Mental Health System Rant, and What Can Be Done Better (a Pipe Dream)

Who takes over when you get a mentally ill family member to the ER? Nobody.

Who takes over when you get a mentally ill family member to the ER? Nobody.

Lately I’ve been trying to get help for a relative who is mentally ill. What passes for a “mental health care system” in the United States is a joke. There is no system. There is a patchwork of uncoordinated crap.

I try to be positive and constructive on this blog, and to offer something of value to my readers. This post will be no exception, but I need to get a short rant out of the way first.

Some observations …

  • HMOs tend to farm out mental health services to independent clinics, and then refuse to coordinate with those clinics (like transferring medical records to the psychiatrist). This means the person with mental illness needs to deal with such logistics (which means a family member or caregiver needs to do it – if they have access and permission).
  • There is an incredibly low bar for “well” or “ok” among most psychiatrists. If you are not currently committed for violent or suicidal behavior, you are doing “well” or “fine.” Even if the patient is delusional and suffering from severe memory issues, they are deemed “ok” if they are not hospitalized.
  • All psychiatric drugs are prescribed on pretty much a crapshoot “let’s see if this works” basis.
  • It is extremely rare for a patient with mental illness to be able to work with a single qualified psychiatrist, or even a single team. The patient is much more likely to see a psychiatrist who is new to their case, ignorant of their history, and under too much time pressure to carefully consider the needs of the patient.
  • Getting committed to psychiatric lockup is horrible for the patient, even if the facility is run well. Everyone is aware of losing their freedom when they lose it. But often it’s the only way for a patient to get care. Usually the care is sub-par, and consists of sedation, cursory evaluation, and rapid discharge.
  • The “residential treatment” options I have seen are really dismal. Ratty houses, cramped quarters, no psychiatrist (or therapist) on staff, lots of TV watching, lots of sitting around. Not a healing environment.

I could go on and on, but my point is simply that there is massive room for improvement. The Mental Health Parity Act (2013 technical amendment) is a start. But what would real improvement look like? What’s the best case scenario?

I’ll put forth my own pipe dream. Here’s what I would want the experience of trying to provide help for a mentally ill family member/loved one to look like:

1. Let’s assume the patient has HMO coverage with Kaiser Permanente, either through employment (unlikely if they are chronically disabled), through Medicare, or independently purchased. (Already we’re in pipe dream land, right? Many people with mental illness don’t have *any* medical insurance).

2. I notice my family member or friend is having severe psychiatric problems (serious depression, mania, psychosis, delusions, hallucinations, confusion, memory loss, etc.). Let’s assume I manage to notice these symptoms before they reach a point of “decompensation” (med speak for losing your shit entirely — especially with schizophrenia).

3. I convince the friend or family member that it’s time to seek help, and (depending on the seriousness of the symptoms) we go to the ER or make a regular doctor’s appointment. Those who have been in the situation know what a Herculean feat of patience, persuasion, and persistence this single step entails.

4. Medical tests (blood work, blood pressure, exam, interview) are run to rule out stroke, side effects of new meds, etc. These tests are either run in the same intake location (ER or doctor’s office) or a medical escort is offered to help the patient and caregiver navigate the system (pipe dream — I know!). If it’s clear the problem is psychiatric in nature, the patient is referred (immediately) to a psychiatrist on call.

5. The on-call psychiatrist begins the diagnostic process, considering recent events in the patient’s life, meds history, family history, nutrition, sleep, past episodes of mental illness, etc. At this point the on-call psychiatrist refers the patient to a permanent psychiatrist (the patient would have the option to change doctors later if desired), and provides the option of a short-term residential voluntary stay in an HMO-managed facility.

6. The permanent/longer-term psychiatrist meets with the patient and caregiver(s) in the context of the short-term residential program or regular appointment. The in-depth diagnostic process begins, and includes the following tests and considerations:

  • detailed patient history (previous episodes, past and current medications, life circumstances)
  • genetic (family history and complete DNA sequencing)
  • nutritional (eating habits, allergen testing, gluten sensitivity, tests for vitamin and mineral deficiencies)
  • infectious disease, as related to psychiatric conditions (neurosyphilis, toxoplasmosis, etc.)
  • recent traumatic events (death in the family, divorce/breakup, loss of a job, etc.)
  • sleep patterns, sleep deprivation
  • changes in medications, side effects of medications
  • recent chemical exposure/toxicity
  • drug/alcohol abuse
  • meditation (not kidding here — I know of two cases of meditation-induced psychosis)
  • recent head injury or concussion
  • brain scan/other neurological tests (looking at both activity and organic structure/pathology including injury or tumor)

