Bipolar 2 From Inside and Out

Posts tagged ‘public perception’

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

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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Remote Work: Help or Harm?

Many people recommend that people who are no longer able to work a full-time job in an office try working from home. (There are ads that say you can make $500 a day doing it, but these claims are dubious at best, scams at worst.) The COVID years demonstrated that it was possible for someone to work from home even at a 40-hour/week job. So what are the benefits and drawbacks of working from home if you have bipolar disorder or another mental illness?

Pros

The benefits of working from home are apparent. If your condition makes it difficult to deal with high-pressure situations with extended contact with other people, remote work is quite appealing. You gain independence, the ability to cut down on distressing social interactions, and time to spend with family members or doing other chores and projects. Working at your own pace without so many distractions may mean that you can complete what’s considered 40 hours of work in less than that. And Zoom meetings are generally more efficient and less stressful than the in-person kind.

When you decide to work from home, you have many more options open to you. You can work part-time, for example, or start your own business. You can even structure your days so that you work for a company part-time and for yourself the rest of the time. You can take on a job that involves no in-person contact with others, such as phone or computer-based customer service, telephone sales, or order-taking. Then there are jobs you can accomplish almost completely on your own, like transcription and other forms of keyboarding, writing articles for clients or instruction manuals for manufacturers, or formatting and editing résumés and other documents. Perhaps you could team with another person who does client contact. If so, you can make a business of graphic design, for example.

Cons

On the other hand, remote work has been blamed for increasing isolation and distress. A study reported in Science revealed that remote work “worsens mental health, particularly for those living alone. Although a large body of research finds that workers want to work remotely, our findings suggest that workers may not realize the costs of remote work for their well-being, which may take time to accumulate….Our estimates indicate that remote work explains a third of the deterioration in mental health between 2011 and 2024.”

It’s true that people who work at home generally have only sporadic contact with other people, except in emails, Zoom meetings, and phone calls. The Science study says that “84 percent of remote workers spend their workday entirely alone. Even when communicating online, people working from home receive less feedback from their co-workers and contact fewer people outside their immediate teams.”

They add, “Despite its advantages, remote work has significantly deepened Americans’ isolation and distress. Our research doesn’t suggest that work can occur only in the office. But it does mean that employees and companies should make a greater effort to prioritize face-to-face time with colleagues.” Any contact with other people seems to make the difference: “People who lived with their spouse and kids saw their mental health hold fairly steady, while those who lived alone experienced a 20 percent decrease in mental well-being.”

My Experience

I used to work full-time in offices, spending a full 17 years at one office job and some time at others. During that time, I struggled with isolation and detachment from my coworkers. I tried. But the corporate culture of “mandatory fun” such as company picnics and parties struck me as challenging and empty, and only a few coworkers included me in their lunch hours and casual conversation. I blame myself as much as anyone. My social skills have never been terrific, especially when it comes to small talk.

Before I was let go from the 17-year job, I increased my own isolation by keeping my office door closed. My job did entail some aspects that required close attention to detail without interruptions. But that was an excuse. I preferred privacy even when doing normal busy work. Although closing one’s door was not strictly forbidden, an open-door policy prevailed. My closed door meant cutting myself off from interaction.

Since leaving the corporate world, I have worked at home at a series of jobs—transcription, editing, ghostwriting, book reviewing, and the like. In most of these jobs, I set my own hours, but I am indeed alone most of the day. I get regular calls from my husband when he’s on his breaks at his outside, people-y job. It helps. And I keep up with remote friends via email, Facebook, phone, and occasional visits.

Has my mental health deteriorated? Not appreciably. I have work to do some of the time and my blogs to write, emails to respond to, books to read, and friends to chat with. I’m occasionally unfocused, and I do experience mild depression and hypomania, but the depression is not anything like the depths of it when I worked in an office.

I can’t imagine going back to office work at this time in my life. I’m happy and stable enough where I am. I don’t want to mess with that.

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What Does the $700 Million of Funding Really Mean?

