Take care of your goldfish

In the October 16 NYT Trilobites blog, we learned, what some of us have long suspected, fish get depressed. "The trigger for most domestic fish depression is likely lack of stimulation," reported Heather Murphy. Fish are naturally curious, Murphy quotes Dr. Victoria Braithwaite who recommends adding new objects to your fish tank, or moving them around.

Since at least in 2008, it has been common knowledge that low levels of anti-depressants are making their way out of our bodies, through the waste stream, and into the ocean (and back into our supply of drinking water). Fairly contained bodies of water, like Puget Sound, don't get flushed thoroughly. Here's a recent summary from 2016 on Vice (and abstract for the underlying research.)

For my Bay Area friends: Drugs in Water.

Here's a poem from five years ago about barnacles and the gasping ssri sea.

If you recall Darwin made his name in barnacles before publishing On the Origin of Species. His friend and mentor, Joseph Hooker, told Darwin that he and his fellow scientists would have little confidence in any speculation about the possibility of species evolving if it came from someone who had not done the real, nitty-gritty taxonomic work of describing some group in detail. Darwin replied to Hooker: “How painfully (to me) true is your remark.” He chose barnacles; he'd collected many in his travels. (Source: Naming Nature.)

In 1854, after 8 years of studying barnacles, Darwin wrote, "I hate a barnacle as no man ever did before, not even a sailor in a slow moving ship."

Just do what you can do. Take care of your goldfish.

Unadulterated

Unadulterated

Outside the Krol hearing

a witness sits

in a holding room,
the door cracked open

so he could breathe.

A paper cup

stained red by worried lips

desiccates under fluorescent light.

White hair buzzing, she flares

gray over me.

You have no place here

so help me god!

As if god or some judge
could ever stop her.

The maroon smeared across the linoleum
must be coffee.

This is a rewrite of Periodic Evaluation. The previous title didn't do much, and I've referenced Krol hearing directly,which while more arcane, is google-able and precise. The new title is also probably too cryptic, but I like the word. There are 4 ways in which the "she" is unadulterated:
1. No lipstick, no hair color ... her natural self
2. Yes, institutionalized, she is taking her meds, but they aren't really changing anything.
3. Allusion to adultery.
4. Like meds, neither god nor the judge is changing anything.

I've tried to clarify the pronouns, and that it was the "she" talking. There are 2 things I worry about in this rewrite: have a lost any immediacy or surprise or velocity? And can the reader see her barging in--the shock, the surprise of her entering the supposedly safe conference room. I've tried many ways to make this more clear, but haven't found one I like.

barnacles

barnacles

sand ran with salt water
back and forth

sallow foam
tumbled down the estrogen enriched beach

over concrete blocks

and asphalt slabs stacked

like uncut gravestones

against the gasping ssri sea

breakwater

sessile in erosive setting

encrusting rebar
turn to chalk lose their name

awareness there
where the water ends each time

Meghan O'Rourke on Grief

In the February 1, 2010, The New Yorker, Meghan O'Rourke asks if there is a better way to be bereaved.   O'Rourke frames her piece around Elisabeth Kubler-Ross, the Swiss psychiatrist, who in 1964 started lecturing on death.   "Death, [Kubler-Ross] felt, had been exiled from medicine."

Her argument was that patients often knew that they were dying, and preferred to have others acknowledge their situation: “The patient is in the process of losing everything and everybody he loves. If he is allowed to express his sorrow he will find a final acceptance much easier.” And she posited that the dying underwent five stages: denial, anger, bargaining, depression, and acceptance.

I've been in grief therapy for more than three years. I'm not as hung up (or put off) by the grief stages as others. I understand them as useful metaphors. In my therapy, Dr. Gail Giacalone, talked about 7 stages--the first three of which are shock, confused thinking, emotional tumult. I'm paraphrasing. I was taught that these three phases can occur on top of each other--which my experience confirms.   I don't recall what the other 4 stages are any more.

O'Rourke writes:

Today, Kübler-Ross’s theory is taken as the definitive account of how we grieve. It pervades pop culture—the opening episodes of this season’s “Grey’s Anatomy” were structured around the five stages—and it shapes our interactions with the bereaved.

