The Invincible Force - Pt 1

"I felt that something had broken within me on which my life had always rested, that I had nothing left to hold on to . . . . an invincible force impelled me to get rid of my existence, in one way or another. It was a force like my old aspiration to live, only it impelled me in the opposite direction."

-- Leo Tolstoy

Part 1 - Part 2 (coming)

Weight Gain Associated With Antipsychotic Drugs

Back in 1999 I was put on Depakote, a prophylactic against mania that, as it turned out, had the effect of slowly but steadily ratcheting up my weight. When I started taking it I weighed 168; within five years I was very nearly at 200 pounds -- sometimes even a bit over. Since I'm only 5'8", that was obviously a problem, both intrinsically and because of a history in my family of heart disease.

Fortunately I managed the disorder conscientiously enough that my psychiatrist felt comfortable eliminating the Depakote and relying principally on Lamictal (which is prescribed mainly as an anti-depressant but has some anti-manic properties as well), coupled with disciplined sleep hygiene.

Lamictal is weight-neutral. I still managed to gain weight while on it, but as it turned out, that owed mainly to eating out a lot (especially fast food) and drinking a lot of beer. In mid-July I started the Weight Watchers program. I have so far lost a bit over twenty pounds, with fewer than eight pounds to go.

Still, not everyone has the luxury of such an option....

In the New York Times, October 28, 2009

Weight Gain Associated With Antipsychotic Drugs
By DUFF WILSON

Young children and adolescents who take the newest generation of antipsychotic medications risk rapid weight gain and metabolic changes that could lead to diabetes, hypertension and other illnesses, according to the biggest study yet of first-time users of the drugs.

The study, to be published Wednesday in The Journal of the American Medical Association, found that 257 young children and adolescents in New York City and on Long Island added 8 to 15 percent to their weight after taking the pills for less than 12 weeks.

The patients, ages 4 to 19, added an average of one to one-and-a-half pounds a week.

“The degree of weight gain is alarming,” said Dr. Wayne K. Goodman, head of a Food and Drug Administration advisory panel on the drugs last summer and chairman of psychiatry at Mount Sinai School of Medicine in Manhattan. “The magnitude is stunning,” he said.

Full Article

Change A Mind About Mental Illness

Facing Facts

What follows is an after dinner talk I gave last week to a group of academics at Capital University in Columbus, Ohio. I'd been asked to offer some reflections on an exhibition in Capital's Schumacher Gallery concerning the lives of Ulysses S. Grant and Robert E. Lee. (It was, incidentally, a traveling exhibit organized by the Virginia Historical Society and New York Historical Society, funded by the National Endowment for the Humanities, and supplemented by artifacts fom the Motts Military Museum.)

I dislike giving presentations that don't build toward projects underway, and since the next speaking engagements on the horizon have to do with mental health advocacy, I decided this would be a good opportunity to experiment with one. The talk was something of a high wire act, interweaving personal observations of Grant and Lee with those concerning bipolar disorder. But judging by the response I received, it worked.

It’s a pleasure to talk with you this evening about Robert E. Lee and Ulysses S. Grant, particularly in light of the exhibition at the Schumacher Gallery. I’ve heard it said that an exhibition, even when installed, is not really an exhibition. It becomes one only people come to experience it. They see in it, and take from it, meanings that the designers of the exhibition did not necessarily intend to impart. This is so because people bring to it their own experiences of life, their own concerns, and above all their own imaginations. Were this not the case, I doubt if exhibits would be at all worth the investment of time, money, and energy required to create them.

During the Civil War a pair of Union officers climbed atop a mountain to survey through telescopes the Confederate encampment beneath them. They saw soldiers brewing coffee, writing letters, reading newspapers, and washing clothes. To one of the officers this was a revelation. “My God, Adjutant,” he said to the other. “They’re human beings, just like us!” The Grant-Lee exhibition invites us to reconsider these two icons of the American military tradition, these central characters in the American Iliad. Their lives had the same common place experiences and the same complexities as our own. They were human beings, just like us.

I grew up with Grant and Lee. I got to know them through children’s books, and particularly got to know Lee through a biography entitled Robert E. Lee and the Road of Honor, written for young people by the Southern progressive journalist Hodding Carter, which I read at the age of eight. But the really critical experience occurred when I was twelve and first read A Stillness at Appomattox, Bruce Catton’s brilliant evocation of the epic struggle between these two commanders in the Civil War’s final year. When I say that I grew up with Grant and Lee I mean this, of course, in an imaginative sense, and yet the imaginations of the young can be so vivid and intense that I still sometimes feel as if I grew up with them in a literal sense. And in terms of their impact on my life, that is quite likely true in the deepest sense of truth.

