World Mental Health Day 2013
World Mental Health Day was first celebrated by the World Federation for Mental Health in 1992, so it is 21 years old today – with an appropriate coming-of-age theme “Mental health of older adults, addressing a growing concern“. Participants include the WHO, health services (the HSE, NHS), service users and advocacy groups (Mental Health Ireland, Aware, Grow).
My qualifications to speak are that I have always been a bit ‘different’ and somewhat depressive, with what is colloquially termed ‘a breakdown’ in 2002. I was diagnosed with depression/anxiety and various other diagnoses, have been hospitalized 5 times for a total of 23 weeks in the past decade, mainly in secure (locked) psychaitric wards. I had an eventual diagnosis of Asperger syndrome in 2009 – and have not been a hospital in-patient since then.
Some Mental health statistics
- 25% of people will experience some kind of mental health problem in the course of a year
- 29% of women and 17% of men have been treated for mental disorder
- Mixed anxiety and depression is the most common mental disorder
- About 10% of children have a mental health problem at any one time
- Depression affects 20% older people
- Only 10% of people in prison have no mental disorder (there is a strong interaction between deprivation, exposure, conflict with others / conflict with authority, all of which are related with unemployment, drug and alcohol use and homelessness, and which lead to over-representation of people with mental illness in prison)
- Women are more likely to have been treated for a mental health problem than men
- Women are twice as likely to experience depression or anxiety
- Men are 3-4 times as likely to experience an alcohol or drug dependency and suicide.
Not everyone suffers mental illness – But mental illness is often accompanied by suffering, because every aspect of intellectual and social funtioning are affected. Being treated for a mental illness is often a consequence of conflict with others, rather than the severity of any symptoms – e.g. conflict within the family, or with authority or with residents as a result of homelessness. Being treated for mental illness therefore contains huge inequalities. You can be “as mad as brush” without any consequences (up to a point) if you live in your own detached home, but not if you share a cramped home with others, or live on the streets.
Amanda Bynes was stopped while driving in March 2012, arrested for Driving Under the Influence in April, charged for 2 hit-and-runs in September, her license was suspended, her car was subsequently impounded after she drove while suspended, she was given 3 years probation in May 2013 for possession of marijuana, attempted tampering with evidence and reckless endangerment (she threw a ‘bong’ or a vase from her 36th-floor apartment).
(All of this might be ‘normal’ in Cork City).
She was then detained under a 72-hour ‘5150’ in July 2013 for arson in front of a stranger’s house. Her mother was granted temporary conservatorship over medical care and finances – Amanda Bynes had a “lack of capacity to give informed consent to medical care.” After a 1368 Penal Code hearing September 2013 she was transferred to specialized treatment in a private facility, where she remains.
Mental Health Commital
Amanda Bynes was subject to a ‘5150’ committal order (under Section 5150 is a section of the California Welfare and Institutions Code), which is equivalent to what we refer to as “being sectioned” (under various sections of the Mental Health Act 1983), or to involuntary admission. Many of the procedures for involuntary admission to psychiatric care, throughout the English-speaking world, refer the same 19th C phrase, “a danger to himself or to others“.
When you are committed, you lose the capacity to consent – to treatment (a kin, guardian or warden with executive power is appointed), and to sexual expression (the other party – even a longtime sexual partner – is guilty of sexual assault, or worse, for any intimate contact with a person of diminished capacity). When I have been admitted, I have had my personal property (keys, wallet, mobile phone, book, headphones, shoelaces, dental floss) removed because they are potentially dangerous, or for safekeeping. There was a pressure to comply with all directions from staff, despite being voluntary (is ‘compliance’ under duress consent?), with threats of more severe drug treatment, threats of Electro-Convulsive Therapy, threats to remove personal privileges (such as access to the hospital shop) and the always-present threat of involuntary committal and compulsory treatment. I was literally and metaphorically stripped of dangerous items, stripped of outdoor clothing, stripped of privacy, placed in a wheelchair on one occasion (‘for insurance purposes’) and stripped of dignity. You may have noticed that taxis will not collect people in pyjamas near psychiatric hospitals, so stripping patients of outdoor clothing is an effective security measure.
