Category Archives: Psychosis

A Rose by any Other Name

Guest Post by Joseph Merlin Bowers from The Unashamed Schizophrenic

I have a friend who is a dedicated and effective advocate for people like me who have serious mental illnesses. Living in a politically correct world, she asked me once what term I would prefer when someone refers to the mentally ill. After all we are told that words matter. Perpetuating stereotypes is the cruel consequence of words like crazy, lunatic, nutcase and the like.

I spent some time trying to think of the perfect word that would be descriptive, non-derogatory and accurately portray one of us with a serious disease of the brain. After some time I came to realize that I just don’t care and I probably should not.Two quotes come to mind: Shakespeare-“A rose by any other name smells just as sweet.” Brene Brown-“Loving ourselves through the process of owning our story is the bravest thing we’ll ever do.”

Whatever word one uses to describe a serious brain disease, what matters is the image the word conveys to the listener and how that listener reacts to that image. I don’t care what you call me. I do care how you react to me and treat me.

I totally own my story. My story involves mental illness. When I went up the stairs in my house with a loaded shotgun intending to kill my grandmother, I was totally bat shit crazy. Sometime latter when in recovery, I apologized to my grandmother for scaring her badly. She said that the doctors told her that it wasn’t really me that assaulted her. That is only true in a sense. I would never have dreamed of harming  my beloved grandmother when my brain was healthy and operating normally. What I did had nothing to do with who or what I really am when healthy. But in another sense it was me. In the grip of insanity, I did what I did. It was me. It wasn’t anybody else. I can’t own my story without acknowledging that.

I belong to the biological explanation for most serious mental illnesses school of thought. I’ve seen brain scan and activity images showing physical differences in the brains of schizophrenics and people with bipolar disorders. When I first encountered this information I had two simultaneous reactions. My first was dismay. If my disease is a physical deformity what hope do I have of recovery. I can’t just change my behavior or my way of looking at things and reacting to events.

My other reaction was a feeling of liberation. My disease was not my fault. It was not my families fault. It was nobody’s fault!

I have friends whose stories are much harder to own than my own. Doing so requires much courage and strength. We have done things we will always regret. We wish to hell we could go back in time and undo what we did. To own our stories is necessary to put them behind us, get on with our lives and live in the now, looking to the future.We know the science of why we behaved in a manner uncharacteristic of who we really are.

We are ashamed of nothing. To react with shame to words like crazy, lunatic or nutcase is self stigmatizing. It involves buying into the fiction that having a mental illness is something to be ashamed of. What other disease of what other organ should one be ashamed of?

When I acted crazy it was because I was crazy. I would prefer to have you say I was crazy than something like “a soon to be consumer of mental health services”.

Canadian Families Coping With Schizophrenia Don’t Have a National Voice

This blog post was written by Susan Inman and appeared in the Huffington Post on March 21. It is a sad shame that there is no longer a viable voice to express the concerns of families with members who suffer from schizophrenia.

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Families who care for people with schizophrenia once had an organization that gave them a national voice. They no longer do. This lack of national representation impacts not just our own situations; it also hurts the people we support, because they are often unable to advocate on their own behalf.

Family caregivers, who had previously established provincial advocacy organizations, came together over 30 years ago to establish the Schizophrenia Society of Canada.

Certain core values originally united these organizations. These values included building close ties with the psychiatric and neuroscience communities which had come to see schizophrenia and bipolar illness as disorders of neural circuitry. These groups sought to provide the most up-to-date education about these illnesses to people with the disorders, to families, clinicians, police, and the public.

As well, these organizations have advocated for high quality supported education, housing, and psychosocial rehabilitation services.

These organizations have also worked to dispel the unjustified blaming of families for psychotic disorders that earlier theories about these illnesses had propagated. The legacy of these beliefs, which have faded from psychiatry, have persisted and negatively impacted other areas of clinical practice. Frequently clinicians are still training in the many credentialed programs that don’t require any science-based curriculum on psychotic disorders.

Until recent years, the goals of these family groups had been represented by the Schizophrenia Society of Canada (SSC). However, while sitting on many national committees as the presumed voice of families, the SSC has failed to support the perspectives of the families who created it. It does not address the lack of appropriate curriculum in training many clinicians. Similarly, it does not work to provide basic information about schizophrenia in the annual national mental illness literacy campaign in which it plays a lead role.

These failures are occurring because its current leadership has given itself a different mandate. It has supported trends in the social sciences that seek to de-medicalize mental illnesses and advance the idea that all problems arise from social and personal adversity.

Instead of fighting against the stigma that too often interferes with the ability of family caregivers to develop collaborative relationship with clinicians, the SSC Executive Director, Chris Summerville, has actively promoted stigmatizing attitudes. For instance, he promotes the notion that families undermine the recovery of their family member by holding stigmatizing attitudes towards them.

Summerville has written that families block their family member’s access to treatment because they don’t want to expose their ‘family secret.’ At the same time he has failed to help people with illnesses, their families, and the public understand anosognosia, the brain based inability of many psychotic people to understand that they are ill. This is the symptom that families struggle with as they try to get an ill family member into treatment.

The SSC has also failed to promote the most progressive, evidence-based psychosocial treatments. In recent years there has been extensive research about the common cognitive losses that are associated with the illness. While most people’s psychotic symptoms can be controlled with anti-psychotic medications, the cognitive losses often persist. These include difficulties with concentration, short term and working memory, problem solving, and judgment. While BC’s Early Psychosis Intervention toolkit makes this information readily available and even educates people about useful cognitive adaptation strategies, the SSC ignores this issue in its educational programs.

Cognitive losses are widely understood to be the biggest factor in the extensive ongoing disability of this population. While espousing its commitment to the Recovery Model, the SSC has not only failed to provide education about cognitive problems. It has also failed to promote the evidence based cognitive remediation programs that can improve recovery; these programs have been expanding in other countries for the past 20 years.

While the SSC has failed to promote programs that are desperately needed, it has played a leadership role in the mis-education of the growing peer support work force. Many of us hoped that the new national guidelines for training peer support workers that the SSC helped create, would begin to provide peer workers with essential information about the illnesses of the people with whom they often work. The guidelines don’t require — or even recommend — that training programs offer any information about mental illnesses. Instead of informing peers about why people suffering from psychosis sometimes need involuntary treatment, peers are encouraged to oppose it.

