Blog

Category
  • Saying Goodbye to an Icon and Lessons Learned

    Everyone, and I do mean EVERYONE, has had an opinion or thought on the loss of Carrie Fisher suddenly last week to a heart attack. Myself included. However, before taking my thoughts public I needed time to process the loss, what it meant and what message was getting lost in the coverage.

    Carrie was an OG mental illness advocate. She spoke openly and frankly in a time that was unpopular to do so.  She wrote with right balance of passion, gravitas and humor regarding the subject. She talked about her disease, her addiction struggles and her experiences with ECT. She talked about her family relationships for better or for worse.

    “We have been given a challenging illness and there is no other option than to meet those challenges. Think of it as an opportunity to be heroic – not ‘I survived living in Mosul during an attack’ heroic, but an emotional survival. An opportunity to be a good example to others who might share our disorder. “ (November 2016)

    She was (and still is) everything I yearned to be, as I related to her story on so many levels. For starters, I once fancied myself Princess Leia as most little girls in the late seventies, early eighties did. However it runs much deeper than that. I saw pieces of my story run parallel to hers. The period in which we are unable to accept the illness, the drinking, the ECT. The courage to say, “hey, I’m having a relapse and shit happens”.

    When I found my feet, my voice, and gained confidence in both myself and my abilities, she spoke to me once more. “Stay afraid. But do it anyway. What’s important is the action. You don’t have to wait to be confident. Just do it and eventually the confidence will follow”. (April 2013)

    Her death stings me. It hurts more than the loss of Robin William’s laughter. Carrie was everything I wanted to be and now in death, everything I hope I’m not. She lived her life exactly the way I hope to live the remainder of my days. Her death, while it has called to attention the differences in heart disease between men and woman, has the ability to shed light on a greater issue: the decreased mortality of those with serious mental illness. 

    Mary Lou Sudders, the Massachusetts Secretary of Health recently remarked those with serious mental illness have a decrease in mortality of 25 years compared to their peers. If we expect to live until 85-90 years of age, then Carrie was right on schedule at age 60 according to that statistic. Countless studies published in journals highlight this issue along various themes. What all the data agrees on is cardiovascular risk is the highest and cardiovascular disease is the most common co-morbidity / cause of death.  Journals agree providers miss the mark in treating co-morbid illnesses in the mentally ill whether it is difficult to suss out a real versus somatic complaint, patient misinterpretation of symptoms, or bias against the patient for their psychiatric diagnosis to begin with.

    I am stung by Carrie’s death as it is too soon. It is my reality without vigilant care on my part. It is my reality unless I insist my PCP and my psychiatrist work as a team. It is my reality unless I change very stubborn habits. I have a lot to live for. And I intend to savor every year I have.

    Perhaps the best way to honor Carrie is talk about mental illness and medical co-morbidities.

    “I am mentally ill. I can say that. I am not ashamed of that. I survived that, I’m still surviving it, but bring it on”.   (December 2000).

     

  • My Bipolar Holiday Survival Guide

    OH, the holidays. A time of cheer, joy, festivity and goodwill. It is also a time of lights, noise, stress, pressure and emotional dysregulation. I know, it’s oh-so-shocking that one is unable to be jolly, however not everyone is able to sprint from Halloween to New Year’s with the enthusiasm (or even the faux enthusiasm) of a 6-year-old hopped up on candy canes and eggnog.

    Which gives us our start: not everyone is as merry and happy as you.

    The holidays are hard for some people. The holidays are hard for many, many reasons that do not even necessarily include mental illness. Be mindful of this fact when encountering fellow man that is not eagerly plotting his Elf on Shelf exploits or posting photos of their tree. A 2014 survey from NAMI found that 24% of those with a diagnosed mental illness find that the holidays exacerbate their illness up to 40%. One survey respondent who suffers with major depression shared that the holidays highlight all that is challenging about living with depression. 

    Not everyone has someone to celebrate with.

    While the world is off planning and attending holiday celebrations and talking with parents and siblings about the Christmas or Hanukkah menu, there are folks who are spending the holiday alone. Perhaps their anxiety doesn’t permit them to leave the house and enjoy the company of others. Perhaps they suffer from SMI and are in the hospital, on the streets, in jail or worse. Perhaps they are just isolated. There are sadly, far too many reasons why someone might be alone on the holiday. Have compassion. Extend an invite. Provide some companionship. If your schedule allows, volunteer.

    But I’m the one with a mental illness. I hate this time of year.

    Me too, sister. Me too. It was not always this way either. Repeat after me: I will do self-care.

    If I keep my own mental health in mind first and foremost and I can participate in the season. How?  Carving out a safe place for when the noise is too much. Last year, during peak squeals of delight and early morning Lego building, I snuck out to my local Starbucks who was open. The twenty minute round trip care ride with a piping hot chai latte was enough to recharge me for a few hours.