What is ‘normal’
What is ‘normal’, and who decides? – The Sun? Your neighbours? Medical experts?
Sir Francis Galton is one (of many) writers and researchers who created the concept of ‘normal as we use it now. Galton was an anthropologist, explorer, geographer, inventor, meteorologist, early geneticist, early researcher in psychometrics, and statistician. He explored ‘normal’ phenomena, referring to the distribution often found in natural populations, rather than the normality of individuals within it. The normal distribution is a shape often found in nature, a distribution typical, frequent or normal when observing natural phenomena. If you look at the steps to an old church or courthouse, the vast bulk of people took the centre-line to the door, many deviated a little to the sides, a few deviated a lot and the very margins are virtually untrod – this shape is a normal distribution.
One phenomenon of particular interest to Galton was the inheritance of positive characteristics, such as stature and intelligence, (and regression to the mean). He was also interested – as were many of his European contemporaries – in phenomena that are now recognized as pseudoscience (physiognomy) or objectionable (eugenics).
Height (‘stature’) of men and women is not a particularly emotionally evocative topic. The two groups are different. The terms ‘average’, ‘below average’ and ‘above average’ might have emotional impact – especially for people at the extremes of their own gender’s distribution. It is the distribution that is normal, not the individual people – but we often talk about “falling within the normal range” or being “below average”. The phrase “A half of all schools are below average, or failing” has been printed by at least one newspaper every single year since I took my first school exams (in 1979).
Intelligence is a much more emotional topic, with terms like subnormal (the term ‘ESN’ or educationally subnormal was used before learning disability or learning impairment), or supernormal. Falling below a functional threshold may be considered pathological, i.e. a clinically significant impairment that requires treatment or intervention. The same emotional intensity applies to anti- or asociality (friendliness), communication (language or art skills), flexibility (Restricted and Repetitive Behaviours) – i.e. the triad of autism impairments – and also to clumsiness (athletic ability) and sensory sensitivity.
Sometimes ‘madness’ can be quantified, often it is a purely subjective judgement of society or others who decide whether or not a person is mentally ill.
There are several ways in which the distribution of a group can change with respect to the population distribution.
A shift in a group, for example children with a learning disability, whose collective mean is lower than the population mean.
A broader distribution with greater representation at the extremes – which seems the case for many traits amongst disabled people, whether physical (height, weight) or more complex.
Sometimes the group’s distribution will both shift and broaden – there may be a highly-recognizeable group deficit (e.g. in sociality, communication, flexibility or IQ), combined with a less-recognized increase in variation. The group is more represented amongst the lowest ability segment of the population – but also, unexpectedly, at the upper extreme.
Madness in the media
Sinead O’Connor was Rolling Stone artist of the year March 1991 for “Nothing compares 2 U”, written and composed by Prince, performed by Sinead O’Connor in 1990 with a music video by John Maybury featuring a close-up of Sinead O’Connor’s face, with tears on her cheeks at the end.
Miley Ray Cyrus, on the cover of Rolling Stones in October 2013 for ‘Wrecking Ball’. Miley Ray Cyrus (the artist formerly known as Disney’s Hannah Montana) sings “Wrecking Ball” with a video modelled on “Nothing Compares 2 U”, starting with a close-cropped face. She names Sinead O’Connor and the “Nothing Compares 2 U” as inspiration.
Sinead O’Connor’s published an open letter on her website stating “I wasn’t going to write this letter, but today i’ve been dodging phone calls from various newspapers who wished me to remark upon your having said in Rolling Stone your Wrecking Ball video was designed to be similar to the one for Nothing Compares … So this is what I need to say … And it is said in the spirit of motherliness and with love. I am extremely concerned for you that those around you have led you to believe, or encouraged you in your own belief, that it is in any way ‘cool’ to be naked and licking sledgehammers in your videos. It is in fact the case that you will obscure your talent by allowing yourself to be pimped, whether its the music business or yourself doing the pimping. Nothing but harm will come in the long run, from allowing yourself to be exploited, and it is absolutely NOT in ANY way an empowerment of yourself or any other young women, for you to send across the message that you are to be valued (even by you) more for your sexual appeal than your obvious talent. I am happy to hear I am somewhat of a role model for you and I hope that because of that you will pay close attention to what I am telling you. The music business doesn’t give a shit about you, or any of us. They will prostitute you for all you are worth, and cleverly make you think its what YOU wanted … and when you end up in rehab as a result of being prostituted, ‘they’ will be sunning themselves on their yachts in Antigua, which they bought by selling your body and you will find yourself very alone.”
