Bipolar 2 From Inside and Out

Posts tagged ‘SMI’

We Don’t Talk About It

When I was first diagnosed with depression (later bipolar disorder), my family was somewhat less than understanding. My father was concerned that he might have to go to family counseling, with the implication that it would involve analyzing or blaming him. My mother informed me that Prozac, which I was prescribed, was “a ticking time bomb” and later said that she thought that if I got a better job, I wouldn’t be depressed anymore. And my sister was dismissive about paying someone a lot of money just so I could talk.

I admit that I did not handle this terribly well. I missed the opportunity to educate my family about these psychological conditions. (I did tell my sister that I was going to a community mental health service that had a sliding scale for payment.) In my defense, I was new to the concepts too, and had barely begun to educate myself about them. I did gradually learn more, but their initial reactions kept me from saying much about it to my family.

As stigma goes, this was pretty mild. They didn’t try to tell me there was nothing wrong with me. They didn’t blame or shame me for reaching out for therapy (other than my sister). But because of this, I didn’t receive much support from my family which would have made my journey easier. That only happened when I married a man who knew something about psychology and learned what would help and what wouldn’t.

Stigma can be a familial problem, but it also happens at a societal level. But mental health concerns are very low on the list of many legislators’ concerns and priorities. Some have denied that mental illness even exists or responded to it by clearing away the unhoused or creating sober houses. Mental illness is seen as a consequence of PTSD, which is talked about mostly in the context of veterans, seldom about other causes like abuse. Also, most of the fundraising for veterans seems to concentrate on limb loss and traumatic brain injury. If funds are going to specific mental disorders other than PTSD, it isn’t emphasized, despite the need.

A lot of what we hear about mental illness is about SMI or serious mental illness. And that often gets conflated with the problems of homelessness, addiction, and violence. But what about all the people with Major Depressive Disorder, Bipolar Disorder, Anxiety Disorders, Personality Disorders, and even Schizophrenia who live in homes and families, who have families of their own, and who have jobs? They’re very rarely talked about. They don’t get emergency funding. They don’t require street psychiatry, emergency housing, forced commitment, and other services that are needed for the most severely ill. They’re not high-profile.

They’re called “high-functioning” and then largely ignored, left to deal with their disorders on their own. Many of them miss out on the therapy, meds, and lifestyle changes that might help them, either because they don’t know where to go or don’t have the funds to access them. Insurance pays for quick fixes of 6-8 weeks, which are the merest band-aid on their problems. Supportive families, biological or chosen, can help them maintain their relationships, living situations, and jobs, but public attention isn’t focused on them in any meaningful way. There are ad campaigns that say “It’s okay not to be okay” and encourage friends to reach out, but they’re vague and short on what to do when you realize you need help. Hotlines focus on suicide and self-harm. They’re certainly needed, but so are resources for the day-to-day, less dramatic disorders.

Stigma, confusion, lack of education, ignorance, and even hostility keep us from the conversations that might lead to actual, useful change. Let’s open up those conversations with our families, friends, coworkers, the press, local and national government, and anyone else who’ll listen. Blogging and maintaining a Facebook group (Hope for Troubled Minds) are among my contributions to the effort.

I’ll keep trying if you will.

Category:

Mental Health

Tagged with:

How Insurance Handles SMI

Why are so many people with Serious Mental Illness (SMI) underinsured or unable to get insurance at all? As you may guess, a large part of the problem lies not with the providers but with the insurance companies.

The recent murder of an insurance company CEO has focused a spotlight on the role of insurance companies in denying health care in general. There’s been a groundswell of people angry at insurance companies coming between sick people and the doctors who prescribe them care. Ridiculous rulings such as providing anesthesia for only a limited time during surgeries have come to light. Denials of life-saving or pain-alleviating medications have been exposed as common.

One part of the problem is “ghost networks.” These involve the list of in-network providers insurance companies provide to their subscribers. Again and again, these have proved to be faulty. The lists contain doctors who are no longer practicing, ones who aren’t actually in-network, and ones who aren’t accepting new patients. There can also be incorrect phone numbers.

