalization is definitely an option if the family member has suicidal ideation.

If they’re in a manic phase, don’t just tell them to “calm down.” That won’t work either. Instead, help them be more grounded and keep potentially harmful behaviors in check. How you do this will vary depending on how their mania manifests. If they are given to reckless driving, for example, you keep the car keys and drive them where they need to go. If they’re an overspender, keep the credit cards and PIN numbers out of reach.

Help your bipolar family member in specific ways. Encourage them to seek therapy. If needed, drive them to their therapist appointments. Pick up refills of their medications for them. Get them a pill caddy to make it easier to take their medications as prescribed.

If your family member is experiencing delusions or psychosis, don’t argue with them about hallucinations, which are very real to them. They may also be suffering from anosognosia, which means they don’t even recognize that they are ill. You may have to intervene more directly, whether that means taking them to the emergency room or admitting them to a psychiatric facility. Do all you can while keeping yourself and the rest of your family members safe. If you or your loved one is in immediate danger, don’t wait—take action!

Kinds of Support

It may seem that you are taking agency away from your family member, and that is to some extent true. But until they’re more stable and able to demonstrate agency over their own condition, helping them negotiate the practicalities of their illness is likely the best thing you can do. You can’t change your family member’s disorder or change them; in most cases, all you can do is support them.

Remember there’s help available. In addition to your local or county National Alliance on Mental Illness (NAMI) chapter, you can get in touch with Depression & Bipolar Support Alliance (DBSA), the Bipolar Caregivers website, or bphope.com, which has online support groups. That last link will take you to a page that lists other organizations and resources that may be available to help you.

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mental health

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