    I have to become more realistic about what I can and cannot do. For me, having small-ish children this can be challenging. However I cannot say yes to every single thing the kids and others want to do. I am happy that after two years, I have a break from the Polar Express train ride. Maybe next year, if the kids are still into it we can return. I avoid the mall at all costs and do Christmas shopping online. It saves me the stress and I don’t end up grabbing things off of Target end caps because “ooh! Look! Shiny! Pretty! On Sale!” 

    It is also important for one, including myself, to step back and think about what is the most valuable and treasured aspect of the holidays personally. Is it the meal? It is tradition? Is it volunteering? Focus on that, the one thing you can identify that does feed your soul during this time. Also the answer is personal and different for each of us. This question has no wrong answer.

    In the meantime, you will find me continuing my clean eating quest this month, avoiding the Salvation Army Santas with those darn bells and say Hi if you see me sneak out to Starbucks on Christmas morning.

    P.S. The most heartfelt thank you to those employees working on the holiday. You have no idea how much those few minutes mean to me.

  • Maintaining a Little Hope

    Next week is Thanksgiving and the official beginning of the hectic holiday season will begin. Since diagnosis, I have learned to live with a pit in my stomach and a hairball of anxiety in my throat from November to January as the trend is for me to have a setback during this season. It is simply stress and as much as I try to anticipate what needs to be done, my brain ends up defeated. I have been thinking a bit more about hope in the last few weeks as it pertains to me, to the season, to evolving moods and to 2017.

    Hope is all I have. Hope that medications continue to work. Hope that I can control my moods. Hope that my disorder remains in remission. Hope that I am a loving wife and mother. Hope that I am a patient and kind friend. Hope that I am a better, more effective provider. Hope that my patients keep hope for themselves.

    2016 has not been the best year for so many of us. I started off rough, with a deep depressive episode. Hope for symptom relief kept me moving forward and out of the hospital. Hope keeps me thinking the year will end differently than it began. I have advocated and spoken to so many congressmen and woman regarding the need for mental health reform. The hope of so many of us got HR2646 passed and we maintain hope that the Senate will soon act, continuing to push reform forward. Hope keeps me in action, showing the “world” exactly what I am capable of even if it’s not in the timeline I would prefer. 

    Four short years ago, I started spiraling down. Four short years ago, I could not recognize the symptoms nor understand that I had a problem. I could not understand I had bipolar disorder. I thought I had an ineffective therapist. Three short years ago, I believed my career was stagnant and over due to my diagnosis. I felt the knowledge of my disorder would preclude me from ever achieving anything further in this life and would ruin my family. Two short years ago I started writing. I started writing to change the way the public viewed mental illness, and in particular a nurse with a mental illness. I did it for myself, to hold onto the hope that my life was bigger than my diagnosis and would mean something to my husband, my children and me. One short year ago, I accepted a position that I never dreamed I would have. Hope always wins when you want it to.

    I suspect one has to be shown hope to have hope. I found hope when a psychiatrist believed in me and told me that during one of my hospitalizations. Prior to that moment I had truly believed I would be spending the remainder of my days in and out of the hospital. Recovering and relapsing repeatedly. I just may still. I cannot predict the future. However I have hope my new-ish pattern of stability and symptom remission will continue.

    What do I look forward to in 2017? I look forward to continuing this career I love. I look forward to working on my doctorate, provided acceptance to a program. I look forward to writing more. I look forward to presenting at a conference. I look forward to continued remission. I look forward to maintain hope.

  • Insurance, the Final Frontier

    In America, we love our health insurance. We also love to hate our health insurance. Most people obtain it through their employer and never have to give it much thought beyond griping about a service not covered, an expensive deductible, or a pharmacy co-pay. Costs are rising and we are being asked to shoulder more of the burden with increased deductibles and co-insurances. However, with coverage provided by employers it still often falls to the back of our minds. 

    I first started thinking about insurance when I spent a year seeing a therapist who did not accept insurance. Why? Because he could. He didn’t want the “hassle” of dealing with insurance companies. We spent a year paying out of pocket for my sessions and hoping to get reimbursed for what we spent. We rarely did, as the insurance company made the paperwork so overwhelming, so challenging to understand that as a family in crisis it seemed like one more headache not needed at the time. The majority of the time we would be told by the insurance company that I exceeded my allotted sessions for the year and “too bad. 

    I did not think about insurance again until I found my dream job, which unfortunately does not provide insurance for employees. Why, you ask? Because there are only 10 full-time employees and employers with less than 50 full-time employees (FTE) are not mandated by the government to provide insurance. There is no tax penalty for said employers, but they would be eligible for tax credits if they chose to offer insurance. Now, as an individual, I can get penalized in a tax penalty if I don’t obtain insurance on my own. My family does not qualify for subsidies in the Affordable Care Exchanges and we are then mandated to pay dearly by purchasing a plan at retail value. For our relatively healthy family of five, it costs approximately a mortgage payment a month. Fortunately, or unfortunately, depending upon how you view it, we pay over 8% of our annual household income in premiums and would not be penalized for lack of coverage.

