Here's the nutshell version of Satel's editorial: No one agrees on what constitutes any one mental illness. We all agree there is no discrete set of symptoms of any psychaitric disorder. We all agree no measurable physical difference between people labeled as mentally ill and people not so labeled has been discovered though I admit I think there is one, so lets keep labeling and force medication on all people anyone things might meet some of the varying symptoms anyone might call mental illness.

She not only admits no one has found proof that the cause of mental illness is not bad parenting, she goes on to say that the symptoms of mental illness haven't been identified.

Also, I find it odd that, given the lack of objective diagnostic tests, that researchers and opinionators such as Satel don't also call for the DSM-V to include some kind of guidance for doctors on re-evaluating a patient's diagnosis every so often, especially with patients who are treatment compliant and making decent progress. I think there's plenty of evidence that the course of mental illnesses can abate over time and it makes sense that some recognition of that fact be carved into the DSM as well.

Philip, didn't you know? Once mentally ill always mentally ill and the pharmaceutical companies wouldn't have it any other way.

And Sally Satel and TAC wouldn't dare risk letting any of us potentially dangerous folk off drugs to go wreak havoc. The prejudiced powers that be who put us all in boxes for power and or profit will do all in their capacity to keep us mentally ill, on drugs and in our places.

It's you and me that have to change that, not opinionators like Miss Sally.

Excuse me while I choke myself.[just kidding]BUT--if one more doctor/psychiatrist tells me "complex" again--just this last week, I had this discussion,[with a psych] it regarded the new DSM coming out and "how it's going to be changing how all doctors diagnose people, and whatever we call her[my daughter]today, will change in 5 years." "It's complex." Okay for 2 years THAT has been the basic diagnosis. Complex.

Easy way out--this just means that "we still don't have a fucking clue, here's the medication paradigm we work with, and after that, no one knows what to do."

Oh, and btw my daughter's brain has $6,000 worth of MRI's completed in 3-D version, and let's just begin a discussion on how Neurologists and Psychiatrists consider their fields different, and do not discuss brains together. Hmmm. I think Pharmaceutical companies think about this shit in a more cohesive way: they get their goal accomplished, as a TEAM. Maybe doctors should start thinking that way.

I don't know where to start...once you have a diagnosis its considered to always be there, its not in the psychiatrist/psychologist framework to consider that major depression or any other diagnosis goes away once present, it may be treated into remission but its always there...
its true that a change in the DSM often does little to change the current practice of psychologists, but for those in training, it can mean an entirely new way of viewing mental illness, for better or worse. I agree with Satel that the DSM is too rigid, but not exactly in the way she sees it. The DSM is too all-or-nothing, either you have the diagnosis or not, which leads to overdiagnosis, if there were more of a continuum there could be room to look at individuals in a more holistic, less label driven way. All this makes me wonder, have you reviewed the PDM, and if so, do you have any thoughts?

What needs to be carved into the DSM is some recognition that people have lives and that lives affect mood. This seems to have been completely thrown out the window in this effort to mold mental illness into a brain disease and create a medical model for psychiatry. Doctors like Sally Satel have (in my view) completely lost perspective on what makes people suffer and we need some heavy duty backlash against the DSM to stop this nonsense.

I can't figure Sally Satel out. Initially, I wrote her off as an E. Fuller Torrey think-alike. Then I read her being tough on disability cheque cheats and got more interested. Then I read her blathering on about a high profile murder-suicide and so I turned her off again.

Satel's words quoted here (no, I didn't bother to read the whole op-ed piece) seem pretty middle of the road. (Really not meaning to pick a fight. This is just an ambivalent comment from an ambivalent contributor to this forum.)

For what it's worth, I believe there are many paths to mental illness and one of them is likely loopy brain chemicals. That wasn't my path so I'm not much interested in people who insist that it was.

I'm more interested in the current research into neuroplasticity (how the brain changes in response to injury/illness). It would be nice if the answer came in my lifetime but, at 41, I'm not holding my breath. Still, I believe the answer lies in neurology, not psychiatry. One's a science; one's witchcraft.

Lastly, and on a radically different note, is there anyone here who wants to be hired as an editor on a one-time basis? My usual editor is unavailable and I'm at draft #2 of a moderately interesting essay on voluntary vs. involuntary treatment for bipolars. If anyone's interested, please email me at efallan at canada dot com.

Perspective is everything, really. http://www.breadnroses.ca is my sometimes hang-out. There, I might be considered a reactionary. (I just told them over there that I could pass for a moderate over here.)

