Sunday, April 15, 2018

That Way Madness Lies

I thought this would be of interest to our readers!

“THAT WAY MADNESS LIES…”  To be screened at the Richmond International Film and Music Festival
 BowTie Criterion
1331 N Boulevard

Richmond, VA 23230
Saturday, April 28. 2018 at 11:45 am
Tickets available at:
Q&A with filmmaker Sandra Luckow 

New York, New York April 15, 2018 – THAT WAY MADNESS LIES…, an award-winning feature length documentary (Best Feature Documentary at the Hot Springs International Women’s Film Festival)  about severe mental illness and its effects on a family, their struggles with the mental health system and the law enforcement system, will be shown on Saturdayy, April 28, at 11:45am, to be followed by a Q&A with filmmaker and Yale School of Art faculty Sandra Luckow. There it will receive a special Jury Award.   First responders in law enforcement and crisis management, mental health advocates and families dealing with a mental health crisis are especially encouraged and welcome to attend. 

“Most honest portrayal of how severe mental illness ravages families and lives that I’ve seen!” - Pete Earley, author of CRAZY: A Father's Search Through America's Mental Health Madness. 

Film synopsis: One woman and her family trek the broken mental health system in an effort to save her brother as he descends into madness. Beginning as a testimony of his sanity, his iPhone diary ultimately becomes an unfiltered look at the mind of an untreated schizophrenic.
Duanne Luckow, 46, began a scary, dangerous and ever-escalating cycle of arrests, incarcerations and mental institutional stays. Three months into his first court-ordered 180-day commitment at Oregon State Hospital, Sandra Luckow, his sister and filmmaker, visited him. He gave her his iPhone with 250 video clips. He wanted his experience documented. With their cameras, they expose an ineffectual and inhuman system as well as delve deep into the strength of family ties. Yale School of Medicine and the Global Mental Health Program at Columbia University say the iPhone footage Duanne shot as he descended into madness offers a rare, unprecedented, unfiltered look at the mind of an untreated schizophrenic. This is a specific harrowing story about a singular family trying to find its way through society's imperfections, stigmas and prejudice when dealing with mental illness. It is a search for answers - a free-fall into a quagmire of conflicting interests, policies, and despair. 

“The title of the film, THAT WAY MADNESS LIES…is a quote from Shakespeare’s King Lear, Act III, Scene IV. It speaks to the complications of dealing with mental illness, and our own uncertainties as to which direction we should pursue towards wellness and peace. “It is my greatest hope that this film will be an agent for changing the way we deal with our mental health in America,” says director Luckow. 

“This is the only film that I know of that has risen to the task of representing the terrors and tragedies of psychosis accurately and with immediacy and therefore the only one I know of that can truly serve educational and advocacy functions in changing the mental health system to one that promotes recovery and community inclusion as opposed to chronicity and dependency.” – said Larry Davidson, Ph.D. Professor of Psychiatry, Yale School of Medicine, one of the many psychiatric professionals around the United States who have called this film an important and accurate depiction of mental illness — one that should be seen by policy makers and those who care about the care and treatment of people living with mental illness in America.

For further information about the film please visit the film’s website at

Wednesday, April 11, 2018

Antidepressant "Withdrawal": Why Aren't Psychiatrists Seeing this "Common" Problem?

Over on The New York Times website, there is an article titled, "Many People Taking Antidepressants Discover They Cannot Quit. "  Benedict Carey and Robert Gebeloff write about how long-term use of antidepressants is increasing, and some people have difficulties coming off the medications with symptoms that constitute a discontinuation syndrome.  I'll let you read the article rather than quote it, because there was a lot wrong with the piece.
It doesn't feel like a new idea that there are people who have protracted and miserable discontinuation syndromes--distinct from a recurrence of symptoms-- after stopping antidepressants. People have been writing in to Shrink Rap about these difficulties for the past decade, there are online forums around it, and The New York Times Magazine did a cover story by a man who stopped his Effexor and went through a difficult time with discontinuation symptoms back in 2007.  