Now the SSC leadership has taken an even more alarming step in securing its vision for this organization. It’s created a survey that has been designed to guide responders to provide the desired responses. The survey wants a mandate to move away for what it calls the “western medicine biomedical disease model” of schizophrenia.

The survey is also looking for support for getting rid of the term “schizophrenia.” However, schizophrenia has long been included in the Diagnostic and Statistical Manual that is used in mental health, criminal justice, education and social services. The diagnosis enables people to access disability payments and many other essential supports.

The SSC survey argues that we should substitute the term “psychotic spectrum disorder” for schizophrenia and points out that this term is used in early intervention programs. It doesn’t say that, when cognitive and other symptoms persist once psychosis is managed, people often receive more specific diagnoses like schizophrenia or schizoaffective disorder.

It’s convenient for national organizations to continue to use the SSC to ensure the presence of a family voice. However, the SSC doesn’t represent the perspectives of the vast majority of family caregivers I’ve met in the last seventeen years.

Maybe it’s time for the leadership of the SSC to create their own organization representing the conditions they consider significant and the alternative treatments they help popularize. They could return the SSC to the families of people with severe mental illnesses who created it.

More on Vince Li and Absolute Discharge

By Dr David Laing Dawson

Let me give a little background to my previous blog on Vince Li.

I have had many patients over the years (50 years now, actually) who have done well with treatment, who recover, who have insight, who promise to stay on their medication. They are good people. I like them. We become friends. With some it can involve an ongoing dialogue about needing or not needing to stay on medication.

But at some point most of them stop their medication, at least once. Their lives have changed. They have been well for 20 years. They meet a family doc who doesn’t understand why they are still taking Olanzapine. They fall in love. They move. They get ill in some other way. The pharmacy changes hands. Their doctor moves. They come under the influence of one of any number of cults, including Scientology. They read the bullshit of the anti-psychiatry crowd, or the homeopaths. Someone offers them cocaine.

So at some point most of them stop their medication at least once.

With psychotic illness the illness returns, and it always returns in the same way. With some my relationship is good enough that I can cajole them into going back on their medication. With some I have had to spend hours offering it while my patient tries to decide if I am a friend or the devil. With others it means a complete relapse and re-hospitalization.

And in most cases, the only ones hurt by this relapse are my patient and his or her family. That is no small thing though. The social, emotional, vocational, educational, and sense- of-self cost is huge. Often a year or more of progress is lost.

Lack of insight may be a good predictor of human behaviour, but insight itself is not. An equally poor predictor of future behaviour is remorse, or a display of remorse. “Good behaviour, model patient or prisoner” has also little to do with what will happen in a different context five years from now. I will agree, however, that a good support system is a good predictor, but we need that support system in place for 40 years.

We clinicians are further hampered by our natural empathy, our natural sympathy that flows toward anyone nearby. It is not special; it is just human. At least twice a week during commercials I see on the television screen an emaciated fly-covered child. I get up and refill my glass. But should that child and his mother be in the room with me, my response would be quite different. Hence, as I have seen many times with CCRB cases over the years, the staff actually caring for and treating the patient are very poor at predicting future behaviour.

Now, I have not examined Mr. Li. It is possible he had a psychotic episode that will never reoccur. In my 50 years experience I know this to be only possible if the initial psychosis was caused by a brain injury, a stroke, toxic substances, or withdrawal from toxic substances, or very severe acute trauma within the time-frame of the psychosis. But from what I have read Mr. Li developed a schizophrenic illness with hallucinations and the specific delusion that resulted in a very specific horrendous crime.

So, from my 50 years of experience, I would say the people who know Mr. Li, who have spent time with him, are the last people who should be making predictions of future behaviour. Secondly, insight, remorse, promises, even absolute statements of conviction are not good predictors of distant future behaviour.

We know this man, when well, is a very nice man, and could be a good citizen of any community. We also know when ill he is capable of committing a horrendous crime.

Would it not be reasonable to use the tools we have to keep him well for the next 40 plus years? To protect Mr. Li and any future community in which he resides? They are not overly constrictive or intrusive considering the possible consequences of a relapse.

By allowing even a remote chance of a repeated homicide by Mr. Li you are doing everyone else diagnosed with a psychotic illness a great disservice.

Addendum to Belief Systems, Mad in America and Anti-psychiatry

By Dr David Laing Dawson and Marvin Ross

Reading the comments to this blog and others of ours, there is a lot of a-historic and naive thinking. Recently, someone posted my Huffington Post blog on Open Dialogue in Finland to the Spotlight on Mental Health group set up by the Boston Globe to foster discussion of their series on the sad state of mental illness treatment and care in Massachusetts. One person criticized it claiming that I had no right to comment because I have never been to Finland, and the Finnish psychiatrist I quoted had no right to be critical because he had never been to Lapland. This is part of what that person said:

That paper by Marvin Ross is written around totally wrong information:

1) Marvin Ross has never been to Lapland to check what he wrote; thus he does not know what he speaks about…

2) The psychiatrist whom he telephoned in Helsinki, i.e. some 800 km from Lapland, had never been either…How she knew any of that I do not know.

One person commented on this blog that 10 times as many people diagnosed with schizophrenia die in the first year post diagnosis than 100 years ago and that olanzapine has killed 200,000 people worldwide.

Taking data from a number of public sources, Dr. Dawson put these statistics together:

Some American Statistics

1880

Total population: 50,000,000

A total of 91,959 “insane persons” were identified, of which 41,083 were living at home, 40,942 were in “hospitals and asylums for the insane,” 9,302 were in almshouses, and only 397 were in jails. The total number of prisoners in all jails and prisons was 58,609, so that severely mentally ill inmates constituted only 0.7 percent of the population of jails and prisons.

Average Life expectancy for entire population: low 40’s for whites

Low 30’s for blacks

2016

2016 total population: 324,000,000

Average life expectancy: men 76, women 81 (lower than Canada and most of Europe, lower still for minority groups. Much of this improvement from 1880 by preventing childhood diseases.)

U. S. Prison population : 2,200,000 (2014)

Or 716 per 100,000 American citizens are in prison. (a seven fold increase from 1880)

Mentally ill in prison estimated/measured to be 30% to over 50%

So 700,000 to over one million mentally ill are incarcerated in US prisons.

Incarceration in jail reduces life expectancy by roughly a factor of 10 years for every 5 years incarcerated. (all inmates)

Estimates/measurements of homeless in the USA:  1.5 to 2 million.