But the plight of people with SMI is even more serious. Insurance companies don’t want subscribers with mental disorders because they don’t make money from them. “One way to get rid of those people or not get them is to not have a great network,” according to someone involved with managing contracts with providers. Patients are pushed out-of-network for more expensive care that’s not covered or covered to a lesser extent by insurance companies. The Affordable Care Act was supposed to guarantee parity for mental health treatment, but that hasn’t always happened, and patients with mental disorders often couldn’t follow up on denials. And Obamacare as it exists now may not last under the new Republican administration.

Then, too, insurers encourage providers to change their treatment plans for clients who have SMI, even if they’re suicidal. Psychiatrists and psychologists find themselves having to tread carefully when writing care plans so that insurers will approve the care that patients need and keep approving longer-term treatment. The insurers can even pressure providers to terminate treatment altogether. Treatment plans that last over six to eight weeks are especially likely to be denied.

Even when insurers do approve treatment plans, another problem is reimbursement to providers. The money they receive is meager and insurers stall in regard to providing it. It can take three or four months to receive any reimbursement at all. This means that providers struggle to keep practicing. Some go out of business and then remain listed on the ghost networks as continuing to provide services.

Some therapists end their relationships with insurance companies because of the frustrations of getting approvals for care. One reported spending eight hours with a client and then having to spend four hours communicating with a difficult insurer while trying to get approvals and payment.

Yet another problem that providers experience is that claims servicing has often been outsourced. Customer service may be handled by representatives in other countries. They may not have access to all the information they need to process claims. Others aren’t familiar with the psychiatric terminology. When providers find it too difficult to follow up on claim denials, they may stop pursuing the matter. The insurance company then doesn’t have to pay for the treatment.

The insurance companies counter that they are following state and federal laws, that their reimbursements represent payments at current market rates, and that their policies are designed to provide access to care for patients with mental illnesses.

And that’s private insurance providers. What about Medicaid?

In four cities, researchers pretended to be Medicaid patients and called clinicians at random regarding their first available appointment. Just over a quarter reported having any available. In LA, only 15% had available appointments and the wait for them could be as much as two months. There were also Medicaid providers on ghost lists like the ones from private insurers.

All these problems certainly contribute to inadequate care for people with SMI. Between finding a provider, receiving a treatment plan, and being at the bottom of insurers’ list of patients to be served, it’s no wonder that so many people who really need care aren’t receiving it.

Will the current level of outrage have any effect on how mental patients receive care? It doesn’t seem likely. Most of the people decrying the brutal treatment by insurance companies are patients experiencing problems other than mental health-related ones. As usual, there are few who speak up for those who need psychiatric treatment, even though egregious obstacles are put in their way. As my father would have put it, mental patients are “sucking hind teat.” And the prospects for that to end look remote. Dealing with the mighty insurance companies is difficult at best and demoralizing at worst. Effective advocacy is needed but unlikely to appear. In the meantime, psychiatric patients are suffering.

Information for this post includes material from Mindsite News, ProPublica, and JAMA.

Category:

Mental Health

Tagged with:

Say It With Casseroles

In the South, casseroles are known as “funeral food.” After a funeral, people gather at the home of the bereaved and bring casseroles for a kind of potluck. The idea is that the family shouldn’t have to entertain the mourners and shouldn’t have to cook for basically the rest of the week. Some people even bring frozen casseroles to extend the usefulness of the food offerings. Tuna noodle casseroles are popular. Chicken rice casseroles. Green bean casseroles. Shepherd’s pies. Eggplant parm. Tater tot casseroles. Frito pies. Lasagna. Sweet potato casseroles. Ham and potato casseroles. Broccoli cauliflower casseroles. Moussaka. Even one that’s simply called “Funeral potatoes.” There are plenty of cakes and pies, too.

Food is an essential when there’s a new baby as well. It’s assumed that the new parent or parents won’t have time to cook substantial meals, so plenty of frozen casseroles are supplied. Visitors don’t arrive en masse and don’t expect to be entertained. They often bring useful items like diapers and wipes. They expect a few minutes of conversation, a look at the infant if they’re asleep, or a chance to hold them for a minute. What they mostly offer is help. Cleaning. Babysitting for older children. Running errands. Preparing bottles if needed. Emotional support is a big form of support as well. Helping the new parent with self-care. Comfort items. Listening. Offering encouragement.

