"It's Complicated" – ECT and more...

A lot is going on today.

Benedict Carey reported in the New York Times the latest intriguing and provocative news in the ongoing and contentious debate over the DSM-V. I'm not going to weigh in on all this, but here are a couple of interesting preliminary analyses from two bloggers I respect though they don't always agree – psychologist John M. Grohol of PsychCentral and Philip Dawdy of Furious Seasons. 

Trust me, there will be tons of people, professionals, bloggers, patients, parents, anyone who has ever been diagnosed or misdiagnosed will discussing this crucial publication when it's released, and Carey explains why:

"The eagerly awaited revisions — to be published, if adopted, in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, due in 2013 — would be the first in a decade.

"For months they have been the subject of intense speculation and lobbying by advocacy groups, and some proposed changes have already been widely discussed — including folding the diagnosis of Asperger’s syndrome into a broader category, autism spectrum disorder.

"But others, including a proposed alternative for bipolar disorder in many children, were unveiled on Tuesday. Experts said the recommendations, posted online at DSM5.org for public comment, could bring rapid change in several areas.

“'Anything you put in that book, any little change you make, has huge implications not only for psychiatry but for pharmaceutical marketing, research, for the legal system, for who’s considered to be normal or not, for who’s considered disabled,” said Dr. Michael First, a professor of psychiatry at Columbia University who edited the fourth edition of the manual but is not involved in the fifth.

“And it has huge implications for stigma,” Dr. First continued, “because the more disorders you put in, the more people get labels, and the higher the risk that some get inappropriate treatment.”

You can be sure, I'll be watching and commenting, too. But not today.

Finally, I've spent too much time corresponding on Facebook with someone who's very critical of my perspectives on ECT and who commented on my last post, which I linked to Facebook.

Darby Penney is a well-known anti-psychiatry activist who vehemently opposes ECT. Among her accusations against me is that I have a "bias toward this brain-damaging treatment." (Darby, you'll be happy to learn that Linda Andre's book finally arrived in the mail this morning, so I'll be adding it to my list of resources.) 

ANTI-PSYCHIATRY ACTIVIST CONTENDS THAT ECT CAUSES "BRAIN DAMAGE"

Penney contends that ECT causes "brain damage" and supports her statement with three clearly "anti-ECT" perspectives. 

Nevertheless, this statement, in spite of her supporters, appears to have no bearing whatsoever on the way Angela is responding to her ECT treatments. 

My question is, "Is memory loss brain damage?" But that's another story.

The point is, I'm trying to be as fair and balanced as I can be. Follow the comments to this series and you'll see all kinds of reactions. They're not edited in any way. I invite all of you with strong feelings about ECT to weigh in. This is a public forum. It's too bad Penney chose to express her opinions on my Facebook page instead of here, but that was her choice. 

Now then...

This is Week Three of Angela's eight-week course of ECT treatments – that could possibly stretch to 12 weeks, depending on her progress and her results. She is also participating in a long-term Toronto-based study involving four University of Toronto-affiliated teaching hospitals that is investigating ECT and the nature of its possible resultant memory loss at a cellular level. This study is in its fourth year and the results will be available in 2011. Although she wanted to increase the frequency of her biweekly treatments to three times a week, because of the design of the study, her psychiatrist told her that wasn't possible.

Since Monday, when Angela had her fifth treatment at 7 a.m., she's been perkier than I've heard her sound in ages. We speak every day. At least once. Often more.

During our conversations this week, we've been carefully distinguishing between how she perceives her mood as compared to how she's feeling about other issues in her life which are problematic, but have nothing to do with her psychiatric condition – her intractable depression with suicidal ideation.

"I'D RATHER HAVE MEMORY PROBLEMS OR BE A BIT CONFUSED THAN BE DEPRESSED"

On Monday, following her treatment, Angela said she was feeling "a little depressed but not suicidal," stressing that she had no memory problems at all. "To be honest, I'd rather have memory problems or be a bit confused, than be depressed," she admitted.

It was her 37th birthday, but she wasn't celebrating in any dramatic way. "We're ordering in Chinese food and watching the hockey game," she said, adding, "and my mother made me fudge, but she overcooked it. It's hard fudge." 

Angela was laughing during this conversation. I could hear her mother joking with her in the background. She was having fun. It was wonderful to hear.

On Tuesday, admittedly less depressed, Angela was annoyed because one of her cats was "misbehaving" – missing the litter box. "But I'm not feeling unhappy," she said.

This morning, she said, "Monday's ECT treatment was the best one I've had so far as far as side effects because there was a minimum memory loss," she said. "And you know, I feel like the treatments are definitely making an improvement over where I was. My affect is not nearly as flat and I'm handling my emotions better."

She said her mother's visit "went really well. I told her about my ECT and I was worried about how she'd react, but essentially she's quite supportive and just wants me to be healthy."

There are other personal issues that are bothering her, but Angela admitted, "I'm handing them better than I know I would have before the treatment."

THIS MORNING, SHE'S A GOOD SEVEN AND A HALF

On our scale of one to 10, she says she's a good seven and a half – a slight improvement over how she was feeling last week.

"If ECT allows you to be better prepared to handle those adversities, then it's worth its weight in gold," she said. 

Angela has a small studio in her home where she enjoys sculpting. When she's depressed, she never feels like working with her clay, but when we ended our conversation this morning, she signed off saying, "I feel like sculpting... and I think I'm going to go back to it."

Angela's ECT continues, but I'm having side effects...

Angela is a seven!

A few minutes ago, I asked her, "On a scale of 1 to ten, if one is suicidal and 10 is normal, where would you say you are?"

"Hmmmmm," she said and within a second. "Seven ... but I just want it to be faster."

She's done a ton of reading and I think she was hoping she would snap out of her suicidal depression after one ECT treatment. There are apocryphal early accounts floating around that report dramatic, seemingly instantaneous response to one or two ECT treatments. They make for a good story.

THE ITALIAN PIONEERS OF ECT

I'm reading about the Italian psychiatrist Dr. Ugo Cerletti and his team in Rome who pioneered modern electroconvulsive therapy in 1938 in Shock Therapy – A History of Electroconvulsive Therapy in Mental Illness by University of Toronto medical historian Edward Shorter and Cardiff University psychiatry professor David Healy.

Their sources include a lab notebook describing the April 11, 1938 first-ever treatment performed on a human being – earlier testing was done on pigs who survived these experiments – by Cerletti and his team.

Doctors had already observed that patients with epilepsy and clinical depression, following a grand mal seizure, found that their depression lifted quite dramatically.

Hence the connection between inducing grand mal seizures in patients with depression to alleviate their symptoms. Electricity seemed much faster and less invasive than insulin or other drugs that were being tried with moderate success at that time.

Cerletti administered ECT to  man called Enrico X, who was homeless, delusional and speaking gibberish. After three weeks of observation, Cerletti and his team had diagnosed him with schizophrenia and without anaesthesia, he was given his first dose of 80 volts of electricity. He didn't lose consciousness, but it did not induce a grand mal seizure and his condition didn't change. After several attempts that day, with almost no effect, Enrico X walked back to his room and Cerletti deemed this first attempt at ECT a failure.

However, on April 20, less than two weeks later, Enrico X was given another slightly higher, 92 volt dose of electricity, and this time, he did have a grand mal seizure and after several minutes, he was able to respond lucidly to questions. 

After six or seven more treatments, eleven in all, Enrico X was not only able to speak, "he was able to write to the physicians of the Clinic a well-composed letter, in which he gave information about his previous illnesses and the attempted treatments and thanked the physicians," Shorter and Healy wrote.