You may have heard about the $700 million that the U.S. government has allocated for funding “behavioral health programs.” A number of different programs are getting slices of that money, as announced by HHS Secretary Robert F. Kennedy, Jr. The Safety Through Recovery, Engagement and Evidence-based Treatment and Support (STREETS) Program, for example, will receive $96 million, while those other programs get to split up $612 million, all in service of President Trump’s Great American Recovery Initiative. Kennedy said that the money would address the “addiction and serious mental illness that fuel homelessness across America.”

Where Is The Money Coming From?

Mindsite News reports that behavioral health experts responded to the announcement by saying that the $700 million was really the release of funds that Congress had already authorized. The spending was already planned to be spent before Secretary Kennedy’s announcement seemed to promise new funding. Until now, the money had been held up rather than being distributed to state and local treatment organizations. The STREETS funds may be pulled from existing programs as well.

Where Is the Money Going?

That $700 million is intended to benefit “multi-agency, street-based behavioral health systems integrating government, healthcare, housing, law enforcement, and courts for people experiencing homelessness with SMI/SUD.” Interestingly, according to Medical Economics, the money will “exclude housing-first approaches and harm-reduction services, aligning awards with the Great American Recovery Initiative and shaping allowable evidence-based models for homelessness-related behavioral health care.”

In other words, if I’m reading this correctly, the funds are really designed mostly to combat homelessness (which the Secretary says will “move people from the streets into treatment and recovery, strengthen families, save lives, and make communities safer”). Getting unhoused people off the streets and out of the public gaze seems to be a more important goal than mental health or addiction services per se. And it ignores the fact that most people with addiction problems or mental illnesses are not unhoused. They could use funding, too.

Experts have suggested that, rather than trying to fund new programs, the money should be spent on what is already working within the treatment and recovery community, as well as on deficiencies in the current state of affairs regarding mental illness, addiction, and homelessness. Kennedy claimed that new, innovative programs would result from the money spent, but behavioral health advocate and political consultant Andrew Kessler points out that many existing problems, such as “a shorthanded workforce, poor reimbursement, and not enough resources to handle the challenges we face,” could be addressed with increased funding.

If that $96 million portion for STREETS doesn’t sound like it will make a dent in the problems nationwide, well, it won’t. It’s going to eight communities, which will each get up to $3 million per year for four years, “to develop multisector, state-of-the-art care systems for people who are homeless and have substance use disorders, serious mental illness, or co-occurring disorders.” Presumably, any success in those locations will be replicated in other communities, or at least other communities will be encouraged to replicate it, though it seems unlikely that they will get federal money to do so.

988 UPDATE

When I posted about the 988 helpline a couple of weeks ago, I promised that if I heard anything new regarding Option 3 of the helpline, which is designated to help people in the LGBTQ+ community, I would let you know. Here it is:

Mindsite News, citing a story in The Advocate, reports that Congress has directed the agency that administers the 988 helpline “to reactivate the [Option 3 for LGBTQ+ crisis calls] service, but says it must do so in accordance with Trump’s Executive Order 14168, which recognizes only two sexes and rejects federal recognition of trans and nonbinary gender identities.” Mindsite adds that “the administration hasn’t explained how the two mandates can coexist or whether transgender youth will be included at all in any restored program.” The administration expects Option 3 to be restored by the end of the year.

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The 988 Helpline and Option 3 UPDATE

Mindsite News, citing a story in The Advocate, reports that Congress has directed the agency that administers the 988 helpline “to reactivate the [Option 3 for LGBTQ+ crisis calls] service, but says it must do so in accordance with Trump’s Executive Order 14168, which recognizes only two sexes and rejects federal recognition of trans and nonbinary gender identities.” Mindsite adds that “the administration hasn’t explained how the two mandates can coexist or whether transgender youth will be included at all in any restored program.” The administration expects Option 3 to be restored by the end of the year.

The 988 crisis helpline has been in place since July 2022, and most people consider it a success. 988 specializes in behavioral health crises and offers crisis counseling and emotional de-escalation, unlike the older 911 hotline, which focuses on problems requiring police, fire, and EMS.