Recently I turned fifty years old. That makes me just seven years younger than was Lee in 1864 and actually eight years older than Grant when he led the Army of the Potomac across the Rapidan River and into battle against Lee’s Army of Northern Virginia. My life has gone in directions very different from theirs and has taken a very different shape. But in dealing with the challenges of my life, I have often looked back on these two men, both what I thought I knew of them as a youth and what I think I know of them now.

The biggest challenge that has faced me in life began to confront me in 1986, when I was diagnosed with bipolar disorder — what used to be called manic depression. For reasons I’ll explain in a bit, it has become important to me to talk about what it is like to live with the disorder, but at the time it was something that I simultaneously acknowledged and ignored, with an odd kind of doublethink that, I have discovered, is not uncommon with people confronting facts that are unavoidable and yet still something one wishes to avoid. For the first few months I saw a psychiatrist and took medications, but then I simply stepped away from that and for eleven years thought and lived as if bipolar disorder were something I had in theory, not in fact.

A hypomanic episode I had at age 38 finally brought me to reality. With hypomania a person can be charismatic, unusually creative, and brilliantly high functioning. But those who know them well recognize that something I wrong. And if the person is wise, so does he. So early one morning, refreshed and wide awake after only two hours of sleep — notwithstanding the fact that given the pace I’d been keeping and the sleeping pill I’d taken I should have been out cold — I came to realize, and I mean really realize, that I had bipolar disorder and always would have it and was lucky during the preceding decade not to have met with disaster. I sat down at my computer and composed a sort of memorandum to myself. I’m going to read some of it here. At first it will seem to have no relevance to Grant or Lee, but then it will take a turn that should surprise you. It certainly did me.

“I’m obliged to do the one thing we humans hate: face facts. There is nothing harder. I have long been amazed to discover how even very intelligent people can so readily run from the facts. It never occurred to me to realize that I have spent eleven years running from the facts. Yet that is what I’ve done.” I went on to say that I had two main thoughts about it. The first one was obvious: “So far I’ve managed to get through the cycles through my ability to cope, though at what unnecessary personal cost I cannot imagine. How long can I expect my luck to hold? I’d better get with a psychiatrist and do what the hell he directs.”

“The second thought,” I continued, “will seem unrelated and perhaps inappropriate to the context, though I assure you it is not. It is that, while neither I nor anyone else could ever prove it, I think I now know why General Robert E. Lee halted his army on the Sharpsburg ridge on September 15, 1862, rather than do the “prudent” thing and recross the Potomac River. Instead he turned to face his much larger enemy and fought a pitched battle (the bloodiest single day of the Civil War) with a wide, unfordable river about a mile to his rear. Military historians have wondered ever since why he did it. Most of the explanations center on operational or political factors. But is it possible that Lee stood at Sharpsburg because something in his own personal history combined with these impersonal factors to compel the decision he made? If so, I think it was his father.

“Light Horse Harry Lee was, in some respects, a more successful man than Robert. He was a hero of the Revolutionary War and a governor of Virginia, among other things. Yet Harry Lee wound up dying far from home and penniless, for reasons that have to do ultimately with a refusal to face facts or to stand and face the consequences of his life. He fled the country rather than go to debtors’ prison for debts he’d contracted in a series of risky land speculation ventures. In September 1962, Robert took a risk by crossing the Potomac and embarking on a raid into Maryland while his army was reduced in numbers and ill-equipped. After the defeat at South Mountain he should have departed from Maryland as soon as he could. But perhaps something in him resisted the idea of running from the consequences of the risk he had taken. Perhaps he realized that if he did so his future generalship would be compromised. (Generals are human beings first of all; the same psychological dynamics that affect the rest of us affect them.) Perhaps in a much different way than I am doing, Robert E. Lee was also facing facts when he made his stand on the high ground west of Antietam Creek.”

I have visited Antietam many times since then, have conducted historians, laymen, West Point cadets and field grade officers on staff rides of the battlefield. I’ve thought a lot about the insight I had on that particular evening. It is still not something I can prove, and yet if anything I feel even more strongly than I did that basically I got it right. I think Lee understood that if he had withdrawn without a fight he would forever have been one kind of commander and that his army would have been one kind of army. By making a stand on Sharpsburg ridge he became another kind of commander with another kind of army — a commander and an army that enjoyed a psychological mastery over its opponent that it never really lost.

I certainly know that if I had continued to evade the fact of my own mood disorder, I would have been a very different man. I would certainly not have come to see that a central task of my life must be to talk openly about the disorder. It isn’t much fun to do. Like anyone else, I would like to lead a “normal” life, whatever that is. I don’t like having to bring upon myself so directly the stigma that attaches to mental illness. But if I, as a high functioning individual who leads what most would deem a reasonably successful life, don’t talk about it, then I’d simply be an accomplice in the perpetuation of the stigma. To give just one example: only about one college student in four believes that someone with a mental illness can eventually recover. And since about one college student in a hundred has been or will be diagnosed with bipolar disorder — to say nothing of a range of other mental illnesses — the stigma, if unaddressed, still has a very large capacity to damage.