ECT TAKES TIMES

So, even the first, most primitive ECT experiment took time.

After Angela's 7 a.m. treatment yesterday – her fourth – which again went smoothly, she had what she typically calls "a bit of confusion." She came out of the anaesthesia quickly with only a mild headache that was relieved with two Tylenols, and no muscle pain at all. That happened only once, after her first treatment.

Last evening, she said she felt "regular" and "not suicidal" – bordering on "glum."

She reflected on all the other "life" issues she's facing right now, complexities that have nothing to do with her psychiatric condition, but influence how she feels emotionally. We are all "package-deals," mind-body-spirit. These are problems of everyday life that anyone would find perplexing. But strictly speaking, she admitted she was beginning to feel a little better. And she sounded more upbeat. She joked with me and laughed. Not typical of a severely depressed personality.

This morning, she said, "I'm feeling better today than yesterday. Yesterday was a little tough, with the confusion. I was putting away my socks and pyjamas and I forgot wear they go. I thought for a minute, and I remembered," she said. "And I'm not as tired as I've been, but there are a lot of other things on my mind. My mother is coming today."

She was about to leave to see her psychiatrist. I asked her if they had discussed the frequency issue and whether she could have three treatments a week instead of two.

"No yet, but I'm going to ask her. I suspect it's determined by the study I'm on," she said, signing off by saying. "I don't feel bad."

MY SIDE EFFECTS FROM ALL THIS "ECT"

This morning I slept in.

I couldn't get out of bed until 8:40 a.m. Very late for me. Usually, I'm up no later than 6 a.m. and working here at my iMac by 7 a.m. 

Last night, I couldn't fall asleep. I couldn't turn my thoughts off. I couldn't stop thinking about ECT. About what I've been learning and researching. About how much I don't yet know and comprehend. About all your different fervent comments and reactions to this series. About how emotional this issue is. About how some of you have reported suffering from ECT and others have been miraculously helped by it. About how angry some of you are. About how others have made peace with the cost of some memory loss for a far greater gift, a vastly improved quality of life.

Last night, I had to take a small 0.5 mg dose of Clonazepam in order to be able to fall asleep. 

So this morning, I made a decision. I'm going to take a brief respite from this series, slow it down a bit. 

I'll continue to give you regular updates on Angela's progress. She'll be having her treatments until March 18 at the earliest and possibly for four more weeks after that.

I'll continue reading medical journals and studies, plus the books I have already started, including the Shorter/Healy history and a fascinating book by Kitty Dukakis and medical journalist Larry Tye called Shock, The Healing Power of Electroconvulsive Therapy – combining a contemporary personal story and a journalistic commentary on ECT.

Linda Andre's book, Doctors of Deception, What They Don't Want You To Know About Shock. It's on order, but Amazon hasn't yet shipped for some reason. When it arrives, I'll read it, too.

There are, however, lots of other interesting and newsworthy stories unfolding around mental health and wellness that I want to explore and that, I am sure, interest you, too.

So, I hope you'll understand. 

And I have another life. I teach at a Toronto community college. I'm not even going to go into the possibility of a Ontario province-wide faculty strike that is looming. I'm not even in the union. I'm not going there right now. All I can say is this is a stress that's weighing hard and heavy on my students and on me.

On a lighter note. My gorgeous four-year-old female Dandie Dinmont Terrier Lucy has just gone "into season" and there's a good chance that we'll be breeding her within the next few weeks. So, perhaps, if all goes well, we'll have new life in this house come spring.

Puppies. 

There is absolutely, positive nothing more delicious and delightful than the prospect of Dandie Dinmont Terrier puppies in the house.

Have a great weekend.

Speak soon!

ECT on Angela's mind and mine...

At 10:14 a.m. Saturday, Angela sent me the following email:

"I decided not to go away with Rob (her boyfriend) this weekend because I'm uncertain as to whether or not I can keep it together. Today, I am tearful, the feeling of sadness is overwhelming and often leads to suicidal thoughts.

"Maybe the ECT doesn't have the clout as yet to keep unwanted thoughts suppressed, and I sure as hell don't have the capacity to keep them at bay.

"I want it to be Monday so I can have another treatment. I want to know if the ECT is going to stick with me and work for me. My patience wears thin, my eyes tearful, and my heart has broken into millions of tiny pieces. 

"I hate this!"

I called her as soon as I read her message. She sounded more buoyant than I had expected. Her sinking mood admittedly was caused by other problems in her life that have nothing whatsoever to do with her psychiatric condition and the trauma that's the root cause of her depression and suicidal ideation.

"Life's complicated," she said, referring to these problems that seem to her to be insurmountable right now with all that's happening to her – all the unknowns and anxieties about her new electroconvulsive therapy protocol. 

She's concerned about her mother who isn't well and will be visiting her this weekend. Angela is terribly anxious about how her mother will react to her having ECT. She hasn't yet told her about it.

"And there's lots more," she added. "It's complicated."

She wanted to spend the weekend alone and I couldn't persuade her to meet me for lunch or to come and have dinner with Marty and me on Saturday night. She didn't seem open to company at all, insisting that she wanted to stay home, by herself, with her three cats – to watch the hockey game.

So, I signed off, reassuring her that I was here and at her beck and call if she wants to talk.

Meanwhile, to say I have ECT on my mind is an understatement.

Constantly, I was monitoring the comments to my Friday post. By Saturday night, there were 12, excluding my responses. (This morning, there are 18 in all.)

But one in particular that came in Saturday disturbed me and not because of its angry tone. I didn't know what to make of it, despite my attempts at researching it. 

I'm no scientist and ECT is a highly scientific, complex procedure with remarkable inconsistencies depending on widely specific variables. 

I was so confused that on Saturday at 6:23 p.m., reluctantly, I wrote to my friend, psychiatrist Ron Pies of Tufts University, who is as committed to public education as I am. We are communicating often these days as I dig deeper into the contentious realm of ECT.

He has introduced me online to psychiatrist Max Fink, a leading U.S. authority on ECT, who generously agreed to answer my questions if I email them to him. On the thorny question of "involuntary" ECT, Ron also consulted leading forensic psychiatry expert Professor Daniel W. Shurman, the M.D. Anderson Foundation Endowed Professor of Health Law, Dedman School of Law at Southern Methodist University. In the weeks to come, I will be sharing this and other information I'm uncovering as Angela continues with her eight-week course of twice weekly ECT treatments. Depending on her response, this course could be extended to 12-weeks.

Time will tell.

In my Saturday night email to Ron, I admitted: "I don't know how to respond to this comment," referring to a writer named Ginger who sited a 2007 study by Columbia University psychologist Harold Sackeim. "I've found Harold Sackeim's paper, but I'm not sure he's using the most up-to-date ECT methodology nor am I sure why he's reversed his opinion.

"Everybody has a story," I wrote. "A different story. I think that there must be variation in quality of equipment and methodology in different hospitals. Differences between outcomes in bilateral versus unilateral. I can't become an expert in ECT. I'm reading as fast as I can, I'm not really adept at interpreting scientific research papers. Perhaps I've opened a Pandora's box with this series and now I'm in real trouble."

Ron responded at 12:10 a.m. on Sunday morning. 

"Believe me, I sympathize. I waded through not only the 2007 paper by Dr. Sackeim's group, but also their 2008 follow-up study, which is of considerable importance, and which (I believe) clearly runs counter to the overblown claims by Linda Andre," of the The Committee for Truth in Psychiatry. 

