This story confirms what many of us have known for some time. Psychiatric medications can be overused to the exclusion of psychosocial supports. I found the discussion on disability to be interesting, but it missed a critical point. Disability, regardless of whether it is psychiatric, neuro-cognitive or physical, has to do with impairment in role or task functioning. Clinical treatment services, be they medication based or psychotherapy based, do not address the disabilities that can frequently accompany serious mental illness.

As budgets have struggled to meet the needs of those with psychiatric disabilities, services designed to improve role or task functioning have disappeared, leaving many with only the clinical services and none to address their disabilities. This may help to explain the "increases" in those with psychiatric disabilities. The continuing paucity of rehabilitation services in WA State is likely to add many more to the psychiatric disability roles. A sad and avoidable outcome.

Even more sad is for this to be happening when so many rehabilitation services are becoming recognized as evidence based practices, that is services with demonstrated utility and quality outcomes. Supported employment, assertive community treatment and the ICCD clubhouse model of psychiatric rehabilitation are all recognized evidence based practices. All are in short supply and/or difficult to access.

Psychiatric disability is a function of serious mental illness and requires significant attention with specialized services. Until such time as these services become more widespread, accessible and evidence based, we will see many more persons with serious mental illness joining the disability rolls with too many remaining there.

Judy, thanks for introducing me to Whitaker's work. A half a century of increasing use of drug therapy for these conditions produces telling results! The statement, "the drug will change the brain in ways that will likely make it necessary to continue taking it" - WOW! This creates a dependence at a high price (both for the person and the pocketbook!) - and the pharmaceutical companies make the huge profits! It is encouraging to see the psychosocial aspect being looked at - I am convinced that there is a spiritual component that when included gives the most holistic perspective of who we are. The more holistic therapies take time to be effective but there are no detrimental side-effects as with the drugs. Maybe with more comprehensive therapies (which include support systems) less drugs will be needed. Thanks for the exciting examples you cite. - Rev. Marvin Eckfeldt

"Psychosocial" strategies, including talk therapy, are great. Too bad so many psychiatrists are turning away from these, as outlined in this March 5 story in the New York Times.

http://www.nytimes.com/2011/03/06/health/policy/06doctors.html

Anti depressants can be a life saver but if you are thinking about going on them, ask your doctor about what it will take to go off them.... And if at all possible ask if talk therapy is an option. You might want to try it before going on the heavier medications.

https://www.pointofreturn.org/brain_zaps.html

I have spoken with people who went off, even after a gradual tapering off period who had these "brain shivers" or as it was described to me "brain zaps" where it felt like electrical shocks were running through their brain.

In no case go off them cold turkey. These drugs can cause serious harm if mis-used.

As Steve Allen so wisely put it, "It's crackers to slip a rozzer the dropsy in snide."

That's another good point, GaryP. Of course, your prescriber should be telling you what it will take to go off them, without you having to ask.

Judy,
You are an excellent teacher, so my brother says. I certainly take him at his word. However, this publication and you, yourself, seem to confuse asking open-ended questions as reporting the news. It seems every time I come to this site, the headlines are some inane open question regarding something I have to convince myself I cared about before reading the headline. I suggest you flip through the various articles and see how many are these questions. Perhaps this is a stylistic issues, but once the pattern occurred to me, glancing at this site has become a source of considerable irritation.

Cheers,
Doug Almquist
Ravenna

Judy, thank you for this--I hadn't heard about Whitaker's book, and it sounds like important reading.

As a psychotherapist, I'm glad to hear signs of a more realistic dialogue about the role of medication in mental-health treatment. I know that the medical model appears to offer a nonjudgmental, pragmatic way to accept and treat emotional and mental suffering. But actually it often shames and discourages people to believe that they have "broken brains," as I've heard many times in my office--a belief which is obviously unhelpful because it's depressing, and also happens to be almost certainly untrue. If the "brain" were "broken," then so many people wouldn't get better with or without treatment.

Anyone who's been clinically depressed (for example) knows that depression is a biochemical event. It affects the way one thinks, sleeps (or doesn't), eats (or doesn't), and relates (or not) to others. But the mistake we seem to be coming out of, finally, is an idea that if mental illness is physical then it isn't also mental, whereas on the other hand if it's "only" mental then it's not real.

One of the most hopeful things about mental illness, I think, is that it *is* mental as well as physical. Instead of a "broken brain," there can be various ways that human beings get stuck in their emotional and mental development--human beings who are endowed with a variety of natural tendencies and resources for getting unstuck.

To use depression as an example, again, many depressed people suffer from really painful, depressing beliefs about themselves--"I'm too much for other people;" "I'm fundamentally weak/not special/not smart enough," "I will always end up alone," and so on. As I understand the research to date, it's somewhat helpful to suggest that people try to consciously change the belief; and medications can make the pain of living with the belief more manageable; but what's *really* helpful is to somehow test and disprove the belief, and learn for oneself that it's not true. Learning is a biochemical event; our minds change as we learn through experiences shared with other people. Which may be why psychosocial approaches work so well for a variety of mental illnesses.

So the questions Whitaker raises sound very important and timely--thanks for raising them!

Judy,

Your reporting on Robert Whitaker's groundbreaking book is insightful and important. I applaud your ability to sift through the complex issues and medical linguistics of this book and distill it into human terms.

I attended one of the lectures last week of Mr. Whitaker's and as a journalist and someone who has had family members with mental illness I found myself riveted by the book's startling hypothesis, that the medicines used to treat mental illness could actually be causing lifelong debilitation.