Estimates of homeless mentally ill range from 30% to over 50%.

So 500,000 to one million mentally ill are either homeless or living in shelters.

The homeless mentally ill are not receiving consistent psychiatric treatment. The incarcerated mentally ill may be receiving some limited treatment.

Adding this up:

One to two million mentally ill people are either homeless or  incarcerated in prison in the USA.

A high proportion of people with severe mental illness live in poverty.

Severe mental illness without treatment confers higher risks and co-morbidities for several serious diseases, such as cardio vascular disease. People with severe mental illness have a much higher risk of cigarette smoking and poor diet.

Untreated depression, bipolar disorder, and schizophrenia confer a much higher risk of suicide.

Homelessness and incarceration in and of itself reduces life expectancy by a considerable number of years. Neither of these groups is consistently receiving psychiatric treatment.

Psychiatric drugs do have side effects. (as do all pharmaceuticals) In a good outpatient or inpatient facility these can be monitored and treatment adjusted in partnership with patients.

But the real causes of contemporary poor life expectancy of the seriously mentally ill can be found in:

  • The illness itself untreated
  • Reduction and closing of hospitals.
  • Incarceration in jails and prisons
  • Poor or no housing. Homelessness
  • Poverty
  • Poor diet. Illicit drug use. Smoking.
  • Stigma leading to isolation and victimization
  • Poor, inadequate, or limited health care
  • Absence of good consistent psychiatric treatment.

And the overall cost of not providing good early consistent psychiatric treatment in both inpatient and outpatient facilities is calculated in the following article:

http://www.usatoday.com/story/news/nation/2014/05/12/mental-health-system-crisis/7746535/

Belief Systems, Mad in America and Anti-Psychiatry

By Marvin Ross

I keep reading comments from people wondering how anyone could possibly support Donald J Trump. Fact checking his statements demonstrates how wrong he is on much of what he says. And then there are the numerous comparisons of statements that he makes that contradict each other.

Not so surprising, sadly enough, when we look at the people who believe what Robert Whitaker and the anti-psychiatry movement believe.

Put simply, Whitaker and the Mad in America anti-psychiatry folks are adamant that anti-psychotic medication for schizophrenia makes people sick and shortens their lives. Research fails to support these contentions but they persist and the data is ignored. The two latest studies provide overwhelming evidence that anti-psychotics help – but more on that in a moment.

The late Dr William M. Glazer of Yale writing in Psychiatric Times four years ago had this to say of Whitaker:

Should we accept the analysis of a journalist who (1) to my knowledge, has not treated a patient or implemented a study and (2) reaches conclusions that run counter to well-established practice guidelines? Whitaker’s ideological viewpoint, which is implied throughout the book, is that our guidelines are inaccurate and driven by industry and our own need for income—that we are dishonest brokers. Beauty is in the eye of the beholder.

Criticisms of Whitaker have been done by many eminent psychiatrists but my favourite is by blogger Natasha Tracy in Healthyplace.com. Natasha explained why she refused to even read his book with these words:

Sure, he cites studies, he just contraindicates what the study actually proves. And nothing ticks me off more than this because people believe him just because there is a linked study – no one ever bothers to check that the study says whatever Whitaker says it does.

Except, of course, the people who do – the doctors. You know, the people who went to medical school for over a decade. You know, the people actually qualified to understand what all the fancy numbers mean. You know, those people.

And I, for one, rely a lot on what doctors make of medical data and they are the ones most able to refute Whitaker’s claims.

As for the contention by Whitaker and his minions that anti-psychotics make people sick, let’s look at two recent studies.

In 2013, the highly respected British Medical Journal, The Lancet, published a German meta-analysis on the efficacy and side effect profile of all anti-psychotics. The results are summarized simply in a blog by Dr Gerhard Gründer with a link to the original study.

The meta-analysis combined 212 studies with a total of 43,049 patients. All of the anti-psychotics produced improvements that were statistically better than placebo. The best agent was clozapine.

The most recent study was conducted in the Province of Quebec and published in July and was based on real world evaluations of all people prescribed with anti-psychotics for schizophrenia between January 1998 and December 2005. The cohort consisted of 18 869 patients. Outcome measures consisted of mental health event (suicide, hospitalization or emergency visit for mental disorders) and physical health event (death other than suicide, hospitalization or emergency visit for physical disorders).

The researchers pointed out that data from randomized control trials are often limited in terms of generalizability thus real world studies like this one are much more realistic. What they found was that taking anti-psychotics reduced the risk of having either a mental or a physical problem compared to those who discontinued taking them. The only anti-psychotic that performed poorly was quetiapine (seroquel) while clozapine had the best results.

The other criticism from the anti-psychiatry bunch is that taking anti-psychotics results in premature death for people with schizophrenia. Studies have shown that people with schizophrenia do die years earlier than others but the reasons are not well understood.  One hypothesis that I mention in my book Schizophrenia Medicine’s Mystery Society’s Shame is discrimination by health care practitioners. Studies show that people with schizophrenia often do not get adequate basic medical care and treatment.

Researchers in Sweden conducted a real world analysis of 21,492 patients with schizophrenia. Subjects were followed up from 2006 through 2010. Data on drug use and outcomes was obtained from national registers.

What was found was that Antipsychotics and antidepressants were associated with a significant reduction in mortality compared with no use. The opposite of what the anti-psychiatry crowd claim. However, there was a clear dose-response curve for benzodiazepine exposure and mortality. More benzos, greater mortality. Note that benzodiazepine drugs are not anti-psychotic medications. They provide short term relief from anxiety, but they are addictive when used over a long period. Which means with long term use people develop tolerance and then crave more. And if they stop them they experience serious withdrawal symptoms. They are never prescribed alone to treat psychosis.

Psychotropic medications prescribed properly to those who need it, are beneficial despite what you may hear from some journalists and a vocal minority.

 

Psychiatry, Eugenics and Mad in America Scare Tactics – Part II

By Dr David Laing Dawson

I am not shocked that we passed through a phase in our evolving civilization when we seriously considered Eugenics. Until we understood a little about genes and inherited traits, every serious abnormality must have been considered an accident or an act of God, perhaps a punishment for some immoral thought or deed. Certainly a stigma and something for a family to hide, if it could. And, at the time, the tribe or village would feel no collective responsibility to look after the impaired child, the disabled adult. This infant and child would be a burden on the family alone until she died, usually very young.

