Ricochet is the best place on the internet to discuss the issues of the day, either through commenting on posts or writing your own for our active and dynamic community in a fully moderated environment. In addition, the Ricochet Audio Network offers over 50 original podcasts with new episodes released every day.
Diagnosis of Mental Illness
One of the great advances of medicine in the 20th century was the ability to accurately diagnose patients. It is something we take for granted today. Indeed, when the story is about a misdiagnosis, it makes the news “I was told I had bug bite, now it is Stage IV Cancer!” The New York Post loves these. We know if we can get a correct diagnosis, there can often be the correct treatment, or at least, we know there is no good treatment but the knowledge itself confers power. This works great for many medical issues. It does not work as well for mental illness.
What we diagnose today as mental illnesses are really syndromes. A syndrome is defined as a group of symptoms that consistently occur together, or a condition characterized by a set of associated symptoms. That’s not really the same as swab culture and finding out you have a strep throat infection. The symptoms of strep throat together are the syndrome. The definitive diagnosis comes from the test. Now, doctors don’t need the test, because, let’s face it, the symptoms of strep throat are pretty similar between people, but we can be sure.
In a mental illness, there is no blood test. There is no brain scan. There is no looking at neurotransmitter levels. There are symptoms. Oh, brain scans can show “features associated with …” and we know that increasing serotonin tends to increase mood. In some people. For some depressions. Maybe. Of course, the level in serotonin varies from person to person, and one person can have lower levels than another and not be depressed. What we have is a cluster of symptoms as a starting point. These get redefined. When I started out 30 years ago, doctors talked about “Agitated Depression.” This was when someone had low mood, lack of interest in pleasure, and often hopelessness but did not have depression’s normal lack of energy. This is not called “Agitated Depression” any longer. Today that is “Bipolar Mixed State.” Same group of symptoms, different syndrome.
When it comes to treatment, there is a wide range of various medications and therapy techniques. We can start with our diagnosis and try various things to see what works. It is not a science. Why is it that one antidepressant works for every member of a family but one? No one can really say. We have some gene testing that can point to how a person will be expected to metabolize some medications, but that is hyped more than it is actually effective. Finding the right medication is an art of trial and error. Of course, with therapy, there are many evidence-based practices that have a variety of proven effects. None of which will matter if the fit between the therapist and the client is poor (which is its own post, I think). Sometimes finding that right fit is also a challenge. And sometimes, the secondary benefits from the mental illness are “too good” to give up. Even when some people are miserable, they can hang on to the devil that they know.
This leaves us in a situation that is oddly modern and ancient. Before modern medicine, there was little good way to diagnose illness, and even when they got it, well, the treatments often ranged from ineffective to deadly. We are better off than that in mental health these days, but remember, lobotomies were a “Best Practice” in the mid-20th Century. Medical providers and therapists work with their clients to find the right approach. The client ends up doing the heavy lifting. Working on one’s mental health is not a passive experience.
As a therapist, I take mental health diagnoses by another provider as a starting point. Yes, I have to diagnose to make third-party payers (insurance) happy (though not for self-pay clients). Yes, it can be useful to know “This client has Bipolar I.” It will guide the questions I ask them about the past and inform the education I give them. It will not, however, be how I see them. They are not “Bipolar,” they have a “Bipolar disorder” and my job is to help them both learn to manage that illness and all the other parts of their life that are not reduced to meaningless due to a diagnosis.
I hope this rather high-level view helps. If you have specific questions, please ask them, and I am happy to respond.
Image from Jumpstory to which I have an account.
Published in General
The other thing I would say is, bodywork of some type can increase your efficacy. Rolfing. Chinese massage. Yoga. Chinese related exercise. It organize your thoughts and helps you remember things.
BrYan does not know about Alice Miller.
Plain exercise too :)
Building on my previous comment: vigorous exercise has been shown to increase the expression of brain-derived neurotrophic factor, at least as well as the SSRIs do.
https://www.science.org/content/article/how-exercise-beefs-brain
I think those are good books, but if you look her up it is just chaos.
How is psychiatry taught today? And are there different types of approaches in teaching? When I did medical school in the 90s, I did a month of adult psych at the VA and a month of child psych at the medical school. It seemed very much that the psychiatry was more about managing medicines and the talk therapy was left to the psychologists. I didn’t seen the psychiatry residents or attendings do talk therapy. It was more like medical rounds…chat with the patient briefly, check any labs and fiddle with the medication or doses.