7. The patient, psychiatrist, and (if invited) caregiver(s) come up with a treatment plan, and treatment goals. The treatment plan would contain the following elements:

  • conservative medication (conservative both in dosage, and in the number of concurrent medications, and in the duration of the prescription — not every psychiatric patient needs to be on meds for the rest of their lives)
  • medication tapering (if the side effects are suspected as being part of the problem, powerful psychiatric medications may need to be tapered off slowly, over a number of weeks or even months)
  • nutrition (high nutrient/low junk diet, with food restrictions if tests indicate such restrictions might be helpful, correcting any nutrient deficiencies)
  • exercise
  • social (time with family and friends)
  • therapeutic (group, music, talk, addiction, whatever is appropriate for the patient)
  • treating any infectious diseases or other treatable organic causes discovered during the diagnostic process

Not all of these elements would be required for every patient … it might be more effective to devise a simpler treatment plan with fewer elements. But they should all be considered by the psychiatrist.

8. The patient should have the option to stay in a voluntary residential program (HMO-managed, covered by insurance), under psychiatric observation, for as long as they need. In cases where powerful medications are being added, tapered off, or modified, months of observation and supervised meds might be required.

9. Follow-up. The patient should be able to meet with the same long-term psychiatrist for years, as needed.

Those who have had experience dealing with the mental health “system” in the United States know how far we are from anything remotely resembling the scenario described above.

But it’s not impossible.

A few years ago I had a hernia repaired, through Kaiser. The entire process was incredibly streamlined and well-managed. Every step of the process was well-organized. The level of care was excellent. Even with insurance, I paid a lot out-of-pocket, but it didn’t bankrupt me.

So large HMOs can provide excellent care. But most of the time, people with mental illness fall through the cracks. They are treated like 2nd-class citizens. They are blamed (or partially blamed) for their own condition. Their treatment is outsourced to poorly funded, haphazardly run clinics. Caregivers must navigate a Byzantine maze of services. The left hand doesn’t talk to the right hand. The ball is constantly dropped. Nobody is willing to take responsibility for the patient’s medical care. Doctors say “it’s a psychiatric problem,” as if the brain were not an organ of the human body.

Psychiatric care should be medical care. One system, accountable and responsible for the wellness of the patient. Just like any other disease!

Psychiatric care is incredibly complicated (and expensive). The patient isn’t thinking clearly, and won’t necessarily comply with recommendations. So HMOs like to avoid the sticky wicket, and outsource the care. But they shouldn’t be allowed to. They should step up and deal with these patients like they do with every other kind of patient. That’s why the Mental Health Parity Act and continued improvements to psychiatric healthcare are important.

25 responses to “Mental Health System Rant, and What Can Be Done Better (a Pipe Dream)

  1. The main problem with mental illness “care” is that the system does not look for root causes and address them. (Actually, this is pretty much true for all medical care except for accident/physical-trauma repair.) So I don’t think the answer is to reform the process!

    Most people with “mental illness” have severe systemic inflammation along with a brain that is sensitive to it, often due to a prior illness, always with a contribution from diet/nutrition/lifestyle. This is also true for people with other brain-related conditions, such as ADHD, autism, epilepsy, etc.

    Digestive enzymes usually make a dramatic difference, both by breaking up toxins and eliminating food sensitivities, and by increasing nutrient absorption. We’ve used the Enzymedica Digest Gold and like it. Because it comes in a cellulose capsule, you need to open the capsules and take the powder with food, or else take the whole capsules 30 minutes before eating, so that the enzymes and food are in your stomach together. (The cellulose capsules take 30 minutes to open up in your stomach.) Or, if you have access to a health-case provider who uses Standard Process supplements, they have a number of options all in gelatin, so they can be taken with food (gelatin dissolves instantly). See Karen DeFelice’s books for more info.

    For autistic kids, digestive enzymes resolve symptoms for about 80% of them, and should have the same effect on other brain-related issues.

    If your relative is receptive to diet changes, there is an auto-immune diet protocol that will definitely help, see the paelomom web site. The blogger, Sarah Ballantyne, has an excellent new book out on treating auto-immune diseases.

