Wednesday, October 8, 2008

The Deadliest Kind of Economic Depression

Here’s a sobering kind of economic indicator: The number of suicides peak at the lowest point of a recession, according to Elizabeth Bernstein’s thoughful piece, “Angst Is Rising, but Many Must Forgo Therapy” in today’s Wall Street Journal Online.
Mind you, as a clinician on the front lines every single day, I haven’t seen evidence of this spike yet. In fact, I don’t think the recession or a depression will particularly affect the most seriously mentally ill patients. After all, they are on the receiving end of government benefits which, barring social cataclysm, is unlikely to end.
The people I worry about, though, are the middle-class clients, squeezed in every way possible. These are the folks who could lose their benefits if they lose their jobs, who are having to scale back just to feed their gas tanks, who are paying soaring prices at the grocery, and who have virtually no safety net, unlike the rich and the poor. They are, in my opinion, most at-risk for stopping or curtailing therapy, becoming more depressed and finally attempting suicide, some of them successfully.
See Bernstein’s article for a discussion on how many therapists and clients are managing in this miserable climate.
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Sunday, October 5, 2008

The Insanity of Methamphetamine

Evidence of the ravages of meth, from the Multnomah County (Oregon) Sheriff’s Office.

The boy jumped up and down on the gurney, naked save for soiled underwear. “Hey, you wanna f*** me? You all wanna f*** me, don’t you?!” he bellowed at us staff surrounding him as we strategized our next move. His screams were punctuated with what sounded like laughs but on more careful listening sounded like involuntary vocal chord spasms. Finally, with a little help from the police officers who delivered this 15-year-old kid to the emergency room, we were able to restrain him chemically and physically.
Some fifteen minutes later, I reentered the room hoping to find a calmer patient I could actually interview. No doubt he needed to be hospitalized, but whether psychiatrically, medically or both was yet to be decided. I was there to determine the psychiatric part.
As I approached the hospital bed to which this child’s legas and arms were leashed by hard rubber restraints, I realized he was motionless, soundly sleeping. He was breathing through his mouth, enough that I could see he had but a few tiny brown stubs doubling as teeth, eroded from at least a few years of what I suspected was methamphetamine abuse. If this wasn’t meth mouth, I didn’t know what was.
My suspicions were confirmed by the police and, later, the boy’s family. He had been a seemingly happy, normally social 11-year-old in the not too distant past, his teary-eyed mother explained. Everything changed with a snort. Apparently he and his skateboarding buddies from the neighborhood had been dabbling with pot for a little added excitement when an older kid in their mostly-white middle class neighborhood introduced them to meth, with promises of pleasure beyond their young imaginings.
From that day on our young patient burrowed himself deeper and deeper into a crystal crypt. His parents, both of whom had to work to keep the patient, his two siblings and themselves in the middle-class lifestyle to which they had all become accustomed, did whatever they could imagine and afford to help their son hoist himself from the tomb to no avail. “He was not interested in stopping and he didn’t care if he lived or died,” his mother recalled.
By 13, he was hallucinating, hearing voices that dictated his every move, but apparently never commanding him to kill himself or others. His addiction snowballed into a daily practice until he disappeared to the streets of Los Angeles nearly prior to this ER visit.
While a denizen of the Hollywood streets, according to police, the patient made his money by selling sexual favors to the men who cruise Santa Monica Boulevard in the twilight hours. Street friends told the officers that for about $10 he would allow anyone to perform oral sex. He’d perform oral sex or allow himself to be anally penetrated, with or without condoms, by any of the johns, ideally for $20, but they said he’d go lower if it was a slow night.
At this point, everyone seemed to agree, this little boy had not only lost his way, but contact with most of reality as well.
Forget malnourishment, meth mouth, depression and anxiety, sexually transmitted diseases, cardiac risks and devastation to one’s life. Amphetamine-Induced Psychosis is a significant byproduct of tweeking. The more speed you do, the more likely you are to lose your mind.
Anecdotally, most of us who work with psychiatric crises can attest that psychotic manifestations following meth use are commonplace. There is an academic problem of teasing out the cases of psychosis where amphetamines are the primary instigator rather than a pre-existing mental illness. The reality, though, is that even if the patient has a history of, say, schizophrenia, their meth use can and will elicit a full-blown psychotic episode.
I’m reminded of a long-ago friend who began experimenting with methamphetamine. Despite all our warnings and protests, he continued using and eventually lost all control. A rising star in the executive suites of entertainment, he lost his job, his reputation, and ultimately his ability to make money. I remember walking into the bedroom of his Hollywood Hills home, its darkness preserved by layers of aluminum foil blocking the bright midday sun, only to find him sitting in a corner talking to voices that existed only in his head. After calling to him several times, he finally recognized my presence.
The last time he was seen, he was homeless and found sleeping in the gazebo of a friend’s backyard. When he was awakened, he expressed paranoid delusions in panicky chatter: The CIA had been following him, listening to his thoughts and he might have to cut his ear off because that’s where their listening device had been implanted. Then, once inside the house, he vanished through a bathroom window, never to be seen again.
Although my friend may have appeared to have been well-enough adjusted and functioning before methamphetamine, I dont’ know that he really was, any more than I believe the thousands of other meth addicts were, either. I say this because I don’t believe you can sever one’s mental health from their addictive propensities. If the drug is not filling some void, I don’t believe there would be as many folks addicted to substances. If one keeps using in spite of the consequences, such as my friend, that indicates to me the expression of a very powerful need. In my friend’s case, I believe meth served as a fast-acting and sexy antidote for his depresson. In patients I have seen, nearly all of them who use meth regard it as an elixir for depression, ADHD, fatigue, and the emptiness of the Borderline Personality. Of course, the drug only leaves them wanting more and feeling worse than when they started, but it provides a fast, euphoric kick-start without having to see a doctor. Yet.
A friend of mine is fond of the saying, “Man doesn’t take the drugs; the drugs take the man.” But they really take so much more: the addict’s family, friends, career, home, personality, body, and sanity. If you have children or work with them, please take a few minutes and visit the Partnership for a Drug-Free America’s Meth Resource Center.
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