“Nearly 4,400 fewer U.S. teens and young adults died by suicide than projected in the first two-and-a-half years of the 988 mental health crisis hotline, a sign the program is working even as it faces long-term funding challenges,” according to the Associated Press.

Those “long-term funding challenges” arise from the way the helpline gets its money. The federal Substance Abuse and Mental Health Services Administration (SAMHSA) provides primary funding for the overarching national network, and they administer the helpline’s operations. Then, the National Suicide Hotline Designation Act of 2020 allows states to pass legislation assessing a small, monthly surcharge on phone and VoIP lines to sustainably fund local crisis call centers. Dozens of states have adopted this model. In states without phone surcharges, local call centers rely on general state budget appropriations, mental health block grants, Medicaid billing, and private donations.

If that system sounds cobbled-together and potentially rickety, well, it is. Aside from the SAMHSA funding, how much your local helpline gets to stay in business is far from guaranteed.

Recently, there was a decision that could put an end to one of the important aspects of 988—Option 3. When callers select Option 3 from the menu, they are connected to a portion of the helpline specifically designed to handle LGBTQ+ callers. Because the LGBTQ+ community accounts for a significant number of suicides, cutting off this kind of help would have been a tragedy that would have led to other tragedies.

It almost happened.

On July 17, 2025, a press release reported, “Today, the 988 LGBTQ+ crisis support line is being shut down as previously ordered by the Trump Administration. In response, a bipartisan group of federal lawmakers and national mental health advocates spoke out against the harmful decision and called for its immediate reversal. Today’s event follows an earlier plea to U.S. Department of Health and Human Services Secretary Robert F. Kennedy, Jr., urging his office to ‘scrap this ill-advised plan.'” The release continued, “Its closure comes at a time of growing need — just last year, nearly 40 percent of LGBTQ+ youth seriously considered suicide, according to national surveys.”

Hannah Wesolowski, chief advocacy officer for the National Alliance on Mental Illness (NAMI), speaking about the absence of Option 3, said that “we lost the trust of a lot of people who no longer saw themselves as being reflected in 988.”

SAMHSA tried to calm the situation: “Everyone who contacts the 988 Lifeline will continue to receive access to skilled, caring, culturally competent crisis counselors who can help with suicidal, substance misuse, or mental health crises, or any other kind of emotional distress.” And The Trevor Project tried to pick up the slack, though it has nowhere near the bandwidth to mount a thorough campaign and serve all those needing help.

Then, on April 24, 2026, a reprieve came. MedPage News reported, “Advocates for the LGBTQ+ community claimed a win this week after the Trump administration pledged to reinstate the 988 Suicide and Crisis Lifeline specialized support program tailored to their needs.”

The report continued, “During a Senate hearing earlier this week, HHS Secretary Robert F. Kennedy Jr. was asked whether he would commit to restoring the tailored line for LGBTQ+ callers to 988, as required by law, after the Trump administration removed it last summer.”

Kennedy, with no apparent sense of irony, was reported as saying, “We are working on getting it up now.”

Chase Anderson, MD, of the University of California, San Francisco, said that while reinstating the specialized 988 line option is a “nice step,” he remains skeptical due to the continued attacks on LGBTQ+ individuals, especially transgender people, by the Trump administration and the Supreme Court.

MedPage Today notes, “The fiscal year 2026 funding bill included $535 million for the 988 Suicide and Crisis Lifeline, including $33.1 million for the LGBTQ+ line. The legislation does not include a timeline for reinstating the program.”

If I hear any more about this issue, I’ll let you know.

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“Deprescribing” Psych Meds

I saw my psychiatrist this week for a med check and asked him about RFK, Jr.’s crusade against antidepressants. He said a good number of his clients had asked him about it. He reassured them that he was not going to cut them off.

Then Dr. G. said, “They’ll pull up to your house in a black Suburban, with face masks on, and ring your doorbell.” (He was joking.) I replied, “I have a gun.” (I wasn’t.)