But coinciding with a time our tribes, our villages, our city-states, and then our countries developed a social conscience, a new social contract, and accepted the collective burden to care for these disabled members, we began to learn of their genetic origins. It would be entirely logical to then consider the possibility of prevention.

When medicine discovers a good thing, it always takes it too far, and then pulls back. When men and institutions have power we always, or some of us at least, abuse it, until we put in some safeguards. And there is always at least one psychopathic charismatic leader lurking nearby willing to bend both science and pseudo science to his own purposes.

But we have, here in the western world, passed through those phases (and hope to not repeat them). Now every year we find genetics is more complicated, that there are more factors involved. And every year we pinpoint at least one more detectable genetic arrangement (combinations, additions, deletions, modifiers, absences) that cause specific and serious abnormalities.

But here is where we are now medically and socially in the Western World: We can test the parents’ genetic makeup, we can test the amniotic fluid, if indicated we can test the fetal cells, we can offer parents a choice to abort or not; we can tell them of projected difficulties, available treatment or lack thereof, likely outcome, and possible future improvements in treatment and cure. We have also socially evolved sufficiently (and are rich enough) for the state to assume some, or, if necessary, all of the burden of care.

That is where we are, notwithstanding the difficulties of providing this care, and the antiabortion crowd: Some genetic certainties, some intrauterine tests, some blood tests for carriers, some absolute and some statistical predictions, and parental choice.

Now we come to genetics and mental illness. We have no certainties; we have some statistics; we have no intrauterine tests, no blood tests, and we have parental choice.

For science to not continue to pursue a genetic line of inquiry for serious mental illness would be a travesty.

Nature/Nurture. I think I entered psychiatry at the height of this academic debate. On one hand the psychoanalysts dominated US psychiatry, while biological psychiatry (Kraepelian psychiatry) dominated British psychiatry. (R.D. Laing was an outlier). Meanwhile psychology figured if you could train a dog to salivate at a bell you could train any kid to do anything. At the same time many poets, essayists, and not a few Marxist sociologists were telling us that the insane were not insane. It was the world around them that was insane. From Biological Determinism to parental cause to the Tabula Rasa and back to Social Determinism.

Other psychiatrists worked hard to find a way of including all possible factors: the bio/psycho/social model. (Which I would like to see redefined as the bio/socio/psychological model, for it is clear to me that our behaviors are driven first by our biology, secondly by our social nature, by social imperatives, and thirdly by our actual psychology, our cognitive processes. (Just watch Donald Trump)

How much of our nature is determined genetically, or epigenetically in the womb, and how much by our experiences as infants and children and teens and adults? When it comes to human behavior it is clearly all of the above, to different degrees and proportions.

The studies show that the risk of developing schizophrenia is 50% if your identical twin has schizophrenia, whether raised together or apart. This was often touted to show that 50% of the causative factors for schizophrenia must be environmental. But we now know that identical twins are not really genetically identical. And the interplay of genes, genome, brain development and environment is time sensitive. (Despite her fluent English my wife still stumbles on some English sounds. They were just not the sounds her brain was hearing at age 3.)

On the other hand identical twins reared apart are later found to have developed surprisingly similar traits, speech patterns, skills, and interests. And on every visit with my daughter in Australia she complains about the knees I bequeathed her.

As I mentioned before, genetics gets more complicated the more we are able to study it. Some DNA sequences seem to predict a mental illness in adolescence or adulthood but not the exact one.

Of course that finding may reflect not so much on environmental influences as on the vagaries of our definitions, our current diagnostic system.

An old colleague once remarked that our criteria for the diagnosis of schizophrenia are at the stage of the diagnosis of Dropsy in about 1880. I think he exaggerated. They are closer today to a diagnosis of Pneumonia in 1940. (Note that we can now distinguish a pneumonia that is bacterial caused, from viral, or autoimmune, or inhalational, and which bacteria, but our antibiotics help only one form of pneumonia, and each of these forms of pneumonia may have one of numerous underlying problems (biological and social) causing the vulnerability to developing pneumonia.)

For mental illness the development of drugs (1960’s on) that actually work much of the time threw a monkey wrench into this ongoing debate and inquiry. It tipped the balance to biological thinking for many of us. But it is a logical fallacy to assume a treatment that works reveals the original cause. The treatment is disrupting the chain of pathogenesis at some point but not necessarily at the origin of the chain.

We will continue to argue nature/nurture, and science will continue to investigate. And doctors will continue to treat with the best tools they have available.

If Dr. Berezin is correct (which he is not) and serious mental illnesses like schizophrenia, manic depressive illness, autism, and debilitating depression, OCD, and anxiety are all caused by “trauma”, much hope is lost and we will not find good treatments and cures for centuries. For today, despite what Donald Trump and Fox News tell us, in our childhoods in Europe and North America we experience far less trauma, strife, deprivation and loss than every generation before us. Yet mental illness persists in surprisingly persistent numbers.

Dr. Berezin is taking a leaf from the Donald J Trump book. He is trying to frighten you with images of violence, abuse, regression, lawlessness for his own purposes. He is waving Eugenics and Hitler at you in much the same way Donald conjures images of rapists, criminals, illegals, and terrorists streaming across the American border.

But lets get real:

Serious mental illness (schizophrenia, manic depressive illness, debilitating anxiety and OCD, true medical, clinical depression) are little helped with non-pharmacological treatments alone. The reason we do not see today, mute and stuporous men and women lying in hospital beds refusing to eat and wasting away is because we have the pharmacological means (and ECT) to treat depression. The reason we do not have four Queen Victorias and six Christs residing in every hospital is because we now have drugs that control Psychotic Illness. The reason we don’t see thin elated starving naked men standing on hills screaming at the moon until they die of exhaustion is because we now  have drugs that control mania. The reason we don’t have as many eccentrics living in squalor collecting their own finger nail clippings and urine is because we now have very effective pharmacology to treat serious OCD.

All of these people also need social help and someone in their corner, but without the actual pharmacological treatment it will get us nowhere.

(Though, I must admit, today, you may be able to see untreated catatonia, untreated stuporous and agitated depression, untreated mania and untreated schizophrenia in some of our correctional facilities).

But lets look at the less serious mental problems as well for a minute. A patient tells me she is afraid of flying, and always avoided it. But her father is dying in another province and she needs to fly there to see him one last time. She is terrified of getting on that plane. She imagines having a panic attack and disrupting the flight.

