Patient Voices: Bipolar Disorder — The New York Times

Patient Voices: Bipolar Disorder — The New York Times

The New York Times
WELL|Patient Voices: Bipolar Disorder

Bipolar disorder is a mental health condition affecting around 60 million people worldwide that causes unusual and sudden shifts in mood and energy. What is it like to have bipolar disorder? How do you balance the mental ups and downs of this disease? Here, in their own words, are the stories of five men and women living with this condition.

Panel to Create Plan to Reduce Number of Mentally Ill People in New York City Jails

Joseph Goldstein
NY Times
June 1, 2014

Mayor Bill de Blasio has asked several of his commissioners and aides to provide him with a plan by September to reduce the rate of incarceration among New Yorkers with mental illness.

The effort, which City Hall will announce on Monday, is the administration’s first major criminal justice initiative. Named the Task Force on Behavioral Health and the Criminal Justice System, it will include recommendations from the police and correction commissioners, the Manhattan district attorney, hospital administrators and judges.

The initiative comes at a time when the city’s jail system is struggling to manage a large number of mentally ill inmates. The Department of Correction is investigating the death of a mentally ill homeless veteran in February who had been left unattended for hours as the temperature in his cell climbed above 100 degrees.

“For far too long, our city’s jails have acted as de facto mental health facilities,” Mr. de Blasio said in a statement, in which he explained that he was directing the task force to develop “innovative strategies to transform, reform and update this city’s criminal justice system” and figure out how “we can provide real, lasting mental health and addiction treatment for those in need.”

While the task force will look at the treatment of mentally ill inmates on Rikers Island, it will also seek ways to reduce the number of people with mental illness who end up in the criminal justice system in the first place.

Elizabeth Glazer, the mayor’s criminal justice coordinator and one of the task force leaders, said that the group would seek ways to encourage alternatives to arrest and prosecution.

“If someone picks up the phone and calls 911 because they see someone acting out on the street, then what does the police officer do?” Ms. Glazer said. “Is this criminal behavior? And a lot of things can be described as criminal behavior, but the best intervention is not necessarily an arrest. What’s the best way to make a diagnosis? Is it up to the officer to make that diagnosis?”

Ms. Glazer said the task force would weigh a number of possible changes, such as teaming officers with social workers or other mental health professionals and providing more intensive training to officers on identifying and dealing with individuals with mental illnesses.

Part of the goal, she said, would be to provide police officers with more options when they respond to the 100,000 calls received each year regarding “emotionally disturbed persons,” a catchall term that covers a range of mental health issues.

The task force’s review of the Police Department’s interactions with the mentally ill is likely to examine its handling of so-called quality-of-life offenses, generally low-level infractions that have been aggressively enforced under the leadership of Commissioner William J. Bratton. These offenses account for a significant percentage of arrests.

“It’s something we have to look at — how these two things intersect,” Ms. Glazer said.

The task force, she said, will also examine ways to provide better mental health care following release from the city’s jails to decrease recidivism.

Dr. Ramanathan Raju, a member of the task force and the president of the city’s Health and Hospitals Corporation, said public hospitals have to explore how to better engage “with the mentally ill after they leave the criminal justice system, so they stay connected to the hospital and the treatment component, and so they don’t regress back to their illness.”

There are “a lot of things we can do better,” he said. One proposal that could receive consideration from the task force, Dr. Raju said, would be to track the medication history of some patients to see whether they are filling prescriptions they need as part of their mental health treatment. Another proposal would be to send a social worker to the addresses of mentally ill patients after their release from jail to check up on them, he said. “When they go back to their communities, do we engage them to seek care?” Dr. Raju asked.


Behavior Therapy Aids Obsessive-Compulsive Disorder

Behavior Therapy Aids Obsessive-Compulsive Disorder

Behavior Therapy Aids Obsessive-Compulsive Disorder


Five antidepressant drugs are approved by the Food and Drug Administration for treating obsessive-compulsive disorder. But they are sometimes ineffective, and guidelines suggest adding an antipsychotic drug to the regimen. Now scientists have found that adding cognitive behavioral therapy, or C.B.T., may be more effective than an antipsychotic.