In ethical terms, there’s no deontological or consequentialist moral imperative at work here. I’m not coming within a country mile of saying that high functioning persons with a mental illness are not allowed the option of maintaining their privacy. The moral reasoning at work here is aretaic; which is to say, it is character-driven. It flows from a personal sense of right and wrong as it applies to me. It’s impossible to trace the roots of the sense of duty I feel about this matter. But it would surprise me very little to learn that it tracks back to Lee, or Grant, or both.

I am the readier to believe this because the ethical reasoning involved is identical to that of three American generals — two of them four-star generals — who have publicly disclosed that they are in treatment for Post Traumatic Stress Disorder. And indeed, at the U.S. Army War College I have found an unusual degree of understanding and support for the choice I’ve made, because of the high incidence of PTSD in the current fight. Bipolar disorder is an illness, PTSD is an injury, but they share key features in common. Both must be managed. Both have a stigma.

I have found that in managing the disorder I regularly drawn upon my military training and experience, my understanding of military culture and history, and my background in strategic studies. The most critical feature is that this background has taught me to avoid making what I consider to be the disastrous errors of conflating the illness with one’s identity — “I am my diagnosis” — or of romanticizing the illness because bipolar disorder is associated with many creative people. I regard myself as being at war with an entity that will never rest until it has killed me, either by lifting me into a manic episode of such heights that I do something lethally foolish, or by casting me into a depression so deep that I end my life by suicide.

I cannot think of a stronger way to externalize the illness. Nor can I think of an inducement more likely to get me to manage it with sustained seriousness of purpose. Neither Grant nor Lee ever read the Prussian military theorist Carl von Clausewitz, but they instinctively understood his observation that, “in war, the best strategy is always to be very strong, first in general and then at the decisive point.” Translated metaphorically, what this means is that if you have bipolar disorder you muster every resource you can. If you have access to a psychiatrist and a therapist, you see them regularly. You take your medications. You make a priority of what the mental health professionals call “good sleep hygiene.” You work out regularly. You find environments and people that are supportive. And when necessary you divorce yourself, calmly but ruthlessly, from environments and people that are not.

You take the illness seriously, but you don’t let it rule your life. I said before that Lee achieved a psychological mastery over the Army of the Potomac that he never really lost. It was a source of enormous frustration to Grant when he tried to use that army as a tool, because it seemed to have over caution encased in its organizational DNA. Confronted on one occasion by a frantic general who warned him of a fatal blow he believed Lee was about to deliver, Grant snapped, "Oh, I am heartily tired of hearing about what Lee is going to do. Some of you always seem to think he is suddenly going to turn a double somersault, and land in our rear and on both of our flanks at the same time. Go back to your command, and try to think what we are going to do ourselves, instead of what Lee is going to do." It is the same with bipolar disorder. Although the disease is an adversary one must respect, it should not be so intimidating as to prevent one from taking the normal risks necessary to achieve success in ordinary life.

By now I hope you can see some of the personal resonance the Grant-Lee exhibition has for me. If it seems as if this understanding derives as much from the mythic dimensions of these men as from the down to earth dimension, that gets at something that as an historian, I’ve learned to accept as being true of most people who find fascination in, and derive meaning from, the human past. Myths can be myths in the sense of falsehood. They can also be myths in the sense of isolating and inscribing deeper truths. So will we ever shake the grip of our myths about Lee and Grant? I doubt it. We need it too much. Although perhaps no longer necessary as an embodiment of the Lost Cause, the myth of Lee has a more universal resonance. Sooner or later, everyone loses. The dreams of youth are left behind, the fatal diagnosis is pronounced. The idea of facing inevitable defeat with courage, dignity, and humanity — as Lee is rightly said to have done — therefore has powerful attraction.

But if we need the myth of Lee, so, too, perhaps, we need the counter myth of Grant. The world is as full of obstacles as it is of losses, and to get anywhere in life one must possess grit, drive, determination, persistence. And so we also need the image of Grant: Grant the implacable, Grant the hammerer, Grant the man who, despite everything, keeps moving on.