I don't think any psychiatrists were surprised to read that SSRI's have a discontinuation syndrome, and because of the symptoms that can develop, we routinely advise people to come off SSRIs and SNRIs slowly, especially from those medications that have a shorter-half life like Paxil and Effexor.  The question is not whether people might have symptoms, but about how difficult it is to manage these difficulties and how long they might last.  So while we have all seen people who have some discomfort after stopping a short half-life SSRI or SNRI, we think of this as something we manage by slowing the taper, switching to Prozac with it's very long half-life, or waiting it out with the idea that symptoms will resolve in 1-3 weeks.  What's different in this article is the idea that this is common, that patients struggle with intolerable symptoms even when they undergo a very slow taper, and that these symptoms can last for months or even years. 
 The article is one-sided in that it talks about the misery of the discontinuation syndrome with the overtone that "if only the doctor had told me that this would happen, I never would have taken the medication."  The article completely neglects the misery and dysfunction of the disorders that lead people to start these medications to begin with! 
The article doesn't mention that one common reason for symptoms upon stopping --for example anxiety or sleep problems -- may be the recurrence of the initial problem that they medication was treating.  In some people, depression is an episodic issue and people can come off medications, with other people, depression, anxiety, obsessive compulsive disorder, premenstrual mood difficulties, and other problems these medications are used to treat are more chronic problems.  In these cases, stopping the medication may be like stopping insulin or synthroid: the problem is still there and staying on the medicine may make more sense.

I think it's easy to be dismissive of the prolonged discontinuation syndrome-- to say that the symptoms simply don't last that long or cause that much misery, and if they do then the patient has obviously had a recurrence of their initial symptoms, something else is wrong, or it's all "in their head"--meaning we don't believe the person is actually having the symptoms they say they are having and they are a result of suggestibility or hysteria. 
So what's good about this article is that it increases awareness of the issue and those people who are having difficult discontinuation problems may well feel a sense of validation in knowing that other people have the same constellation of symptoms. 

I believe that there are patients who have these long and miserable discontinuation problems -- many have written into  the comment section of Shrink Rap over the years, and The New York Times found some to interview, including one psychiatrist who was having trouble coming off Cymbalta.   What I haven't figured out is this: Why haven't I ever seen any of these patients? It seems that when people have trouble coming off antidepressants, that slowing down the taper works, or the symptoms  are self-limited and resolve in 10 days, or the patient decides to resume the medication.  So while I've read about these miserable stories for a decade now, I've never seen someone have a protracted and miserable time coming off despite a slow and careful taper.  It's been 25+ years and a lot of SSRIs, including many people who casually mention that they stopped taking their medications without consulting me first.  I asked in an online forum if other psychiatrists have seen this phenomena, and a few mentioned that sometimes patients had trouble stopping antidepressants, but no one offered that they had seen this degree of misery.  So while I do believe it exists, I also think it's not terribly common in psychiatric practice, that for most people discontinuation symptoms can be managed with careful and thoughtful tapering, and that while some people may have extreme difficulties, these awful scenarios are not "common" as The New York Times article asserts.
 But there is a lot wrong with this article.  There is the fear that the article will serve to scare people who might benefit from medications, and thereby discourage people from getting treatment.  We've seen that already: when a black box warning was put on antidepressants regarding suicidal ideation in children and adolescents, prescribing went down, and suicide rates went up.  Figuring out this balance is difficult, and it would be so nice if we knew who might benefit from medications and who is more likely to be harmed than helped by medications.  

Finally, what's really wrong with this article is that it uses language that likens antidepressants to addictive drugs of abuse, and it stigmatizes those who need to continue them.  People don't get addicted to anti-depressants: they don't use them to get high, they don't crave the medications, and they don't engage in addictive behaviors such as escalating the doses without medical guidance  or getting medications in deceptive ways.  Awareness of a problem may be good, but it needs to be done in a responsible and balanced way.

Monday, April 02, 2018

Stop Stigmatizing Psychiatric Treatment!

Stigma is a sticky, two-sided issue, one that we talk about often in our field of psychiatry.  Many things are stigmatized. While mental illness is an obvious one --and I'll come back to this-- many other things are stigmatized as well.  To name just a few: drug use, smoking, being a criminal, going to jail, behaving in a disruptive way, smelling badly and being physically unkempt in certain settings, begging for money in public, being on public assistance (in certain circles), beating your children (again, in certain circles), incest (in all cultures), being morbidly obese (especially when it happens in someone who makes poor food choices, as opposed to being the result of an illness), suicide, behaving badly after drinking alcohol,  sexually harassing your colleagues in certain circles, and I could go on and on.  