    Why the obsession over insurance? Let’s look at a hypothetical but all too real scenario for Americans who rely on the Affordable Care Act for coverage. For the sake of utilizing what I know I will pick on my family.

    Well, as person with mental illness, I depend on that coverage to keep me in remission. I depend on that coverage for my prescriptions and ability to afford to see my treatment team. I never wanted to be a position where I would have to choose money over mental health. Except now I am. What if we were to fall behind in premium payments by just one month? Insurance companies are now actively dropping coverage for just that, without opportunity to make good on the premium due. One would learn of coverage loss either via letter or when attempted to pay. The insurance companies are now holding firm that there is no recourse in such situations until the new calendar year occurs. One can always appeal, however appeals are based on whether or not medications and care are for what the insurance companies deem as life-threatening. Let me repeat that: what the insurance company deems as a life-threatening condition or medication. Mental illnesses get denied on the basis that the condition is not life-threatening and medications are not life-saving.

    My family and I beg to differ based on the history of mood episodes. We object based on the number of times suicide was attempted while manic. We object based on the simple fact that with consistent medication I have proven the ability to remain stable, employed, out of the hospital and most importantly without active suicidal ideation. My medications are life-saving. They saved my life. They saved my life repeatedly.

    This means in a mood episode, I cannot afford my medications. This means I cannot afford to see my treatment team. We have children to feed, to clothe, and provide opportunities for. Keeping food on the table will always trump paying out of pocket for my psychiatrist. This means in my current mixed state – still running amok – I have to cancel my previously scheduled psychiatrist appointment because I cannot afford it. This means I white-knuckle it until January 1, 2017.

    I don’t parent well white-knuckling. I don’t “wife” well white-knuckling. I throw all my emotional energy into my job, as I always do which leaves nothing left over at the end of a workday for the people who actually matter most to both my heart and my brain.

    Despite this hypothetical scenario described, what still angers me, leaving me simultaneously sad is that I would still be one of the lucky ones in this country in terms of mental health care and access for my illness. I have the ability to speak up, fight, appeal and appeal again to get coverage reinstated. There are an awful lot of people in our country who cannot, whether it is out of fear, stigma, lack of financial resources or the physical ability (such as our homeless).  It is inexcusable in today’s day and age. It is inexcusable 6 years into the Affordable Care Act. It is inexcusable 8 years after the passage of The Mental Health Parity and Addiction Equity Act.

    My mental illness and need for insurance coverage for treatment and medication is no less important than someone with cancer or heart disease. What will happen should I have a hypothetical brain attack of neurotransmitters running wildly in my head and become unstable? I do not want this disease to claim me as a statistic, nor anyone else for that matter.

     

  • Is it me or Isn't it me?

    “It is you. Not everyone has your diagnosis.”

    We go back and forth in the mental health community about language all the time, how it can hurt, how labels matter (or don’t for some). One infallible truth however is that words do hurt and we can’t take them back. I did an exercise with my children on the day prior to school starting to demonstrate this very point, taking a tube of Aim toothpaste, squeezing the entire tube onto a plate. I asked the kids if they thought they could get the toothpaste back in the tube exactly as it been previously. They laughed and told me “no way!” We reviewed that once words are out there, you cannot put them and some people will never be the same. We took the time to talk about being kind, thoughtful citizens of the school community. I do not know three days into the school how long the toothpaste experiment will last, but we are working on it.

    “It is you. Not everyone has your diagnosis." 

    Not everyone has my diagnosis. It’s true. As of 2014, there are an estimated 5.3 million adults in the United States with bipolar disorder. This statistic does not differentiate between bipolar 1 and 2 disorder. (www.treatmentadvocacycenter.org/resources/briefing-papers-and-fact-sheets/159/463)

    I somehow do not believe words like this can be slung so carelessly at someone however in my situation. Those eight words leave someone, including me, with the impression that my disorder and my symptoms are my fault. I’m 41 years old. I know when I am being a jerk for the sake of being a jerk. I also know when I feel utterly helpless and cannot control my swirling tornado of emotion, thought and word due to a mood episode and resurgence of symptoms. Thus begging the question, is it really me?

    There is nothing I dislike more than my diagnosis and the impact it will wreak on my daily life from time to time. There is nothing worse than hearing your child ask you where Mommy went because “this isn’t my Mommy right now” when you are in a manic rage. It stops you in your tracks, kicks you in the stomach and renders one unable to breathe. It hurts because I didn’t ask for this. I did not ask to become ill. My children didn’t ask for an ill parent either. All of us (the kids and myself) asked for love and some understanding of our behaviors. The kids, because they are immature with developing brains and will do obnoxious things at times. Me, because I cannot achieve remission again without love, patience, time and a solid treatment team.

    “It is you. Not everyone has your diagnosis.”

    Not everyone has my diagnosis, and the things I CAN control are simple: putting down the phone and staying away from social media when it’s bothersome to me and liable to set me off. Sitting down every single night with the kids for dinner. Instituting family time every single night regardless of how tired I am. Bedtime snuggles and hugs. I can show my kids how much Mommy is always there, even when my brain is misbehaving, neurotransmitters have run amok and makes it physically impossible.