    • Tim — I agree that nutritional factors are important. But you may not have considered how difficult it is to persuade a person suffering from severe mental illness to eat well. I have 0% control over my adult relative’s diet. Yet I still want to try to help them. The kind of help my relative needs is *way* beyond my own capacity to offer … even if I somehow knew the perfect treatment plan. That’s why I NEED reform of the mental health care system. Should this reform include consideration of nutritional factors in both the diagnostic and treatment phases? Absolutely.

      • Yes, it can be impossible to get compliance with a protocol that would resolve things, and it would be wonderful to have a health care system that works on root causes instead of just dispensing pharmaceuticals. I think that changing the treatment paradigm is more important than changing the mental-health-care system. As long as people think the answer is to see a psychiatrist and take meds, things won’t change — people will still be sick, just medicated with all the side-effects and limitations of drugs. Once people understand that feeling good is totally under their control, we’ll see significant progress.

        The nice thing about taking digestive enzymes is that it is minimally disruptive, no diet/lifestyle changes are needed, so the chances for compliance are much better than with more extensive changes. If someone can do more, their chances are better, of course, approaching 100% with the best protocols.

        • Tim — I appreciate your thoughtful comment, but I disagree with you on one point which I think is very important: the idea that “feeling good is totally under their control.” For healthy people, there are choices we can make that tend to lead to feeling good and feeling happy. For people with severe mental illness, the situation is much different. It’s important not to blame the victim. The “root cause” may be genetic, or a severe childhood trauma or brain injury, or an infectious disease that affects the brain. To tell a person with severe mental illness that they just take care of themselves (fish oil, enzymes, paleo diet, whatever) and they’ll feel better is usually not a helpful or effective approach (at least in my experience, and I’ve actually tried this a number of times!).

          I agree that nutrition, exercise, and supplements can often be part of an effective treatment plan. I also agree that more resources should be dedicated to diagnosis — to finding a root cause. But what if a root cause can’t be found? What if it’s a combination of factors? Should effective medication be denied to the patient?

          • I want to see people empowered to take care of their own health, not blamed as a victim!

            Modern medicine is in the business of prescribing pharmaceutical drugs, not in the business of providing good health. Going the pharmaceutical route can provide short-term symptom relief, but guarantees side effects, more meds, and poor health on a long-term basis. This is particularly true of drugs intended to alleviate mental illness. Even drugs considered benign, such as asprin or acetaminophen, have consequences.

            The underlying problem with mental illness, autism, ADHD, and all the illness we see as people age is chronic inflammation. This means that the immune system is always turned on, cortisol is elevated, and sleep is disrupted. Inflammation increases levels of peroxynitrite, which damages proteins, causes dysfunctional metabolism, and can lead to autoimmune diseases which cause further damage. There is a vicious circle here: chronic inflammation leads to more inflammation. Various tissues are affected depending on prior illness, genetic variation, autoimmune responses, etc. When the brain is affected, the result is mental illness, autism, ADD/ADHD, epilepsy, addiction.

            All of the protocols that address root causes work by reducing inflammation. Omega-3 fats balance the immune system and reduce inflammation, paleo diets eliminate grains/legumes and their toxins thus reducing inflammation, digestive enzymes increase nutrient absorption and reduce leaky-gut-centric inflammation, vitamins and trace minerals as needed help your metabolism and immune system and reduce gut-centric inflammation. Sunlight and Vitamin D potentiate and calm the immune system. If you have chronic systemic infection from virus/bacteria/fungus/parasites, that creates inflammation. Heavy metal and environmental toxins can create ongoing high levels of inflammation. Food and environmental sensitivities ramp up inflammation.

            Not saying it is easy to resolve all this — just that modern medicine will not. (Although in fairness there is a small percentage of doctors who might actually improve your health, but they rare.)

            So, should someone who is highly dysfunctional take “effective meds”? I am not aware of any such produced by the pharmaceutical industry.

            There are a lot of effective nutrition/lifestyle changes, herbs, herbal extracts, and nutritional supplements, for all the issues listed above, but they won’t be prescribed by your doctor.

            • “The underlying problem with mental illness, autism, ADHD, and all the illness we see as people age is chronic inflammation”

              Based on what evidence? What about genetic factors?

            • Looks like the thread got nested too deep, so I couldn’t reply to your comment directly.