"Even with my training, I had trouble teasing out the clinical significance of many of these findings, as contrasted with the statistical significance. There is a big difference. The bottom line: it's like in real estate, but instead of "Location, location, location," the slogan is "Technique, technique, technique!" 

"So much depends on using the newest and most "cognition-sparing" techniques. When you do so the results appear to be very good, without substantial cognitive loss in most individuals, and with substantial improvement in mood."

Ron signed off promising to find "a more definitive response" within a few days after getting "some consultation of my own."

Meanwhile, I found this TED.com talk by Sherwin Nuland on Electroshock Therapy. Nuland is an American surgeon, now retired, and prolific, award-winning author. He gave this stunning this talk in 2001 and it was first released in 2007. It's well worth 22 minutes of your time.

On Sunday morning, Angela and I spoke on the phone three or four times.

"I can't wait until Monday," she said anxiously and often. "I can't wait for my next treatment. I want it to kick in. It seems to take so long. I don't want to wait. I want to be cured now. "

She's also anxious because her current psychiatrist who is administering her ECT treatments is only going to continue for this week and next week, she'll have another doctor, a doctor she hasn't yet met. "I wish there was more consistency," she said.

I reminded her that the University Health Network is a teaching hospital and this is a standard practice in teaching hospitals. That wasn't what she wanted to hear.  

Her despondency continued later Sunday evening. It was mild. She would giggle from time to time and joke with me, even though the word she tended to use to describe how she felt was "glum." When I asked her about her suicidal thoughts, she said she kept thinking, "What's the point of all this?" 

I sent her the link to Nuland's talk and another 12-minute talk he gave in 2003 that was posted last month, On Hope. She said she'd have a look.

Yesterday morning, her third ECT treatment went without a hitch. When I called her at 9:45 a.m., she didn't answer the phone. At 10:43 a.m., she sent me the following note:

"Just checking in post ECT... Have a little confusion but nothing serious. I don't feel well today... suicidal thoughts and just glum. Wish this treatment will hurry up and work!!!

"Hope you're having a good day!"

We spoke a few hours later and her confusion was gone. She couldn't understand why she wasn't having three treatments a week, the way ECT is typically administered in the U.S. and in the U.K. She said she'd prefer that.

This morning, still "glum," she said a few hours ago. "I remember absolutely everything now and the suicidal thoughts are gone completely. No side effects. But why does this take so long to kick in." 

Later today she'll be seeing her psychiatrist. I sense from what she says and even more, from some of her silences, that she doesn't realize just how much she needs this therapeutic support right now.

I suspect they'll have lots to discuss.

ECT is "like abortion" & Angela's 2nd treatment...

Yesterday morning at 11:55 a.m., I spoke to Angela briefly several hours after she had her second ECT treatment at the University Health Network – Toronto General site. She sounded sleepy, so tired, we agreed to connect later.

I called at about 9:30 p.m. and there was no answer. I sent her an email and at 6:51 a.m. this morning, she wrote:

"I spent most of the day and evening sleeping. Sorry I missed your call. All is well. I was tired yesterday. Had a tiny bit of confusion after the treatment but it cleared up quite quickly. I'm awake at the moment but will likely have a nap..."

At 8:30 a.m. Angela called to give me a more detailed report.

First, I asked her about her muscles and the aching she felt after her first ECT treatment on Monday. 

"It's all gone and this time, it wasn't a problem. I had a little headache, but I took two regular Tylenols and they took it away," she said.

"NO SIDE EFFECTS AT ALL" 

I asked her about her "tiny bit of confusion."

She said, "It was really mild. It was like, I knew what I wanted to say but I couldn't find the words. It was like, if I got up to go the kitchen to get something, when I got there I couldn't remember what I wanted. But then, I'd think about it and I'd remember. It lasted for about two hours, but it wasn't at all debilitating. It was very transient and extremely mild and it went away."

Her ECT treatment experience yesterday mirrored her Monday treatment, "except I was first and I had a different anesthesiologist. I liked the first one better," she said. "The first one explained everything he was doing and this one didn't talk to me. And yesterday, there were students there. Nursing students. But it's a teaching hospital. I don't mind."

I wanted to be sure about the side effects, so I said, "So this time, would you say that two hours after your second ECT treatment, you had no side-effects?"

Angela said, "That's right. No side effects at all."

Again, she said she came out of the anesthetic quickly and easily and was back home at about 9:30 a.m.

Since starting her ECT treatments on Monday, Angela also reported that she hasn't had any suicidal thoughts. 

"There's a difference," she said. "I'm still emotional about things, certain things still upset me, but they're not as upsetting. The 'upset' isn't as prominent. But it could be a placebo effect."

I asked her about her appetite.

"It's extremely poor, but that's been 'my normal' for several months. Me and appetite is a funny thing," she added. "I was anorexic when I was younger. Now, I tend to forget about eating. I think it's because of the medication. It has a lot of anorexic properties."

I suggested she might monitor that a bit and we signed off. She sounded positive and during our conversation she giggled more than I had remembered in recent months. Monday, she'll have her third ECT treatment and this weekend, she's going away with her man.

"ECT IS LIKE ABORTION – IT'S A RED-FLAG"

Meanwhile, your silence is deafening. There have been no comments here for close to a week. Only a couple on my Networked blog on Facebook, questioning my sanity in pursuing this coverage.

You're probably wondering why I'm spending so much time on ECT, a hot-button issue in the world of mental health that fires up emotions of anger, fear and irrationality. 

Dr. Bob and I have often discussed electroconvulsive therapy. He compares it to abortion because it's so hotly-debated and emotionally-driven. "It's a red flag. I don't think it will ever come to any resolution," he has often said.

We've talked about it because of my own relatively benign experience with it more than 40 years ago and more recently because of the rabid reaction I received the last time I posted about it. I was raked over the coals in several personal email messages from David W. Oaks of MindFreedom International which is leading a zealous campaign against "forced" or "involuntary" ECT treatments, apparently administered in the U.S. and other countries.

Over the weekend, I received this message on my Facebook account from a leading U.S. mental health advocate:

Darby Penney wrote, "Sandy, you say you 'know a lot' about ECT, but it doesn't sound like you advised your friend about the very real risks of permanent memory loss and brain damage from ECT. Or the fact that recent peer-reviewed research found that there's no basis to psychiatry's oft-repeated opinion that ECT is effective in preventing suicide. I'll bet her psychiatrists didn't tell her about these things either..."

(I value peer-reviewed research, but I also value scientific studies like the multi-site neuropsychological study that Angela is involved in. The principal investigator is psychologist and senior scientist Brian Levine of Toronto's Rotman Research Institute at Baycrest that is investigating memory loss at a cellular level will be completed in about one year. I'll keep you posted.)

As for the issue of "forced" ECT, it's a huge hornet's nest and I'm not going into it right now (but I will), except to say that MindFreedom International is essentially an anti-psychiatry, consumer-survivor and psychiatric-survivor-driven organization.

To clarify... you know that I am not anti-psychiatry. Nor do I identify with any political anti-psychiatry movement, or any movement. I'm not anti-anything. I am pro-Recovery. I am pro-open mindedness. I'm interested in learning as much as I can about everything related to mental health and wellness. I value individual experiences as well as academic research. I listen to everyone.

I detest labels of any kind. If you're going to label me anything, label me "human."

I am interested in history. I am interested in truths. I accept that there is no absolute truth, except that one. There are many truths. We all have our own truths. That said, in this series, I am simply following the experiences of a 36-year-old Toronto-born woman suffering with severe drug-resistant depression and suicidal ideation through a course of electroconvulsive therapy – which she decided to have one her own without any prompting or even suggestion from her psychiatrist.