    I can’t put the toothpaste back in either. All I can do is work as hard as possible every day to make sure I never squeeze it out in the first place.

  • Mania, the Remix

    Raise your hand if you love a good remix. Personally, I am all about the remix. My current favorite is the Mike Posner “I Took a Pill in Ibiza” See B remix taking a lovely acoustic song and transforming it into a jam worthy of the finest kitchen dance party one was ever invited to. There are always exceptions to the remix rule and the original holds, such as the current Calvin Harris /Rihanna collaboration “This is What You Came For.” Strictly the original please for my tastes.

    I Took a Pill in Ibiza, remix, Vevo        

    This Is What You Came For, Vevo

    Raise your again if you are wondering what this has to do with mental illness. I assure you plenty. Now I am in the midst of what feels like the Calvin Harris of all remixes – manic episode with mixed features.

    DSM V criteria of a manic episode with mixed features states: “Full criteria are met for a manic episode or hypomanic episode and at least three of the following symptoms are present during the majority of days of the current or most recent episode of mania or hypomania

    -       Prominent dysphoria or depressed mood as indicated by either subjective report or observation made by others.

    -       Diminished interest or pleasure in all, or almost all, activities (as indicated by either subjective account or observation made by others

    -       Psychomotor retardation nearly every day (observable by others, not just subjective feelings of being slowed down).

    -       Fatigue or loss of energy.

    -       Feelings of worthlessness or excessive or inappropriate guilt (not merely self-reproach or guilt about being sick).

    -       Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide.

    The mixed symptoms are observable by others and represent a change from the person’s usual behavior. The mixed symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication other treatment).

    Let’s review (briefly) a manic episode: a distinct period of abnormality and persistently elevated, expansive or irritable mood and abnormally and persistently goal-directed activity or energy, lasting at least one week and present most of the day, nearly every day (or any duration if hospitalization).

    During the period of mood disturbance and increased energy or activity or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior

    -       Inflatable self-esteem or grandiosity

    -       Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

    -       More talkative than usual or pressure to keep talking

    -       Flight of ideas or subjective experience that thoughts are racing

    -       Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed

    -       Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).

    -       Excessive involvement in activities that have a high potential for painful consequences (e.g.’ engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

    The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

    The episode is not attributable to the physiological effects of a substance or to another medical condition.”

    (Taken directly from the text of the DSM-V, section on bipolar disorders)

    How is my mixed episode playing out? I’ve met the criteria for mania through well over a week now of increased-goal directed activity, less sleep, more talkative, flight of ideas, distractibility and the buying sprees. The mixed component? Decreased mood, thoughts of worthlessness, crying daily, fatigue and thoughts of death.

    I don’t want to have another episode. I wanted to blame my irritable, hateful state on the state of the world today. That is not going to go over well either. People are going to be haters, but my disorder is life-long with periods of relapse and remission. My pdoc is on vacation and the coverage in his office always throws more benzodiazepines at me to solve the problem. That is not what I need. What I need is to lose the fear of speaking up about my mood and getting help with the team I trust the most is unavailable.

    When I changed specialties for my nurse practitioner practice, I guarded my stability and current remission state more carefully than the gold at Fort Knox. I slept, I deceased alcohol consumption, and I took my medications more faithfully than ever before. On a visceral level, I know that this episode is not my fault. I know this episode happened to just occur in spite of the best care possible.

    Here is what frightens me the most about this mixed episode. One, it caught me off guard and I could not recognize it for what it was for several weeks, as I have never experienced one before. Two, I am scared to speak up without my treatment team in town. I am a medical provider and people rely on me. Unless you stand in my shoes, you cannot possible understand what it is like to keep your brain held together for 8 hours every day, in a state of constant adrenaline because patients will always come first and to cause harm would cause you to go to the depths of hell. Three, do I need a medication change – AGAIN?

    Lastly, I fear I will become a victim of the system. I worry my disorder will claim me versus the other way around. I constantly worry about being just another statistic of this brain disease.

    It’s not quite Vegas for this remix and I don’t have a huge crowd cheering me on unlike our dear Calvin, though.

  • Learning to Savor the Small Moments

    I have found as I navigate this bizarre world of both patient and provider that it is the small moments that can make the biggest impact. We often are not even cognizant of the impact until much later, but they make an impact and a difference in our journey and path we forge trying to achieve the wonder that we call remission from symptoms. This week for me has been fragile, full of triggering moments leaving me feeling as if I’m dangling on a cliff’s edge one moment and then left speechless with a small moment of how far I have come the next.