Miley Ray Cyrus chose not respond to the criticism, instead tweeting “Before Amanda Bynes…. There was….” with a two-year-old screengrab of a request for help with psychiatric care written (and subsequently deleted) by Sinead O’Connor. She followed this with a video still of Sinead O’Connor ripping up a photograph of the Pope (from the Late Late Show) and a decalaration that she had no time to respond:
The Sinead O’Connor screengrab
The screengrab (reading in sequence from the bottom upwards) says:
“i realise i will be in trouble 4 doing this but.. ireland is a VERY hard place to find help in. So having tried 1st im asking
does any1 know a psychiatrist in dublin or wicklow who could urgently see me today please? im really un-well… and in danger…
the sindo article about them trying to lose barry his job and every1 being shit to him 4 marrying me has spun me off and im ill
and i desperately need to get back on meds today. am in serious danger. please e mail me if u know or are
a psychiatrist who can help me today… dont tweet i b away from computer i broke my ankle have to go casualty
pls.. can any psychiatrist see me today an get me back on meds an help me without me having to go hospital?
me dont wanna leave me kids. or fuck up me work. im sorry worrying any1.. is just am sick and ireland shit for finding help cant think of
any other way”
– an articulate and coherent explanation of her personal circumstances and the structural problems in mental healthcare in Ireland.
Last week I met with a junior doctor on rotation (in the past four years I have not met my current psychiatrist – or any consultant psychiatrist). The junior doctor had no access to clinical notes (which are ‘with the social worker’), he provided 2 minutes in which discussion of any personal issue was not possible (unless I wanted to demonstrate that I was “a danger to myself or others“).
Sinead O’Connor released more open letters, and in the fourth says:
“You’ve said on Matt Lauer’s show ( where you again refer to me as “crazy”) that you don’t understand why I have been upset with you. I find that hard to understand frankly, since you’re clearly very far from being a stupid woman. My problem with you stems from your response to my first letter. Until you exposed me ( And Amanda Bynes) to abuse on the grounds of my having sought help (extremely coherently) to save my life, when experiencing suicidal compulsion as a side effect of a medication called Tegretol, I had no problem with you whatsoever.”
… “Look Miley, what you did to myself and Amanda encouraged enormous abuse of us both, publicly and privately. And will certainly have made it difficult for young people who admire you and who may be suffering with mental health problems or suicidal ideation to feel they can be open and seek help, since you had us mocked for seeking help.”
… “The type of media bullying which resulted from what you did causes suicides. And perpetuates the idea that those deemed by the media to be crazy are fit for nothing but to be mocked and insulted. This causes deaths. Period.”
Alan Farrell TD (FG, Dublin Fingal) tweeted “While I think Sinead O’Connor is as mad as a brush; having watched a snipit of her on The Late Late, she is correct re denigration of women“. In response to outrage he tweeted “what is far more worthy of our concern is the willingness of our ‘national’ broadcaster to give such a person an airing” and then “my opinion stands”. He was then shamed into “Sorry Sinead ” with a link to his FG website apology “I would like to apologise to you for any hurt that I have caused you by my remark on twitter on Friday night. I should not have said it, I have deleted the tweet and I hope you will accept my apology. I agree completely with what you said about the exploitation of young women.”
Individually, one person’s opinion does not matter, except that this individual reflects public insensitivity, and he does so in his capacity as a public representative. The implication of his apology is: He still thinks she is as mad as a brush, he does agree with her about denigratiuon of women, but he is sorry for the way that she feels (rather than sorry for his own actions).