Yes, it is certainly true that life circumstances alone do not account for all aspects of mental illness and I realize I've been pushing that side of things pretty hard -- more as a devil's advocate than anything but I still think leaving that out of the loop in determining solutions is for the birds really. There's a patient's life and how he tells his story, genetic predisposition (for handling stress for instance) and finally social ills. It's a complex business and the DSM for all its many pages and disorders attempts to simplify something that can't be reduced so easily to formulas.

I can't stand the DSM...so stringent and when physicians rely solely upon that and just throw people into little boxes based upon a checklist, it drives me mad.

It almost seems that either the doctors are incompetent, lazy or both.

Well, a lot of them are.

Signed,
Tired and cranky PA

Francesca, the problem with the "loopy brain chemical" theory is that it dehumanizes people, and, of course, also, no one can prove it. I have no doubt that people are born with somewhat different personalities. The individual variations in human personality are a delight, and yet, mental illness must always be caused by something. As the guy somewhere out there in cyberspace wrote, to blame the brain for mental illness, is like blaming the bat for a home run. Telling people the personality traits they were born with are defective is horrific. Allowing people to change those traits if they want to, humane.

Sally, with respect, I disagree. Why would loopy brain chemicals (bipolar) be any more dehumanizing than a defective pancreas (diabetes)? It's not a moral judgment -- it's a possible reason for emotional distress.

You're right that the chemical balance theory hasn't been proved. Neither have any of the many other theories on the causes of mental illness: closed head injury; crazy-making people; sexual abuse; toxic environment; lack of sunlight ....

I try to steer away from statistics and studies (so-called evidence-based medicine) towards patient-based medicine. Anecdotally (a dirty word in the science world), I have found that closed head injuries cause mania. In me. Electroshock, car accident, drinking too much and falling down all appear to have had the same effect. On me.

Except for those manic episodes, I would be diagnosed with unipolar depression. Again, merely anecdotally, I have found that my downs tend to come in October. I've also found that I need to get a good night's sleep or I fall apart very, very quickly. I also have to watch what I eat, e.g. aspartame and monosodium glutamate make me feel horrible. I regularly get what I call the "proteinateous" shakes where I get weak, dizzy and need cheese or milk or some other source of protein to recover. I need lots of physical exercise. I need a room of my own. I need to keep my drinking down to a dull roar.

I found a drug which seems to work for me -- Seroquel. I've done the risk/benefit analysis and decided to go with it. I know it's an atypical anti-psychotic but I use it as a sedative. I use it reactively, taking it only when I feel like screaming. I was given 2 weeks' worth, to be taken 25 mg in the morning and 600 mg at bedtime. I can't afford to go through them that quickly, so I'm taking 200 or 300 mg a day, taken whenever.

I have no follow-up arranged and no doctor lined up to check on me. I'm just flying solo and doing the best I can. Aren't we all? That's why I love this blog -- it's a place to trade unbiased information. I live in Canada, home of the world's best health system (just ask Michael Moore), yet medical science failed me.

It's my belief that Seroquel is saving my life. Could be the placebo effect, could be my neurochemicals rebalancing, could be aliens, could be anything at all. I really don't give a shit WHY I feel better but I certainly revel in the fact that I DO feel better.

These are nuggets of wisdom I've picked up over my 20 years as a mental patient. Use them if you want. Ignore them if you want. But understand that, in the debate, I'm on your side, not theirs.

"Sally," you literally took the words right out of my mouth. :)

In response to the above post (written I think not by another Sally but by Francesca), the loopy brain chemicals theory dehumanizes people by telling them their perceptions are invalid. I agree that we are on the same side. I think its important to understand how terrible the defective brain theory really is.

If you argue that because I was born with a different personality than you, I get upset when exposed to stress more quickly, or become unhappy sooner and stay that way longer, I'm fine with that. It's when you argue that these differences in humans mean that one is superior to another that I have problems. If I am less tolerant of stress than you, there's a place for me in stopping stress, and if you are more tolerant, you might be better in a stressful job than me. As for mania, it is crucial when someone is manic that the underlying causes of the mania be understood, that the person not be written of as "crazy, brain defective," as has been proven by all research which all indicates that at the very least people labeled as bipolar respond better to talk therapy than to drugs, or at the very least, even in biased big pharma studies, need therapy in conjunction with drugs.

Like mental illness, diabetes usually has a strong environmental component, to say it doesn't would be a mistake.

And tangentally, I don't care what anybody says, if a 10 year old commits suicide, she's been abused by somebody. A ten year old doesn't commit suicide because of a spontaneously defective brain.

I would argue that all of the other potential causes of mental illness you mention are proven, i.e. "closed head injury, crazy-making people, sexual abuse, toxic environment, lack of sunlight." To say emotional distress is caused by the brain and nothing else is to say that someone who experiences emotional distress caused by the brain and nothing else must be controlled and segregated because we don't know what they might do, thus dehumanizing the person, when in fact one could say that we don't know what any human might do and thus the person labeled as having a defective brain is not really defective or sub human.