Still, the fear is real. I’m not sure if Kennedy has an actual plan to curb what he considers an overprescribing of antidepressants. But those of us who need them are genuinely afraid that he will find some way to take them away from us. Maybe he’ll try to cut down the supply coming from the drug companies. Maybe he’ll invent some system by which doctors will be penalized for writing “too many” prescriptions. Or maybe he’ll put in place his threatened “wellness farms,” where people with mental illness will supposedly be cured by fresh air, organic food, no medication, and hard outdoor labor, much as he has recommended for “reparenting” children on ADHD meds.

The psychiatric community is as alarmed as their clients. At this year’s meeting of the American Psychiatric Association, doctors expressed fears that if Kennedy’s recommendations are put in force—and maybe even if they’re not—people who currently take antidepressants or other meds may decide to quit cold turkey or taper off without their physician’s advice and supervision, both of which are dangerous. Physicians also fear that patients will refuse necessary medications and relapse without them.

Kennedy has particularly targeted SSRIs (Selective Serotonin Reuptake Inhibitors) such as Zoloft (sertraline), Prozac (fluoxetine), Lexapro (escitalopram), and Paxil (paroxetine). Other targeted medications include antipsychotic medications, mood stabilizers, stimulants, weight-loss drugs, ADHD medications like Adderall, and combinations of these drugs. All these, Kennedy says, add up to a “dependency crisis driven by overmedicalization.” He has described the people who take these medications as “addicts.”

Kennedy compared coming off SSRIs to his experiences with trying to curb his heroin addiction: “You just have to steel yourself for 72 bad hours.” (He said that he had tried to quit and gone through withdrawal “a hundred times.”) He has also said, without evidence, that SSRIs are partly responsible for the rise in school shootings and other mass shootings.

The New York Times reported that at the Mental Health and Overmedicalization Summit organized by the MAHA (Make America Healthy Again) Institute, speakers were discussing “a variety of steps to address the overprescription of psychiatric medications, such as phasing out school-based mental health screenings, requiring written informed consent before starting medications, and featuring prominent, cigarette-style warnings on packaging.” It’s also been proposed that clinicians be paid through government programs to “deprescribe” patients. Too, there were discussions about changes in insurance billing and an “expert panel” with the mission to “develop clinical guidelines for deprescribing.” “This summer,” the Department of Health and Human Services says, “The Substance Abuse and Mental Health Services Administration, or SAMHSA, will release training modules focusing on the risks of psychiatric medications and on tapering and deprescribing.”

The risks of coming off psychotropic meds went largely unaddressed. People who have tried to do so without proper medical supervision have reported “brain fog,” as well as “emotional blunting, loss of motivation, suicidal ideation, and difficulty in withdrawing.” Some have also reported “shocklike sensations, flu-like symptoms, insomnia, nausea, and restlessness.”

It’s true that many medications, including some psychiatric medications, have been overprescribed. But they’ve been judged safe enough to be prescribed by primary care physicians as well as psychiatrists. Targeting and demonizing SSRIs and ADHD medications will leave patients with few ways to get the treatment they need. NPR reports that Dr. Theresa Miskimen Rivera, president of the American Psychiatric Association, has said, “It really is an oversimplification. And it really ignores the larger reality, which is that too many patients really cannot access timely, comprehensive care that is much needed for our nation.”

Personally, I have been taking various combinations of these medications, including SSRIs, for decades. My psychiatrists have never recommended stopping them, and I have never wanted to. The medications and the dosages have changed over the years, as needed. Psychotropic medications have literally saved my life as well as my sanity, and allowed me to function well in my relationships, my career, and my other activities. I don’t consider them cure-alls; I still have occasional symptoms of depression and hypomania. But being told by a government agency to quit them, or even to taper off them, scares me. I hope Kennedy’s ideas are never instituted, but given all the other recommendations he has proposed, I’m far from sure that they won’t be.

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Global Wins for Mental Health

Most of us know quite a bit about the U.S. mental health system, if it can be called that. We know about its successes and its failures, its help and its harm, and its practitioners and patients. But what about other countries? What large and small actions do they take to help people with psychiatric symptoms or disorders in their countries?