Scientists have found that grief, like fear, is a stress reaction, attended by deep physiological changes.   Levels of stress hormones like cortisol increase.   Sleep patterns are disrupted.   The immune system is weakened.  Mourners may experience loss of appetite, palpitations, even hallucinations.  They sometimes imagine that the deceased has appeared to them, in the form of a bird, say, or a cat.  It is not unusual for a mourner to talk out loud—to cry out—to a lost one, in an elevator, or while walking the dog.

Additional studies suggest that grief comes in waves, welling up and dominating your emotional life, then subsiding, only to recur.  As George A. Bonanno, a clinical psychologist at Columbia University, writes in “The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After Loss” (Basic; $25.95), “When we look more closely at the emotional experiences of bereaved people over time, the level of fluctuation is nothing short of spectacular.”  This oscillation, he theorizes, offers relief from the stress grief creates.  “Sorrow . . . turns out to be
not a state but a process,” C. S. Lewis wrote in 1961. “It needs not a map but a history.”

This "grief comes in waves" idea was very useful to me.   When I saw the six, nine foot swells cresting, it was useful for me to know that it would pass, recede.   When you body surf you lose if you fight the water.  You can't possibly be strong enough to stop it.   It was equally useful for me to know the wave would come again.

O'Rourke continues:

To say that grief recurs is not to say that it necessarily cripples.

Even Bonanno, trying to offer a neutral clinical description of grief, betrays how deeply he has bought into the muscle-through-it idea when he describes a patient who let sad feelings “bubble up” only when she could “afford to.” Many mourners experience grief as a kind of isolation—one that is exacerbated by the fact that one’s peers, neighbors, and co-workers may not really want to know how you are. We’ve adopted a sort of “ask, don’t tell” policy. The question “How are you?” is an expression of concern, but mourners quickly figure out that it shouldn’t be mistaken for
an actual inquiry.

Another thing Dr. Giacalone made sure I understood: "Bill, no one walks in your shoes," "everyone grieves in their own way, in their own time."  Some people would be good at showing sympathy, others would be awful.  Some wouldn't be able to engage at all.   In my case, some close friends took more than a year to get past the cliche.  There are others, even today, who haven't spoken to me.   I know the silent ones were hurting, may still hurt.

Meanwhile, the American Psychiatric Association is considering adding “complicated grief” to the fifth edition of its DSM (the Diagnostic and Statistical Manual of Mental Disorders). Certainly, some mourners need more than the loving support of friends and family. But making a disease of grief may be another sign of a huge, and potentially pernicious, shift that took place in the West over the past century—what we might call the privatization of grief.

This is a topic I would love to discuss with O'Rourke.  I want to make sure we know what is the forest and what are the trees.  Grief therapy is useful.  If having a code for it in the DSM helps medical insurance cover it, that is good.   That is not the same thing as making it a disease.  Well-baby visits are covered by insurance.  Getting your teeth cleaned every six months is covered.   There should be mechanisms in place to encourage preventative care.

The other point O'Rourke is making in the quote above, and probably the one more important to her, is the "privatization of grief."   Here I agree.  Community, friends, family are very important.   Even as the bereaved is wanting isolation, and is pushing people away, it is still a comfort to know there are people in the next room.   One of the more special things friends did for me was to bring me dinners for months afterwards.

Even a good death is seldom good for the survivors .... In [Emily Dickinson's] poem “I Measure Every Grief I Meet,” the speaker’s curiosity about other people’s grief is a way of conveying how heavy her own is:

I wonder if It weighs like Mine—
Or has an Easier size.

I wonder if They bore it long—
Or did it just begin—
I could not tell the Date of Mine—
It feels so old a pain—

I wonder if it hurts to live—
And if They have to try—
And whether—could They choose between—
It would not be—to die.

Listen to O'Rourke talk about her piece with The New Yorker's Blake Eskin:

Libby read Naomi Shihab Nye's poem, Kindness, at Jack's memorial service.   Here's a link to Kindness from Garrison Kieller's Writers Almanac on NPR. I've excerpted this:

Then it is only kindness that makes sense anymore,
only kindness that ties your shoes
and sends you out into the day to mail letters and purchase bread,
only kindness that raises its head
from the crowd of the world to say
it is I you have been looking for,
and then goes with you everywhere
like a shadow or a friend.