Let's see what happens.

THE ANTI-PSYCHIATRY MOVEMENT ATTACKS

Historically, the anti-psychiatry movement has been attacking ECT for hundreds of years and it includes "writers, former patients (not all of whom have fully recovered), physicians, legislators and several prominent anti-psychiatry psychiatrists, most notably Thomas Szasz and R. D. Laing," according to Zigmond M. Lebensohn, MD., Chief-Emeritus, Department of Psychiatry, Sibley Memorial Hospital, Washington, in his article "The History of Electroconvulsive Therapy in the United States and Its Place in American Psychiatry: A Personal Memoir," from the May/June 1999 (Vol. 40, No. 3) issue of Comprehensive Psychiatry.

Tufts University clinical psychiatrist Ron Pies, MD (who kindly and generously takes the time to answer any question I ask him) adds this: "The general mistrust of institutional psychiatry in the U.S. (and elsewhere) is often fostered (ironically) by some in the mental health field, including several well-known psychiatrists who have written influential (if misguided) books. 

"Unfortunately, the association of institutional psychiatry with involuntary commitment raises fears about psychiatric treatments in general, including but not limited to ECT. (By the way, most people in the U.S. are not aware that it is a judge, not a psychiatrist or other physician, that "commits" a patient to long-term, involuntary hospitalization, which varies from state to state in the U.S.)."

Today, from what Angela is reporting, ECT bears no resemblance to the way it is often portrayed sensationally by Hollywood – cruelly, as a form of social control. These images have polluted our perceptions of this treatment used primarily in cases where patients have intractable depression and in some cases (like Angela's) may be dangerous to themselves because of their suicidal thoughts. 

In "earlier ECT procedures – 'bilateral' involving both sides of the brain – significant memory problems were more common," reports Pies. "With the newest ECT techniques most studies using neuropsychological testing have shown no significant residual memory problems six months after ECT. But, there are isolated cases in which substantial memory problems may be reported for unclear reasons. These are often the cases that get written up or circulated on the Internet anti-psychiatry websites." (See the Ray Sandford case.)

"Much less publicized are reports of the many thousands of highly successful cases of ECT use, without any substantial or pervasive memory impairment, using the most modern ECT techniques."

And doesn't this make sense, when you think about it?

After all, how many of us are running around trumpeting to the world our psychiatric histories and all the therapeutic tools of all kinds that have helped us to live meaningful, productive and successful lives.

If only more people did...

 

ECT: Up close and personal – the first treatment ...

At 7 a.m. this past Monday morning, my friend Angela (not her real name) walked into the University Health Network on University Avenue in Toronto and took the elevator up to the second floor surgical admissions desk, where she was registered for her first Electroconvulsive Therapy treatment.

Because she has joined a long-term, multi-site Toronto study to examine the hotly debated issue of memory loss and ECT, last week she signed consent papers (routine for anyone choosing to have ECT), had blood work, four hours of tests, including a two-hour MRI of her brain, and a consultation with an anesthesiologist.

She also met with the doctor who will administer her treatments that will be unilateral, twice weekly and last between eight and 12 weeks.

After years of fighting simply to get up in the morning with her deadening depression, unable to work and struggling against constant suicidal thoughts, Angela had concluded that ECT was her last chance. Her doctors have prescribed eight different antidepressants, alone and in combination with a number of anti-psychotics. To sleep, she needs sleeping pills. 

None of these medications have helped her. Her melancholy persists. She feels desolate, as if a psychic blankness is blanketing her and killing her spirit. Now, working with her psychiatrist who agreed that ECT was a viable option, when Angela suggested it, she was feeling more upbeat in anticipation of her first treatment.

She had researched ECT meticulously, besides discussing it with her psychiatrist and with me. She knew that I had had several courses of bilateral ECT in the 1960s and 1970s with no memory loss or any other side effect. I told her that it had helped me when I was psychotic. So now, with more optimism than she's felt in years, Angela was looking forward to the relief of this storied, controversial, much maligned and misunderstood procedure with its long and curious history.

"I read so many reports about its effectiveness," she told me last week. "I'm not worried."

After registering, she was taken to a small waiting room, called after a few minutes, and taken to another room where she was instructed to change into two hospital gowns and slippers. Then, Angela was led to a larger room where she laid on a bed and was covered with warm flannel blankets. A nurse attached three small electrodes to her upper right and left chest and lower down over her left rib cage for an electrocardiogram. She was then hooked up to a machine that monitored all her vital signs – blood pressure, heart rate, oxygen saturation, respiratory rate, temperature and pulse.

Her anesthesiologist came by to check her weight and told her that he was preparing two medications that would be infused intravenously – a short-acting anesthetic called sodium pentathol and a muscle relaxant called succinylcholine.

These medications were not used in the early days of modern ECT, and certainly not in the most iconic of Hollywood's depictions of ECT – the 1975 Milos Forman film One Flew Over The Cuckoo's Nest adapted from Ken Kesey's 1962 novel. In that film, a drama, ECT appears to be cruelly administered for social control without anesthetics and muscle relaxants. 

The methodology has "absolutely" changed since then, said my friend and mentor Dr. Ron Pies, clinical professor of psychiatry at Boston's Tufts University and psychiatry professor and lecturer on Bioethics and Humanities at SUNY Upstate Medical University in Syracuse. He is also author of Everything Has Two Handles: The Stoic's Guide to the Art of Living as well as a book of poetry, a play and several psychiatric texts.

"In the early days of ECT, it was given without benefit of anesthetics or muscle relaxants – this is the origin of the horror-movie scenes often still shown in popular depictions of ECT," he explained. "The role of ECT is often confused with psychiatry's record of frankly unethical and deplorable treatment (during the 1930's-1960's) known as lobotomy which many people confuse with ECT. For example, here's a quote from a review of the movie One Flew Over the Cuckoo's Nest:

"Seeing people taken from the ward to another place and only returning to be even less than what they were when they left caused McMurphy to want to play hero. They were being taken to a room and being given electroshock therapy. In others words, lobotomy."

Pies added, "Of course, lobotomy has absolutely nothing to do with ECT, and is no longer performed in the U.S. or other advanced countries. This began to change in the 1950s and 1960s, at least in the west. In more recent years, refinements in electrode placement and in the amount and nature of the electrical stimulus have led to a procedure with far fewer side effects than in the early days. The actual medical risks of the ECT procedure itself acutely are comparable to those involved in having your tonsils taken out."

Angela admitted that nothing hurt her in the least. Even when the anesthesiologist inserted the IV needle into the left radical vein of her left hand, "down the line of my thumb," she said. A few minutes later, an oxygen mask was placed on her face and the doctor who was going to administer the ECT came in wheeling the ECT machine with her on a cart. She introduced herself and said she would be giving her the ECT treatments for the next two weeks.

"Like everyone else there, she was very nice and respectful," Angela said.

While the psychiatrist was getting the equipment ready, a nurse put gel on Angela's head and right temple and she was hooked up to an electroencephalogram machine to monitor her brain waves.

When the anesthesiologist announced he was ready to give her the medications, Angela remembers saying to the psychiatrist, "While you're in there, can you help me with my math skills."

The doctor laughed and said, "I don't know. I think I'll have to have a consult with your psychiatrist."

When the medications were started, the anethesiologist said, "Try to keep your eyes open. Most people say the medication tastes like garlic."