First, we know that approximately 78 countries around the world have socialized medicine or some form of universal health care that includes psychiatric services. Some have reported long wait times to get help, but others are easier to access. Most psychiatric drugs are subsidized. And the societies function in ways that foster mental health. Let’s look at a couple of programs that seem to be working.

Denmark

Denmark has a program designed to fight the stigma that accompanies mental disorders. It’s called One of Us.

Giuseppe Parlatore, who lives with paranoid schizophrenia, felt the stigma himself when a former teacher assumed—and said to him—that he must be either self-harming or violent and dangerous to others. He felt shame.

Parlatore, who was diagnosed in 2009, has worked hard to cope with his symptoms and carve out a life for himself. Now he is a leading mental health advocate, working with officials to lessen the stigma of mental disorders.

One of Us works with people called ambassadors, who have mental illnesses, to work with schools, police, and hospitals, sharing their stories and focusing on recovery. The emphasis on hospitals and police, they feel, is necessitated by the fact that personnel mainly see mental patients when they are in crisis rather than when they are coping better with their illnesses.

The Danish Health Authority also has a department of prevention and inequity. Anti-stigma campaigns are a part of the Ministry of Health. They hope to see lasting effects among the population, rather than just short-term upticks in awareness. The Danes see social contacts as more likely to change opinions than education alone.

Still, the battle against stigma requires persistence. Parlatore says that for him, it’s a “generational project.”

Japan

In Japan, there is a thing called kodokushi or “the lonely death.” The population of Japan is aging, and many older adults have little to no social contact. They can die alone and not be discovered for a long time. Social isolation leads to stress and loneliness. But a program designed to encourage physical health is having an effect on the elderly people’s mental health as well.

The “yogurt ladies” started as a way to promote health by selling yogurt to households. They were easily identifiable by their blue uniforms and bicycles. They succeeded very well in making people aware of gut health.

But gut health is also related to stress and chronic loneliness, two factors affecting mental health. Social isolation is, in turn, involved with gut microbiome diversity.

Loneliness is taken seriously in Japan. The government even includes a Ministry of Loneliness, as well as a task force on social isolation. The yogurt ladies provide weekly check-ins, a friendly face, and a chance to interact with someone. They see themselves as people who look out for others. Their services are a practical factor in maintaining gut health, but they perform an important function in reducing social isolation and preventing the “lonely deaths.” The lift they provide weekly is an important factor in maintaining mental health for the aging population of Japan.

Why don’t we have programs like this in the U.S.? I think you know the answer.

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Unpaid Drug Reps

Eight years ago, I wrote a post about how I despise TV commercials for psychiatric drugs. The New York Times has caught up with me. On February 16th (updated on the 17th), they published a story titled “Should Drug Companies Be Advertising to Consumers?” The article concentrated on drugs advertised to seniors, but what they said holds true for psychotropic drugs as well.

The problems of drugs advertised directly to consumers started in 1997, when regulations covering drug ads were loosened. Until then, drugs had been advertised to doctors who were going to be prescribing them. Then, print ads appeared in magazines and journals targeted to prescribers. In addition, drug reps visited doctors’ offices, handing out drug samples and literature, along with tchotchkes decorated with the drugs’ names. The reps also often brought carry-in lunches for the whole office and sometimes wooed particularly influential doctors with golf outings and other gifts and junkets.

That system had its drawbacks, it’s true, but so does the new one. When it was first allowed, drug ads appeared in consumer magazines, often as multi-page fold-outs because so much information about dosages, effects, and side effects had to be included.

Before long, however, the drug companies started to take advantage of television and the internet. And take advantage they did. As the Times reported, last year, “total spending on direct-to-consumer advertising of prescription drugs topped $9 billion.” Only New Zealand and the U.S. permit direct-to-consumer advertising.

The result is that consumers have become drug reps. The TV ads say, “Ask your doctor if Drug X is right for you.” What happens instead is that patients come in to their doctor and say, “I want Drug X.” And if the doctor doesn’t comply, the patient moves on to another doctor who will provide the requested drug. Instead of investing in a flock of drug reps, the pharmaceutical companies are investing in advertising that replaces many reps with many consumers who know much less about the drugs. In effect, the patient has become the drug rep, trying to influence the doctor to use a particular medication.