Great post, to second what others have said. As a layman (read: ignorant) I am al over the road on the subject, and perhaps you could help.
I know people who’ve had severe issues – bipolar, schizophrenia – and drugs have helped, a lot. I also know some people who were put on chemicals to treat what seems like being human – the ups, the downs. It seems like much of what drives the prescribing is pathologizing of the human condition. Is this a reasonable conclusion?
Is there an underlying but unspoken agreement among doctors that the specificity of some diagnoses is a way of making the science seem more settled than it is?
Most important – how much of the “mental illness” we see in the street population is a result not of the brain gone awry on its own, but pushed into a mad kaleidoscopic realm by drugs? The popular narrative says they’re all victims of their own skewed chemistry, pushed out on the streets by a heartless capitalist society (rEagAn cLosEd tHe asYluMs), but it seems to me that the ones who are not schizophrenic went mad from their habits.
I can say that it is about managing medicine. Talk therapy is the realm of psychotherapists like myself. In an ideal world, we work with the providers. Most psychiatric meds are prescribed by GPs not specialists. There is a huge shortage of the specialists.
To some degree. I do think psychiatric medications are often prescribed when they should not be, and there are people who look too quickly to the magic pill as a solution their problems. That said, depressive disorder is a real thing and can be life-threatening. ADHD is also a real thing (or things), even if it is way over-diagnosed.
Yes.
It’s hard to say. Illegal drugs certainly play a big role; they can be a cause of mental illness as well as exacerbating an existing illness, but that’s difficult to sort out after the fact.
Taking these one at a time:
For me personally, and for the therapists I know, we are not interested in pathologizing of the human condition. The recent changes to grief in the DSM-V, for instance, were not appreciated by many in my profession. I can say that from where I see clients, medications have a huge positive impact for many people. There is a lot of low level depression, of what we label “dysthymia”. I have seen people start a basic antidepressant and come back saying “I did not I could feel this way”. They have been moved from an average mood of 3-4 to 5-6 and are delighted.
I might further say that I find most pathology (outside of things like Schizophrenia) is normal human functioning taken to an extreme. That probably is its own post, but a quick example is OCD. Everyone has intrusive thoughts at times. In OCD this is ramped up, as we say, to 11.
For underlying agreements, I can say there is not a great settling of the science, even if the doctors want it. Two different doctors or therapists can diagnosis people differently, especially as there are overlaps. For instance, if someone is both manic and psychotic, they can meet the criteria for either Bipolar I, Severe with Psychotic Features, or Schizoaffective Disorder, Bipolar Type. I know psychiatrist who say with a tongue only partially in cheek that they diagnosis based on what medications people respond too. Frankly, most therapists don’t care what the label is, but what works to help the person get better. Doctors can be another story. They are trained differently.
As far as the homeless problem, this is most certainly its own post or series of posts. Based on my own personal experience, and backed up by data, most people who are chronically homeless lack the functioning to manage their lives in a way that will allow them to hold down a job and stable living situation. As to why this is, both mental illness and substance abuse are usually the cause. However, it is a mistake to seperate the two. We can argue that taking substances is a choice (another post, I think). I can say that people get addicted to substances because they are not happy or healthy. Rare is the person addicted to opiates because he tried them: there is almost always an underlying cause. I see substance use as a type of mental illness.
Now, we need more psychiatric hospital beds. Let me point to an article that first appeared in National Review:
America Badly Needs More Psychiatric Treatment Beds. The take away is this line:
That is way too far in one direction. It would be like having as many medical hospital beds per person as we did in 1850. When, according to government studies, one in five adult Americans will have a significant mental illness in their lifetime, this is just wrong. Significant, by the way, means impacting their functioning in work, school, or relationships in negative way over several months. This was not Reagan. This was bipartisan and started in the 60’s. The Left wanted better treatment, the Right wanted to save money. But like I said, that is its own post.
And let me emphasize this one point in its own comment:
The majority of psychiatric medications are not prescribed by psychiatric specialists.
I urge you to refer yourself or any one who needs care to a specialist. I know there are not enough. Find one. You would not treat heart disease with just your GP.
My rule of thumb, the GP gets one crack at the antidepressant. Then onto the specialist.
That’s true in my experience also. My sense is that the pathologolization (so to speak) happens in some of the general public (I see it in millenials of my aquaintance) who then get psych meds from their GP. But that’s only my sense. I could be wrong.
I think the question people like James ask is, “Wouldn’t these people be better off in the long run if they struggled through the conflict, and developed spiritually?” On the other hand, depression itself interferes with one’s ability to pursue change. The person with a 5-6 mood is more likely to put the work in than the person with 3-4 mood.