Stigma, as you can tell by my short list, is a bit diffuse and subject to individual consideration, pertains to lots of troublesome behaviors, and depends almost wholly on the environment and consideration of others, and what is stigmatized  changes over time.  While stigma is troublesome in that it causes people to feel shame and self-loathing, it also has a role in society.  Stigma inspires some people to change  or avoid certain behaviors.  People certainly smoke less since it's become highly stigmatized and those who want to smoke at work are sent out into the cold to stand in little boxed off smoking areas.  There is a stigma to going to prison and being labeled a criminal and this is part of the deterrent to crime.  While suicide rates are rising, many people still don't end their lives for fear of stigmatizing their family, and as much as I see suicidal thoughts as a symptom of an illness, I do imagine that more people would choose to end their own lives if it left a legacy with no stigma whatsoever.  While it may have once been cool to be a "player," it's no longer okay to grope your co-workers.

But what about mental illness?  Mental illness is not a behavior and it's not a choice, it's a constellation of uncomfortable psychic events, or symptoms, and sometimes having a mental illness leads people to behave in stigmatized ways.  But the illness itself?  Yes, it's mostly still stigmatized, despite our best efforts, but some conditions certainly more so than others.  We have not really clarified exactly what mental illness even is, but the reaction you'll get to saying you've had panic attacks in the past may be a bit different to the one you'll get if you announce that during manic episodes you run through the streets naked and max out your credit cards.  

So I don't want to talk about the stigma of mental illness and substance abuse today,  I want to talk about the continued stigma of getting treatment for these issues.  Because one of the problems with stigma is that it discourages people from admitting to themselves or others that they have these problems and getting help, and so the treatment itself is stigmatized.

This is the funny thing: most things that are stigmatized are unpleasant or have unpleasant consequences.  Jail is uncomfortable and leaves you with a bad mark.  Getting psychiatric treatment is not usually unpleasant, and it often leads to very GOOD things.  Being in therapy is stigmatized in many circles, but once over the hurdle, people ENJOY coming to therapy.  You talk to someone who cares about you about the difficult things in your life, you have a safe place to process what goes on in your head, and often just talking is a relief.  Most people like their therapists and look forward to sessions.  If things are not going well, the session is a place to process what's going on, to have someone who listens with concern, who may or may not offer helpful suggestions, who carries your history and story.  This can be a great relief and a tremendous comfort.  But people don't just come in when the world is crashing, often they are happy to come to a session and announce that things are going well!  They want their therapist to be pleased for them.  And therapy is about the same things for everyone: talking about the stuff you can't talk to everyone else in your life about, often talking about issues with interpersonal relationships, and the obstacles to getting what you want out of life.  It's the same for those with serious mental illness as it is for those who function well.  So why do we stigmatize something that people enjoy, that helps them?  This I find perplexing.

And what psych meds?  The stigma that comes with taking them is huge and there is even a culture of what some have called "pill shaming."  Granted, some medications have side effects or cause weight gain or sexual dysfunction, it's not all good.  But many people take psych meds and feel so much better.  They become more functional, they feel less misery, they stop hearing voices, they stop behaving in those ways that are associate with mental illness and they gain a resilience and reserve that is helpful.   Yet most people don't proudly announce that they get monthly antipsychotic injections or that lithium has been a live saver that allows them to have their highly functional life.  At one point, it was probably fine to say you popped a Xanax for anxiety, but now even appropriate benzodiezapine use use gets lumped in with addictive issues.  

And rehab?  Oh, my, outside of Recovery circles, most people don't advertise that they have been to detox or rehab.  Why not?  Good rehab is a wonderful thing.  It takes people out of the foxhole of addictive misery and gets them back into a place where they can love and function.  

We're never going to stop stigmatizing mental health problems, especially if we continue to insist that they are the cause of people becoming mass murderers.  But let's work hard on it: mental illness does not explain many things that the American public thinks it does.  And let's try very hard not to stigmatize treatment!  Treatment is good, it gives people their lives back, it helps them shed oppressive symptoms,  it feels good and it's nothing to be ashamed of.