"And if ever, by some unlucky chance, anything unpleasant should somehow happen, why, there's always soma to give you a holiday from the facts. And there's always soma to calm your anger, to reconcile you to your enemies, to make you patient and long-suffering. In the past you could only accomplish these things by making a great effort and after years of hard moral training. Now, you swallow two or three half-gramme tablets, and there you are. Anybody can be virtous now. You can carry at least half your mortality about in a bottle.” -Aldous Huxley, Brave New World

In reply to Yet Another Harrowing Tale of White Collar Addiction, a friend and fellow journalist wrote me a letter detailing her personal history with psychiatric diagnosis and some of her thoughts on the process, which she has graciously allowed me to share here.  In my post, I suggested that the problems with psychiatric diagnosis are not specific to ADHD.  Camille’s case illustrates this well.

Camille - her middle name - is a beautiful, poised young woman, with a graduate degree in the sciences, a once-successful freelance writing career, and a history of depression.  Two years ago, Camille went to her local healthcare clinic complaining of general anxiety and sleep problems, hoping to be seen by a therapist.  Instead, within a month, her psychiatrist had prescribed her five drugs to help regulate her mood: Adderall (a stimulant), Ativan (an anti-anxiety medication), Celexa (an anti-depressant), Trazodone (a sleep aid and anti-depressant), and Yazmin (hormonal birth control).  Since she did not meet the criteria for a major psychiatric disorder, such as bipolar or schizophrenia, she has never seen a therapist.  Since that time, she has become addicted to Ativan, and has suffered severe withdrawal the few times she has tried to go off it.  Her weight has plummeted.  She has difficulty distinguishing waking life from dreams.  The problems she hoped to resolve in therapy remain largely unresolved.

Excerpts of her story follow below.

On immediately being prescribed Ativan

I didn’t know much about benzos [the class of drug Ativan belongs to] when I was prescribed.  That was actually the first thing I was prescribed, following my very first screening appointment. I expressed hesitation, since I had come to talk to a psychologist.  I sincerely wasn't sure yet if I wanted medication. She (the nurse) said, "Don't worry, it will just calm you down, make you feel better, it's like valium. " Anyway, I filled the prescription, came home and researched it a bunch, sat on it for a couple weeks and finally tried it because I was so sick of not being able to sleep. Turns out it's more physiologically addictive than Adderall or coke or even speed.  The pharmaceutical company that manufactures it does not authorize it for use longer than three weeks. No doctor, nurse, or pharmacist ever mentioned that to me. At one point I told my psychiatrist that I had read about this and he prescribed me something else, another benzo, to calm my fears. But the withdrawal issue is the same with all benzos, so I just kept taking the Ativan.

On how she was prescribed Adderall, off-label, for depression

I did what so many have done to get an Adderall prescription. At the time, I thought it was a well-informed decision. I thought it would improve my psychological situation by making me more productive and focused, and thus less depressed about being unproductive. And despite what I’m about to tell you about my psychiatrist, I take responsibility in my head for having asked for Adderall.

If you were to ask me, I guess I’d say I’m a smart, perceptive person with a long history of use or contact with the effects of prescription and non-prescription drugs.  I walked into my psychiatrist’s office knowing what I was doing.  Ultimately though, it’s still the person with the medical degree’s responsibility to read people, to detect key aspects of the way they're engaging the situation, and to properly diagnose and medicate a patient.

I think my guy [my psychiatrist] just recognized early on that I was smart and knew myself, so then released himself of doing any further investigation because he trusted me to accurately describe my needs.  The new guy they gave me after that guy retired was no different.  Once I said something to him about Adderall and he responded, "Well, sounds like you know more than I do about it, so I'll take your word for it."  I had actually wanted to have a conversation with him about some of the physiological effects of the drug, having read a lot about it, and it became clear that was not going to be possible. So it was just, "Ok, I guess I'll just take that triplicate [prescription] and be on my way." (I didn't actually say that). He has since allowed me to pick up triplicates from the receptionist once every 3 months. I haven't seen or talked to him since the summer. Again, I think he was just like, “OK she's smart and isn't a fiend, so I don't have to worry about her as a liability.”

I can say I don’t regret being prescribed it.   I’m just not satisfied with the way it was handled.  At the time, I was like, “woohoo, that was easy!”  But looking back on the way my doctors have handled (and not handled) me, it was irresponsible.

On how the system works for ‘normal’ patients

I understand, perhaps more than most people who haven't worked in a doctor's office, that they have to keep on schedule and recognize which patients they're going to need to spend more time with, so any easy person like me is great for them -- wam-bam!  That's how reasonably normal-presenting patients slip by.  The strange part is that ‘normal’-presenting patients seem to get prescribed more controlled substances than people diagnosed with mental disorders like bipolar or schizophrenia.  With my health plan, only a diagnosis of a severe mental disorder would grant me individual therapy, but depression and anxiety got me prescribed controlled substances in 20 minutes flat.

My original psychiatrist mostly worked in the psychiatric ER; I was one of his few outpatients. He was excellent at reading extreme behaviors and symptoms and knowing exactly what to put in their veins and what to write on their charts. He got frequent pages that he had to call back immediately during our meetings. That was his forte. Relatively normal people were his hobby. He mostly talked to me about movies and always told me I was pretty (in an absolutely not hitting-on way, but more of a "I'm a dad, I know about how the world works, and you're smart and sweet and cute, and so it'll all work out for you" way).