Angela thought it tasted like gasoline.

"Then I was out," she said. 

Her next memory was waking up in the recovery room. The nurse told her she came out of the anesthetic very quickly and offered her more warm flannel blankets. 

"I was monitored the whole time, from the moment I woke up from the anesthesia," Angela said.

After a while, she was wheeled into the Medical Day Unit. 

"A nurse asked me how I felt," Angela said. "I told her I had a headache and they gave me something for the pain through the IV."

After another assessment of my vital signs, the nurses asked her if she wanted anything to drink. (She hadn't eaten or drank anything since 12 midnight the night before the procedure.)

"I said, 'No, I feel ready to leave.' But they kept me for another 15 minutes. Finally, I left at 9:15 a.m."

We spoke on Monday afternoon at 12:55 p.m.

Angela said she felt like she had had dental surgery and it was hard for her to open her jaw.

"It's probably because my muscles were clenched," she said. "But really, it was nothing. The whole procedure was nothing."

I asked her how her memory was.

"No problem," she said. "I remember everything, except I feel like I was hit on the side of the head with a baseball bat. But you know what? I would have done this two years ago, if I had had a psychiatrist. I've had more memory loss from smoking pot. I just feel a little tired."

At 8:43 p.m. Monday evening, she reported that her headache was much better. She had taken some Advil. 

"My body feels a little achy, like I'd just done a work out. But I don't feel suicidal. I know that. And the repetitive thoughts about my childhood trauma seem dulled." 

On Tuesday afternoon, she said her headache was gone, though she still felt a little achy. 

"I think I'm going to give sculpting a try," she said. She hadn't sculpted in months. 

"I feel a little guarded because I want this to work, but I slept well with my sleeping medication, though I was up too early, at 5:30 a.m. At least, I had no dreams."

She added, "I feel not bad at all. So far. So good"

 

ECT: Up close and personal...

She called me about two weeks ago. Her voice was almost inaudible. Robotic-sounding. All she said was, "What do you know about ECT?"

As it happens, I know a lot. And we discussed it. Or rather, I discussed it. She listened so intently, it felt as if there was physical tension on my land-line.

She said, at one point, "I can't turn off the suicidal thoughts. And nothing is working." 

She has been struggling, no, suffering with fierce, deep and intractable depression for several years, as long as I've known her. About three years ago, she became so immobilized by her depression, she had to leave a senior position with a marketing firm. 

"My mind wasn't working any more. I had tip-of-the-finger syndrome. I couldn't quite come up with the right words."

That's when the suicidal thoughts started, though she didn't tell me at the time.

Last spring, for the first time, she called me one night, threatening to kill herself. As soon as I got off the phone with her, I called her partner and he told me she'd been threatening for days. "She's been calling several people. She's done this before." This time, he sounded worried.

For years, a series of family doctors had been prescribing anti-depressants. None of them worked. She had spent a fortune seeing psychologists and other counsellors because she hadn't been able to find a psychiatrist she felt she could work with. 

She couldn't sleep, so her GP added sleeping pills to the mix. They didn't help. She would fall asleep and awaken at 3 a.m. They fogged her up so much, one night she accidentally overdosed and ended up in Emergency having her stomach pumped. Although she was feeling suicidal, she swore at that the time, "that was no attempt." 

Five months ago, finally, she was able to start seeing a very good psychiatrist at a Toronto teaching hospital, with an expertise in women's issues, depression and psychopharmacology, who reassessed her medications and started her on a new regime. 

"They make me feel like I have no personality," she would say.

I told her to give it time. It takes time. I was wrong.

"I feel monochrome. I'm still not sleeping. I feel flat."

When I saw her, she tried her best to rally for me. She did everything she could to try to break through the haze. She took up sculpture. She dragged herself to her local gym. But most of the time, she stayed at home and thought about what a relief it would be to "not exist anymore." 

Over the holidays, she and her man went up north for a few days, but her depression and her suicidal thoughts travelled with her. Then, on Thursday, January 7, at about 6:30 p.m. she called and asked me about ECT.

I told her about my experiences in the 1960s and 1970s. I told her about several people I know personally who have had remarkable success with ECT. I sent her the two links to the July 2008 posts I wrote here about ECT and other "current" therapies. I told her that it's definitely something to consider.

On January 11, she called sounding more lively than she had in months. "I told my psychiatrist I'm thinking about ECT and she said 'it's certainly something we can explore.' I've decided I want to do it."

She had done her research. 

"Where did you get the idea to even consider it," I asked.

"It came to me out of the blue," she said. "I think I was watching something on TV. I can't remember. I just know nothing is working and this is a chance."

A few days later, she received a call from the psychiatrist who will administer her ECT treatments. Her psychiatrist had made the connection.

"I wasn't expecting him to call me," she told me. "It was a real surprise. He was great. So encouraging and informative. He had already spoken with my psychiatrist and he knew all about me. He said he thought it would be best for me to have two sessions a week of unilateral ECT for between eight and 12 weeks. Early morning sessions. He asked me to join a study and I said I would."

I couldn't remember her sounding so positive.

"Do you think I could follow your experiences while you're going through it?" I asked. "Since you're in this study, you're helping to further scientific research. My writing about your entire experience might help people see ECT as it really is and how it really works. It might clear up some misconceptions."

She said, "Yes, of course. That would be a good idea. It might really help. But please don't use my real name, okay?"

"Okay," I said. "Thank you."

The way I see it ...

It's taken me a while to process my impressions and thoughts about Ethan Watters' provocative essay The Americanization of Mental Illness that ran in last Sunday's New York Times Magazine.

If you want to know the truth, I've been living with him – or it feels that way – all week. Initially, his article excited me, especially in its criticism of the way American psychiatry is "homogenizing the way the world goes mad."

Of course, this isn't entirely true. Nor is it new. Here's what I wrote in an article titled "My Life in Labels" in the Spring/Summer 2007 issue of the Canadian Mental Health Association magazine Network:

"Years ago, a diagnosis could depend on where you lived. In the 1970s, the joke among North American psychiatrists was that ''you could cure schizophrenia if you could fly to Europe,'" where psychiatrists there, using the tighter diagnostic criteria of the World Health Organization's International Classification of Diseases or ICD, would more likely diagnose you with bipolar disorder, which was more treatable. Here, where the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders or DSM is the standard reference, you would most likely get stuck with schizophrenia – then, much harder to treat and often considered hopeless. Now, such discrepancies are less likely as diagnostics have become more globally understood."

Watters essay was adapted from his brand new book Crazy Like Us: The Globalization of the American Psyche, which was published last Tuesday and which I haven't yet read. 

That, in itself, is a problem. 

Several writers have reacted to this story over the past week and there are links to their posts in the comments to my last post. I wanted to know how a Western-trained psychiatrist would react to Watters blistering critique of Western – read American – psychiatry and it's global reach. I fired off an email to my friend and mentor, Tufts University clinical psychiatrist and researcher Dr. Ron Pies.

A couple of points were of interest to me and Ron addressed them in a way that I found both wise and humane. After all, I take a holistic approach to health and well-being that encompasses mind, body, soul and spirit. The whole package. So does he. As does my psychiatrist.

"BRAIN DISEASE" VERSUS "MENTAL ILLNESS"

On the subject of "brain disease" vs. "mental illness" – here's what Dr. Pies wrote in his response to my email:

"I think this is a sterile debate that has plagued the field for decades, and is the baneful legacy of our friend Rene Descartes, with his mind/body dualism! My own view, which was anticipated by the late Robert Kendall, M.D., is that 'disease' is properly attributed to persons – not 'minds' or 'bodies.' As Kendall puts it in J. Schaler's book, Szasz Under Fire, p. 41)...