TV drug ads are sophisticated. Even the psychotropics have songs and slogans and color palettes, just like the ads for other drugs or indeed, soft drinks or cruise lines. Even the much-touted antidepressant Caplyta, which has had some of the slickest, most attention-grabbing ads, uses the song “This Little Light of Mine,” with slightly altered lyrics. Austedo, for tardive dyskenisia, features the slogan “As You Go With Austedo.” Cobenfy ads, for schizophrenia, sing, “Imagine What You Could Be. Cobenfy.”

The commercials do have recitations of the possible side effects, which are accompanied by tiny type on the screen. Often, the side effects seem to contradict what the drug is for: a bone-strengthening pill has a side effect of “unexpected thigh-bone breaks”; depression and bipolar meds have side effects of suicidal thoughts; one for tardive dyskinesia warns of “body stiffness, drooling, trouble moving or walking, trouble keeping your balance, shaking (tremors), or falls.” And there are other warnings: potentially fatal skin rashes (most likely Stevens-Johnson Syndrome), for example, or harm to an unborn baby.

The manufacturers probably count on the consumers not reading the tiny warnings. (The voice-over sometimes says, “These are not all the possible side effects.”) An ad will say, “Weight gain is not often seen,” but the tiny type says how much weight gain in mathematical terms such as “<.27 percent” that can be confusing to a layperson. If you read the type, you can also find that, for example, other side effects are not mentioned in the lists of possible outcomes. (“You should ask your doctor about these and other possible side effects.”) Some of the studies they quote seem to have reported results after only five weeks–not that the public can be expected to know the scientific niceties. I’m aware that I don’t understand them all myself. There may be aspects I’m not catching.

At the end of a psychotropics commercial, the now-stable person/actor/model engages in a variety of pursuits: being outdoors, playing with children or grandchildren, playing guitar, or taking painting lessons. There’s no indication that the meds may not work without an additional drug or drugs, that they may take six weeks or more to begin working, or that they may have no effect at all. In short, the TV commercials build unrealistic expectations for wonder drugs.

Certainly, many people have found that a drug or “cocktail” of drugs has alleviated their symptoms, though not cured the underlying disorder. I’m one of those people. But my information about my medications came from my doctor, not an advertising agency.

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Update: The Keto Diet

Almost exactly a year ago, I wrote a post called “Is a Keto Diet Good for Bipolar?” In it, I examined the keto diet, one that involves consuming a very low amount of carbohydrates and replacing them with fat to help your body burn fat for energy. That means you should avoid sugary foods, grains and starches, most fruit, beans and legumes, root vegetables and tubers, low-fat or diet products, unhealthy fats, alcohol, and sugar-free diet foods.

What’s left? Good fats like avocados and EVOO, as well as meat, fatty fish, eggs, butter and cream, cheese, nuts, seeds, low-carb veggies, and herbs and spices.

So, what does that sound like—a diet high in meat and fats that avoids most fruit, beans, legumes, and ultra-processed foods? That’s right: the new upside-down food pyramid instituted by Robert F. Kennedy, Jr., the U.S. Health Secretary.

In that previous post, I talked about studies that examined the keto diet as applied to depression and bipolar disorder in particular. The bottom line I left to WebMD: “The advice from WebMD is that there is ‘insufficient evidence’ to recommend the diet as beneficial for mood disorders. They don’t recommend it as a treatment option. As with any diet plan, consulting your doctor first is a good idea.”

Now, however, RFK, Jr., is touting the benefits of a ketogenic diet as a “cure” for schizophrenia. The New York Times called it “an unfounded claim that experts say vastly overstates preliminary research into whether the high-fat, low-carbohydrate diet might help patients with the disorder.”

In fact, the Secretary said, “We now know that the things that you eat are driving mental illness in this country.” He claimed that an unnamed doctor at Harvard had cured schizophrenia, and talked of studies “where people lose their bipolar diagnosis by changing their diet.” He was apparently referring to a 2019 experiment in which two patients “experienced complete remission of symptoms” with the keto diet. He said both patients “were able to stop antipsychotic medications and have remained in remission for years now.” Dr. Palmer, who originally reported the results, made no comment for the Times story.