    I encountered a woman this week who is the twin of a nurse I had during the last psychiatric hospitalization, back in June 2013. She was a kind white haired woman who took the time to sit with me during her shift and check in. She talked with me about how we were nearly neighbors, told me things about common threads we wove, and talked to me at length about sometimes how long it can take to find the right cocktail of medication for bipolar disorder. She knew because of a family member. She shared that with me. She shared that when it works and you find the magic combination it’s like Christmas morning.  It did not take as long for me to find the magic combination as it took for her family member. I digress. I was so excited when I saw this woman this week for I was sure it was my former nurse. I wanted nothing more to embrace her and tell her how her words helped me and were an integral part of the reason I am here today, doing what I do. She is one of very few providers from my inpatient stays who made a difference and I wanted her to hear that and see it in the flesh.

    I had one horrible psychiatric hospitalization in February 2013 that left me feeling disoriented and not ready for reentry when I came out. My husband, when he picked me up, handed me a Starbucks venti chai latte extra hot with soymilk along with a brand new iPhone 5 fully loaded with all the apps he thought I would like. Both have been my crutch ever since and typically not far from my hand. The other night, my youngest (by two minutes) informed me I spent too much time with my phone and that it was going to stop. I looked at him and agreed. Last night, I picked up all the boys and took them on a date. No phone. We had a ball. I learned so much about them and we laughed, played games, and talked through our meal. I didn’t pick it up again until I was in bed for the night. They have slowly been learning I am a safe, dependable parent, but now they can learn I am a present parent too. I just have to figure out what we can do tonight – phone free and without my crutch.

    The best part about my job as a psych APRN is when a patient finds their own small moment that is pivotal for them, helped them see the hope in a situation they thought otherwise and they bring it to me. My patients don’t know my story; they don’t understand the passion I pour into my career to see them succeed, as it is irrelevant to achieving remission for them. And they definitely don’t get to see my happy dance after they leave on their small moment days. But it’s there.

    Now I just hope my front office staff never figures out YouTube.

  • Facebook, Social Media and Mental Illness

    Facebook, or social media use in general, brings out the best and the worst traits in humans. When one throws a mental illness into the mix, it can be both calming at times and incredibly triggering.

    As someone with bipolar I disorder, reasons why I like it:

    I have a good family, none of whom live nearby. It often provides a chance to see what is going on without picking up the dreaded phone. Sure, the phone is in my hand as I scroll through the newsfeed but one, that’s just a detail. Two, I have severe phone anxiety and three, the idea of calling to order pizza sends my heart rate soaring over two hundred. Surely you cannot reasonably expect me to have an actual phone conversation just because we share DNA?

    The same can be said for my friends. It is a useful tool to reconnect people whom you remember. Friendships are renewed, revived. We all grew up. For folks like me who came from a small close-knit community, it is nice to see how people are doing. Most of us even got better looking with age. (What is that saying about women and fine wines? EXACTLY.) Let’s face it, we all produced adorable children who may not always behave adorably, but they sure do say some hilarious things that must be shared. And I love seeing all of it, from all of you. And again, that no phone thing.

    Cat videos. Movie trailers. The New Yorker (I heart Andy Borowitz 4-EVA). Thoughtful debate. Divisive debate. The conversations it provokes privately in homes. The friendships it renews. Dog videos. For the love of pugs.

    And lastly the awe-inspiring community of like-minded advocates I have to both grow with and support me. We are all on different journeys and came together through various paths but share one common goal: better care for the seriously mentally ill.

    Reasons why I don’t like it

    Everyone loves a good funny meme to chuckle over. Why not? We need more laughter in such a serious world. My sense of humor is just as good as the next person. What I do not enjoy is the proliferation of mental illness themed memes meant to provoke laughter and merriment over actual illnesses people suffer with. We are battling our minds on a daily basis. People do not post memes inciting laughs and teasing those who suffer from physical ailments. Could you imagine the outrage if you saw one for childhood cancer? Or cancer in general? Parkinson’s? ALS?

    I do not always want to be the heavy. I do not relish pointing out the insensitivities simply because I made a conscious choice to be open with my diagnosis, protecting the many, many confidences entrusted to me since I went public. Yet I will, for that is a privilege of one of the highest honors people could give me.

    The math is simple. 1 in 4 adults have a diagnosable mental disorder in their lifetime. ONE in FOUR.  So if Ann has 640 Facebook friends that means 160 would carry a diagnosis. If Bob has 200 Facebook friends, 50 would. Look around the room you are in. Can you even tell who may or may not carry a diagnosis? OF COURSE NOT! No one will trust you enough to tell you either to use you as a support system when you are then one making fun of their illness publicly, especially without their permission even if you are not even referring to them.  Yes, humor is needed to get through the dark days. My husband and I are known to make horrible jokes about my bipolar disorder to each other to get through the hard times. It stays private, between us.

    There are a couple of memes I want to call your attention to:

    When I put my patient “hat” on, I just do not see how one willingly goes to the hospital unless they know their situation is so dire they will not turn around without hospitalization. Typically, admission occurs with an individual frightened, in tears and feeling that they will die unless they go. Patients genuinely feel backed into a corner and completely out of options. They feel that all medications have failed them. Some patients are involuntarily admitted for concerns of safety and harm, be it themselves or toward others. 