"Neither minds nor bodies suffer from diseases. Only people ... do so, and when they do both mind and body, psyche and soma, are usually involved."

Pies added, "The idea actually goes back to the great physician Maimonides, who said, "The physician does not cure a disease, but a diseased person." 

I am comfortable with the person I am, warts and all. Though I'm no cultural anthropologist, when it comes to psychiatry, in all honesty, I've been studying it from the inside for close to 50 years as a patient. No formal training, just one long extended, sometimes bumpy but endlessly fascinating field trip that began in 1960. 

In those days you rarely ever saw the word "psychiatry" in a daily newspaper or magazine. Psychiatry was almost unmentionable. It seemed to be more black magic than medicine. It was just a few years into its "chemical" age and just out of the age of the frontal lobotomy.

Also, I'm Canadian, with a slightly different take on some things, including psychiatry and medicine. I've grown up in a family of doctors, most of them specialists and academics. I've also learned that one's family culture, perhaps more than one's national, ethnic or even religious cultures, is astoundingly powerful in determining how you see yourself, your beliefs, your values and your personal outlook on life – especially if it is determined that you have a "mental illness."

Case in point. Until about four years ago, I really bought into the "Western Biomedical Model" of mental illnesses – hook, line and sinker. I was convinced that my mental illness was chronic, like diabetes (ugh!) and I was, indeed, deficient in some deep-seated way. I knew the chemical imbalance theory of the causes of mental illnesses is just that – a theory and unproven, according to Dr. Bob – still, I function best with a medication, one tool in many I use to stay as healthy as I can. (I have a large toolbox.)

Still, I believed that there was something wrong with my mind. This, despite a successful journalistic career, a wonderful new marriage and a good life. I believed that there was something terribly wrong with me but that through my therapy, I was righting it. 

INTERNALIZING YOUR DIAGNOSIS

Long ago, I internalized my diagnoses – and oh, what damage that does to one's psyche, let me tell you, especially when you're 18 and you discover have schizophrenia. It took another seven years to right that misdiagnosis. All this was part of my family's culture, too. After all, I am still seen as The Family's Resident Nut Case and recently, one of my relatives said, in a rather accusatory tone, "You've made a career out of your mental illness." 

Several things have happened to change that. Now, I know I'm okay. And I choose to believe that we're all "next to normal."

First, I was asked to speak to a group of psychosocial rehabilitation specialists and in doing my homework, I discovered the mental health recovery movement. 

This was an epiphany for me. A seismic shift in my consciousness. It was possible to be in recovery. I could recover. In fact, I already was in recovery. I didn't even know it. Can you believe how stupid I was?

I had known there were other non-psychiatric mental health models like Fountain House, which started the International Clubhouse Movement, but this time, the reality that you can recover from schizophrenia and bipolar disorder and other serious mental health problems and live a meaningful life – like mine – really sank in. 

So I started seriously researching.

Around the same time, my mother told me about a Benedict Carey story in the New York Times. "You must read it. It sounds just like you," she said. The headline – Hypomanic? Absolutely. But Oh So Productive! When I showed it to Dr. Bob, initially he resisted, but ultimately, he agreed and changed my diagnosis. After all, I've been manic, psychotic, but never depressed. I'm unipolar with a vulnerability to mania. Where's the bipolarity in that?

Though Dr. Bob wasn't enthusiastic about the idea of mental health recovery when we first discussed it, he's gradually changed his mind about its potential power and the way it transforms people's lives. I've grown increasingly recovery-oriented and also increasingly skeptical of the way the American biomedical model operates. For many reasons. Diagnosing young children with psychiatric conditions and prescribing powerful medications for them – medications untested for children – is criminal, as far as I'm concerned. There are other tools, other ways, other approaches. 

PEOPLE IN THE INTERNATIONAL RECOVERY MOVEMENT DEMANDING CHANGE

The point is, I started doing my own cross-cultural research about what was happening in other countries and cultures and I discovered that the American way is light years behind a significant majority of people in the recovery movement around the world demanding change.

Take Britain's Time to Change. Last week, this program to end discrimination "faced by people who experience mental health problems" (I love the language they use) announced another new ambitious community in Islington mounting a campaign to promote mental health equality. 

Community Mental Health and Recovery is a growing global movement in the world even though much of the medical establishment doesn't recognize it or simply pays lip service to it. Watters doesn't even mention recovery in his article, though he's right, according to Pies, "to call attention to the ways that culture and ethnicity can shape both diagnosis and expression of psychiatric symptoms." 

I guess the main problem I have with his essay is that I don't like generalizing about people and mental health and well being and diagnostics. Mental health is not a constant state for anyone, ever. Nor is having a mental health issue. We, individuals, are changing all the time. Our lives, our circumstances, our work environments, our relationships are in constant flux. We're all different, every day, and no diagnostic label is really 100% accurate. It's a ball park. A designation for a doctor to use. A place to start. Also, it's very useful for insurance companies. 

We're all unique, despite our diagnoses. As I've said for years, "I'm not my mental illness." Labels are for jars, not people.

MANY PROBLEMS PLAGUE MODERN PSYCHIATRY

There are many problems plaguing modern psychiatry. Every psychiatrist has his or her own approach. Even Watters' wife, who is a psychiatrist, and a very good psychiatrist, he says. There's the rocky modern landscape of psychiatry, influenced by new medications and new technologies. There's the pull of the neurosciences against and not always in concert with the healing powers of the psychotherapies. There's our quick fix, pill-popping culture. And there's the discrimination and negative stereotyping and prejudice that we must continue to fight with education. And open minds.

Lots to think about and to ponder. But I will add this. On his Psychiatric Times blog The Couch in Crisis Dr. Ron Pies posted about the Watters essay, too. It's worth a read.

I'm still processing. Today, I'm seeing Dr. Bob. We'll have lots to talk about.

Take care.

Speak soon!

About "The Americanization of Mental Illness" and then some...

What a week! 

It began on Sunday when I read a fascinating and provocative critique of the global influences of Western psychiatry by Ethan Watters titled The Americanization of Mental Illness in the Sunday New York Times Magazine,. Great title.  

I went through that piece initially on Saturday night online, when my friend Susan, a New Jersey-based bipolar blogger emailed me about it thinking it might be a good story to write about here.

Her email arrived while I was madly preparing for my first classes at Seneca College that began this week, so I decided I'd read this lengthy feature more carefully in print with my hard-copy of The Sunday Times the next morning, which I did.

Still, it started percolating at the back of mind. Though I expected the blogosphere to light up with comments, it didn't, as far as I could tell. Only Gianna Kali at Beyond Meds mentioned it and linked to it.

Reading it on Sunday morning in print, I penciled it up like a student preparing for a class. I found myself feeling comfortable and at ease, repeatedly nodding in agreement. After all, many of the points Watters makes, I've made here numerous times. 

Then at 5:11 a.m. Monday morning, as I was getting ready to leave for my class, my niece who teaches philosophy at a northeastern university sent me a link to it.

"hi sandy," she wrote. She never capitalizes in her missives to me. "did you see this? i haven't finished it yet  but it is very interesting and i think i'm going to include it in my emotions class..."

Interesting. Then, a red light went on in my mind. 

I started asking myself questions. I was beginning to wonder if there was something missing in Watters approach to a series of highly complex issues. He's a San Francisco-based published author and journalist with interests in cross-cultural psychiatry, anthropology, globalization and psychology, according to his blog. 