Hi, Sally. Yeah, that was me. We're preaching to the choir with these dialogues and we've got some bad miscommunication going on.

I feel misunderstood -- I only suggested that loopy brain chemicals were ONE of MANY paths to mental illness. It's hard to PROVE what path caused which mental illness. Indeed, my own path seems to have had nothing to do with brain chemicals (save as the correlate, not as the cause) and everything to do with closed head injuries. I can't PROVE it, just as they can't DISPROVE it. I can only go with what seems to be the case, based on 20 years' experience.

Update: I just touched base with my local mental health centre (crisis line upon to 5:00 p.m. every day!). There's a three-week waitlist for a shrink. Last Monday, I was released "against medical advice" and given a two-week supply of drugs. (Slight temporal problem, there, methinks.)

The intake counsellor suggested a walk-in clinic. (Yeah, I'll just saunter in to a walk-in clinic and ask for Lithium and Seroquel. No questions asked. No problem.)

(Sarcasm, in case I'm not getting my point across. It's my ultimate answer to absurdity.)

Francesca, I get a little defensive (okay more than a little, maybe hysterical) about the brain chemical thing. Sorry. Good luck with your meds, be safe.

Don't be sorry, Sally, because you make excellent points and give me yet another point of view to ponder. I kind of feel one step removed from the whole debate: just show me the evidence and I'll make up my mind, without thinking any one theory has any more claim to fame than any other.

To be honest with you, the neurotransmitter theory seems the most blameless, from a patient's point of view, and I kind of admire people that believe it. Their resolve tends to fall apart in a discussion, though. Just ask them which neurotransmitter is to blame or what they think about down-regulation or neurovascular coupling and whether they've read Grace Jackson or Eliot Valenstein, and they tend to get sketchier on their theory.

A couple of issues ago, in Harper's, there was a great article by Gary Greenberg called "Manufacturing Depression" which is certainly worth a read. Greenberg participated in a drug trial and had lots to say on the experience.

I was relieved to hear (from the intake nurse) that Seroquel "couldn't be abused." That's good (but demonstrably false) news because it means a walk-in clinic might be more forthcoming. She sounded nice and worth meeting. I used to have a case manager whom I quite liked and she came to visit me wherever I was living. It's better than being inside, I guess.

Francesca, I read the Greenberg article. It was a breath of fresh air. As an abused child whose parents wanted me to be crazy for years, I find the neurotransmitter theory offensive because it allows abusive nuts like my parents to dramatically claim that I was born crazy and because of this they suffer,(my "diagnoses": dysthemia and generalized anxiety disorder both in remission). My disagreement with the neurotransmitter theory doesn't mean I think all mental distress is caused by parental abuse by any means. I think it may be that because of the horrors I've suffered from my family's attempts to have me labeled bipolar, I'm unable to consider how the neurotransmitter theory can be helpful to anyone.

I'm chiming in here where I don't belong---but when I saw the "Seroquel can't be abused" part I had to add Legally Bombed which has links from Furious Seasons and bpchicks discussing snorting Seroquel. I met a woman who uses meth and she told me she would rather use meth than Seroquel.

Sally, I totally understand your point of view now. My parents weren't abusive but they were indeed crazy-makers. I don't know your situation but I do believe that, generally speaking, mental patients should give their original families a wide berth.

Louis Wynne ("Healing the Hurting Soul") said, basically, that in order to get a mental patient, you have to start with a black sheep. To get a black sheep, you have to get someone to be financially dependent and acting oddly. Somebody is benefitting from this dysfunction. My advice, not that you asked, is to find out who is driving this and then cut them loose.

Stephany, your post doesn't totally surprise me. You can snort vodka if you want a faster effect. I don't happen to like snorting as a delivery method but I'll mention it to my druggie friends as I could use the money. (Kidding. Sort of.) I've also got a cache of Lithium that I'm saving for an art project.

Unfortunately, I think that the author is yet another BP person in denial about her illness. Saying that the medications had lots of horrible side effects is a very common excuse for someone like this to use. The denial will probably go on and on unless peole like this are ever able to face up to the truth and take on the work of getting better. If I sound judgmental, well, I am. My mother is a lifelong BPI who destroyed her own life and devastated the lives of those around her because she would never admit she was sick, and would never take meds. *I* am BP-NOS, and hell will FREEZE OVER before I ever stop taking medications, self-adjust, or fool myself into thinking that "I don't need them." Acceptance of reality and a refusal to stay in denial CAN HAPPEN! They're very hard. But I'm really kind of all out of patience with this. If I can do it, lady, so can you. Get off your butt, take responsibility for your life, and quit making excuses.