Mental

by Jaime Lowe

  So I called a psychopharmacologist, Dr. Richard Brown, an associate professor of clinical psychiatry at Columbia University to try to figure out a more specific answer. Brown was one of Depakote’s earliest advocates. The drug had been approved in France in the 1960s and in Germany in the early 1970s, and by 1982 Dr. Brown was using it to treat bipolar disorder off-label in the United States. “From 1980 to ’92, I lectured and helped psychiatrists use Depakote,” Dr. Brown told me. “People were screaming at me and called me public health enemy number one. They said, ‘You’re going to kill people with this drug.’” I asked him why I would be prescribed two different kinds of Depakote interchangeably, and he said, “What’s happened is that most psychiatrists have no clue that ER is better than DR, and many prescribe generic DR. And because it’s been off-patent for several years there’s no economic incentive to educate doctors on how to use Depakote effectively.” He explained that Abbott launched Depakote DR first and Depakote ER second. He said most psychiatrists were just unaware of Depakote ER’s improvements over the first formulation. It lessened the side effects and made the pill easier to tolerate. But Schwartz had prescribed ER and yet the pharmacy doled out DR? Sometimes, that happens for insurance reasons, sometimes it’s just a lack of information, sometimes it’s a mistake, he said.

  Dr. Brown also said that there is a clear hierarchy in the psychiatric community and the medical field in general—that being a psychopharmacologist is looked down upon. “The typical training program doesn’t give psychiatrists what they need to know about how to prescribe medications. Two thirds of psychotropics aren’t prescribed by psychiatrists anyway—it’s an internist or a general practitioner. Psychopharmacologists are thought of as people who are not that smart.” But obviously there is a difference in what kind of medication you are prescribed, down to the make and model. “There should be a separate specialty board in certification in psychopharmacology, and that has been stymied by the old white guys, and they’re afraid that they wouldn’t be able to practice anymore because they would never pass that certification. It comes down to money and turf and prestige.” Depakote isn’t the only drug that is prescribed early and often for depression and bipolar disorder without enough information. “Tegretol could work really well but it has a lot of side effects. It can wipe out your white blood cell count. You only use it if everything else has failed. Lamictal is okay but it only works for one out of nine people and that’s only for depression. So eight people aren’t actually seeing results. A lot of doctors think Lamictal is for mania and aren’t told otherwise.” (Dr. Schwartz had worried about Lamictal as an option for me, and therefore it was low on the list of possible medications.) Brown went on to say what many mental health advocates and those with mental illnesses have expressed for years—mental health is simply not treated the same as physical health. Not by insurance companies, politicians, or the field of medicine. “For thousands of years people haven’t treated psychiatric patients with compassion and respect, and they have been discriminated against. There just isn’t true mental health parity; health insurance companies do not treat it the same way.”

  Dr. Brown and I continued talking about how politics and lobbyists have no business dictating access to medication, and yet in the United States, they do. He made the point that in countries with government-provided health care systems there is a way to track patients and the side effects and efficacy of drugs after the drugs have been released to market because the patients are a ready-made study. The government and health care system has a control group and access to all their subsequent reactions. We also talked about holistic approaches to mental health and how Eastern medicine considers mental illness.

  He ended our talk by telling me that when I was off the lithium entirely, he wanted to give me some mushrooms. His great-uncles had been mushroom farmers in the hills of Kentucky, and he knew of some that were curative, specifically for kidney dysfunction. “I don’t think we really know exactly how they work, but we know these mushrooms help kidney function and improve the function. It’s probably a tubular issue. It’s a brand of cordyceps, it’s also called cordimmune. Call me when you’re off the lithium and we’ll talk about it.”

  I then asked him if being open to other psychiatric methods like breathing or mushrooms made the mainstream medical community skeptical of him. He paused and said yes. But he was the first person I talked to who incorporated medicinal, analytical, and alternative approaches to mental illness.