Does he have a psychiatric diagnosis, I wondered? I couldn't find any evidence of it, but to be honest, I didn't spend a great deal of time looking. I didn't have the time. I was racing against the clock trying to finish my course prepping.

Since Watters was so critical of American psychiatry, I decided to ask an American psychiatrist what he thought of this essay and I whipped off a series of questions to my friend and muse, my font of knowledge and wisdom, Dr. Ron Pies, Tufts University clinical psychiatrist and researcher and Editor-in-Chief of Psychiatric Times, the largest international online psychiatric magazine on the planet. 

Ron also contributes to The New York Times, The Boston Globe and PsychCentral's World of Psychology as well as endless psychiatric journals. 

I've devoted a number of posts to him here, too.  

Then, at 6:45 a.m., nervously, I drove off to school for my first class of the term – an 8 a.m. Monday class – a students' favourite. 

This is the first of my two Seneca classes. Twenty-two out of 35 students showed up and they were jittery. Not only because of today's Ontario Community College OPSEU province-wide faculty strike vote (I'm not in the union as a part-time teacher, so I'm not voting, by the way) but because of my course and what its demands will mean for them.

It was a good class. When I got home, I continued my correspondence with Ron. What a wild few days.

Yesterday at another Seneca campus at 1:30 p.m. I went through the same nerve-wracking experience with another 35 students.

Why nerve-wracking, you ask? 

Because I teach an elective course, required of all Seneca students who wish to graduate, no matter what program they are in, and I have a very diverse groups of students. Lots of business students of every stripe from administration and financial management to marketing and accounting, plus fire protection technology, early childhood education, library technology, fashion and any other of the dozens of programs Seneca offers. 

My classrooms look like a mini-United Nations. It's extraordinary. Teaching is learning, and I swear, teaching an elective at Seneca is a post-graduate degree in itself.

My course is called Leadership in Society and it is for college students who want to make a difference – more than money. It's what I do here. It defines my life today.

This course has become a life-changing experience for many of my students. It combines leadership training and Community Service-based learning, a growing movement in North American colleges and universities. In my course, 30% of their final mark is based on a major Community Service Project requiring each student to do a minimum of 20-hours of community service over a period of three to five consecutive weeks with a non-profit organization – in addition to their full academic load. 

They learn to write reflectively, keeping weekly journals. They must go out and find and interview a community leader. I teach them how to conduct an interview.

It's a major commitment. The subtextual prerequisite is that they care about making changes for the greater good of the community or society. Many students do. Others don't but learn to care, and often they continue their community service long after the course ends.

This is my course. I was asked to develop it in the Fall of 2007 while teaching Women Studies and I've been teaching two classes every Fall and Winter term since. It's a work in progress. In constant development. I've made a lot of mistakes but I've learned more than I could ever imagine.

I love teaching this course. It's my passion because, like creating and writing Coming Out Crazy here at HealthZone and exchanging ideas and community-building with you, teaching and learning are what I love to do most. I'm happier with these two part-time jobs, than I ever was in my full-time journalistic career. I make less money. I have no benefits. My life is rich, rewarding, meaningful and endlessly challenging and exciting. 

Proof that making a difference and having true meaning in your life is more rewarding than a huge bank balance. All you need is enough. Thank you, Daniel H. Pink! He happens to be one of my resources for my course.

Yet this course is often a very tough sell to the students. Yesterday, in one of my classes, I had 35 students registered. They arrived late. They didn't want to do Community Service and were very vocal about it. They were also so disruptive during that class, I came home with a backache, a headache and a stomachache. Thoroughly spent. No energy to write this post. 

I've learned that disruption in a classroom is contagious. A few can destroy the class culture for everyone. I was so stressed out, I had a snack and went to sleep at 5:30 p.m. worrying about how I would be able to manage this group for the next three months.

I felt awful, even though Ron Pies had blogged about the Watters piece himself and cited me and another doctor as having inspired it.

"Thanks for providing the 'spark'! --- Best, Ron," he wrote in an email at 4:45 p.m. yesterday.

I was a mess.

Sometimes I think the ongoing stresses of everyday life are insidious and potentially dangerous. Their relentless pressures hammer away at you, again and again, week-in and week-out. They're cumulative and more difficult to live with and manage that annual stresses like Christmas or peak stresses like having to move to a new home or the shock of losing your job or even experiencing the death of someone dear to you.

Their repetitive onslaught on our minds, spirits and bodies is doggedly destructive and distressing. 

Yesterday night, I was devastated. Then, just before I went to sleep, I checked my class lists. All those disruptive students had dropped my course. My class list was down to 29. 

So, on Friday, I will share with you my concerns and what I've learned about "The Americanization of Mental Illness..." I promise. I'll share some of the correspondence I had with Ron Pies, with whom I do not always agree, by the way. How could we? I have a 49-year psychiatric history. I'm Canadian. He was a toddler when I went to see my first psychiatrist in 1960. He's also a polymath with interests in philosophy, Talmudic studies, poetry and ethics. He's published widely and not just psychiatric texts but a wonderful book I give as a gift called Everything Has Two Handles – The Stoic Guide to the Art of Living (Hamilton Books, 2008). He's one of the wisest people I know, but we come from very different places. Yet we respect each other. I adore him.

So, today, I'm decompressing and planning my classes for tomorrow. I teach at two campuses every Thursday. I have 100 minutes to get from one campus to another. It's tough, when your students need you and want talk to you!

I pray that it does not snow on Thursdays this winter.

Be well. Stay warm. Speak soon.

You...

If you read the comments to this blog with any regularity, you know that I am enormously grateful for your feedback. They are a rich dialogue between you and with me, because I try my best to answer as many comments personally. Often, ideas evolve through the comments that further the discussion in the main posts. They're synergistic. Like brainstorming session because your ideas and reactions and experiences are so stimulating and inspiring to me.

WITHOUT YOU, I WOULDN'T BE HERE

The main point is, without you, I wouldn't be here. And between you and me, I love being here. This blog is my passion. I love writing it. It's the most satisfying journalistic experience of my 38-year professional journalistic career. (I started young, very young. Trust me.)

You, as veterans of the mental health system, know more than most people - especially doctors and psychiatrists and neuroscientists - about how it feels to be on the other end of a "notebook." Collectively, your expertise, your insights, your experiences in the mental health world is monumental. 

So, today, I'm going to muse about why, share the spotlight with you, and share some insights that have come my way in particularly in personal correspondence from those of you who struggle with and have learned so many "truths" travelling along their roads to Recovery, but are a little shy about being in the limelight.

I REMEMBER HOW ANXIOUS I WAS COMMENTING FOR THE FIRST TIME

Believe me, I empathize. I remember how anxious I was commenting for the first time on Liz Spikol's high-profile and multiple award winning Philadelphia Weekly bipolar blog The Trouble With Spikol. 

Liz hooked me immediately because she used to post short videos of herself and she seemed so friendly and down-to-earth and lacking in ego, which she is, by the way. But she also has a huge following and she monitors her comments, so I didn't know if mine would make it. This was nerve-wracking for me. 

At the time, I knew nothing about blogging. It was in April 2008, just after we launched HealthZone and Coming Out Crazy - this link is my inaugural post, which ran on April 9 of that year.

Back then, I was just getting my feet wet as a blogger. (Until I began blogging, I had never read a blog and knew little about the blogosphere. In our embryonic days, we were not live and interactive, so being interactive and engaging publicly and openly with the Internet was scary. I didn't know, then, that the blogosphere could be very forgiving, but at the same time, risky, too.