Researchers studied 100 people with O.C.D. who were taking antidepressants without sufficient improvement. They randomized 40 to the antipsychotic risperidone (brand name Risperdal), 20 to a placebo pill, and 40 to exposure and ritual prevention, a special form of C.B.T. delivered twice a week over eight weeks. All continued their antidepressants as well.

The study was published online in JAMA Psychiatry, and several of the authors have financial relationships with pharmaceutical companies.

Using well-validated scales and questionnaires, the researchers found that 80 percent of the C.B.T. patients responded with reduced symptoms and improved functioning and quality of life. About 23 percent got better on risperidone, and 15 percent on the placebo.

“It’s important to discontinue antipsychotics if there isn’t continued benefit after four weeks,” said the lead author, Dr. Helen Blair Simpson, a professor of psychiatry at Columbia. “O.C.D. patients who still have symptoms should first be offered the addition of C.B.T., and some will achieve minimal symptoms.

“There’s a hopeful message here,” she added. “There are good treatments.”

A version of this article appears in print on 09/17/2013, on page D6 of the NewYork edition with the headline: Mind: Behavior Therapy Aids O.C.D.

Affordable Care Act Fills Need in Mental Health Care

Affordable Care Act Fills Need in Mental Health Care


Like millions of Americans, we have struggled with addiction. Fortunately, we were able to access the treatment and recovery services necessary to get well. But for many people facing addiction or mental health issues without the necessary insurance coverage, such lifesaving services have been out of reach.

The Affordable Care Act changes that. A provision that passed with unanimous support requires that starting in 2014, health insurance plans cover mental health and addiction services as part of the essential benefits.

As a result of these historic changes, approximately 68 million Americans will have access to lifesaving mental health and addiction treatment services. Furthermore, these services, which have been misunderstood and marginalized for so long, will finally be fully integrated as part of a comprehensive approach to health care. That is, if the law is implemented as intended.

The far-reaching impact of this change cannot be overestimated. Research has found that one out of every five Americans will experience some type of mental illness at least once in their lifetime while over 20 million Americans currently need treatment for a problem with alcohol or drugs.

Untreated mental health and substance-use disorders cost American employers an estimated $17 billion annually in absenteeism and lost productivity. Studies have shown that every dollar spent on mental health care results in a savings of $12.

But Americans don’t need a lot of statistics to know that effective programs to address mental health and addiction save lives. Polls show that three in four Americans are concerned that people addicted to alcohol or drugs may not be able to get treatment because of cost or lack of insurance coverage.

While health care reform is designed to address these obstacles, unfortunately, there are many opportunities for this historic achievement to be derailed.

As part of health care reform implementation, every state is required to inform the Department of Health and Human Services of its choice of a benchmark plan, the minimum level of benefits for all insurance plans in the state. The benchmark plans are required to include coverage for mental health and addiction, but as with so many things, the devil will be in the details.

Variation among the states is to be expected — indeed, each state should tailor its plan to meet the needs of its residents. Yet some elements must be standardized for the full potential of this change to be realized.
Many state benchmark plans suffer from a lack of transparency and specificity about benefit coverage. As a result, it is difficult to determine whether certain substance-use and mental health services are covered, consistent with legal requirements. In addition, lifesaving benefits are potentially being excluded in certain states, including residential addiction treatment and certain medication-assisted treatments, an area that has seen tremendous advancements in the past decade.

Recently, the federal government released for comment proposed regulations regarding which services should be considered “essential” and thus required to be covered. Unfortunately, the new rules lack clarity regarding the standard for sufficient coverage for mental health and substance-use services.

The Mental Health Parity and Addictions Equity Act of 2008, which we sponsored and President George W. Bush signed into law, required that insurance coverage for mental health and addiction be equal to coverage of other illnesses. Health care reform set these principles in concrete and extended them. The next few months will be critical to ensuring the principle of parity becomes reality.

As HHS Secretary Kathleen Sebelius and her staff review benchmark plans and craft a final essential health benefits rule, it is vitally important to ensure the states receive sufficient federal guidance to comply with the consumer protections in the law. For true parity to be realized, HHS must ensure that plans cover a sufficient continuum of mental health and addiction-care services and that individuals have good access to that lifesaving care.