Even an illness or operation generates plenty of contact. People visit in the hospital, bringing flowers, treats, plushies, prayer circles, and more. They stay as long as you want or leave when you’re feeling tired. They ask if there’s anything they can bring you, and then they do. They ask if your plants need watering. When you come home, there may again be casseroles, especially if it’s been a major operation like knee replacement. There are offers of picking up groceries or medication. They ask what you need and, nine times out of ten, they follow through. They call to check up on you or just to talk.

It’s all different if you have SMI, however. SMI is just not a “casserole illness.”

If you have a public meltdown, no visitors, no encouragement. No casseroles.

If you spend time on a psych ward, no visitors, no flowers. No casseroles.

If you aren’t able to go to an event or meet for coffee, no sympathy, no prayer circle. No casseroles.

If you’re not able to get out of bed all week, no housekeeping, no errands run. No casseroles.

And if you survive a suicide attempt, no understanding, no acknowledgment. No casseroles.

I get it. I do. People don’t know what to say, so they don’t. They don’t know what you need, so they don’t offer it. They don’t know how to cheer you up (and they can’t), so they stay away. They’re afraid of psych wards, so they don’t visit.

Casseroles can’t hurt and might help.

What it all comes down to is stigma and ignorance. There are no social conventions that apply to those with SMI. Except for the most fortunate among us, we’re on our own.

Category:

Mental Health

Tagged with:

Green Flags, for a Change

I recently saw a meme that pointed out the red flags in a relationship, such as getting rid of friends and family; financial control; insisting on knowing whereabouts; gaslighting; intermittent reinforcement; and, of course, physical, sexual, verbal, or emotional abuse.

But the meme went on to say that, just as there are red flags of a bad relationship – one you shouldn’t get into or should get out of – there are green flags that indicate when a relationship is healthy and positive.

I’ve had relationships of both kinds and, although I didn’t recognize them at the time, have learned the hard way to notice and avoid the red flags. But I’ve also learned how to recognize the green flags.

It’s only fair to say that recognizing both red flags and green flags is more difficult when you live with SMI. It clouds your perceptions. It makes it harder to recognize when and why you should get out of a bad relationship and when a new one is a safe space to be in. We doubt ourselves so much that our vision gets clouded.

So, what do I see as the green “go ahead” flags in a relationship? Besides the absence of all the red flags, I mean.

Listening to you is the first one and maybe the most important. Along with that comes validating your perception of reality. It’s a hard thing to find, especially if you and your new partner have disagreements – which all couples do. You can disagree with someone without tearing them down, even if you have an emotional reaction to whatever you’re disagreeing about. It can actually be easier to agree on religion and politics than it is when the topic pushes one of your buttons. Realizing that you disagree but respect and love the person anyway is a hard thing to do and a harder one to say, but it’s important.

It’s also very important to act on what you say and to make your words and actions congruent. This is the very basis of integrity and trust. We’ve all met someone who says one thing and does another. It’s beyond disappointing. In fact, it’s one of the biggest red flags there is. Not being able to rely on your partner to do what they say they’ll do is a breach of trust. To cite one example (not completely at random), there’s the person who says that an open relationship is the ideal but then demeans you when you act on it – the same way they have always done.

Laughter is vital in any relationship. In order to share jokes and laugh with a person, you must be able to relax with them. Trust is involved here, too. You have to be able to trust that the other person won’t use “humor” to attack you, especially in front of other people. Sarcasm directed at you sours the good feelings you may have had. But genuine laughter, whether at a joke, a silly song, or a funny movie, brings people together. If you have SMI, laughter may have been long absent from your life. Getting back the capacity to laugh is a revelation.

Another aspect of a relationship that can be pivotal is understanding each other’s “love language.” This idea comes from a book by Dr. Gary Chapman that was published in 1995, The Five Love Languages. The five languages – ways that people communicate their love – are words of affirmation, quality time, gifts, acts of service, and physical touch. Problems happen when one partner doesn’t speak the same language as the other; for example, when one gives the other literal gifts while the other yearns for time together or physical touch. Figuring out your partner’s love language and adjusting yours to match theirs can be difficult.