    In my case, each and every time the only reason I signed paperwork for a voluntary admission was because I was told it was better for me that way. I never wanted to go, not once. Not one of my four admissions. The last admission I had my hospital chart stated that if I tried to leave grounds and go home prior to the time a transfer to a psychiatric bed could occur, the police would be called, I would be barred from leaving and committed involuntarily. So much for the voluntary paperwork I signed.

     

    There is no cool table in the cafeteria. There are tables. Period. People find a seat, eat and leave. Conversation is at a minimum. You might trade muffins. You might barter for cigarettes if you smoke. You might talk meds if you are feeling really feisty and got caffeine in your coffee. At the end of day, you are in a psychiatric facility and what is there to discuss?

    The one I take the most offense to tried to gain traction as a game on Facebook. I found it so triggering, I actually defriended numerous people over this.

     

    I’ll paint a more accurate picture of how this would look for you

    YOUR ROOMMATE: Up all night crying with a sitter at their side because they attempted suicide and wound up in the psychiatric hospital instead. They are frightened to death to be there. You can’t tell if it is their first hospitalization or their fifth. Perhaps they are most frightened that they are still alive. The tears you hear all night are of a soul in deep, deep pain.

    PERSON LICKING WINDOWS: Is in such severe psychosis it makes you uncomfortable. You wonder why no one is doing anything to break the psychotic state or is his or her mind irreparably broken at this point. You begin to cry yourself.

    PERSON HELPING YOU ESCAPE: Isn’t really helping you escape. They are telling you everything that they think you should know because 1. they want you to view them as the Alpha of the unit and 2. all the things they tell you to the doctors on rounds have absolutely nothing to do with you or your case.

    THE DOCTOR: A person who shows up for five minutes a day, asks how many groups you show up to and increases your off unit privileges based on the answer. Also asks you five or six questions to determine discharge readiness and medications. Never answers family phone calls and punts them to the social worker that avoids you.

    PERSON RUNNING AROUND NAKED: This might make for great cinema, however with 4 hospitalizations and counting I have yet to see this. We get to wear our street clothes to avoid feeling completely marginalized. The more accurate picture is The Person Who Wore the Same Outfit for the Most Days In A Row. See also: Psychosis, because the unit washing machine is bugged and contaminates the clothing.

    PERSON YELLING NONSENSE: This could be anyone. This could be from meals consistently being delivered late when it is all anyone has to look forward to. It could be because no one showed up to visit again and you’ve been there for three weeks. It could be because the same three patient monopolize the one phone on the unit for all 30 patients. Perhaps you are sick of having to do the same kitten puzzle every day from the 1980s as an activity. Maybe five days into your stay, the 6th day suddenly your ponytail is deemed a safety hazard after five days of a nonissue. Maybe you just want a nurse to listen and not push medications.

    PERSON YOU WENT CRAZY WITH: What the Sam Hill is that even supposed to mean? Someone went crazy with me on purpose and got admitted with me on purpose? Now I know the inventor of this little game is just an a$$hole, pardon my French.

    Now I believe we can all agree we have been properly educated and shall think the humor and memes through a little more. After all, I have the best weapon: a graphic designer husband and I am not afraid to use him.

    He is a professional photographer to boot and has made some pretty inspirational memes when asked.

     

  • The Medical Provider Bias of the Psychiatric Patient

    There has been so much going on in the last week in terms of my physical health, it has been overpowering my need to protect my mental health. I fell apart physically, rather abruptly and unexpectedly. Testing has proven inconclusive thus far, which is both encouraging and discouraging. I am encouraged to know there is no serious ailment, however discouraged that my symptoms remain vague and without cause. With my husband consistently at my side, and a dear friend who stood up and staunchly advocated for my needs we were able to come up with a plan to move forward, so I will be fine as always. I'm a tough bird. 

    What I wanted to call your attention to was a guest post I wrote a year ago for another website that I linked below and am republishing: the topic of feeling that our physical concerns are not taken seriously when a provider sees in the EHR that they are dealing with a primary psychiatric diagnosis before they meet you. There is a very real bias that exists and the more we ae aware of it and talk about it, the better our care can and will be. 

    http://www.everythingbutthecat.net/#!Guest-Blog-Medical-Provider-Bias-of-the-Psychiatric-Patient/c1kyp/55a39e840cf21636d2fcd246 (first published July 23, 2015)

    A patient presents to their local emergency department at the prodding of their spouse in the midst of experiencing about 36 hours of mid-sternal chest tightness with an inability take a deep breath. It is not relieved with antacids or aspirin. The patient feels worse when moving around. They are checked in to the emergency department, and EKG is done and they are sent back to the waiting room to wait. And wait. And wait.  After a few hours, a polite inquiry is made as to when the patient might be seen knowing chest pain is usually considered to be a serious malady. They are told the ECG was normal and that they are waiting for a doctor to come speak with them. Frustrated, the patient leaves and a two days later seeks help with the primary care provider (PCP) who diagnoses them with costochondritis, which is an inflammation of the cartilage connecting the sternum to the rib cage and the pain can often mimic that of a heart attack.  It is easily treated with a two-week course of a non-steroid anti-inflammatory medication. The medical record shows the patient was seen for the primary problem of anxiety, secondary problem of chest discomfort. 