Millions of people are hoping the new health care law will make life better — for them and those they love. But there must be clarity and transparency to ensure fairness and effectiveness.

The need for mental health and addiction treatment is urgent; the public support is widespread; and the path forward is within reach. Now is the time for policymakers to ensure the promise of truly integrated, comprehensive care for those facing mental health and addiction issues is finally realized.


Memoir Traces How Cartoonist Lost Her ‘Marbles’

Memoir Traces How Cartoonist Lost Her ‘Marbles’

When you think of mental illness, you don't often think of comics; but for cartoonist Ellen Forney, the two came crashing together just before her 30th birthday. That's when she found out she has bipolar disorder, a diagnosis that finally explained her super-charged highs and debilitating lows.

Now that diagnosis is also the subject of Forney's new graphic memoir. It's called Marbles, as in losing one's marbles — a hint that this memoir is both painful and funny. It opens just after a wild trip to a tattoo parlor leads Forney to a psychiatrist. She joins NPR's Renee Montagne to discuss what that psychiatrist told her and how she came to reconcile her illness with her artwork.

Interview Highlights

On learning she was bipolar

“The psychiatrist was the one, after the second visit, who told me that I was bipolar. And I didn't believe it briefly. We went through the symptoms together in the DSM — the Diagnostic and Statistical Manual of Mental Disorders, basically the bible of mental disorders. And we went through the symptoms, one by one, and it sank in. And it was just a very, very strange, strange feeling to see what I had thought of — in particular when I was manic — as super-duper me; exponentially me; very, very, very me. And to see it right there in a book.”

On becoming part of “Club Van Gogh,” a list of writers and artists with depression

“I think that Van Gogh is really the ultimate crazy artist that we all think of. And so there was a certain sense of cred to being part of that [club]. I found that list both encouraging, and I felt like I had company; and at the same time it was terrifying because all of these artists and writers who had done such brilliant work hadn't been medicated, for the most part.”

On the notion that treating her condition might medicate away her creativity

“I find that stability is good for my creativity. There are different artists that I found that feel differently. Poet Anne Sexton was one. It was her opinion that it was the responsibility of artists to feel intense pain so that we could express that for other people who couldn't express it themselves.

“But then, of course, she committed suicide as well. So if you're talking about how creative someone with a mood disorder can be, that really cuts short your creativity and productivity if you cut your own life short.”

On a section of the book that shows her being swept into mania

“On the left side of the page, there's this sense of what stability is about. There's a house and a dock. And then, swooping over onto the right side of the page, is me desperately reaching for the dock, with the rope that had secured me there broken and [me] knowing that I was [being] swept into this depiction that I did of mania, which is this big cloud of mermaids and hearts and stars and swirls and woosh! And I could feel that I was slipping, that I was becoming unmoored, and there was really nothing that I could do to keep that from happening.”

On the book's sense of humor

“It was very important to have humor in the book. For one, it's much easier to take in a difficult story if there's relief. There's a relief in being able to laugh. Like, for instance, in the book there's a scene where, because of my health insurance that didn't cover mental health, I had to go to the cheapest place for my meds that I could find, and that was Costco. And so I would, very depressed, have to drive myself down to this huge, brightly lit, full of enormous tubs of peanut butter and Twizzlers [Costco], and I would go to the pharmacy there. And they did this thing at the time that I hope they don't do anymore, which is, with all of the rest of the people around, they call your name — your full name, 'Ellen Forney' — and to make sure they have the right prescription, they say, 'Lithium.' And so that kind of thing, maybe it wasn't funny at the time — and I would have to say it was not funny at the time — in retrospect, just the absurdity of it [is] very funny.”

  You will be able to listen to the story by going to the website below.


Gandhi: Depression’s Spiritual Transformation

Gandhi: Depression’s Spiritual Transformation

Mohandas Gandhi was one of the principle leaders of India’s movement for independence from the British Empire. Independence was achieved in 1947. He is also recognized as the world’s foremost proponent of non-violent civil disobedience as a force for change, which greatly influenced the civil rights movement in the United States in the 1950s and 1960s.