              The view that mental illness and other brain dysfunction stem from inflammation is not universally accepted, but is consistent with all the evidence that I’ve seen, and explains everything afaik. For example, here is an article that relates depression to inflammation: http://www.healthline.com/health-news/mental-mood-disorders-tied-to-autoimmune-diseases-infection-061213. When you look at protocols that treat mental illness, almost always they are directly associated with reduced inflammation. For example, most schizophrenics have a full recovery on a gluten-free/dairy-free diet, which has the effect of reducing systemic inflammation. Low-dose naltrexone therapy for auto-immune illness has the effect of blocking the immune system’s TLR4 receptors, which respond to LPS leaked from gram-negative bacteria in the gut, so reduces inflammation. One of the side effects of LDN is improved mental health: http://www.lowdosenaltrexone.org/ldn_trials.htm. There is lots more, easy to find…

              That increased peroxynitrite is the underlying mechanism for inflammation-cause dysfunction is well-supported. There is a good survey article at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2248324/. Martin Pall’s book, Explaining Unexplained Illness goes deeper into the mechanisms by which peroxynitrite causes damage, and how it is possible to get into a vicious circle with inflammation increasing peroxynitrite, and the peroxynitrite increasing inflammation… (http://www.amazon.com/Explaining-Unexplained-Illnesses-Fibromyalgia-Post-Traumatic/dp/078902389X/ref=sr_1_1?ie=UTF8&qid=1394396310&sr=8-1&keywords=martin+pall).

            • Re genetic/epigenetic factors, most people living in a optimal environment for their genes would be very healthy. If you look at the studies of populations living in their traditional environments, they have extremely low incidence of cancer, degeneration with aging, mental illness, etc. (Weston Price supports this, obviously, but more confirmation is easy to find.) So I think most people today have physical/mental dysfunction because of the mismatch between what they need to be healthy and our environment.

              There is a small percentage of people who have true genetic issues that keep them from being healthy even in the best possible environment. As far as I can see, this is a small percentage, perhaps one in 1,000.

  2. JD. Your insight is remarkable as usual. I personally have witnessed the problem with the present day lack of system, education and culture and vision and sensibility to manage a mentally ill patient, both in doctors, the medical ” system” and family. I am an attorney and I had a client, in his mid sixties, quiet succesfull in his business, with a great character, resiliance, etc. but after he was sued to pay millions of dollars he became very stressfull and his good doctor recommended anxiety medication, then antidepressants, he ended up going to a psychiatrist and I started to see the decline in his physicial and mental health once he started to take such medication. I had always been aware of the serious second effects of antidepressants and psychotropic medications and the irresponsability of doctors in prescribing them. After 3 years his case was finally over and when I called him to give him the good news and he did not care much for it, I became so worried for him, days after I cold him with no repply, called his office and he had not been there for days, for 2 weeks I tried to get a hold of him until one day he answered and told me he had been for weeks very sick from his ” illness” he said
    but on that day he was doing a little better. And I said which ” illness” to my self. It was clear that the doctors had told him that he was seriously ill with chronic depression and they could only but medicate him. I told him please you need to see your psychiatrist immediately I have seen how since you started with your medication your mood and energy has changed so dramatically even your firm character, please ask him to review the medication and to get psychological therapy, in all your life you were never a depressed or nervous person on the contrary, please don’ t consider yourself and Ill person. It is only temporary. He told he could not sleep for so long and that he would see his psychiatrist the next day and the next time we would speak he would be better. I don’ t know if he did or not but 2 days after I spoke with him he commited suicide. I thought he was in a deep ditch but would never know because of my lack of education in this matter like his family and his doctors that a person with clinical depression caused by medication, intensified by medication or by nature should be never left alone, that medication implies close and permanent watch from doctors and family, that the FDA has black labeled all this type of medications as probable cause of suicide. That the Association of Psychiatrists in the US and around the world have seen the importance of cognitive-behavioral psychological therapy when treating people with depression. We all have to be watching for the sings. People taking medication can develop a temporary psychosis and other serious effects that can lead to suicidal thoughts and actions. After this happened I spoke with a cognitive-behavioral therapist and she told me that never a psychiatrist has send her a patient to complement their treatment notwithstanding the important research on this matter. Now I know better but as you also mentioned in your article you have cero control over your relative and that is many times the issue. Even when you are seen the severity and forseen the outcome in a relative, friend, person in a mental health problem situation how can you force him or her or her family, caretaker, spouse to sick urgent and immediate help or their doctors to do so? if they are not in a psychotic state were police can be called to assiste this person in not harming himself or others because is so inminent?
    If something liked that happened to me at some point in my life what would I want others to do? Should I informed, even put it in writing for my family and friends and doctors so they do not have any excuse in not doing anything? Should we all do that? bring this issue to our home, friends, doctors table?