A fear of flying. A phobia of flying. Those of us who have such a phobia can usually manage by avoiding travel by plane.

But my patient. She needs to make this trip. Now perhaps I should send her to a trauma therapist who might uncover the fact a school friend was lost over Lockerbie and have her grieve about this, and still be afraid of flying; or perhaps to a cognitive behavioural therapist who might try to convince her that her fears are unfounded, pointing out how air travel is safer than car travel; or perhaps a desensitization approach in which the counselor uses relaxation techniques and has her imagine being at the airport, boarding the plane, and perhaps accompanying her to the airport on the day of travel; or perhaps I should find out if the fear is based on sitting so close to 300 strangers for 5 hours, or riding in a 20 ton contraption at the speed of sound two miles in the air; or spending 5 hours locked in a cigar shaped coffin with 300 strangers…..

Or I might simply prescribe for her five dollars worth of Lorazepam and offer a few encouraging words to get her through the trip.

Then lets look at something in between, like ADHD, one of the diagnoses mentioned by Dr. Berezin.

It is not a difficult equation for me. The child can’t sit still in class, he is too easily distracted, lacks focus, can’t concentrate, always being reprimanded by the teacher, socially ostracized because he intrudes, he pokes, he speaks out of turn, he angers too easily.

To become a successful adult he needs to succeed in at least one thing, if not more than one thing, in his childhood. If, with accommodation at school, and some parental strategies, some adaptational strategies, such as being allowed to wear earphones and take an exercise break every 20 minutes, have one-on-one instruction, good diet, better sleep – if these work, then he may not need medication.

If they don’t work it means he will fail socially and academically and maybe at home as well. He will be in trouble all the time. He will become surly, or give up, or become more aggressive, or depressed. In his teens he will self-medicate.

If the difference between a child failing or succeeding socially and academically is a single pill taken with breakfast it would be, to use that word again, a travesty to not prescribe that pill. And that is true whether the ultimate or necessary causative factor is inherited or acquired, or some complex combination of biological vulnerability, epigenetics, infantile and toddler experience, parenting styles, pedagogic methods, diet, and video game addiction.

 

 

A Subjective Unscientific Analysis of Anti-Psychiatry Advocates

By Marvin Ross

Many of my Huffington Post Blogs attract some very nasty comments from the various anti-psychiatry adherents. The same applies to the blogs by my colleague Susan Inman and we get some on this blog. The Boston Globe award winning Spotlight Team featured in the film Spotlight, just did a series of articles on the sad state of mental health care in Massachusetts. Wanting to foster dialogue, they set up a Facebook Page for comments. And did they ever get comments!

I’ve been looking at more than my fair share of these comments over the years but decided to try to categorize them. So here goes.

1. I was badly treated, mistreated, misdiagnosed therefore all of psychiatry is evil. In some cases, this alleged mistreatment occurred over 50 years ago. I do believe that this happened in most cases and it should not have happened but it did. Personally, I’ve run into (or family members have) some very incompetent and inept treatment by doctors and/or hospitals. This has occurred in inpatient stays, visits to doctors or in emergency rooms. And some of these misadventures have been serious but I do not spend my time denouncing all hospitals, all doctors or all Emergency Rooms. What I have done is to complain to the appropriate authorities. And most of the time I’m successful.

As my English mom used to say, “don’t throw the baby out with the bathwater”

  2. The other very common cry is that I got help and recovered therefore everyone can recover and if they can’t, it is because the docs are bad or are trying to keep people sick to make money and peddle drugs. I’m sure there is an error term in logic where you extrapolate your particular situation to everyone. That is what these critics are doing. It is like saying I survived prostate cancer which has a 5 year survival of 98.8% so that someone with pancreatic cancer can too. Pancreatic cancer only  has a 4% 5 year survival rate. It is not the same nor is say mild anxiety comparable to treatment resistant schizophrenia. Stop mixing apples and oranges.

3. Involuntary treatment for those who are so sick that they pose a danger to themselves, others, or will deteriorate further without involuntary committal means that the state will lock up, drug and keep everyone indefinitely. None of these fears are true so learn what is entailed and get over it. And when I post a video or an article by someone like Erin Hawkes who went through about a dozen involuntary treatments till a pharmaceutical agent was found that removed her delusions, stop insulting her as some have done by calling her a victim and that she is suffering from Stockholm Syndrome.

How will you learn if you refuse to listen to other opinions?

What I suspect that these involuntary opponents do not understand is that people are not locked up without just cause or forever. There are safeguards in place to ensure regular reviews and appeals. In Ontario a few years ago, a group of so called psychiatric survivors challenged the constitutionality of community treatment orders and supplied the courts with affidavits from people who found them to be bad. This is what I wrote about that in the Huffington Post:

Justice Belobaba only had to look at the affidavit that the plaintiffs filed as part of their attack on CTOs to get an idea of how well they can work. Amy Ness had, prior to being put on a CTO, been involuntarily committed for showing violent behaviour in 2004. In 2007, while hospitalized, Ms. Ness kicked her mother in the back and hit her repeatedly. Then, in 2009, Ms. Ness grabbed a large kitchen knife and marched upstairs toward her mother after discovering a magazine about schizophrenia. In another incident, Ms. Ness kicked and punched the emergency department psychiatrist. By the time she was given a CTO in 2009, she had five hospitalizations.

Since then, while on a CTO, the judge pointed out, she takes her medication and sees her case worker on a regular basis. She has not been hospitalized, she maintains her housing and she works as a volunteer, has a job and takes courses. She does think, however, that the CTO is an attack on her personal dignity.

Herschel Hardin, a civil libertarian once wrote that:

“The opposition to involuntary committal and treatment betrays a profound misunderstanding of the principle of civil liberties. Medication can free victims from their illness – free them from the Bastille of their psychoses – and restore their dignity, their free will and the meaningful exercise of their liberties.”

A psychiatrist I know who is a libertarian (someone who believes that people should be allowed to do and say what they want without any interference from the government) told me that when your brain is immersed in psychoses, you are not capable of doing or saying what you want. Therefore, he was fully supportive of involuntary treatment so that people could get to the position where they had the capacity to do what they want.

4. And then we come to what Dr Joe Schwarcz on his radio show, Dr Joe, calls scientific illiteracy. He used that in his July 10 interview with my colleague, Dr Terry Polevoy, in a discussion on EM Power + and the conviction of the Stephans for failing to provide the necessities of life for their child who died of bacterial meningitis. They refused all conventional medical care, gave him vitamins, herbal products and echinacea till the poor little toddler stopped breathing.