The post promoting the claims was taken down from the website when evidence was requested to support the assertions.

The ketogenic diet is popular but difficult to stick to with its emphasis on fats over carbs. It’s up to you whether you try it to treat a mental disorder, but my honest opinion is that you shouldn’t stop taking your meds or doing your therapy. Try the keto diet in addition to them if you want to. Stopping your meds with the help of a physician who can guide you in tapering off safely is essential. Don’t go cold turkey, even if you do think the keto diet might help you. It’s simply not safe.

Unlike RFK, Jr., I’m not giving medical advice, only my opinion. Your mileage may vary. Your primary care physician or psychiatrist knows you and your condition best. Ask their advice and follow it.

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Changes in the DSM?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) has gone through changes, and its creators are discussing further changes that need to be made. The DSM-V was updated in 2022 to produce the DSM-V-TR (Text Revision). The new set of changes may result in a DSM-VI. (That’s not an official name, but people are already referring to it that way.)

Over the years, the changes to the DSM have sometimes been made to address a better understanding of what constitutes a mental disorder. For example, homosexuality was listed in the original DSM (1952) as a “Sociopathic Personality Disturbance,” considered a “sexual deviation.” The definition was gradually chipped away according to societal pressure from advocates and a dawning realization that homosexuality was not a mental disorder. It wasn’t until 1987 that the diagnosis or versions of it were completely eliminated.

Autism took a similar path. In the 1952 edition of the manual, autism was categorized under “schizophrenic reaction (childhood type).” It was not recognized as a separate developmental diagnosis on a spectrum until the DSM-III in 1980. Schizophrenia has nothing to do with it, and the newer text reflects that understanding.

Rather than the be-all and end-all of psychiatric knowledge and diagnosis, the DSM-V is better understood as a guidebook that helps practitioners drill down through a puzzling array of symptoms to reach at least a preliminary diagnosis. While the publication date for the newest revision of the DSM is still up in the air, the fact that it needs updating is clear.

So, what changes are in store in the next edition? Well, for one, the American Psychiatric Association (APA) is changing the name of the manual to “Diagnostic Science (or Scientific) Manual of Mental Disorders.” That’s hardly a significant change, given that psychiatry is less of a science and more of a practice (or art). The committees of experts who are doing the revisions will be augmented by people who have lived experience of the various disorders and people who are critics of the current DSM—of which there are many. Among the criticisms is the fact that the manual pathologizes everyday events into psychological disorders. Children’s temper tantrums become Oppositional Defiant Disorder, for example. This medicalization of everyday behaviors may result in overdiagnosis, not to mention overmedication. And it’s particularly true that an ER doctor confronted with someone who has a mental disorder cannot, in the 15 minutes they’re able to spend with the person, tell whether their hallucinations are due to schizophrenia, bipolar 1, drugs, or some other cause.

The new DSM will reportedly change the way it defines diagnoses, from a reliance on symptoms and characteristics to include consideration of environmental, socioeconomic, cultural, developmental, and biological factors. For example, whether a person has experienced physical or sexual abuse in childhood will contribute to trauma diagnoses. It’s hoped that considering the whole person, not just their symptoms, will lead to a better understanding of psychiatric and psychological conditions.

Clarification of diagnoses to include new features or diagnostic criteria, however, can lead to oversimplification, something that will need to be considered in preparing the new edition. Biological features of disorders are supposed to be included, despite the fact that there are no objective tests, such as genetic tests or fMRI, to pinpoint a psychiatric diagnosis. This, of course, may necessitate further revision of the DSM as such testing improves. It’s hard to imagine how a discussion of future advances in diagnosis will help current practitioners until those advances are made. It’s an acknowledgment that even further revisions will ultimately be required.