    http://www.nejm.org/doi/full/10.1056/NEJM200005183422001

    http://ajp.psychiatryonline.org/mobile/article.aspx?articleid=1688270&journalID=13

    • Whew — rough story. It’s hard to know what to do in such situations. Even if you take on the care of someone else’s mental health as a “project” there is no guarantee of positive returns. Patients with serious mental illness need comprehensive professional care (sometimes around-the-clock), not just help from family and friends. Unfortunately that kind of care is almost impossible to get unless the patient is violent or clearly suicidal, and in those cases they receive care at the expense of their freedom and dignity (lockup in the psych ward … or prison).

  3. Well said JD. I hope that we can talk soon about options.

  4. Thanks for your rant, and suggestions. I think many of us can relate.

    Because of the ins and outs of what’s available through the new ACA, my family and I have just switched to Kaiser–about which I have heard mostly good thing. However, when I mentioned the switch to my current therapist, she shared with me a rather shocking insight into their mental health care approach. Bear with me…

    Apparently there is a 10-point scale called the Global Assessment of Functioning in the current DSM (Diagnostic and Statistical Manual). The scale looks at various levels of mental health functioning and assigns a point value. For example, 60-51 is defined as “Moderate symptoms (e.g., flat and circumstantial speech, occasional panic attacks) OR moderate difficulty in social occupational, or social functioning (e.g., few friends, conflicts with co-workers).”

    The catch is that Kaiser’s stated goal (at least according to my (non-Kaiser) therapist), is to return you to the highest level of functioning you had in the past year. So if you are a 50 when you enter the Kaiser system but only ever functioned at a 70 within the past year, that will be their goal. And a 70–“Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships” –does not sound like a definition of good health to me. Or, even worse, if you’re suicidal but functioned at 50 at some point, that’s as far up as you can aspire to go with Kaiser’s help.

    Apparently this will change in October when the new DSM comes out. But how? We don’t know.

    • Interesting … didn’t know that!

    • A cousin of mine with a Ph.D. in Psychology Cognitive Behavorial therapy told me that the latest Manual was influenced by the Pharmaceudical Companies to the point that now the parameters for illness evalutation are based basically in the amounts and type of medication given to the patient!! So illogical and unfair.

  5. Well written article. I do hope that one day the dream of a better health care process for mental illness treatment eventuates, Your detailed plan appears comprehensive and well thought out after much consideration. Another step is possibly the recognition and removal of any stigma or embarrassment about mental health issues. In my experience, most people prefer to ignore the topic as they aren’t informed, are fearful or possibly because it seems all too hard to solve. This problem should belong to all of us, whether we like it or not.

    • Agreed! Claire Danes’ role in Homeland is starting some interesting mainstream conversations re: severe mental illness (which is a significant step in terms of stigma removal).

  6. Re: meditation induced psychosis, here’s a cool article about Dr. Willoughby Britton who does research on that:

    http://www.psychologytomorrowmagazine.com/enlightenments-evil-twin/

    She spoke at a conference I helped organize this past weekend and had a really cool talk. The talk may not be posted on youtube for a while cause she were concerned about some of her unpublished data being misconstrued by the media, but you may want to subscribe to the youtube page or sign up for the email newsletter to get the update about the videos becoming available: http://uoftmindmatters.com/

    While I’m at it: you would probably be interested in the videos from Mind Matters 1. It was about whether foolishness can cause psychopathology. Dr. Jordan Peterson, in particular, has a fascinating talk and he started with accusing of the DSM categories of mental illness being essentially like astrological categories.

  7. Tim — thanks for sharing the research links above. I have looked for the research linking gluten/casein-free diets to a reduction in schizophrenia symptoms. From what I seen dietary modifications do help a small number of patients, but nothing like a “cure”. Still, it seems to be a low-risk recommendation, so why not try? I wish I had more influence over my mentally ill family member’s diet and supplement intake! Unfortunately he is very “anti-vitamin” and sees even the most benign suggestions on my part as interference. I know I am not alone in this experience. I would like to see more psychiatrists recommend dietary changes and specific supplements, in addition to effective medication regimens (yes, I do believe many psychiatric medications are effective — I have seen friends and family members go from suicidal to non-suicidal, from psychotic to calm and rational, etc.). Some psychiatrists do seem open to this approach, for example Emily Deans:

    http://evolutionarypsychiatry.blogspot.com/2013/11/gluten-and-schizophrenia-again-with.html

    If anyone can recommend a Bay Area psychiatrist who has experience with holistic approaches (not holistic in a new-age sense, but holistic meaning including diet, nutrition, exercise, genetic analysis, etc. — the whole package and not just “the right meds”), please let me know.