  One night when H was away, the sky shook and lit up like war. It was four a.m. or five, still dark and scary. I was startled when I heard half a dozen loud baritone booms, each followed by an immediate shock of light. I checked my phone for bomb alerts, I thought the city was in peril, that Trump had incited war, that attack was imminent if not actually right now. I grabbed a couple of the extra pillows and moved away from our windows and huddled under the duvet. I hoped and rationalized that the sound was thunder and lightning. It obviously had to be. Either way, there was nothing I could do but breathe and wait. It was just thunder, the skies opening up, but I thought about that terror of war—real bombs, sounds that indicate death and destruction, not just low-grade anxiety. I thought about what it meant to live under Trump, whose finger was this close to the nuclear codes and whose mouth was liable to make his fingers do the talking. Dr. Brown had been to South Sudan and Rwanda and had done breathing clinics with survivors of genocide, people suffering from extreme PTSD. I imagined war, living amongst the ruins of villages and family homes. I couldn’t really imagine it, not from the comfort of my sheltered bed. Dr. Brown told me that people born with mental illness in some villages in South Sudan are chained to trees and left to suffer through schizophrenic episodes tethered on the outskirts of their communities and separate from their families. They get parasites, their disease gets worse, and it’s all for a lack of mental health care and lack of basic understanding. Some facilities in Ghana sequester their mentally ill off to one “hospital,” where patients ranging from bipolar to epileptic are locked in cages and medicated without monitoring or expertise.

  The United States is further along in dealing with mental illness, but not by much. In 2008 when George W. Bush signed the Mental Health Parity Act into law, it required all insurers to cover behavioral health the same way plans covered any other type of medical treatment; but insurance companies found loopholes and ways to circumvent coverage. Years later, when Obamacare was implemented, in a significant move toward parity, it forbade health plans from rejecting people with preexisting conditions—including mental illness and addiction. “We have made progress expanding mental health coverage and elevating the conversation about mental health,” President Barack Obama said in a statement. “But too many people still do not get the help they need.” Many therapists—psychiatrists, psychologists, and those in behavioral health—won’t take private insurance, exchange plans, or Medicaid plans because they don’t pay providers well, which means outpatient care is still an issue. Covered treatment becomes an emergency room issue and is reactionary rather than preventive. And, according to the National Alliance on Mental Illness, in our contemporary mental health crisis, people are more likely to encounter police than get medical help. “As a result, 2 million people with mental illness are booked into jails each year. Nearly 15 percent of men and 30 percent of women booked into jails have a serious mental health condition. . . . Once in jail, many individuals don’t receive the treatment they need and end up getting worse, not better. They stay longer than their counterparts without mental illness.” Former congressman and mental health advocate Patrick Kennedy has said the result is that those who can afford to go out of network do; those who can’t afford it often forgo care altogether. In the eighteen years I’ve lived in New York, it’s cost me more than one hundred thousand dollars in outpatient care to see Dr. Schwartz (and that is subtracting his absence during August). I can do that because I am functional enough to work. It’s my highest expense, second
only to housing. But for the almost 43 million Americans with mental illness, that simply isn’t an option. In October 2016, the Obama administration released a report of findings from a presidential task force commissioned to improve parity. But with the Trump administration and the Republican Congress promising to gut the Affordable Care Act, parity seems like a delusion at best. Parity seems like the wrong word for what is necessary—parity implies two separate entities. For mental health coverage and the study of it to advance at all, physical health needs to be regarded as something that encompasses both body and mind. Angst and his holistic approach to psychiatric health remain the gold standard. But health insurance companies and the pharmaceutical industrial complex don’t seem remotely interested in pursuing a health care system that would actually contribute to overall health. In fact, the labyrinthine process for reimbursement, coverage, rules, and regulations for both doctors and patients amplifies mental illness and anxiety. Every time I’m put on hold or puzzle through a pharmaceutical query, my back tightens, my jaw locks, and I have to calm myself down and coach myself through it. Most of the time I give up.

  Over the years, twenty or thirty or more friends, relatives, friends of relatives, and relatives of friends have talked with me about being diagnosed, going through moments of insanity, taking medication, being depressed, being manic, or being manic-depressed. We’ve swapped survival tales. But in the past decade or so, I’ve also known at least half a dozen people who committed suicide. People who seemed like they could get through a day but clearly—at some point—just couldn’t. I was talking with Mason about how some people can push through and others can’t and that it seems so arbitrary. Why meds work for some and not others? How family and community can work? And why sometimes everything just fails. The bottom falls out.