You put yourself out there, less so in The Comments, than in my main posts. Still, it's a daunting experience until you've done it a few times. As Malcolm Gladwell asserts in his controversial, highly readable and bestseller Outliers, The Story of Success, it takes practice. Not 10,000 hours, but a few.

This week, one of my regular "anonymous" readers sent me the following note in response to Wednesday's post.

"So sorry to hear you are still under the weather, but I hope you can give in to your 'rest' regimen. Thank you for your most recent effort on your blog, despite ill health.

"A HOT BATH AND GREAT LITERATURE AS A SLOW CURE FOR DEPRESSION" 

"I had a laugh about you mentioning the comparison between diabetes and depression, often put forth by every garden variety shrink. I had a similar experience with a well-meaning but distinctly insipid psychiatrist, soon after returning from living abroad. I told her I was a great follower of The Greeks. The Greeks suggested a hot bath and great literature as a slow cure for depression. 

"I find at the depths of sadness, one must go inside oneself, that the remedy comes from within. We slowly come back to our essential self or soul, and there we find peace.

"Yet in our rapid age, no one seems aware that quick cures are often only superficial. So far, I have avoided antidepressants, yet I suppose they work for some people. I think I am with Tennessee Williams who reportedly once said, 'If I lose my demons, I may lose my angels, too.'"

In a subsequent note that arrived a few minutes later, this reader added:

"Couldn't resist firing off this quote to you. Seemed somehow relevant in the light of my last message.

"'All great truths begin as blasphemies.' This, from George Bernard Shaw. I guess he was a bit of a contrarian, and somehow when I question the status quo on mental health I feel like one, too. Something to ponder. I found it an interesting quote."

And ponder, I did. I love pondering.

YOU GIVE ME SUCH RICHES

See? You give me such riches. This is just one recent example. I have dozens in my inbox. I hope one day this exquisitely enlightened person will be able to make the leap into the Comments so her wisdom, insight and literary largesse will be seen and shared with everyone in our community. So she can engage with all of you who are similarly thoughtful, understanding, empathetic, in endlessly diverse and fascinating ways. Experts on mental health and wellness and Recovery.

Now, you know why I am so beholden to you. All of you. Why I thank you constantly.

I'll rest my case. And rest, too.

Have a great weekend. For me, school starts on Monday morning at 8 a.m. I have much to do. I need my energy.

Be good to yourselves and speak soon.

Beginning MMX with Recovery...

Hello! I've missed you. I'm happy to report that during my break there was some action in the comments which always warms the cockles of my heart. Thank you. What a lovely gift they were and they kept me on my toes.

I hope you are well and thriving now that the 2009 holidays are history. I hope they were smooth and whizzed by without any major bumps. Now you can look forward to Family Day, our nice innocuous statutory holiday on Monday, February 15, the day after Valentine's Day this year. A real double-header. It coincides with Presidents' Day in the U.S.

For those who are given this day off, it will be a lovely mid-winter day to relax, recharge, go to a movie, ski, snowboard or simply snuggle up with a good book. 

I feel in my gut that MMX, as the Roman's would say, is going to be an exciting year. As soon as it starts for me. Gut is the operative word here. Mine is not in terrific shape at the moment.

You see, it's been a long, hot (as in high temperature, mine) holiday in our house, mainly because I've been sick. Still am. You don't want to know the details, but let us say that "rest" is what the doctor ordered and "rest" is not one of my strong suits. In school, I would fail "rest" and I would ace multitasking. 

Oh well. That's the story.

There is an interesting item in today's New York Times by one of my favourite mental health writers Benedict Carey. The headline says it all – Popular Drugs May Help Only Severe Depression. By no means a new story, it's based on a new report published today in The Journal of the American Medical Association. 

It certainly supports the strong contention I have about quick-fix, pill-popping approaches to mental health recovery. For cases of severe depression, this report finds quite conclusively that antidepressants are substantially more effective in cases of severe depression than in cases of mild or moderate depression.

This has been debated for some time and now a large and wide-ranging randomized study has come up with some conclusive findings. I have always sensed this to be true and further, than when antidepressants are prescribed, psychiatrists should be monitoring their patients closely and talk therapy should be part of the healing regimen. It is no secret that pills without therapy are never as effective as pills in combination with therapy. And that doesn't mean "a 15 minute appointment and prescription." That's not psychotherapy.

Carey sites Dr. Erick H. Turner, a psychiatrist at Oregon Health and Science University, who says, "I think the study could dampen enthusiasm for antidepressant medications a bit, and that may be a good thing. People's expectations for the drugs won't be so high, and doctors won't be surprised if they're not curing every patient they see with medications."

Dr. Turner adds, "The findings shouldn't dampen expectations so much that people refuse to even try medication."

Turner's last comment intrigues me. Mental health issues like depression are treatable, yes. But curable? Such a curious word for what most medical doctors consider mental illnesses to be – namely chronic, "like diabetes." Oh, how I hate that comparison.

One can go into recovery through medication, therapy, peer support, the process of self-actualization through meaningful and fulfilling work and having a stable family and home life. Recovery is a process. Not a pill. Not a cure. It's ongoing. It means many things, as I have often written. Have a look at The 10 Fundamental Components of Recovery from the U.S. National Consensus Statement on Mental Health Recovery. 

Among them: Self-Direction, Empowerment, Peer Support, Respect, Responsibility and Hope. Similar to those underlying fundamentals of recovery at The Krasman Centre in two locations just north of Toronto. These centres are staffed completely by people in recovery from mental health issues. 

As I reported last year in my story about mental health recovery in The Walrus magazine, "Today recovery is a fully realized and internationally recognized approach to attaining wellness... Still, it's hard to pin down an exact definition of recovery. 

"Tanya Shute, the executive director of Krasman and a survivor, describes it as 'a person's ability to self-actualize, with or despite one's mental health experience.' Elaine Amsterdam of Toronto's Gerstein Crisis Centres says, 'It's about living well,' adding, 'The meaning of that is different for everyone and can include a range of different approaches.' 

"But the whiteboard that hangs on the Krasman Centre's kitchen wall (in it's Richmond Hill location) notes five key concepts in indelible black ink: hope, personal responsibility, education, self-advocacy, and support."

We must all find our own way and it is that processing that we can begin experiencing recovery.

As Carey stresses, in some cases certain antidepressant are very helpful, in severe cases of depression. In his story today, he concludes with the words of one of the team of researchers in this study which included psychologists "who favour talk therapy and doctors who consult widely with drug makers."

On is Dr. Robert J. DeRubeis of the University of Pennsylvania, who stated, "The message of patients with mild to moderate depression is, 'Look, medications are always an option, but there's little evidence that they add to other efforts to shake the depression – whether it's exercise, seeing the doctor, reading about the disorder or going for psychotherapy."

This is such a positive message. Depression which isn't severe responds to many different and very accessible approaches, not the least of which is knowledge and understanding, learning about depression, facing it plus, peer support, doing things that make you feel better which can be anything from reaching out to an organization like the Mood Disorders Association of Ontario or joining your local community centre and signing up for Belly Dancing classes. Taking a class in Mindfulness Meditation, perhaps, or knowing when the best medicine is a lovely warm bubble bath or listening to your favourite music or a walk in the park with your dog or with a friend or with your thoughts. 

Recovery is within reach. As long as you're willing to reach out.

Isn't this going to be a good year? Full of hope.

Now, I'm back to my bed.

Speak soon and be well.