Other examples of public attitudes that surround us every day are Halloween outfits, advertising with ‘mad’ characters, films, television and (always) the newspaper amateur diagnoses of every crime as being motivated by ‘madness’:
(Women are also treated to also ‘Anna Rexia’ and other gendered mocking depictions).
It should be noted that the BBC recently asked “Is it wrong to jokily call someone ‘mental’?”, with a wide variety of responses – I heard the funniest jokes about madness inside psychiatric hospital, including the fellow-inmate with major depression who described how he panicked, after taking a massive overdose, that the pills were past their use-by date.
What about kids with autism spectrum disorder? – or any other learning impairment?
“Big Question: If all behaviours are a communication why do we use, medication, star charts and smiley faces to eliminate them?” – Linda Woodcock, Studio III (2009 presentation) – Linda Woodcock is the co-author author of the title “Managing Family Meltdown: The Low Arousal Approach and Autism”, published by Jessica Kingsley Publishers. She is the National Lead on Parent and Family Training for The Studio III Group, an organization specializing in non-aversive behaviour management. Linda also has a son on the autism spectrum with challenging behaviours.
Not all restrictive and repetitive bahaviour or all non-functional routine is distressing or harmful – some aberrant, abnormal, mad behaviour provides positive pleasure. If you can sell the output of aberration then you are an artist, an intellectual or a pioneer.
There are no drugs to treat the core symptoms of autism, yet drugs are used to ‘treat’ behaviour and mood from 3 years upwards – antipsychotics, antidepressants, anticonvulsants and sleeping pills. Are they treating a person or aiding compliance with normality?
Aman et al (2005): “There was a very large increase in antidepressant utilization from 1993 to 2001, with significant increases also occurring for antipsychotics, psychostimulants, and alpha-agonists and beta-blockers. Among youths with autism, the use of any psychotropic increased from 30.5% in NC-1 to 45.2% in NC-2. Psychotropic medication patterns were remarkably consistent across North Carolina and Ohio, except that significantly more autism supplements were used in Ohio. We also examined subject and demographic variables across studies and found several robust correlates of psychotropic medication use. Greater age and handicap, and more restrictive placements, were associated with the use of several drug classes.” Aman et al (2005) Medication patterns in patients with autism: temporal, regional, and demographic influences. J Child Adolesc Psychopharmacol. 2005 Feb;15(1):116-26.
The American Psychiatric Association wrote in 2006: “epidemiological community surveys indicate that 33% to 47% of children with ASD receive at least one psychotropic medication during a 1-year period … The most commonly used psychotropic medications in ASD are antidepressants, antipsychotics, stimulants, and the alpha-agonist clonidine. Also used are mood stabilizers, such as lithium and divalproex sodium. The strength of the evidence for the efficacy of these medications is variable, ranging from placebo-controlled clinical trials to open-label case reports.” APA (2006).
Posey et al (2008): “A survey of psychotropic drug use in children with PDD found that approximately half of subjects are currently being prescribed a psychotropic drug and that 16.5% are taking an antipsychotic drug.” Posey et al (2008) Antipsychotics in the treatment of autism. J. Clin. Invest. 118:6–14 (2008).
Many drugs are used off-label – either outside the labelled target age, or to exploit the known side-effects. Lyrica (pregabilin) is an anticonvulsant for neuropathic pain that happens to treat GAD, chronic pain and migraine. Riluzole (Rilutek) and Gabapentin (Neurontin) are anticonvulsants that happen to be mood stabilizers. Risperidone is an atypical antipsychotic that acts as a mood stabilizer. Olanzapine (Zyprexa) is an antipsychotic that regulates aggression.
Ending on a positive note
Mad Pride Ireland holds a public event every June. Aims include an end to force in psychiatric care – the compulsion to behave as expected, consent to treatment, and decriminalizing emotions outside ‘normal’. A Mad Pride flashmob video from the English Market was shown at the APA this year.
Sinead O’Connor’s open letters and the music videos: http://beaut.ie/2013/poll-miley-cyrus-vs-sinead-oconnor-views/