There was a case of scientific illiteracy in that the parents are totally opposed to vaccinations and work for a  company that encourages people with mental illnesses to go off meds in favour of their proprietary vitamins. They had no idea why they were convicted, lashed out at the jury who convicted them and then, at their sentencing hearing, the wife shocked even her own lawyer when she told the court that the Crown had used a phony autopsy report as evidence.

Other examples are that anti-depressants cause violence and suicide. Violence possibly in those under 24 according to a large Swedish study but not in adults. However, the authors state that these findings need validation. There is no definitive proof of this and no evidence of increased violence in adults.

As for anti-depressants causing suicide, a warning that this might be a concern was posted on the labels. Doctors were advised to be cautious when prescribing these for depressed young people.Consequently, this resulted in an increase in suicide attempts.

“Evidence now shows that antidepressant prescription rates dropped precipitously beginning with the public health advisory in March 2004, which preceded the black box warning in October 2004. Since the initial public health advisory, antidepressant prescriptions for children and adolescents decreased, with a consequent increase (14%) in incidence of suicide in these populations.”

On my to-read list is Ordinarily Well The Case for Antidepressants by psychiatrist Peter D Kramer. Kramer is the author of Listening to Prozac and, in this new book, he continues with proof that antidepressants do work and are not simply placebos. Not only do they work, but they are life savers.

In the New York Times review by Scott Stossel, the reviewer points out that when Kramer first began visiting psychiatric wards in the 1970’s, they were filled with people suffering what was then known as “end-state depression”. These were depressed patients in what appeared to be psychotic catatonic states.

Patients like that have not been seen for decades which he attributes to the aggressive use of antidepressants.

And, lest we forget, there is also the common view that the chronicity of psychiatric disorders are caused by the drugs that doctors force on their patients. People love to quote the work of Martin Harrow in Chicago but I suspect that many have not actually read his studies. Some people, he found,  did better after going off anti-psychotics over time than those who continued with their use but that is not surprising. It has always been known that some people improve while others have chronic problems and still others are not able to be helped with anything.

What they do not realize is that in Harrow’s study, 79 per cent and 64 per cent of the patients were on medication at 10- and 15-year follow ups. And that Harrow points out that not all schizophrenia patients are alike and that one treatment fits all is “not consonant with the current data or with clinical experience.” His data suggests that there are unique differences in those who can go off medications compared to those who cannot. And he points out that it is not possible to predict who may be able to go off medication and those who need the long term treatment. Intensified research is needed.

So stop with the reference to Harrow that no one needs meds. And stop also with promoting Open Dialogue when, first, it has never been empirically validated and second, many of their patients are on medication.

5. Regrettably, many of these people lack any civility whatsoever. People are entitled to offer their comments but they should not do so anonymously. And they should show some respect for those who have different views. I’m told that some have been banned from the Spotlight Facebook page and I’ve just banned one anonymous person who posts here for his/her personal attacks. I mentioned above that Erin has been called a willing victim and one who suffers with the Stockholm syndrome for her video and her article. Refute the points she makes but leave the insults aside.

And, one post that I removed from the After Her Brain Broke page on Susan Inman in response to he video What Families Need From the Mental Health System claimed that Susan keeps her daughter locked up and ill and that she likely suffers from Munchausen by proxy.

 

Family Day, Serious Mental Illness and Murder

By Marvin Ross

I’m posting this on Family Day in Ontario. This is a new statutory holiday promised by former Premier Dalton McGuinty during the election campaign of 2007. It was, of course, part of his platform so that he could win re-election by giving people an extra day off between New Year and Easter and sold as an opportunity for people to celebrate family.

Unfortunately, families with serious mental illness in them lost out when the recommendations of an all party Select Committee on Mental Illness and Addictions Report of 2010 was largely ignored by that government. There is little for many of these families in Ontario to celebrate as you will see from my Huffinton Post blog that follows. It was published on February 9 and I will update it at the end.

Was Ontario Complicit in a Father’s Murder?

Last Spring, I mentioned the problems that a Richmond Hill, Ontario family was having with acquiring adequate service for their son with schizophrenia in one of my Huffington Post blogs. That was one of the many blogs I write on the pathetic state of care that we have for the treatment of those with serious mental illness.

Sadly, the father in this case, Bob Veltheer, was murdered on Sunday evening February 7 and, the next day, his son Jacob was arrested. Bob and his wife talked to me before I wrote the blog wanting to reveal just how badly people with serious mental illness are treated by the health system but decided to remain silent other than what I reported then.

Before I outline what I know of the care their son received, I should mention that Bob was the founding member and president of Home on the Hill, an agency set up to try to get housing for the mentally ill when their families could no longer keep them at home. I had been invited to speak at their monthly meetings a few times as had my blogging partner in another blog we share, Dr David Laing Dawson.

Last year, Jacob, who suffers from schizophrenia, was found sitting on a bus at the end of the line in Newmarket, Ontario presumably having failed to get off when it passed through Richmond Hill. He was suicidal, so the police were called and he was taken to South Lake Hospital. After a week and still suicidal, according to the family, he was discharged against the wishes of his family and that is what I reported.

Upon discharge, he ran off, as do many people with schizophrenia, and the York Regional Police went looking for him. He was found after three days and returned home only to disappear again. This time, when he was found, he was admitted to MacKenzie Health in Richmond Hill. After a brief stay, he was discharged with a community treatment order to a residence. A community treatment order is a legally binding order that the individual must accept regular medical help and medication. If they fail to abide by this, they can be returned to hospital by police.

Jacob, it seems, was too sick for the residence to cope with (but not sick enough to be in hospital) and was evicted from the residence. What should the parents do but what all parents do and that was to take him home. Just recently, the team that supervised his orders (the South Lake Assertive Community Treatment team), wanted him discharged to the care of the family doctor. His mother had just made contact with a local Richmond Hill psychiatrist and was waiting to hear back to see whether that doctor would see him.

Friday night, Bob had a meeting with a member of Home on the Hill executive at his house and I was told that Jacob was so distraught that he was pacing about the house talking to himself (or his voices or demons) in a loud voice. That Sunday night, the police allege that Jacob murdered his father.