Most important, I think, is perseverance. I often say that we could describe ourselves as “The Couple Too Stubborn to Quit.” We’ve been married now for 40 years. We’ve had bad times when we went to couples counseling – more than once. We’ve even tried to work out if each of us could make it if we separated.

So, those are my “green flags” for a relationship: listening, trust, laughter, understanding, and sticking with it. There may be more, and I’d love to hear from you what others you’ve found.

Keep This Blog Alive!

Choose an amount

¤2.50
¤5.00
¤10.00

Or enter a custom amount

¤

Your contribution is appreciated.

Donate

Category:

Mental Health

Tagged with:

Mental Illness or Autism?

The other day I inadvertently created a firestorm on facebook. Someone posted: Question: What makes schizophrenia a mental illness and autism not a mental illness? Answer: Politics, advocacy, and marketing.

I didn’t understand the thrust of the post, so I asked a question: “Are you saying that autism should be classed as a mental illness or that schizophrenia shouldn’t be?”

Then the floodgates open. There were over 100 responses to the post, of which mine was just one. They ranged from “autism is not a mental illness” to “autism is a form of mental illness” to “autism is a developmental disorder” to “schizophrenia and autism are both neurodivergent conditions.” Few, if any, seemed to address the original question of politics, advocacy, and marketing. (I have no knowledge whether any of the responders were medical or other professionals; persons with one or the other diagnosis; or family members of those with the, let’s call them conditions for now.)

Some people responded that the term “mental illness” should not be used, because it was inaccurate, or stigmatizing, or both. They found the phrase “mental illness” offensive. “Mental disease” was suggested as a better alternative, though for the life of me I can’t see much difference between them. To me, “illness” and “disease” mean basically the same thing. One can go down the rabbit hole here. Is MS a condition or an illness or a disease or a disorder? Is a broken leg a condition? It’s certainly not an illness – unless it gets infected – or a disease. Someone said that mental illness implied a permanent condition, rather than a challenge that can be treated. My bipolar disorder can certainly be treated, and is. But it is also a permanent condition.

Some of the phraseology that was most often used to define autism were neurodivergent, neurological condition, developmental disorder, neurological condition that often presents with mental illness like anxiety. But neurodivergent was also used to described schizophrenia, which was sometimes linked to brain anatomy and genetics. Some classed them both as “disorders of the brain.”

Others pointed out societal or functional differences or other definitions – schizophrenia can be used in court for a “diminished capacity defense”; autism is listed in the DSM-V (Diagnostic and Statistical Manual, considered by many the gold standard for definitions and symptoms of mental illnesses); the age of onset for autism is three, or three to 18, while schizophrenia is usually diagnosed at 18 and over, but not always; autism used to be called childhood schizophrenia; schizophrenia is caused by over-pruning of the neurons, which disrupt the normal growth of the brain; ASD could be a result of disruptions in normal brain growth. Someone pointed out that with both autism and schizophrenia, there are different levels of severity.

Various books and articles were cited. Challenging questions were asked: Do those who insist that autism is not a mental illness think having a mental illness is shameful, whereas having autism is not shameful or perhaps is not an illness at all. Others considered treatments: Medications can help with mental illnesses but are not generally prescribed for autism. People with one or the other condition do not qualify for treatment.

And some responses were entirely cryptic: B careful what you wish 4.

But back to the original post. I think the poster was trying to say that the autism community did a better job of spreading the word about the condition and thereby defining it, in this case as not-a-mental-illness.

And it’s true that – whatever you think of them as an organization – Autism Speaks has gotten the word out about autism. They excel at awareness (of themselves as well as autism). They organize huge charity walks. They have numerous TV commercials. Their puzzle piece symbol – again, whatever you think of it – is for many the easily identifiable graphic that says, “autism.”