Gandhi was born in 1869. During his life, he lived through episodes of depression, including a suicide attempt as a teenager. He was also said to be shy and sensitive.

Following India’s independence, he endured his most severe episode of depression.  India faced many tragic problems, including poverty and hunger. These issues weighed heavily on him as the “father of his country.”

Gandhi also felt a sense of personal failure. Independence was achieved at the cost of India being divided along religious lines into two separation nations: India, where the population was predominantly Hindu, and Pakistan, where the population was Muslim. The partition led to bloody riots in many cities between Hindus and Muslims. Gandhi saw it as a rejection of his philosophy of non-violence and collapse of his life’s work.

Gandhi spoke of his depression openly, confounded and frustrated because he lacked patience and “technique” to overcome it.

He once believed he could live to be 125, but told a reporter, “I have lost the hope because of the terrible happenings in the world. I don’t want to live in darkness.” The tone of his speeches, his “voice,” grew less optimistic.

Gandhi’s sense of failure and depression led to deeper reflection over his philosophy of non-violence and his life’s work. In a sense, he revisited choices he had made over the years, struggling with self-doubt. The result was reaffirmation, and to some degree, transformation.

Reflection often is part of cycles of growth in all people, especially those confronted by loss. This includes individuals living with mental illness as part of a process of recovery.

As a lawyer in South Africa, early in his career, Gandhi led opposition to legal discrimination against the Indian minority. It was the period when he first developed his philosophy of non-violent civil disobedience. When he returned to India in 1915, because of his work in South Africa, he became known as “Mahatma,” meaning “Great Soul.”

It was a title Gandhi did not like, until the last year of his life, as part of his transformation. He told a granddaughter: “I am a true Mahatma.”

His outlook included a sense of fatalism. Because of his teachings and work, he always believed he would die at the hands of an assassin, a death he said, he would gladly accept. In 1948, a Hindu extremist shot Gandhi to death, as part of a conspiracy whose members believed he favored Muslims in trying to end India’s violence.

Much of this article, including quotations, is based on the essay “From Mohandas to Mahatma:  The Spiritual Metamorphosis of Gandhi” by Karen E. James in Essays in History, Vol. 28, pp. 5-20  Corcoran Department of History  of the University of Virginia (1984), at


Seeing Things? Hearing Things? Many of Us Do

Seeing Things? Hearing Things? Many of Us Do

HALLUCINATIONS are very startling and frightening: you suddenly see, or hear or smell something — something that is not there. Your immediate, bewildered feeling is, what is going on? Where is this coming from? The hallucination is convincingly real, produced by the same neural pathways as actual perception, and yet no one else seems to see it. And then you are forced to the conclusion that something — something unprecedented — is happening in your own brain or mind. Are you going insane, getting dementia, having a stroke?

In other cultures, hallucinations have been regarded as gifts from the gods or the Muses, but in modern times they seem to carry an ominous significance in the public (and also the medical) mind, as portents of severe mental or neurological disorders. Having hallucinations is a fearful secret for many people — millions of people — never to be mentioned, hardly to be acknowledged to oneself, and yet far from uncommon. The vast majority are benign — and, indeed, in many circumstances, perfectly normal. Most of us have experienced them from time to time, during a fever or with the sensory monotony of a desert or empty road, or sometimes, seemingly, out of the blue.

Many of us, as we lie in bed with closed eyes, awaiting sleep, have so-called hypnagogic hallucinations — geometric patterns, or faces, sometimes landscapes. Such patterns or scenes may be almost too faint to notice, or they may be very elaborate, brilliantly colored and rapidly changing — people used to compare them to slide shows.

At the other end of sleep are hypnopompic hallucinations, seen with open eyes, upon first waking. These may be ordinary (an intensification of color perhaps, or someone calling your name) or terrifying (especially if combined with sleep paralysis) — a vast spider, a pterodactyl above the bed, poised to strike.