This horrific tragedy could probably have been prevented had Jacob been kept in hospital long enough to stabilize him properly and, if that was not possible, to give him a secure place where he could live. The number of psychiatric beds in Ontario has been declining considerably over the past few decades but the total extent is not available since statistics on that can’t be found. And I’ve tried. The most recent Ontario report released in December of 2015 called Taking Stock found that access to services varies across the province and is inconsistent.

Late last year, the brand new psychiatric hospital in Hamilton closed a ward because of budgetary problems although that hospital has 6 vice presidents, 31 directors, a medical director earning $500K a year and a CEO making $750K a year. And, as I wrote a year ago, Ontario has had 17 reports on the sad state of mental health care between 1983 and 2011 but little has been done.

This is not the first preventable death, nor will it be the last unless we finally start to care. In my book on schizophrenia, I describe a case where a family in Mississauga, Ontario desperately tried to get help for their son. They could not and he ended up killing both his parents. I met the son a couple of years ago and found him to be a very pleasant and sane individual. But that was after years in a forensic psychiatric hospital where he has been getting treatment. Imagine if his family were able to get that when they first tried.

I am not Emil Zola nor was Bob Veltheer, but I accuse the complacency of the Ontario government for his death. Government bureaucrats have been informed repeatedly both verbally and in writing about the need for accountability, program evaluation, transparency regarding mis-spending, mis-use of privacy legislation and the historical resistance to partner and collaborate with families. The Central Local Health Integration Network where Bob resided, I’m told, had recently been notified about the profound need for hospital beds by Home on the Hill.

Home on the HIll has been attempting to meet with the new Health Minister, Jane Philpott, whose constituency is near Richmond Hill but have not heard back yet.

I would like to see either a Coroner’s Inquest or a Royal Commission into the circumstances that led up to this horrific event. And I would like to see Ontario finally do something other than commission studies which they then ignore.

Update

This blog received a great deal of attention as it was distributed widely and to a number of politicians where the Veltheer family live. I attended the funeral on February 13 along with politicians from the all three levels of government. The local town councillor who is a supporter of the work of Home on the Hill plans to bring this to the attention of the Ontario Minister of Health as is the local representative in the Ontario legislature. The representative who sits in the Canadian House of Commons is planning to raise this event in the House of Commons and a meeting has been arranged with the Federal Minister of Health.

We all hope that Bob’s death and the pain that his family is going through will result in some positive changes. Ontario which has direct responsibility for providing health care needs to get off its duff, stop generating reports which they ignore, and start providing the services that have been recommended so many times by so many reports.

The Federal government needs to take the money they are wasting on a Mental Health Commission that has no direct authority and does nothing but generate its own reports and put it to providing funding programs in the provinces. And just maybe, Prime Minister Justin Trudeau whose mother, Margaret suffers with bipolar disorder, will understand and do something.

Doing something would be a welcome change and would honour the memory of Bob and all the others who have been sacrificed by our lack of resources.

Journalists, Medical Research and Medical Practice

By Marvin Ross and Dr David Laing Dawson

As a medical writer and as someone who works in the daily trenches of serious mental illness in my own family, I find people like Robert Whitaker dangerous. For those who aren’t familiar with him, he is a medical journalist from Boston who is highly critical of the long term use of medication for schizophrenia even though he is neither a scientific researcher nor clinician.

My earlier criticisms of his work appeared in the Huffington Post as Journalists are not medical experts and Leave the schizophrenia diagnosis to the experts please.

One of Whitaker’s key criticisms is that the long term use of antipsychotics in the treatment of schizophrenia makes people worse not better. A group of researchers in New York set out to see if they could replicate what they called his “troubling interpretation” and published their results in a recent issue of the American Journal of Orthopsychiatry.

Their hypothesis was what Whitaker contended that the long term use of antipsychotics resulted in worse outcomes than people who are not treated. They wondered if a systematic appraisal of all the literature would produce the same results as claimed by Whitaker. They looked at 18 studies which included the four that Whitaker used. They pointed out that Whitaker used an additional 6 studies to come to his conclusion but they did not include them because they were review articles that did not report separated data on the exposure groups or were ecological studies which did not report on individual level data.

Of the 18 studies they looked at, only 3 supported the hypothesis that long term treatment with medication causes harm to patients. 8 studies found the opposite and 7 were mixed. These researchers, however, also did not find that long term treatment resulted in greater benefits than harm which is, frankly, not surprising. Some recent studies show that some people with schizophrenia can manage well without long term drug use which Whitaker likes to cite. But there is also no way to predict who can actually achieve that. That is a caveat in all those studies and a fact that Whitaker seems to ignore. (see my post on leave the diagnosis to experts).

Lumping all people with schizophrenia together for a study is bound to have problems since schizophrenia is very likely more than one disease. When Bleuler first coined the term schizophrenia in 1908, he called it the schizophrenias to indicate that it was more like a spectrum than a single entity. Unfortunately, science has not reached the point where the different forms can be identified. An editorial in the January 1, 2016 issue of the American Journal of Psychiatry makes that very point. Current treatment algorithms, it says, do not take into account the substantial interindividual variability in response to antipsychotic drugs.

And, a recent study of first episode patients published in the Journal of Clinical Psychiatry found a greater relapse for those who went off medication after they were stabilized. Decisions to try to reduce doses and to go off are best left to the individual patients working with their psychiatrist. Going off or staying on medication is described by my blogging colleague Dr Dawson who has close to 50 years clinical experience treating patients in a variety of situations. Here is what he has to say:

We doctors over treat at times and under treat at other times. And occasionally we get it just right.

Studies show that family doctors are much more likely to under treat than over treat (pain, depression, arthritis), with specialists erring in the other direction. This is as one would expect, for specialists receive their patients after a family doctor has deemed the case too complex, too resistant to a first line of treatment, or simply beyond her zone of knowledge, skill and comfort.

I have been guilty of both under treating and over treating, probably more often the former. These are type 1 and type 2 errors. If we work to totally eliminate one type of error we will increase the incidence of the other.

We need to be vigilant catching both types of error and correct or ask for help, without letting our egos get in the way.

My patient tells me she is feeling much better now that she has stopped taking those pills I prescribed for her. And at that moment I must allow my feeling of relief and pleasure seeing her look and sound better over-ride this small insult to my ego. Unless I know for sure this is a relapsing illness that will re-emerge within a few weeks, perhaps worse than before.