I have to say I don't like Kieller's voice reading the poem, so you can skip that.

Scientists try to stop schizophrenia in its tracks

On Sunday, this article was posted on MSNBC.  I read an article like this completely differently than I would have a few years ago.  This idea that psychosis is a distinct phase in some illnesses like schizophrenia and manic-depression was news to me. And that mental illness is a progressive disease.  I thought back then that crazy just meant crazy. (I don't know if it is true for schizophrenia, but Kramer in his book Against Depression, demonstrates that depression, untreated, deepens over time and becomes more frequent.)

I'm then very keen on what are the early warning signs that hint that psychosis is coming.

Then I look for the bottom line ... does the new treatment or program have proven results?  In this case not yet, but the article gives anecdotal evidence that PIER is helpful.

Subtle, early signs Researchers have known about this warning phase [or prodrome] for decades, but they're still working on how to treat it. Now they're calling in tools like brain scans, DNA studies and hormone research to dig into its biology. They hope that will reveal new ways to detect who's on the road to psychosis and to stop that progression.

In the prodrome, people can see and hear imaginary things or have odd thoughts. But significantly, they understand these experiences are just illusions, or they have a reasonable explanation. In contrast, people with psychosis firmly cling to unreasonable explanations instead.

PIER emphasizes non-drug therapies for its patients, ages 12 to 25, although about three-quarters of them take anti-psychotic medication.

The treatment regimen includes group meetings in which patients and families brainstorm about handling the condition's day-to-day stresses. It also focuses on keeping patients in school and in touch with their families and social networks.

When it comes to treating the prodrome, scientists say they have some promising approaches but no firmly proven treatments to prevent psychosis from appearing.

New Yorker article of Psychopathy

Psychopathy is not my favorite subject.  But I find myself reading a cross section of articles on mental health, and letting the ideas pollinate across the various subjects.  In this article I do sense distance between the author John Seabrook and the researchers, Dr. Kiehl and his mentor Dr. Hare.  For example when Seabrook was interviewing Dr. Hare, he commented, "Hare was friendly but wary of me."  I share that sense of distance with the author.  I know the subject is important, but I'm not sure I want to get too close to it.

I've excerpted some quotes below just to give a bit of the background on Hare and Kiehl.

At thirty-eight, Kiehl is one of the world’s leading younger investigators in psychopathy, the condition of moral emptiness that affects between fifteen to twenty-five per cent of the North American prison population, and is believed by some psychologists to exist in one per cent of the general adult male population.

In order to distinguish psychopaths from non-psychopaths among the Western volunteers, Kiehl and his students use the revised version of the Psychopathy Checklist, or PCL-R, a twenty-item diagnostic instrument created by Robert Hare, a Canadian psychologist, based on his long experience in working with psychopaths in prisons. Kiehl was taught to use the checklist by Hare himself, under whom he earned his doctorate, at the University of British Columbia.

Today, Kiehl and Hare have a complementary but complicated relationship. Kiehl claims Hare as a mentor, and sees his own work as validating Hare’s checklist, by advancing a neurological mechanism for psychopathy. Hare is less gung ho about using fMRI as a diagnostic tool. “Some claim, in a sense, this is the new phrenology,” Hare said, referring to the discredited nineteenth-century practice of reading the bumps on people’s heads, “only this time the bumps are on the inside.” (Hare himself is a “strong proponent” of brain-imaging technology, but he noted that scans in isolation will always be insufficient.) Hare sees himself as a generalist, and Kiehl as “more of a data-driven guy.” Hare added that, while Kiehl’s brashness sometimes puts people off, “that’s why Kent gets things done.

And it was this paragraph below, that made me want to excerpt the article for this blog.  It illustrates much of the misinformation out there which we have to deal with regarding mental health awareness.  And this misinformation or distortion (I'm searching for the right word ... casualness?) is coming straight from the mouth of Dr. Kiehl, a PHD, doing fundamental research, an expert in the field.  1. The DSM definitions are subjective, cover a broad, continuous range of symptoms, and are mutable.  You cannot take a blood test and get a definitive diagnosis.  When Dr. Kiehl says "so much" it almost implies too much.  2. He mentions the famous drug companies that fund research, and profit from treatment.  Quotes like this make the general public suspicious of what is happening.  When you read commentary in the MSM you always run into this.  3.  The categorization of the disorder is influenced on whether it treatable or not.  (I have added the blue for emphasis.)