Note From a Consumer

Last Thursday I attended a showing here of Minds on the Edge: Facing Mental Illness. (My last entry showed the promo.) The documentary, the latest in the Fred Friendly Seminar series, is being aired on PBS this month. It uses a format you may have seen over the years in previous installments (since its inception there have been over a hundred):

The Seminars always begin with a little story and a problem that could confront almost anyone. The implications of this problem, whatever it may be, then ripple out to encompass larger and larger issues and trigger ethical, emotional, legal, and public policy questions that are always overlapping and sometimes in conflict. Each Seminar program brings together a carefully chosen panel that contributes professional expertise as well as personal experience to the discussion. As the panelists wrestle with the issues presented in the hypothetical story, they are encouraged not just to say what they think about an issue, but to say what they would do in difficult decision-making situations if they were personally involved. The viewers are along for the ride, emotionally and intellectually, as the story creates a link for citizens between their lives and issues in the headlines that so often seem remote, abstract and unconnected to their day to day concerns.

It's an effective method. Minds on the Edge addresses mainly the problems involved first, in getting persons experiencing a mental illness crisis into treatment (the assumption is that most such persons resist treatment); and second, the way in which the mental health "system" takes care of persons once they do get treatment. I place "system" in quotes because, as the program makes clear, no system exists, merely a jumble of well intentioned but underfunded and uncoordinated efforts by a variety of hospital, outpatient, governmental, and non profit organizations.

You can find the entire program online. It runs just slightly over an hour, and on the whole it's fascinating but pretty depressing.

In addition to watching it on PBS or online, you can watch it at a screening at some church, civic organization, or similar venue. This screening I attended was organized by the local chapter of NAMI (National Alliance on Mental Illness). About forty people were also in attendance. NAMI divides the mental health world into three types of person: providers, consumers, and loved ones. Providers are mental health professionals, advocates, etc. Consumers are people like me; i.e., those who have a mental illness and are therefore consumers (or at least potential consumers) of mental health care. Loved ones are the friends and family -- usually parents and/or siblings -- of consumers. The categories can overlap. Providers, in several instances, are also consumers. I suppose they could be loved ones as well.

By the way, I'm not wild about being called a consumer. Words carry freight. The phrase consumer not only sounds kind of weird to me but also implies that being in treatment for a mental illness is central to my identity. As I hope I've made clear by now, I dislike any phraseology that conflates an illness one has with a statement of what one is. Still, it's plain that consumer was chosen faute de mieux, so I guess I can live with it.

Following the screening was a sort of panel discussion that involved a consumer (who happened also to be the chapter president), a provider, and two loved ones (a father and mother with a son who has bipolar disorder). Early in the discussion it became apparent that most of the audience consisted of self-identified loved ones. I seemed to be one of the few consumers in attendance.

I had learned about the screening following a brief conversation in August at the annual Army War College "county fair," an elaborate event in which dozens of local merchants, non profit groups, etc., congregate for an all day event designed to give the incoming resident class and their families an idea of the services locally available. I had a brief exchange with the people manning the NAMI booth, mentioned that I had bipolar disorder, and offered to join their speaker's bureau if they had one. They did. The most appropriate one seemed to be a program called In Our Own Voice. Here's a description from the web site:

In Our Own Voice (IOOV) is a unique public education program developed by NAMI, in which two trained consumer speakers share compelling personal stories about living with mental illness and achieving recovery.

The program was started with a grant from Eli Lilly and Company.

IOOV is an opportunity for those who have struggled with mental illness to gain confidence and to share their individual experiences of recovery and transformation.

Throughout the IOOV presentation, audience members are encouraged to offer feedback and ask questions. Audience participation is an important aspect of IOOV because the more audience members become involved, the closer they come to understanding what it is like to live with a mental illness and stay in recovery.

IOOV presentations are given to consumer groups, students, law enforcement officials, educators, providers, faith community members, politicians, professionals, inmates, and interested civic groups.

All presentations are offered free of charge.

My first presentation is slated for November 16 at a Family to Family Education Program, a free, 12-week course for family caregivers of individuals with severe mental illnesses.

I have, of course, written in several venues about having bipolar disorder. But, aside from speaking to a psychology class at Dickinson College, this will be the first time I've given a regular talk on the subject. I feel slightly daunted at the prospect. To begin with, I'm fortunate enough to have a mental illness that, compared to what others have to face, is mild. It's a pain in the ass sometimes, but it's never seriously interfered with my ability to function normally. Indeed, I've always felt that from a mental health advocacy standpoint, my chief value is as a high functioning individual willing to say forthrightly that he has a mental illness. People who can keep their diagnosis private generally tend to do so.

As a corollary, I worry that anything I have to say will be a) irrelevant to the situations of my audience; or worse b) will convey the disastrous impression that if I can manage the illness so "easily," then so could their family members if only they applied themselves. The only solution I can think of is to offer the appropriate caveats, concentrate on my own experience, and avoid saying anything that sounds prescriptive. And anyway, the main thing I would want to convey is how impressed I am that they are actively supporting their loved ones -- I mean consumers. Aside from being under the care of a psychiatrist and therapist, I can think of nothing more critical to helping someone with a mental illness manage it most effectively.

Minds on the Edge