I also know that it may take a relapse or two or three before we are both sure it is better to suffer the minor discomforts caused by these pharmaceutical agents than the blackness of severe depression, the torture of obsessions, the horrors of psychosis, or the social destruction of mania.

It is really a very small percentage of people who have suffered these severe illnesses who would willingly give up the medication that treats and prevents them. I am usually the one to suggest it may be time for a cautious reduction.

And those that quit them and return to a state of depression, obsession, psychosis, or mania do so for a variety of reasons. Occasionally the side effects were much too severe, or the drug was not helping much. The financial cost too much to bear. The very fact of needing these medications to keep sane can be, for some, an intolerable thought. A manic may remember the ecstasy and not the night in a jail cell, for which he can blame others. Another may find that the drugs he can buy on the street give him, at least temporarily, total relief. Still another may quit simply because there is no one near to remind him, to support him, occasionally to insist. And then a few who prefer to believe their true nature consists of special powers, a supreme intelligence, a grand future, clear reason to be, to be loved by a movie star, to be a hero, to have a unique relationship with God, to have a clear and present or distant antagonist – who prefer to live with this sense of self no matter the earthly consequences – which can always be explained away – than to accept the earth-bound but often meager existence provided by faithfully taking one’s medication.

But most people, when sane, prefer to remain sane, even if it means a dry mouth, a little dizziness upon arising too quickly, blood tests more frequently, a harder time keeping weight under control.

As one patient recently said to me: “Thank God for these big pharmaceutical companies.”

To which I responded, “Not everyone would share that sentiment.”

And he then said, “Why not? Without them you and I would be having this conversation in the asylum.”

Is There a Professional Turf War in the Mental Health Field?

By Marvin Ross – First published in the Huffington Post on March 9, 2015

One of my pet peeves is the use of the term “mental health problems and issues” to reflect mental illness. Some have told me that if we imply that people are mentally ill then we are stigmatizing them because we are saying that there is something wrong with their brain. Well, there is, and so what? With cancer, we don’t say someone has cell problems and issues but rather they have cancer and we are usually pretty specific because there are so many different forms of cancer each with its own unique outcomes.

And the same goes for mental illness. But, someone recently pointed out to me that the reason we use the vague term “mental health problems and issues” is that what we are seeing is a turf war amongst professionals. And I think that person is right.

When we think of an illness, we think medical doctor. When you are ill, you see an MD who uses diagnostic skills, tests, imaging — a methodology developed over time, to determine what the problem is. Once determined, the MD decides on a course of action (with the patient) which may include referral to another more appropriate health professional (dietitian, counsellor, medical specialist, hospitalization) or medication. The MD is at the apex of the pyramid and the gatekeeper for others.

Now as my cynical friend stated, there is only one relatively finite pot of money for services for the mentally ill and, if we call it an illness, then the medical docs are going to get most of it. Other professionals will get the crumbs. However, if we don’t call it an illness but a problem, then it becomes more appropriate for other professionals like psychologists, social workers and others to be the first line of assessment and treatment.

Last year, one of my blogs upset the Canadian Psychological Association because I pointed out that in 2006, they were concerned that the newly formed Mental Health Commission of Canada would focus on mental illness to the exclusion of mental disorders and behavioural health. That generated a reply from Karen Cohen, the CEO of the CPA.

In November of last year, the British Psychological Society issued a report called Understanding Psychosis and Schizophrenia where they conclude that “psychosis can be understood and treated in the same way as other psychological problems such as anxiety or shyness.” And that “Hearing voices or feeling paranoid are common experiences which can often be a reaction to trauma, abuse or deprivation. Calling them symptoms of mental illness, psychosis or schizophrenia is only one way of thinking about them, with advantages and disadvantages.” And they conclude that “Psychological therapies — talking treatments such as Cognitive Behaviour Therapy (CBT) — are very helpful for many people.”

What they have done is to trivialize schizophrenia and suggest that its treatment be shifted to themselves and that they can uncover the underlying trauma that is the cause over the course of many talk sessions and help.

To be fair, before they had any effective treatments, psychiatrists tried this as well, and it did not work.

First out of the gate to criticize this report were three bloggers on theMental Elf. Keith Laws, a Professor of Cognitive Neuropsychology, analyzed their claim on the efficacy of CBT and found that the research does not support the statement that it is as effective a treatment as medication. Alex Langford, a psychiatry trainee who also studied psychology, challenged their conclusions on medication and pointed out that there is “solid evidence for elevated presynaptic dopamine levels being a key abnormality in psychosis, and there is copious evidence that inhibiting the action of this excess dopamine using antipsychotics leads to clinical improvement in psychosis.” Samei Huda, a Consultant Psychiatrist, points out that the “reduction of psychosis to just hallucinations and delusions is flawed.” He points out that “Cognitive impairment and negative symptoms (depression, lack of enjoyment, lethargy) are important as they often have a bigger effect on social functioning than hallucinations or delusions.”

James Coyne, a psychologist himself and one who is very critical of his colleagues, pointed out that:

Key stakeholders were simply excluded — primary care physicians, social workers, psychiatrists, police and corrections personnel who must make decisions about how to deal with disturbed behavior, and — most importantly — the family members of persons with severe disturbance. There was no check on the psychologists simply slanting the document to conform to their own narrow professional self-interests, which we are asked to accept as ‘expertise’.

He goes on to say that this paper is not evidence based and that “quotes are carefully selected to support the psychologists opinions expressed before the document was prepared — like 15 years ago in their Recent Advances in Understanding Mental Illness and Psychotic Experiences. ”

Dr Ronald Pies, a psychiatrist, writes that what is missing from the report “is any deep understanding of the psychic suffering occasioned by severe and enduring psychotic states, including but not limited to schizophrenia.” The psychologists see psychosis and schizophrenia simply as hearing voices that others do not and/or having fears or beliefs that those around us do not share. Pies points out that this is a shallow and superficial description of the psychotic experience and does scant justice to the nightmarish reality of severe psychotic states.

In fact, he finds that the psychologists responsible for this report do nothing but trivialize the profound suffering that is psychosis and schizophrenia.

It is well to remember that the prime directive for any physician, including psychiatrists, is not to “be clever”; not to “define abnormal,” not even “to diagnose,” but to reduce suffering.

And while the psychologists lobby for a greater piece of the treatment pie or, as Coyne says slanting to there own “narrow professional self-interests,” and debate with other professionals, the suffering of those with the most serious of mental health problems and issues — real illnesses — continues.