    A patient presents to a neurologist who specializes in the treatment of migraines at the behest of their other providers for better management of their migraines. On the day of the appointment, they are experiencing a migraine, having gait difficulty and vomiting in the waiting room, with a prolonged waiting time on the day of the appointment.  The neurologist told the patient that their migraines were made up and being used as a method to get attention. The patient was further told that these migraines were all in their head and not real.  They left without medical care. 

    Outrageous right? In today’s day and age of medicine where patient satisfaction rules that day how dare someone’s chest pain be ignored, then find out they are viewed by providers as anxious despite an actual medical condition they were diagnosed with and how could a neurologist tell a patient vomiting from migraine that this was a made-up attention-seeking headache? What if I told you both of the above patient’s charts carried a diagnosis of bipolar disorder. In the age of electronic medical records, providers are fairly savvy on a patient’s medical condition and past histories before ever seeing or interviewing a patient. Are you still outraged? I hope so. Hold onto it for a moment. 

    I was intrigued by this bias of a seemingly different standard of medical care as it appeared it was being offered to a patient with a pre-existing psychiatric diagnosis versus a patient without one.  For example, the chest pain differential diagnosis (once EKG ruled out changes concerning for heart attack) is still long and warrants work-up. Fortunately for our patient, they were okay. Imagine however if they returned say 24 hours later in extremis. It is still baffling how when at no time they were anxious, they were calm and stated the facts of what was happening to them, their PCP still found a primary episode diagnosis of anxiety necessary, not the costochondritis the patient was prescribed treatment for. The migraine patient was greeted by the neurologist with the words “Oh, I see you’re a bipolar.” While that is not exactly politically correct, it should have raised red flags for the neurologist that this patient has headaches since migraines are a proven co-morbid condition, not suggest that the patient was confabulating a disorder and wasting their time. Did the patient “make-up” the vomit in the waiting room trash can too? 

    I know these two anecdotes do not even begin to scratch the surface of bias psychiatric patients experience while trying to obtain medical care. I did a literature review to attempt to grasp the extent of the problem. Not entirely unsurprisingly I was not able to find much. However I did learn a lot of information.

    In a 2013 study, Maina, Bechon, Rigardetto and Salvi noted that those with bipolar disorder have worse physical health and life expectancy reduced by approximately 30% compared to the general population (Note: that number is higher than I have previously seen). They found patients with bipolar disorder are more likely to have cardiovascular conditions, hypertension, diabetes, hypothyroidism, respiratory illness, liver dysfunction and peptic ulcers. 55% of the patients they examined had a co-morbid condition. The most common co-morbid conditions were either endocrine or cardiovascular.  64% of patients who had an endocrine disorder experienced metabolic syndrome. The biggest risk factors they found for predicting the risk of a co-morbid condition were female gender and duration of untreated illness. It was noted that individuals with bipolar disorder are more likely to demonstrate “risky” behaviors health-wise in terms of diet, poor exercise habits, sub-optimal self care, limited access to health care and perhaps unwillingness to obtain health care during periods of depression. It was also noted that the medications used to treat bipolar disorder are lifetime medications and place the patient at risk for obesity, metabolic syndrome and thus cardiovascular disease and diabetes.  (Maina G, Bechon E, Rigardetto S, Salvi V. General Medical Conditions Are Associated with Delay to Treatment in Patients with Bipolar Disorder. Psychosomatics. 2013:54-437-442.)

    I looked at a 2013 study from Crump, Sundquist K, Winkleby, and Sundquist J, which knowing bipolar disorder is associated with increased mortality sought to examine what effects the disorder has on the individuals physical health over a 7 year period. Their study found that for the individuals identified as having bipolar disorder over 60% were middle-aged, the majority were women, they were more likely to use alcohol or other illicit substances and have lower educational or income levels.  They found that these patients had three times the amount of outpatient visits and two times as many hospital admissions on an annual basis. The diagnoses these patient were more at risk for was influenza or pneumonia, COPD, diabetes, cardiovascular disease – specifically mentioning stroke. When mortality was examined, it was found that women, on average, passed away 9 years earlier than other women and men, on average, passed away 8.5 years earlier than other men. This represents a 2.3 and 2.0 fold increase in mortality. It also calls to attention the notion that those with bipolar disorder are less likely to receive primary medical care, thus in essence preventative medicine for many of these disorders. Modifiable behaviors are also noted, such as, obesity, smoking and substance abuse. (Crump C, Sundquist K, Winkleby M, Sundquist J. Comorbidities and Mortality in Bipolar Disorder: A Swedish National Cohort Study. JAMA Psychiatry. 2013;70(9):931-939.