Mental illness, whatever you prefer to call it, does not have that same kind of presence in the public eye. For one thing, there are so many different conditions that it’s hard to choose one to spotlight. Depression seems to be the condition-du-jour. The conversations around it are that anyone can have it and there is help available, which is all well and good. But the vast majority of these messages come from people who are selling or associated with medications or call-a-therapist lines – money-making operations. Nor do the ads always get depression right, many making it seem like no worse than a mild hangover.

SMI (serious mental illnesses such as bipolar disorder and schizophrenia) are only now entering the public discourse, and again, mainly for advertisements of drug treatments. The ones for schizophrenia seldom discuss any symptoms of the disorder – they just show a happy person playing a guitar or some such desired outcome. They don’t convey much about the condition of schizophrenia, its symptoms, how it affects families, or much of anything else.

As for other psychiatric conditions, there is much silence. PTSD is discussed, but only of the “wounded warrior” variety, not the kind that can result from other traumas. Anorexia/bulimia, OCD, social and generalized anxiety, narcissism, and the whole spectrum of personality disorders get little to no screen time.

There is growing discussion about things society – and especially first responders – should know or do about people with psychiatric conditions, but those are largely at the talking stage and a few pilot projects. When the subject hits TV, it is usually triggered (sorry) by an individual incident and is more likely to involve unorganized protests rather than coordinated efforts to address the larger problem. And at times, it seems that no one is listening.

Especially to the people with “forgotten” mental conditions – those that don’t have drug treatments or celebrity proponents or coordinated responses. It’s not that I think autism doesn’t deserve the attention it gets – though clearly there are more discussions to be had around the subject. I just sometimes despair of getting attention for mental illnesses.

But to go back again to the original post, mental illness and autism are two different things that cannot be easily compared. But it is true that autism, at the moment, has an organization with a loud voice behind it. Mental health, not so much.

Category:

Mental Health

Tagged with:

I Don’t Need a “Pep Talk”

MarekPhotoDesign.com/adobestock.com

Here’s the thing. Many people, when you mention a problem, feel obliged to help you fix it or fix it for you. When the problem is related to mental illness, though, that can be counterproductive.

The fact is, most serious mental illness can’t be fixed, at least not by a friend or loved one. To try is to invite frustration on the part of the fixer and worse feelings on the part of the fixee.

Some of the worst help we are offered are pep talks, which are meant to be encouraging. Smile more. Keep trying. Other people have it worse. Everyone goes through this.

No, says my stubbornly glitchy brain. Everyone does not go through a major depressive episode. And when I’m having one is not the time I can concentrate on what constitutes “worse.” I can try all I want, but my bipolar disorder isn’t going to just go away. And smiling when I’m ready to cry is a suggestion that denies my perception of reality and encourages me to lie about my feelings.

You can see much of this kind of advice on Facebook, for example. There are always memes that exhort you to look on the sunny side, have a positive mental attitude, or choose to be happy. But it’s easy enough to scroll by them.

These pep talks hurt more when they’re offered in person by someone you know or even love, especially when that person knows you have a mental disorder. You can’t just scroll by someone you love telling you that, in effect, it’s your own fault that you don’t get better.

I know these sentiments are kindly meant (except for the ones that blame you for your own condition). But the reality is that we can’t cure ourselves of SMI by smiling, or jogging, or thinking happy thoughts, or eating turmeric. We can’t cure ourselves at all.

But we can make things better, through therapy and medication, and yes, through some things that are not cures themselves but adjuncts to healing – physical activity, engagement, mindfulness, self-care, and the like. Who knows? Maybe even turmeric.

So, if pep talks don’t work, what can you do instead? What might actually help your friend or loved one? Here are a few suggestions.

Treat the person with mental illness the way you would treat a person with any other illness. I’m not suggesting sympathy cards are appropriate, but a phone call or text message saying you care is usually welcome.

Listen without judgment. Don’t offer advice. If the person opens up to you, respect that. Don’t minimize the problems. If the person doesn’t respond, wait a while and try again.

None of that will “fix” the person, but you know what? Neither will a pep talk. My brain, for one, is simply unable to process them, digs in its metaphoric heels, and says, “Oh, yeah?”

So, what are some things you can say instead of giving a pep talk? Try these.