  “I think, we are all looking for that thing that can get us to even,” Mason said. “That thing that makes it easier to just be who we are even in bad states, to get to even.” I took “even” to mean functional. Beyond diagnosis, beyond medication, beyond therapy, and beyond understanding my disorder—I’m human, we are all human. Everyone is trying to get to even. Lithium got me to even.

  As I decreased the dosage of lithium, I thought I would send it off in some spectacular way to thank this miracle salt for its service. After coursing through my veins for twenty-four years, lithium would always be a part of me. Maybe I would drive to Saratoga Springs or fly to Canada and soak in the Halcyon Hot Springs. I thought of all the ways I could honor my pills. A vigil, a ceremonial toilet flushing, a last swig with a Michelada and nachos. I thought I could sprinkle a capsule from the highest of heights, dusting my city with a light coating—the crystalline salt that has kept me sane. I thought about the Sweetwater Park Hotel, built in 1887 in Lithia Springs, Georgia, with the central focus of taking in lithium luxuriously. There were 250 rooms in the hotel, each with hot and cold baths pumping in water from the springs next to open fireplaces and balconies offering views of the Blue Ridge Mountains. I craved a place like that for a grand send-off, but Sweetwater burned down in 1912 and now there’s a gas station in its place. In the end I did nothing. I was tired. I was tired of thinking about it. I felt okay, I felt happy, but I knew for at least a year, maybe two, maybe for life that I’d always wonder if happy was manic or manic was happy and if lithium was the only thing that prevented my happy from becoming mania. Those last 250 milligrams coursed through my body and within twenty-four hours—lithium’s half-life—the element passed unnoticed.

  A couple of months after I had been on Depakote alone, Dr. Schwartz asked me, as he had every week, “How are you doing? How are the side effects?”

  “I have mild indigestion still.”

  “But not as extreme?”

  “No,” I said. “My hair is still falling out. I look like a troll doll.”

  “But you still have hair.”

  “Yes, it just looks different, like alopecia has set in,” I said.

  “But you’re not manic?”

  “No.”

  “And you’re not depressed?”

  “No.”

  One night, about three weeks after the lithium had passed through, I was describing some mild insomnia to my mom. I told her that I was awoken around four a.m. by the nearly full moon, shining like the sun through our windows. All week the moon would wake me up, and I would stay awake staring at it. She paused on the other end of the phone. I could tell she was thinking: Is this a manic thing? And then I was thinking that, too. Was I communing with the moon because I thought it was cool, or was I doing it because the Depakote wasn’t working? My mom listened more and I explained that I must have been stressed about something else, and I know just by questioning if I am manic, I am probably not manic. (That is the first rule of Manic Club.) But the bigger question remains: Who am I in relationship to the medication, to the disease, to my experience? How did lithium shape me? It gave me twenty-four years of sanity—to live, to grow, to love, to flourish, and to fail. It gave me the chance to fuck up my life and repair it, to function, as if I were just another “normal” person.

  But here’s the thing: I am among the 1 percent of the mentally ill. I am the luckiest mentally ill person. I am the mentally illest. I was lucky. I have a family that supports me and understands me; most don’t. I was lucky. I was born into a family with enough money that I knew I would be financially supported if absolutely necessary and I would have health coverage no matter what; most people can’t afford a Band-Aid and a neck brace. I was lucky. I was diagnosed young and had the chance to get treatment; most mental illnesses can fester undiagnosed for decades. I was lucky. I grew up in the age of mental illness role models; previous generations didn’t talk about emotion or medication. I was lucky. Lithium worked for me almost immediately; some patients have to take half a dozen drugs and still don’t feel okay. I was lucky. When my life burned down, my industry, family, and friends forgave me and helped me rebuild. I was lucky. I had several psychiatrists walk me through this shit; most people don’t even get a social worker. I was lucky. My kidney is degenerating, but Dr. Lane and Dr. Schwartz caught it in time, and Dr. DeVita is nursing it along; some people lose their kidney function altogether. I was lucky. Switching meds was hard but I got the right kind of Depakote; some might have stopped at DR or one of the sixteen different versions of Depakote that affect people in entirely different ways. I was lucky. I get to experience all of life, one I would never trade for normal, whatever that is.