The insurance industry will also be very interested in the new edition, whenever it comes out. In addition to definitions of the different conditions and lists of symptoms that can be used to make a diagnosis, the DSM also provides billing codes for the various disorders. And, as we know, getting insurance reimbursement for a particular diagnosis is difficult at best unless it has a billing code attached to it.

What the average patient will think about the updated DSM, if they know about it at all, remains to be seen. At any rate, it’s encouraging to think that the psychiatrists’ “Bible” may lead to more accurate diagnoses and better treatments. I just can’t shake the feeling that as soon as it is published, it will already be obsolete, needing ongoing tweaks that won’t be included until such time as another substantial revision is considered necessary. How long will we live with DSM-V (TR), essentially an unfinished work? I suppose at some point, the APA must decide when the DSM-VI, a work-in-progress, is “good enough” to publish.

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The Difference a Diagnosis Makes

Is a diagnosis of mental illness a bad thing or a good thing? It depends on whom you ask.

On one hand, some argue that a diagnosis is merely a label. It puts people into neat little boxes defined by the DSM and determines how society reacts to and treats them. (The DSM, of course, is for doctors, but some version of what it says sneaks out into the general public. Then it’s fair game for tossing around and labeling people by the uninformed or the barely-informed.)

The labels are harmful, this school of thought goes. A schizophrenic is violent and incurable. Bipolar disorder means daily giant mood swings and real danger if said person goes “off their meds.” Narcissists, gaslighters, and sociopaths are people who act in any way that you don’t appreciate. Autism, notoriously and according to people who should know better, is the gateway to a valueless life.

With diagnosis come stereotyping and shame. Rather than reacting to these harmful effects, some people focus instead on what creates the stereotyping and shame—the diagnosis, which is seen as a lifelong label. Protests decrying this labelling happen outside psychiatric and psychological gatherings and garner media attention. And if that makes life easier for a person with a diagnosis or generates greater understanding, then it’s a good thing.

Diagnosis-as-label is an example of the harm that diagnosis can do. Nor is it limited to the general public. Once a person is in the system with a diagnosis of whatever condition, they’re generally stuck with it. Reassessment and a realization that a diagnosis is misapplied come too rarely. Personality disorders, for example, are squishy around the edges. Similar criteria could lead to a diagnosis of narcissistic personality disorder or sociopathy, to use an extreme example. Careful consideration will distinguish between the two, but how often are such distinctions applied? Once “in the system” with a particular diagnosis, a person tends to remain in that slot despite different doctors and different treatments.

But that’s not the way it’s supposed to be. A diagnosis, rather than being a lifelong label, is meant to be a signpost pointing toward likely development of the illness and ways to treat it successfully. That’s the ideal, of course, and sometimes, being only human, practitioners can get sloppy or too narrowly focused and add to the ills of bad diagnosing.

I can truly speak only for what happened to me. At a certain point in my life, I didn’t know what was wrong with me, but it was clear to me that I was not mentally healthy, the term used at the time. I went to a community mental health center and was diagnosed with major depression. That was a good diagnosis, as far as it went. It put my life more squarely in focus and allowed me to get the medication and therapy I so desperately needed.

I lived for many years with that diagnosis and was considerably helped by the treatments for it. But, eventually, a doctor put together the puzzle pieces and rediagnosed me. Instead of having depression, I had bipolar disorder, type 2, with anxiety. This diagnosis more clearly reflected my symptoms and led to more effective treatment. In that way, one diagnosis improved my life, and a second, more accurate one improved my life more. I can only think of this as a good thing.

Was the diagnosis seen by some as a label and a stereotype? Of course. I can think of one particular coworker, hearing that I was bipolar, gave me the look that said, “You have two heads,” pasted on a strained smile, and backed away slowly. But, on the whole, the diagnosis helped me.

A recent article in the New York Times had this to say about diagnosis: “The shame that once accompanied many disorders has lifted. Screening for mental health problems is now common in schools. Social media gives us the tools to diagnose ourselves. And clinicians, in a time of mental health crisis, see an opportunity to treat illnesses early….As our diagnostic categories expand to include ever milder versions of disease, researchers propose that the act of naming a malady can itself bring relief.”

It’s something to hope for, anyway.

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