Keep in mind, I did not hide that much from him. I cried in his office more than once. I answered ‘Yes’ when he asked if I had ever thought about suicide. But comb my hair and look him in the eye and give a 3-minute speech about my sister's success with Adderall and I'm at the pharmacy 15 minutes later. Thing is, you or I, not even being psychiatrists, would be able to flag people much more immediately and accurately than these doctors.

Camille's account is troubling.  She was denied therapy to cut costs.  She was prescribed an anti-anxiety drug that is highly addictive in a casual, off-hand manner.  Indeed, her doctor wrote her prescriptions like he was doling out vitamins: one to treat anxiety, one to treat insomnia, one to treat depression, one to treat PMS, one to treat lethargy.  That Camille is smart and well-educated did not insulate her from such reckless malpractice; instead, it may have worked against her.  Her doctors 'trusted her', she says, and she liked that they trusted her.  But for all Camille's research, she is not herself a trained psychiatrist, and as she would be the first to admit, she's not sure she should have been the one in charge of her own treatment plan.

There's one more important detail missing from this story.  Camille did not tell her psychiatrists that she is an alcoholic.  Camille did not reveal her addiction issues because, she says, "As soon as you're labeled an addict, you're an addict for life in the eyes of any health insurance company. They know they will either be paying to treat the damage you do to yourself or paying to prevent you from doing damage to yourself."  Actually, there's a question of whether she would have received treatment at all.  A close friend of mine, an alcoholic in the style of Winston Churchill, was denied access to an anxiety treatment program after opening up about his drinking.  The reason?  Liability issues.

On how she thinks the system should change

It's not likely that psychiatrists are going to start spending more of their time with patients. So I think there should be a requirement that some number of close friends and/or family members verify what you're saying about your symptoms.  With these kinds of drugs, you should have to bring in two people who are willing to provide identification and sign their statements about you.  That way, the doctor can get a fuller picture of  your situation, which would help in detecting inconsistencies and drug-seeking behavior.  Plus, your friends would be going on record alongside you.  Even if it were confidential, it would still present a risk, should you overdose or commit suicide, and that risk would incentivize them to be honest.

"Troubled people can't navigate treatment alone," she concludes, "and if doctors are not going to be the shepherds they signed on to be, perhaps their friends and family could be."

While I agree with Camille that an ideal treatment program would incorporate the narratives of friends and family, I don't see how it can ever be made a requirement.  Not everyone who suffers from mental illness has a reliable support network in place to advocate on their behalf, or to call into question their version of reality. (Some people's families are more crazy than they are.) Would Camille have been better off if a family member had revealed her alcoholism in a sworn statement?  Perhaps -- but only because it might have been better if she had never been subjected to that barbaric 'treatment' in the first place.  If there had been better treatment options in place, it's not clear what rendering her both uninsurable and untreatable would have achieved.

What are we to make of Camille?  While it's difficult to say how representative she is, I've spent years listening to stories like hers.  There's the librarian who found herself suddenly depressed on a new birth control pill, and when she asked her doctor to switch brands, was instead recommended several options of anti-depressant.  Or the mechanic who was prescribed a heavy duty anti-psychotic ten minutes into his first appointment, after he admitted that a relative of his had recently been diagnosed with bipolar, and that he occasionally 'drank a bit'.

He had gone in to discuss his issues with social anxiety, but found the conversation quickly derailed after he mentioned his relative.  He told me he didn't know quite how to answer many of the questions, which seemed vaguely worded, and open to interpretation -- like a horoscope, he thought.  Soon, he said, the psychiatrist was drawing a triangle in the air and explaining his fate to him: "It's the unfortunate triad of genes, environment, and behavior..."  He never went back.

Perhaps the  most disturbing story I've heard comes from a friend who was interning in a medical clinic in El Paso, Texas that treated battered women, many of them immigrants from south of the border.  One might expect that these women would be referred to therapists or social services, but that was not the standard of care, not at that clinic.  Instead, they were prescribed Prozac, a practice that recalls that haunting rhyme from Brave New World which ends: Love's as good as soma.

What troubles us about these stories is the way that the tangled skein of human lives are reduced down to symptoms, while cause and context are forgotten or outright ignored.  To give a physical analogy: I might feel a sharp pain in my lower calf because I have 'flesh-eating' necrotizing fasciitis.  Or it may be that I have badly strained a muscle after a particularly strenuous work-out.  In one case, intravenous antibiotics and surgery are called for; in the other, an ibuprofen and a massage would do the trick just fine.  Even a physician facing a motivated hypochondriac could tell the difference.  But listening to how psychotropic drugs are prescribed, one comes away with the uncomfortable feeling that when it comes to disorders of the mind, many doctors simply can't tell the difference.  And they're not being paid to.

Related Readings:

The Epidemic of Mental Illness: Why? in the New York Review of Books

The subjective nature of psychiatric diagnosis: Medicalising natural and normal responses to life experiences is a dangerous game in the New Statesman

Ill-Treated: The continuing history of psychiatric abuses in Reason