    • I like Emily Deans too, that is a good article, thanks.

      My info on gluten-free/dairy-free treatment for schizophrenia comes from Hoffer’s books, I don’t know if he published any papers on it. I suspect from Emily Dean’s article that if antibodies to gluten/dairy were used as markers for gluten/dairy-free treatment compliance, that significant symptom reduction would go along with getting these markers down to typical levels.

      Re meds, I’m glad they appear to have helped your friends/family, but I have not seen any good experiences among the people I know who’ve used them. There is a book in my stack, Blaming the Brain: The Truth About Drugs and Mental Health, by Elliot Valenstein, that looks pretty good. It reviews the poor evidence for using meds for mental illness, as it appears that most drugs are comparable to placebo (e.g. about 1/3 respond well, 1/3 have some improvement, and 1/3 have no change). Also see http://www.astrocyte-design.com/pseudoscience/index.html

      Then of course there is the downside of meds: increased suicide. Here is a good article on one drug, describing how the dismal safety results of a drug trial were made to look OK: http://www.madinamerica.com/2012/02/the-real-suicide-data-from-the-tads-study-comes-to-light/

  8. This article highlights the serious lack of coordination between medical care and psychiatric care:

    http://www.sfgate.com/health/article/Severe-mental-illness-robbing-years-from-lives-3249171.php

  9. I can definitely relate to your frustration! I also have a relative (sister) diagnosed with schizophrenia. The system has failed her horribly, despite active help from parents and siblings. Apparently the “system” assumes that a mentally ill person has the “right” to accept or even determine their treatment. If they refuse (as my sister did), there is no way that the family can intervene in her behalf!!! Consequently, they are often victimized- gullible beyond belief- and are easy targets for those wishing to take advantage of them in many ways (sexual, financial, and more). It makes me sick….

    • Thanks for your comment Linda. California’s 5150 law protects patients with mental illness; psychiatric lockup is a last resort for cases where the person is a clear danger to themselves or others. This, combined with the lack of other good options, is enormously frustrating for families. Still, I think it’s a good law — I would like to see changes in other areas, like the quality and scope of medical care made available.

      Some states do require mandatory medication for certain types of schizophrenia. This makes sense if a person has shown violent tendencies, but otherwise I think patients should be able to choose their own course of treatment. Most psychiatric medications have severe side effects, and in some cases environmental changes are just as effective (exercise and fish oil for some types of depression, for example).

  10. Kaiser mental health care workers aren’t happy with the level of care they are able to provide, and are demanding greater resources:

    http://www.berkeleydailyplanet.com/issue/2014-04-25/article/42052?headline=Mental-Health-Clinicians-Hold-One-Day-Strike-at-Kaiser-Oakland–By-Justin-DeFreitas\

  11. I like this post a lot, but I would just like to point out, as a person with Bipolar Disorder, that not everyone has a caregiver. People with genetic mental illnesses often come from a family with parents who are also mentally ill, and often end up with a lifetime of severely suppressed choices due to being born with a chronic illness into a low income family full of people who were not able to work up to their full capacity because of their own illnesses. My father is gone, and my mother counts herself incredibly lucky if she can get a full night’s sleep once every two weeks.

    The thing I wish I could tell the whole world about my illness is that it isn’t just that I feel down or act strangely- even with medication, I regularly have mania and mixed episodes that limit my ability to handle certain types of stimuli, and depression saps the chemicals in your brain that motivate you to do things. So as someone who works full time, that limits how much energy I have to put into my own self care. It also limits the type of job you can do, whether you can go to college, etc. And of course it’s possible to eat very healthily and live well on less money, but usually that involves giving up time, which a mentally ill person may not be able to do the same way a mentally healthy person can. So between the depressed income and the limitations, telling someone something like “Just start eating such and such a diet and you will feel way better” may be true, but may not be possible. Unfortunately, the same goes for the mental health system and the social programs there to help people who have hard times- often those systems are byzantine and difficult. And it should never be assumed that people who need help can make working these systems their full time jobs, or that they have someone else in their life who can.

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