I commend you on your thorough examination of the questions raised in this book, and I hope that by shining a light on this research there will be more questions raised, and new studies done about what we as a society are doing to care for those with these disabilities.

Thank you for tackling this, and Crosscut for recognizing that we need this kind of informed, alternative investigation to help us all see things more clearly. You're writing on these issues continues to inspire hope, I think, for finding better solutions.

What is not mentioned in this article is that some people find that using Alcohol and Marijuana are easier to use and self medicate than the prescription drugs. There have been a lot of anecdotal evidence that these drugs while also can have severe side effects are the drug of choice of many homeless. Their homeless'ness being a part of the mental illness and their "chosen" treatment.

Also not mentioned is that many private health plans cover only one to two weeks worth of inpatient treatment. This leaves families struggling with a crisis to either drain their finances, or try to dump the person into the state run system. With the state using the "medicate them, release them" plan which in general prolongs the episodes.

While many readers know my position on Universal Health Care, here is a place where directed treatment with daily followups would reduce the overall cost to us the taxpayers for all the trouble that mentally ill homeless can cause. And possibly help these people recover enough to rejoin society.

The other thing not mentioned is that there is a class of people with mental illness who are untreatable in the wild. I'm writing about the paranoid. These people distrust the medications and their caregivers such that they will refuse any treatment. In incarceration may be the only successful way to treat them. Yet current laws make this extremely difficult because they have to essentially commit themselves, yet their paranoia keeps them from trusting that the system will take care or help them.

In the long term we are going to look back at our treatment of mental illness with the way we view "blood letting." As we really have very little idea of what the heck we are doing, or why any of it works.

A variable that is only lightly covered in this article is the age of the patient. My schizophrenic mother took medications for the last twenty years of her life (she lived to be 89), for the final ten years a rather heavy dose. It made her life bearable and even enjoyable at times. I am fairly certain she gave up a lot of cognition for that peace but, at her age, the drug was more than a fair exchange, it was a blessing. Giving that treatment to someone who is young seems like a much poorer and riskier trade.

JRBee is correct, there are proven strategies, but they're increasingly difficult to access because there's no funding. For people who are developmentally disabled and also have psychiatric difficulties, as is the case with my daughter, there are no "appropriate" housing settings. The less-appropriate settings (either in the mental health system or the DD system) have no openings because people in those settings don't generally move out -- they need that type of housing. So yes, too many people are on the disability rolls, and there's too little help for them, which is especially tragic because we know what works. We just don't want to pay for it.

In an email, Eleanor Owen, a co-founder of the National Alliance on Mental Illness (NAMI) and founder of WAMI (Washington Advocates for the Mentally Ill), now NAMI-WA, wrote:

Article well-worth distributing. However, the real driver of over-consumption of atypical and anti-depressants, is the vested interest of prescribers and providers of on-going "treatment" -- particularly of individuals who are on Medicaid. Too many of these "customers" could be "tapered off," but the health care providers and prescribers are just as unwilling as Macy's or Sears to give up a good customer. Indeed, why have so many providers developed permanent housing for these customers and not developed small businesses? The investments would have been similar. In one instance, the apprentice would move on to greater autonomy; in the chosen one, the customer is a captive for as long as Medicaid has funds to pay for "perpetual care."

I'm not sure what Eleanor Owen is trying to say. She doesn't know the specifics of what is prescribed for individual Medicaid clients, since that's confidential, so she doesn't know whether they could be tapered off or not. Psychiatrists who prescribe for Medicaid clients aren't getting rich off them; reimbursement for Medicaid is about one-third as much as for people with regular insurance, and thus most private psychiatrists don't take Medicaid clients. Permanent housing is not dependent upon who is prescribed what but rather upon private and governmental funding. Small business development has nothing to do with Medicaid. The word "apprentice" makes no sense whatsoever. All in all, her comments make no sense.

Thank you Judy. This is an excellent article. As usual, you are enLIGHTening!

As a physician who has treated mental illness for 25 years, and who also has personal experience with mental illness in my family, I am convinced that it is not "one or the other" - but the most important help for people with mental illness is education, family and community support, psychotherapy, and meaningful employment if possible, as well as supportive living arrangements. And while expensive, I also agree that this focus and help would be cheaper than what's happening now.

However, I feel that medication definitely has its time and place. Too many physicians have just prescribed a pill only, and have not even done appropriate medical follow-up for their patients. But I saw too many miracles in my practice as a result of appropriate medicine treatment, i conjunction with, I've noted above, appropriate other therapies and support.

And in my practice I took many many people off psychiatric meds after an acute crisis or no longer than 6 months of medical treatment plus psychosocial support - only a small number needed to stay on medication long-term, and only after they and I concluded they definitely needed it, after drug free trials.

I appreciated you final paragraphs about a future when mental health treatment will become affordable and available to all, and our society will have effective support programs in place.

Thanks again,

Nancy

Good article. I have suffered from OCD-type symptoms for the last decade or so, from my mid-forties to today (mid-fifties). Fortunately they have abated quite a bit. I decided I did not want to take any drugs and have not done so. I certainly think the drugs are greatly overused, but they can be lifesavers for some so I don't have a doctrinaire position.

People experience "mental health" symptoms for a variety of reasons; spiritual, social, even lack of exercise. And, as the article mentions, we live in an increasingly fragmented society (and I might add, a noisy one often detached from the nurturing ministries of nature). And the expectation that we will always be happy and never have struggles is irrational.