True.
Yes, but that’s intramural; practitioners don’t challenge it enough in public. To be fair, this is more a problem with the health care system. ICD-10 coding, or you don’t get paid.
Well stated.
True, but please note that the quote references “state psychiatric-hospital beds.” These are the institutions where patients spend years, and sometimes the rest of their lives. These are in extremely short supply. I have seen patients stay for months in an acute care hospital waiting for placement at a state hospital. Acute care psychiatric hospitals in this day and age are completely inappropriate to the needs of these patients.
There is also a shortage of community psychiatric beds, but I suspect this is in part driven by hospital policy. Hospital administrators get extremely antsy if census drops below 100%.
The biggest problem in long-term community care for paranoid schizophrenics is the financial and moral responsibility. It’s more than any individual or small group can handle. Just as parents realize at some magic moment, we too need to shift our weight to rehabilitation and independence. Rehabilitation is possible.
How do we make that happen? We need teams. I think Cape Cod accomplished a lot in this area partly because the numbers were relatively small and because we think like a small region composed of fifteen strong and independent towns. That work pyramid is a habit of ours for solving problems. When community care became the standard, Cape Cod got to work. It’s a wonderful story, albeit with difficult moments along the way.
I recently read a wonderful book by Gil Winch. He talks about getting people who have severe disabilities into employment. Winch is on a crusade, and I am rooting for him all the way. The greatest moment in his personal odyssey in this professional area was his success in working with a paranoid schizophrenic. It made me laugh. As we all know, that’s the most challenging of all. He is justifiably proud of his accomplishments. He has the determination to succeed, and I wish him well.
Part of the problem for recovering schizophrenics is in the financial end of it. Getting SSI is a six-month process, and it’s complicated, and no one wants to go through it. If we want to reduce the numbers of mentally ill homeless people, it is paramount that we start with the financial system that is rigid to the point of being deadly.
And we need to make up our minds to build congregate and assisted living housing. I have seen it up close. It’s the only answer.
We have let these problems grow so big over the last thirty years that I fear for people now. There’s going to be a revolt, and someone is going to take drastic and inhumane and cruel action against mentally ill people. The impatience in our communities against the mentally ill is growing every day. (I would include the addicts here, who are simply self-medicating.) I am worried about what will happen to the mentally ill people.
This is why the new round of advocacy for the mentally ill has to be focused on rehabilitation. I’d start with Dr. Hyde’s book. He has passed away, but his spirit lives on in the thousands of patients he helped with his rules for daily life. :-)
I knew Dr. Hyde well, by the way. I watched him care for the person I was caring for, and he was the only person I ever knew who understood her. I got to know other psychiatrists, but those doctors could never have gotten my friend to the point that they could treat her. He understood things that no one else did or does now.
Yes and Yes!
I agree with a lot of this. the thing is, the taxpayer does not.
I interrupt this conversation to say that Howie Carr is trying to figure out how to get illegal immigrants to Martha’s Vineyard. lol He wants to put buses on the freight ferry. lol
This is an incredible post. Thank you Bryan.
This is a great thread, and I really appreciate everyone who’s commented. I have only one observation and that’s that a psychiatrist Dr. McHugh seemed to be be very supportive of talk therapy and said that many abstract approaches to understanding the mind tend to coincide. One thing that he predicted was that schizophrenia, as opposed to other mental illnesses, would be understood and treated chemically as a brain disorder rather than a disorder of the mind.
It is different in my experience. Something has gone horribly wrong.
You mean the emphasis on pharmaceuticals?
There was a state hospital in the capital. They closed it back in the day when that was an in thing to do. What has happened since?
1. The city is overrun with the homeless.
2. Much of the land was reclaimed for a revenue-generating minor league baseball stadium.
3. Buildings were torn down and the land for a while sat idle but is now being used to build upscale apartments for people who can afford the cost of city living.
The state hospital was replaced with housing and recreation for those with jobs and money.
The good
4. A Christian ministry in the capital does administer to the homeless but needs many donations to feed folks. They have some beds and warm meals.
5. Another Christian ministry picks up homeless vets, houses and feeds them, gets them to the VA, and tries to rehab them. Occupants must follow strict rules, including attending Bible study. Those who can’t follow the rules must leave. Military people do seem to do better in a structured environment around other military people. However, there is only so much they can do with many of the homeless.
However, the homeless situation seems as bad as ever.
No , I mean in the brain of the person.