Hallucinations (of sight, sound, smell or other sensations) can be associated with migraine or seizures, with fever or delirium. In chronic disease hospitals, nursing homes, and I.C.U.’s, hallucinations are often a result of too many medications and interactions between them, compounded by illness, anxiety and unfamiliar surroundings.

But hallucinations can have a positive and comforting role, too — this is especially true with bereavement hallucinations, seeing the face or hearing the voice of one’s deceased spouse, siblings, parents or child — and may play an important part in the mourning process. Such bereavement hallucinations frequently occur in the first year or two of bereavement, when they are most “needed.”

Working in old-age homes for many years, I have been struck by how many elderly people with impaired hearing are prone to auditory and, even more commonly, musical hallucinations — involuntary music in their minds that seems so real that at first they may think it is a neighbor’s stereo.

People with impaired sight, similarly, may start to have strange, visual hallucinations, sometimes just of patterns but often more elaborate visions of complex scenes or ranks of people in exotic dress. Perhaps 20 percent of those losing their vision or hearing may have such hallucinations.

I was called in to see one patient, Rosalie, a blind lady in her 90s, when she started to have visual hallucinations; the staff psychiatrist was also summoned. Rosalie was concerned that she might be having a stroke or getting Alzheimer’s  or reacting to some medication. But I was able to reassure her that nothing was amiss neurologically. I explained to her that if the visual parts of the brain are deprived of actual input, they are hungry for stimulation and may concoct images of their own. Rosalie was greatly relieved by this, and delighted to know that there was even a name for her condition: “Tell the nurses,” she said, drawing herself up in her chair, “that I have Charles Bonnet syndrome!”

Rosalie asked me how many people had C.B.S., and I told her hundreds of thousands, perhaps, in the United States alone. I told her that many people were afraid to mention their hallucinations. I described a recent study of elderly blind patients in the Netherlands which found that only a quarter of people with C.B.S. mentioned it to their doctors — the others were too afraid or too ashamed. It is only when physicians gently inquire (often avoiding the word “hallucination”) that people feel free to admit seeing things that are not there — despite their blindness.

Rosalie was indignant at this, and said, “You must write about it — tell my story!” I do tell her story, at length, in my book on hallucinations, along with the stories of many others. Most of these people have been reluctant to admit to their hallucinations. Often, when they do, they are misdiagnosed or undiagnosed — told that it’s nothing, or that their condition has no explanation.

Misdiagnosis is especially common if people admit to “hearing voices.” In a famous 1973 study by the Stanford psychologist David Rosenhan, eight “pseudopatients” presented themselves at various hospitals across the country, saying that they “heard voices.” All behaved normally otherwise, but were nonetheless determined to be (and treated as) schizophrenic (apart from one, who was given the diagnosis of “manic-depressive psychosis”). In this and follow-up studies, Professor Rosenhan demonstrated convincingly that auditory hallucinations and schizophrenia were synonymous in the medical mind.

WHILE many people with schizophrenia do hear voices at certain times in their lives, the inverse is not true: most people who hear voices (as much as 10 percent of the population) are not mentally ill. For them, hearing voices is a normal mode of experience.

My patients tell me about their hallucinations because I am open to hearing about them, because they know me and trust that I can usually run down the cause of their hallucinations. For the most part, these experiences are unthreatening and, once accommodated, even mildly diverting.

David Stewart, a Charles Bonnet syndrome patient with whom I corresponded, writes of his hallucinations as being “altogether friendly,” and imagines his eyes saying: “Sorry to have let you down. We recognize that blindness is no fun, so we’ve organized this small syndrome, a sort of coda to your sighted life. It’s not much, but it’s the best we can manage.”

Mr. Stewart has been able to take his hallucinations in good humor, since he knows they are not a sign of mental decline or madness. For too many patients, though, the shame, the secrecy, the stigma, persists.

Oliver Sacks is a professor of neurology at the N.Y.U. School of Medicine and the  author, most recently, of the forthcoming book “Hallucinations.”

Published: November 3, 2012


Patrick Kennedy: We need a different attitude on mental illness

Former Congressman Patrick Kennedy discusses the stigma surrounding mental health and mental illness.

by CNN