    The final study I want to call attention to is from 2014 by Gras, Swart, Sloof, van Weeghel et al looking at stigmatizing attitudes healthcare professionals may hold toward psychiatric patients. They acknowledge upfront their study was limited by a bias toward providers likely wanting to provide a socially appropriate answer. They sought to look at the beliefs held by general medical professionals (GPs), general mental health care professionals  (MHCs) and forensic psychiatric professionals (FPs). They hypothesized that the GPs would hold the most stigmatizing beliefs; the MHCs would hold the most accepting and the FPS would be in the middle.  They found that all three groups held a “moderately positive attitude” and that their hypothesis was correct. It was noted that only between 26-38% of the providers across all three groups admitted having personal experience with mental illness. (Gras L, Swart M, Sloof C, van Weeghel J, et al. Differential stigmatizing attitudes of healthcare professionals towards psychiatry and patients with mental health problems: something to worry about? A pilot study. Soc Psychiatry Psychiatr Epidemiol (2015) 50:299-306)

    It is worth noting that bias exists, and that primary care providers have been shown to hold a more stigmatizing attitude than other providers. It could be hypothesized that same said attitude carries over to providers of a non-psychiatric specialty, however given a paucity of data available in my literature review, we don’t know that answer.

    Patients with a psychiatric diagnosis deserve better in our care and need to stand up for ourselves. We deserve the same standard of care for our healthcare needs as anyone else. We ask for and expect parity with our insurance and it is reasonable that the very same parity would extend to our medical care. The data clearly shows the collective we hold a higher risk of cardiovascular disease, endocrine disorders, stroke, and risky modifiable behaviors. There is no reason for any single one of us to hold increased mortality versus the general population if our care providers sit down and pay attention. I did not even get a chance to discuss the increase lifetime risk of suicide that an individual with bipolar disorder carries over the general population. 

    Why don’t we empower our care providers to provide us with the very same standard of care that a non-psychiatric patient would receive? In an increasing era of patient satisfaction and concierge care, speak up and talk to your providers. Encourage them to listen to you. Would a non-psychiatric patient be told their medical ailment is made up? Would a non-psychiatric patient be seen for a physical complaint but end up with the primary visit complaint a diagnosis straight out of the DSM. If the answer is NO, then stand up and speak up.

  • My Shit Is Real

    I am sitting here awake in the early dawn hours; long before my alarm is due to go off because my sleep is off again. Insomnia is creeping back into my life and as you know, the fear of hypomania or mania is real for me.  It is never a good sign when a seasoned individual on the support group scene once remarked, “I remember your mania. That was a bad one.” I remember most of it too. It was.

    I have so many thoughts, so many feelings with the struggle to put things down on paper at times. As if seeing the words in black and white allows them to become more visceral, therefore only making sense that I would procrastinate on writing about these things to avoid the reality of my fears.

    I stopped watching Netflix before bed. I read instead. I could bring back the evening shower, a long instilled habit from shift work, to help me wind down more. Last night I sat outside in the backyard, without the fire pit roaring just talking with my husband, completely relaxed. Certainly that should have helped. My alcohol intake is rare due to my medications. Exercise, though. That would help fatigue me more.

    I do not understand how working parents find the time to fit exercise in. I’m up early, put in a full day at work, try to enjoy the kids before bed and then it seems it is time for me to retire. The body is willing to sleep; yet the mind is resistant. I like the idea of exercise, my Pinterest board is chock full of exercises I am capable of doing in my unconditioned state. Now the mind is willing, yet the body is resistant.

    Do I retire later in the evening? Do I go to bed too early? Is that the issue? I am so afraid if I stay up, then fall asleep on the couch and then move upstairs I will be unable to fall back asleep. How many sleepless nights have I had when something woke me, and my mind could not just stop and relax thereafter? Countless.

    My mind. Not my brain, which contains my bipolar disorder but my mind. Me. My intellect. So many thoughts run through it. Am I better or worse for reading so much lately? Everything makes me think. I finished a book two days ago that has just haunted me. While it was someone else’s story told so beautifully, I was devastated when I finished to learn there was one small piece of the story in which the ending was not what I expected. Which made me think: why do some marriages crumble in the face of or the aftermath of an illness and some not? 

    Why is my husband still here? What makes us so special that we can work through all the crap that bipolar disorder throws at us and come out a better team? Do we bicker? Yes. Do we fight? Sure. Do we disagree on how to handle some issues? All the time. Yet we stay unified and pushed through all the garbage, all the bad and remain loving to each other because at the end of the day if the five of us are still a family then nothing else matters.

    Why does that not happen for everyone? It is hard sometimes to comprehend that I am one of the lucky ones in our mental health system. I was able to come back from a serious mental illness and am able to achieve periods of remission. I have been able to go just over three years without needing the hospital again. To have a family who stands by me every single step of the way. I have insurance and more importantly, a provider who accepts insurance to care for me.

    This is just a fraction of the things that go through my mind on any given moment, hour, day, night. As someone said earlier today – My shit is real. And it is. It is so very real. For all of us.