And now we are (inevitably) getting to the dreaded mind-body problem. That is, as Bryan says, a post on its own. And I’ll gladly admit that I don’t have the philosophical chops to go there.
I will, however, outline how I think about it.
Example: my whole family is killed in a plane crash. My mind perceives the meaning of this, and I enter a depression, as is natural when people grieve. I become “stuck” in my depression due to biological factors of which we have a vague understanding (I believe I can state with a good level of confidence that those biological factors do in fact exist). My depression can then be treated with antidepressants, which help bring me out of that depression.
Anyway, that’s how I make sense of it.
Maybe the brain is like the dashboard and controls of a car.
I personally believe (for now, and only sketchily) that we are lifeless clay or dust until God breathes a living spirit into us, at which point body (brain) and spirit (mind) become a soul. It’s as if the brain is the vessel containing the spirit, and the spirit operates through the brain. So both have to be functioning well for things to go right.
But there are problems with this.
Thank you for addressing my questions, first of all. I’ve learned a lot.
As for the last point about needing more beds, yes, yes, YES. Tonight my wife was listening to a radio show interview with someone – social activist, comedian, couldn’t tell, what’s the diff sometimes – and he said that he had crazy people on his street because Reagan closed all the mental health shelters. I yelled from the other room “THAT’S NOT HOW IT HAPPENED,” and wondered whether the show would be flagged on social media for disinformation.
Prrrrobably not.
Well, it is something like totally dysfunctional cities, run by Democrats for 50 years, blaming Republicans for their problems.
Glad you learned something. I have succeeded in my goal with a n of at least 1.
This post is a useful reminder for me, because I’ve been struggling for years with my attitude about all of this. I have a close family member who is largely nonfunctional because of depression and anxiety; various diagnoses have been offered over the years, but I think the current thinking is Bipolar II and generalized anxiety. I’ve been frustrated to watch years of therapy appointments and constantly changing prescriptions, and it has been hard for me to avoid feeling frustrated and cynical.
But a couple of years ago my wife and I attended a free class offered by the National Alliance on Mental Illness (NAMI). I went almost grudgingly because I expected to be fed a bunch of squishy nonsense, but it was actually a fantastic experience. In part it was therapeutic to learn how many other people had been through similar (and far worse) experiences. But it was also helpful and eye-opening for me to learn just how much guesswork, how much trial and error, is involved in this field. Art rather than science, as you say.
I still struggle with my skepticism, in part because I have no way of evaluating the quality of the care my family member is getting. As months and years go by with no change, it’s easy to fall into the trap of wondering if this is all just laziness, enabled by a dysfunctional mental-health industry. But then I remember what I learned in the NAMI class, and I remind myself that my family member does want to get better. There actually is something wrong. I just wish it weren’t so maddeningly elusive.
Alzheimer’s can be temporarily diminished by Tylenol. The individual needs the same amount that is used when the individual is suffering from a bad cold.
This was researched in the mid 1990’s but then the astounding discovery was buried. (Note to people who are caring for an Alzheimer patient – in the mid 1990’s, most Alzheimer patients had no pharmaceutical meds for that condition. If your relative is on Big Pharma meds, you would have to ask the pharmacist or dr if Tylenol would work okay in conjunction with the current prescribed meds.) I don’t know that Tylenol cures the Alzheimer’s outright. But it definitely can lift the severity of it.
Bipolar condition can be wiped out by chlorine dioxide, also known as MMS. That is such a cheap treatment that it has never been “properly” investigated. Also the FDA has put out the word that it will kill those who take it. (Funny thing is, I know of 3 individuals who used it as a prophylactic against COVID. None ever got COVID, and all are still very much alive despite the FDA warning.)
Depression – even very extreme cases of it – can lift immediately if the depressed individual uses care in their diet to not ingest any MSG. MSG is in almost all breaded products like fish fillets and fish cakes, coatings for chicken. In almost all store bought pastries and other baked good. Even in Newman ‘s rather pricey “organic” cookies.
Food labels now almost never include the expression “MSG.” But the substitute wording is “spices” “natural flavoring” or “modified tapioca starch” “modified corn starch” or any modified anything starch.
Lack of sleep can force an individual into a schizoid state of being. I wish that there would be intense research into how it is that a serious lack of sleep induces it. Maybe there are researchers out there who have studied the chemical cascade that occurs when an individual is 20 to 50 hours behind in their needed sleep. If that situation was well understood, maybe schizophrenia could be remedied as well.
This is patent nonsense.