  I am lucky. Not everyone is.

  EPILOGUE: HOPE SPRINGS ETERNAL

  No episodes yet!

  NOTES

  CHAPTER 3: IF NAZIS DON’T GET YOU, THE MOCCASINS WILL

  A child’s brain was once thought: According to research conducted by Dr. Jay Giedd of the National Institute of Mental Health, cited in Valerie F. Reyna, Sandra B. Chapman, Michael R. Dougherty, and Jere Confrey, eds., The Adolescent Brain: Learning, Reasoning, and Decision Making (Washington, DC: American Psychological Association, 2011).

  CHAPTER 4: FAT AND BLOOD AND CIRCULAR INSANITY

  Bipolar disorder is now defined: National Institute of Mental Health, https://www.nimh.nih.gov.

  The generic definition: Mayo Clinic, http://www.mayoclinic.org.

  The use of lithium as a therapy: According to Jules Baillarger and Jean-Pierre Falret, cited in Aysegül Yildiz, Pedro Ruiz, Charles Nemeroff, The Bipolar Book: History, Neurobiology, and Treatment (New York: Oxford University Press, 2015).

  “The people ought to know”: Jules Angst and Andreas Marneros, “Bipolarity from Ancient to Modern Times: Conception, Birth and Rebirth,” Journal of Affective Disorders, vol. 67, no. 1-3 (December 2001).

  The physician Aretaeus of Cappadocia: Carlos A. Zarate Jr. and Husseini K. Manji, Bipolar Depression: Molecular Neurobiology, Clinical Diagnosis and Pharmacotherapy (Basel: Birkhäuser, 2009).

  “an animal within an animal”: Robert Lee, M.D., A Tre
atise on Hysteria (London: J. and A. Churchill, 1871).

  The real progress was made: Angst and Marneros, “Bipolarity from Ancient to Modern Times.”

  CHAPTER 6: RABID MUTANT SQUIRRELS, FRONTAL LOBE, BEAST IN THE ATTIC

  Outside the doors of Bedlam: Jerry White, A Great and Monstrous Thing: London in the Eighteenth Century (Cambridge, MA: Harvard University Press, 2013).

  But, miraculously, he survived: Malcolm Macmillan, An Odd Kind of Fame: Stories of Phineas Gage (Cambridge, MA: MIT Press, 2000).

  CHAPTER 12: SEX ‘N’ EGG ‘N’ CHEESE

  In 2016, however, a study by Dartmouth: Heidi C. Meyer and David J. Bucci, “Imbalanced Activity in the Orbitofrontal Cortex and Nucleus Accumbens Impairs Behavioral Inhibition,” Current Biology, vol. 26, no. 20 (October 24, 2016).

  CHAPTER 13: HYSTERICAL METAMORPHOSIS

  In 2011, the CDC: Roni Caryn Rabin, “Nearly 1 in 5 Women in U.S. Survey Say They Have Been Sexually Assaulted,” New York Times, December 14, 2011.

  Erika Kinetz wrote: Erika Kinetz, “Is Hysteria Real?” New York Times, September 26, 2006.

  In 2012, four researchers wrote: Cecilia Tasca, Mariangela Rapetti, Mauro Giovanni Carta, and Bianca Fadda, “Women and Hysteria in the History of Mental Health,” Clinical Practice & Epidemiology in Mental Health, vol. 8 (2012).

  “When these symptoms indicate”: Rachel Maines, The Technology of Orgasm (Baltimore, MD: Johns Hopkins University Press, revised edition 2001).

  CHAPTER 15: AND NOW FOR A PSYCHOTIC BREAK . . .

  At the turn of the century when Carl Jung entered: Carl Jung, Memories, Dreams, Reflections, edited by Aniela Jaffe (New York: Vintage, reissue 1989).