If a biological basis for psychopathy could be established and pharmacological treatments developed, the idea that many people have at least a little of the psychopath in them could well become accepted. As Kiehl points out, “It used to be the case that it was very hard to meet clinical criteria for depression in the fifties and sixties. However, the definition of depression has been broadened so much with DSM-IV that nearly every person will meet the criteria at some point in their lives. One reason for this is that drug companies have lobbied to change the criteria—because they have a treatment, a drug, that can help people even with moderate levels of depression. It’s a completely different issue whether this is appropriate.” He added that “even moderate levels of psychopathy may someday be considered a disorder—especially if we can treat it.”

"Mental Health awareness raised in campaign"

The Bernardsville News posted my letter to the editor Thursday.  I’ve made progress this week.

I met today with Pam Mastro, the Somerset County Mental Health Administrator.  Pam has an open door policy and will take phone calls from anyone with a question or need about mental health.  She is eager to help roll out a education and awareness program in our town.  Her email is mastro@co.somerset.nj.us.

Earlier this week I met with Mary Lynn Bradshaw and Barbara Barklay.  They are coordinators for the Stephens Ministers program at the Liberty Corner Presbyterian Church.  The program is non-denominational, and is open to anyone in the community.  The Basking Ridge Presbyterian Church has this program as well.  A quote from their brochure:

Our congregation’s Stephen Ministry equips lay people to provide confidential, one-to-one, Christian care to individuals in our congregation and community who are experiencing difficulty in their lives.

One of the things I am focused on is how does someone make that first phone call for help.  Because of the many obstacles to seeking care, I think the Stephen Ministers are a good model of lay people, in the community, that are available and can help refer the person to the right place for care.  Each volunteer has 50 hours of training.  The have a list of doctors and therapists within the community, who are all credentialed, and have been endorsed by the local program.

I see the benefit of a group like this, and am wondering if a more secular version of this could also be created for people perhaps not comfortable with a Christian oriented ministry.

More discussion will be coming.

Against Depression

Dr. Peter Kramer’s 2005 book, Against Depression, blows me away. I have read a lot of books in the last couple of years, but this is a rare one, that has me jotting notes on every page.

His chapter 12, “Magnitude,” answers the question: how bad is depression:

“Depression is the most devastating disease known to human kind.” (Researchers measure this statistically in terms of “good days” lost.)

In 1996, the most extensive global-burden-of-disease study, conducted by the WHO, the World Bank, and Harvard, concluded that “depression will be second only to ischemic heart disease–in terms of disability caused.”

“Estimates put the annual workplace cost in … America at over forty billion dollars.”

“The best studies show that over 16 percent of Americans suffer major depression in the course of a lifetime.”

“Depression often begins in adolescence. A recent study looked at children between the ages of twelve and seventeen, a stage of life when illness is rare. In the prior six months, 7 percent of boys and almost 14 percent of girls had met the full criteria for major depression.”

Impact on the elderly, “researchers evaluated more than 5000 mean and women age sixty-five and older … over a six year period. Those with high depression scores were over 40 percent more likely to die than those with low depression scores.”

In a cardiac study: after controlling for variables like social class, health risk factors (such as smoking), and other concurrent disease, depression still accounted for a 24 percent increase in deaths–from such causes as heart attack and pneumonia. “Think of it: a cardiac study that finds depression as deadly as congestive heart failure.”

These statements all relate to major depression. Earlier in the book, on page 69, Kramer writes:

“Depression is characterized less by acuity than duration. Depression is what settles in to stay.” 

In these excerpts, I feel like I’ve done the book a disservice. I’m an engineer. Facts are my friends. So I start with the numbers. But Kramer’s writing is clear, convincing, artful. As I make my way through the book I see myself shifting seamlessly from one role to the next: patient, father, child, husband.