I’m here for you.

You can always call me.

I’m sorry you’re hurting.

Tell me if you need anything.

Do you need distraction?

Do you need to be alone for a while?

Do you need to talk?

What can I do for you? (The answer may be, “nothing,” but at least you cared enough to ask.)

If you are also suffering from SMI, there is even more you can do. You can say, “I understand how you feel,” and mean it. You can recommend a therapist. You can congratulate the person on any accomplishment, the kind that wouldn’t seem like an accomplishment to anyone else.

In general, stay away from platitudes, feel-good sentiments, and quick fixes – unless you know that the person responds well to that kind of encouragement. They’re too easy to say and too hard to follow through on. Save them for people who are simply having a bad day, not someone who has mental illness.

Category:

Mental Health

Tagged with:

What Should Medical Students Learn About Mental Illness?

I recently saw a news story reporting that a single medical school, Des Moines (IA) University, has made it mandatory for medical students to learn how to care for patients with mental illness.

Funny. I would have thought that was already happening in medical schools across the country. Apparently not. Although medical schools teach prospective doctors to diagnose mental illness, the article notes, they do not require students to learn how to care for the mentally ill. When the class started in 2018, it was an elective, but it later became a requirement.

The curriculum includes having people in recovery from mental illness, loved ones of patients, and healthcare providers speak to the class. It is hoped that this will combat the stigma that arises from student doctors only seeing mental patients on locked wards when they are in severe crisis.

Of course, confinement on a locked ward is not typical for people with SMI. Many people with bipolar disorder and even schizophrenia, for example, require inpatient treatment only occasionally, spending the majority of their lives receiving treatment, medication, and therapy as outpatients. One wonders if the stigma surrounding mental patients extends to them as well. Do some GPs tend to ignore physical disorders while focusing on the mental ones? It’s fairly well known that doctors sometimes focus on a person’s weight as being the cause of all their symptoms instead of looking for (or testing for) other conditions. Might there be a similar narrowing of focus regarding mental patients?

Looking at the course, the answer may be yes. Interestingly, the main concern in developing the course seems to be that because doctors were so uncomfortable treating psychiatric patients that they focused on the SMI and never diagnosed and treated conditions such as heart disease, hypertension, and other medical problems. Professor Dr. Lisa Streyfeller cites what she calls “really horrifying statistics that folks with severe mental illnesses die on average 15 to 30 years earlier than people who don’t have those illnesses.”

As important as it is that people with SMI receive treatment for their psychiatric conditions, physicians need to be aware that such people have physical needs and illnesses as well. And as encouraging as it is that mental patients themselves, and their loved ones and caregivers, are included in the curriculum, the article made no mention of teaching prospective doctors how to interact with mental patients they encounter in their practices. If such courses do not exist in medical schools other than DMU, where are doctors going to learn how to talk with and understand the many, many patients they will have who suffer with anxiety, depression, mania, anorexia, and the dozens of other diagnoses?

In some communities, first responders such as police and EMS workers are beginning to have mental health practitioners go on “ride-alongs” to help educate emergency personnel on how to handle situations involving the mentally distressed. Classes like the one at DMU (if others existed) could benefit from having students “ride along,” doing internships or rotations with established doctors who treat the physical as well as the mental symptoms of their patients. Perhaps psychiatric rotations in medical schools could include student practice in community or campus mental health centers instead of just locked wards. Perhaps medical schools could involve students in role-plays involving speaking with and treating the mentally ill, the way they sometimes do for prospective doctors’ encounters with terminal patients.

With NAMI reporting that 1 in 5 U.S. adults – 20% – experience mental illness each year and that
1 in 25 U.S. adults – 4% – experience serious mental illness each year, the odds are overwhelming that future doctors will need to learn how to treat patients both physically and mentally, as well as simply on a human level.

Here’s hoping that the DMU model class idea spreads – and that medical school education on mental health someday will be covered more thoroughly than a single class and a visit to the locked ward.

 

Reference:

https://whotv.com/2020/01/08/dmu-becomes-first-medical-school-to-require-mental-health-course-for-students/

Category:

Mental Health

Tagged with: