DEPRESSION-YOU ARE NOT ALONE

 

 

 By Dónal MacEoin.

Galway, Ireland.

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Epigraph

“Progress is impossible without change, and those who cannot change their minds cannot change anything”- George Bernard Shaw.

Abstract

The turn of the 21st century has been a particularly socially exhausting period of time. For mental health rights, the past twenty years have brought some encouragement, at least to civilly conscious groups. The trouble is, there are evidently many discursive compartments to understanding the psychiatric power structure, and, therefore psychiatric administration of anti-psychotic medication. From what I have personally experienced, the psychiatric super-structure is failing. The flaws with psychiatry as a method of en-masse mental health treatment are abundant. The practise of psychiatry lacks in transparency, and evokes some of the most-disingenuous human exchanges on the planet. From my personal dealings with various consultant psychiatrists who work for the Health Service Executive (HSE), what I have gathered is that they mostly fall into two categories. Ranked first, in both concern and majority, would be the psychiatric malignant narcissist, who falls into all of the typical tropes and sequences within the Narcissistic Personality Disorder (NPD) spectrum. The second, would be a more covert (perhaps by necessity) sort of consultant, who assumes that it must always be safe to back up another psychiatrist, when it only ever, most probably, feels safe. What raised more concerns during all of the time that I have spent around consultant psychiatrists, is that this is a pattern that one can expect will reoccur within subgroups of psychiatrists over, and over again. Additionally, there is the lack of transparency, and inability of most people suffering from NPD to have the proper insight to perform consistently, and responsibly, when it comes to their work life and personal life balance. Not only is the propensity for things to backfire likely much higher than most people on the covert end of the spectrum seem to realise, but, the likelihood of things ‘escalating out of control’ from that point, are consequently just as high.

I have spent around half a year in total as a legal detainee of Adult Acute Mental Health Units’ (AAMHU). I have seen many people come, and go through the Mental Health System in my home country of Ireland. I have seen many instances, where, others have fallen subject to the ill-fate of thinking that their mental health problems could not become larger than they were before they entered a mental health unit. With my educational background being fairly grounded in the behavioural sciences’, I have been forced to disagree with the practising psychiatrists that I have encountered. I have taken on the role of someone who

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cares about the structures of society, and the way that we behave within them; and so, I have developed a sense of responsibility to raise awareness on the discipline of psychiatry.

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Introduction

To begin, I would like to provide some much needed context on the sort of circumstances that should help keep the focus of the article in perspective. I have formed a strong personal opinion on the subject, which is in no doubt biased, but, only due to personal circumstances that allowed me to obtain an almost unimaginable fractal of objectivity. As a professional, I feel as though I have a fairly balanced and inclusive perspective, which will predominantly seek to delineate between mental health rights, administerial decision making, and mental health science. I am going to attempt to keep my personal feelings from bleeding through into my critical perspective. However, I feel as though there is a particularly unique element to my experience that may be best used to interpret what could all too easily become a self-perpetuating and global trend. Therefore, I have decided to write a bit of a reminiscent ‘chapter’, as a means of communicating the qualitative information necessary to fully grasp the currently precarious state of mental health in Ireland.

‘After I was admitted to an AAMHU for the third time in September 2018, I figured that I may as well learn a bit about the medication that I was being administered. It really only took some quick searches on Google, and a few somewhat dense paragraphs. Eventually, I practised some of what I found in conversations with other patients (including one consultant psychiatrist who was more like a roommate, and a friend for a few weeks). He that the dopamine response system is involved in many of the basic everyday functions that our bodies need to perform. I must have been noticeably interested as my roommate looked eager to tell me more about the neuro-scientific aspect of psychiatry. I could tell that was mainly what interested him about the profession. I asked him about the pharmaceutical aspect, and his dissatisfaction seemed to mirror my own. The summary of what he said confirmed my prior beliefs about the prescriptions that I had been receiving. It was not just that I no longer felt motivated to strive for the rewarding ‘moments’ in life, even the getting up to try was being inhibited. Gaining more knowledge on the subject has been easy since these first few crucial phases of comprehension, and more like it. I took up familiarising myself with some of the rudimentary fundamentals of the dopamine (DA) respond and award systems via podcasts, interviews, and everyday life. It is a lengthy process we will all continue to learn throughout our lifetime. I used to feel as though these moments were more important looking back. Moving forward is the most important thing to do, especially when you are ready. I have often felt that my life has been obstructed by this social structure, and that it is interfering with my ability to make my way through life. It is supposed to be the structure which helps me, as a citizen, improve my mental health. The structure has caused nothing but instability in my life. The frustration that I have felt from the severely sub-standard care that I have received as a patient at the mental health unit in Galway is just one of the many ongoing things that my consultant has ‘to do’. That’s what it has felt like after those six months total of admission, and that is why I am sure this system is broken. The psychiatric system in Galway works in the interests of the psychiatrists.

So, there is a good chance that my life isn’t the only complicated ‘piece of work’ that my psychiatrist, as a ‘consultant’, has to deal with. It isn’t a good feeling, being on the receiving end of narcissistic abuse. Don’t forget, there is also a big difference between; a narcissist, and, a malignant narcissist. My former consultant was the latter. All of her dopamine comes from prescribing people like me ‘scripts’, and all of the trauma that I suffer through in life, is, used as an excuse to do so. Meanwhile, if I were to try and talk about trauma with my psychiatrist, she would quickly end the civility of the conversation by talking over me, and repeat that

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process for ten minutes, twice a week, for a few weeks until- it was time for another script. After I am discharged from an admission, I feel the urge to stop taking the meds, then go off them, and go back to life. That’s always going to be the choice when you know your rights.

What would someone who has resumed their life because they have a rough idea of their rights appear to, from the perspective of someone whose job it is to deal with anxieties, and stressors, and what is termed ‘mental illness?’. It was like they were mad that I ‘got away’. This person obscures my rights, some of which I learned (and wrote) about for my final year exams, and tries to prescribe me years’ worth of antipsychotics, when my ‘illness’ could have honestly been sorted by a tub of ‘Ben and Jerry’s’ and a healthy sob.

The pharmaceuticals, on the other hand? Didn’t help. I stopped taking them, and got better. The only thing that could bring me back down that I could not foresee was that my psychiatrist would “organise another involuntary admission” for me. This was exclaimed to me as if it was a favour. It was unbelievable. My consultant went and followed up on that promise. Without having lived through it, it will always seem unimaginable, but, having the circumstances of your life determined by a mental health professional who acts as if she knows exactly who you are after having spoken to you for half an hour does not feel ‘real’. To sit across from someone who you expected to be a reputable person and have them tell you that you are not well, and that your earlier attempts to seek help from more preferable professionals was ‘mentally unwell’. Unreal. To have her describe your explanations of the slander, and threats, and abuse that you have suffered through as ‘persecutions’. Unreal.

To hear this person go on and talk about the moments that hurt the most, and describe them as ‘episodes’; that same person who erroneously assumed that I am the sort of person who thinks I’m the main character in every show, or movie that I watch, and that when a song comes on the radio that I like, the world played it for me. It doesn’t often feel as if there is any avoiding them these days. The gaslighting, the gatekeeping, the goalposts, their games. It’s not always been easy to be a ‘good sport’.

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Motivational Response to Acute Mental Health Treatment-Alternative dopamine pathways, alternative dopamine rewards.

The institutions that practise psychiatric care in Ireland are becoming increasingly hindered. In some places (as it has been in the mental health unit in Galway), it feels as though you would need a folder containing all of your rights in order to avoid- what they will otherwise openly claim- is their right to forcibly administer anti-psychotic drugs. From an ethnographic perspective, appropriate time to ensure healthcare measures has never been given to the patients, in either of the mental health institutes that I have received treatment in. The argument that my consultant made to me was that my brain needed to ‘cool down’, and so I took some of the antipsychotics that she prescribed me. Since then, I have come to better understand the chemistry of the process. I don’t feel as though I should have been administered antipsychotics. However, my consultant also argued that the cannabis that I had been using was ‘affecting my brain’. Since there was a presence of cannabis in my system, and I was administered the pharmaceuticals, I have concluded (at least for myself) that psychiatric ‘care’, is sometimes abusive.

In fact, it no longer feels comfortable to have mental health knowledge. For example, how is one supposed to cope with the knowledge that the first few antipsychotics you take when you are admitted to a mental health unit might be reacting harmfully with the existing drugs in your system? The brain will always be averse to counteracting substances, but also, there are then the counteracting beliefs. There has been regular coercive obscuring of my mental health rights. Sometimes, my ‘freedoms’, including use of my phone, have been used by my psychiatrist to blackmail me. Yet they are still referred to as ‘freedoms’. These are the sort of things that cause a patient increased levels of distress.

In most cases, I feel psychiatric patients should, at the very least, be allowed to let narcotic substances leave their system naturally before any attempt to ‘persuade’ them to take antipsychotic medication. There has also been a worrying trend that I’ve noticed in the medical community (in Ireland) involving the addition of guidelines that prompt medical personnel (psych, and general), to ‘escalate’ when a patient is resistant to treatment. Personally, I feel as though the potential stress and anxiety that this form of treatment can produce should be enough to rule it out as a method of care within the medical community. “It has long been known that stressful and aversive experiences cause large changes in DA concentrations in downstream brain structures, and that behavioral reactions to these experiences are dramatically altered by DA agonists, antagonists, and lesions” (Bromberg-Martin, Matsumoto, Hikosaka, 7). Moreover, moments where the patient wants to express some form of concern are impossible to get back. They may forget to express an “internal fact”, something which could be crucial to ensuring the proper treatment measures are taken into place (Barnes, 162).

As far as I am aware, I do not feel as though there has been enough convergence on the topic of ‘escalation’ within the global medical community, and, therefore perhaps this is a measure that could be considered as specific to University College Hospital Galway, and other hospitals in the Republic of Ireland. Nonetheless, “collective constraint, as in the enforcement of a law” (Barnes, 162), or, in this case ‘hasty’ guidelines, are not offering enough to account for a patient’s health and ability to express themselves. I say this coming from a place of experience, it can feel worrying.

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“The short-term relief seems to be replaced by long-term harms. Animal studies strongly suggest that these drugs can produce brain damage, which is probably the case for all psychotropic drugs”.- Peter Gøtzsche, Nordic Cochrane Centre in Denmark.

During my time as a patient in multiple mental health unit’s, I have witnessed various patients suffering from the deterioration of functional, everyday capacity. Most of what can be seen is patients with visible symptoms of kinaesthesia. When the length of time the patient is advised to take the drug is determined by the consultant psychiatrist, what can a patient without the mental capacity to argue for self-determination do? Many of these patients could have a better life on less anti-psychotics. Symptoms such as these should perhaps prompt the medical staff to reduce the dose of meds. Says it right on the box in fact. According to statistics, “almost 40% of people with psychosis are on levels of antipsychotics exceeding recommended limits” (James, A).

Furthermore, “antipsychotics almost triple a person’s risk of dying prematurely” (James, A). However, our mental health service here in Ireland looks past many of these facts. This leaves some patients to suffer from organ damage: “systematic reviews have found that all patients treated with conventional antipsychotic therapy have an increased risk of hepatic dysfunction. The median percentage was 32% (range: 5-78%)” (Qinyu, Zhengui, 47). I’m willing to bet that the majority of patients are never told the risks involved in taking anti-psychotics for extended durations. I know I wasn’t. Usually, patients simply want to get out of the ‘unit’- because it is not a healthy place for them to be. On the other end of the spectrum, the more ‘short-term’ patients will take to drugs as soon as they get out of the mental health unit, leading to yet another potentially damaging process for the brain to go through.

As some consultants don’t deal therapeutically with addiction, this process is likely to repeat itself over and over. The Ventral Tegmental Area, or, VTA, “is comprised of a group of neurons located around the midline of the midbrain floor and contains mainly neurons that produce DA” (Dafny, Rosenfeld, 719). If the VTA-DA that is being produced as a response to drug addiction is being inhibited (by the antipsychotic) on its path to DA receptors, then all of the VTA-DA produced for “behavioural disorders, cognition, motivation, and locomotor activity” (Dafny, Rosenfeld, 719), are being inhibited as well. Imagine you have been administered anti-psychotics for a few weeks while attending a mental health unit. Your consultant has given you the meds to relieve your drug addiction, and reduce the irritability of symptoms of your behavioural disorder. You’ve spent your time in the unit hungry to get out. It’s been boring, stressful, and all you want is to be free again. You’re discharged and walk out into the open air. Your brains cognitive rate increases because ‘the moment is finally here’. You’ve been looking forward to having some self-determination back. You eagerly make your way outside the hospital grounds feeling more limber and motivated. The VTA addiction-corresponding DA starts being produced as you wonder what you will do for the night. You walk downtown and think to yourself; “why don’t I call a few of the lads and go out for a bit of partying?”. Depending on the concentration, the type of antipsychotic (and the party), you could end up celebrating by giving yourself some minor brain damage. Not the sort of thing that should be overlooked.

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Optogenetic research suggests that this sort of neuromodulation of VTA neurons “induces a strong conditioned place preference which only occurs when stimulation is applied in a bursting pattern”, or, in this case, when a patients normal life patterns are resumed, with the activities, and surroundings of the person beginning to evoke responses from the VTA (Bromberg-Martin, Matsumoto, Hikosaka, 5). Seeing as many young people these days congregate in familiar spaces to party and socialise, the tendency for this sort of pattern to continue is concerning. Even more so, is the likelihood that a person who had no intention of continuing to use drugs after discharge, will be peer pressured into taking drugs once they are surrounded by their friends. The diversity in dopamine responses to aversive events is detailed in: ‘Dopamine in motivational control: rewarding, aversive, and alerting’ (2010). The article delineates between the many forms of dopamine responses. Where peer pressure is concerned, it is tough to avoid the affirmative signalling of the brain. “Both rewarding and aversive events trigger orienting of attention, cognitive processing, and increases in general motivation” (Bromberg-Martin, Matsumoto, Hikosaka, 6).

The reality is, most people would already feel the aversive response to addiction by simply being around a drug, in a space where the drug had been consumed, or being around the people associated with the substance. Let’s say you’ve just arrived at the lads house. They have acquired some drugs because you’ve just been let out of the mental health unit, but, you weren’t sure if you wanted to take any after your admission. They haven’t even asked if you will be having any, and you are already feeling an aversive DA response. Some basic chit-chat takes place, and then your friend looks over at you with a familiar grin. He asks if you are having a smoke while extending his hand to pass you a joint of cannabis. You think of all the good times you have had smoking, in the same room, with the same lads, and you grin to yourself. The reward response has already taken over, and before you know it, the party’s going.

The question must be asked, do the downsides of antipsychotics as an increasingly popular form of treatment- including their counter-reaction to popular narcotics such as cannabis- not overwhelm the exceptionally low potential benefits when compared to some of the competing mental health methods, techniques, and exercises? Personally, I feel as though proper sleep, daily exercise, a diet suited to the blood type of the patient, and some techniques, such as mindfulness and meditation would exceed the current treatment procedures. Keep in mind, the European Mental Health Act (2001) states that “the best interests of the person shall be the principal consideration” (section 4), yet, as Peter Gøtzsche cautions “it seems that a considerable number of patients are subjected to the adverse effects of antipsychotics without clear benefit” (theguardian.com). A healthy living routine such as this, and significantly lower doses of anti-psychotics would garner much better treatment results, and much higher quality of life for patients. After-all, anti-psychotic medication can have very disadvantageous effects. How can someone work, for example, if they are losing the proper motor function of their arms and legs, their mind is foggy, and their energy depleted? Let alone that, having your DA receptors inhibited does not feel natural, healthy, or smart. It is, mentally and medically speaking, revolting to be forced into taking high doses of this form of medication.

The physical results of this treatment might not quite be brain damage, but innumerous alterations to the brain, over time, will scientifically add up to effects similar to that of brain damage. By way of continually robbing the patient of the natural DA elements that are slowly produced in our brains; those, of which compose the natural rhythm of a healthy individuals life, patients are forced to form unnatural alternative pathways that may take them from a state near enough to full recovery, to a state of confusion, loss of identity, and psychosocial

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trauma. Then, of course, there are the unwanted side effects, adverse symptoms, and, unfortunately in some regions with slow mental health progress, there will even be instances of psychological scarring. There is nothing to gain for most people taking antipsychotics. Misfortunately, “on the ethical aspect, the debating sides disagree on how to weight the impact of the decreased risk for exacerbation versus the certainty of mild- to-moderate AE (Averse Event) and the risk of severe AE on the patient’s quality of life” (Davidson, 216). The worrying trend, in my opinion, is that some patients are being misdiagnosed, and should not be prescribed antipsychotics at all. Some will have use of the anti-psychotics, but likely only for a short time. Some may warrant extensive use, but will their doses be too high? If you ask me, probably.

HSE’s Administration of Antipsychotic Medication.

In a lot of cases, the lack of proper doses can be seen (some side effects too averse to mention). However, these modern acute mental health units operate away from general society. It is difficult for the public to form an opinion on something which they cannot empathically respond to, and therefore the public currently cannot form motivational salience with regards to psychiatric reform. I feel it is safe to say that there will be more demand for salient mental health information to be identified and made easily available to the Irish public. There has been extreme demand for mental health services on social media during the NPHET restrictions. Can the public trust that the HSE can supply what is needed?

The substandard administration of antipsychotic medication, and, therefore some of the official psychiatric administrators at UCHG most certainly are, bureaucratically speaking, rife in their careless distribution of anti-psychotic drugs. For the mental health sector in Galway, and throughout Ireland, much more than just personnel would need to be changed in order to see a more up to date system.

“In practice, there need to be regular reviews of treatments between a patient and their psychiatrist in order to continually weigh up the pros and cons of any treatment.”- Dr. Michael Bloomfield-The Guardian.

I reflect strongly with Dr. Bloomfield’s opinion. The absence of the psychological treatment upon admittance to mental health units’, is contributing to the poorer health of some patients in our state institutions. Personally, I don’t feel as though 10 minute meetings (with a ‘consultant’ psychiatrist), a couple times a week, are enough to work through some of the complex stressors that are associated with trauma. The multi-disciplinary team (MDT), idea is a good one, because it offers the patient something. Although, at present, a lot of that is simply hope. The potential is there for progress to be made with every patient. However, the reality that I felt was clear during personal experiences taking anti-psychotic medications, is that they are debilitating. I feel as though the psychiatrist, being part of a multi-disciplinary ‘team’, should not be the professional with all of the decision-making capacity.

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They should no longer claim to have such capacity in the first place, given recent developments in the Mental Health Rights Movement, particularly the UNCRPD. Now would be a good time for the multi-disciplinary team model to take shape. Currently, the system is so flawed, the inability for the patient to develop new neural pathways freely (due to inhibition), leads to redundancy of other forms of treatment i.e.; occupational therapy, psychology etc… Mental health is not what meds you are taking. The structure is, from the tax-payer’s perspective, a cash furnace.

Sociological and Political Developments.

A report, titled: ‘Ireland’s first report to the UN under the Convention on the Rights of Persons with Disabilities’, has been issued after, in 2006, the UN adopted the UNCRPD within its corporation. The Irish government signed the convention in 2007, yet, has more or less acted as though it was ‘signing up’. It was only ratified- or fully recognised- in 2018. It is certainly not being fully upheld to this day, and I feel that many psychiatrists are still ‘taking liberties’, with their chosen methods of treatment. Section 144, worryingly, and discernibly, reads like evidence of the governments prevailing resistance to adhere to the model of supported decision-making mentioned in reference to UNCRPD ‘Article 12- Equal Recognition before the Law’. After all, the ‘first initial report’ did not arrive until 2020- fourteen years after the convention. Somehow, the Assisted Decision Making (Capacity) Act 2015 (ADMC), made it into legislative processes before the Irish government even began to think about the newfound rights of the most vulnerable groups amongst our population. Section 165 shows how quickly the motion has been promoted by Fine Gael (FG).

“165. Ahead of the ADMC’s commencement, draft rules of court to facilitate the operation of the new capacity regime have been prepared by the Courts Service which is continuing to consult with the DSS (Decision Support Service) Director and relevant court offices on the matter”.

Further deliberation on this topic would offer some much needed clarification. Through the gaze of a politically oriented perspective, this seems like an issue in the making. However, to keep with the scope of this article, I feel as though it is safe to say that there is a predominantly urgent need for mental health reform in the Republic of Ireland. It is becoming more of a discussion of what structures are now obsolete, and which individuals need to be introduced to enact the correct matters of civil diplomacy necessary for social development. This is one of those moments which offers an opportunity for change. Better mental health in Ireland. The need for it has felt so aversive, that it is starting to seem like most of the public has forgotten what the reward will feel like. After the past few years, I personally want to see progress.

Teleologically speaking, the queasy development years of the psychiatric discipline are beginning to become more profound. However, there have been around as many ‘next generation’ anti-psychotic’s as there have been ‘iPhone’s’. Maybe, these new generations of antipsychotics have changed the psychiatric space a bit, but, they are nothing so long as the

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older generations of psychiatrists remain obsolete. If the discipline remains as toxic as it is, many instances where the very same patterns of behaviour and illness that psychiatrist’s spend all of their time analysing in others, will become ingrained within the psychiatrists own mentality. It brings to mind the old adage; who shaves the barber? In the modern world, this is an obsolete notion; we all shave ourselves. It is a paradox that is outgrown by evolution. One must think, how many have asked themselves similar questions about psychiatrists? Who treats them, and, if no-one, can psychiatry possibly fulfil its role in society? Would we be better off looking after ourselves, and each other?

Conclusions

In short, people should understand antipsychotic medication as; a means to ease the dissatisfaction of not being able to perform our societal roles properly, because of the shifting normative behaviours of the present generation of the human race. Many of the psychiatric decisions that I have seen in the past few years (2017-2020) have been performed outside the confines of the Mental Health Act 2001, and United Nations Convention on the Rights of People with Disabilities. Where the pharmaceutical administration in socially obsolete mental health unit’s is not conducted properly- and responsibly- in accordance with internationally recognised legislation, the residing communities will most probably be much more susceptible to toxic narcissistic cycles, gaslighting, and demoralisation. The route forward is not so gloomy, when there are measures taken against the reoccurrence of past failures. Within the mental health community; there is need for more transparency, there is need for self-determination, and, there is certainly need for more respect. 

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Works cited:

Bromberg-Martin, Ethan S et al. “Dopamine in motivational control: rewarding, aversive, and alerting.” Neuron vol. 68,5 (2010): 815-34. doi:10.1016/j.neuron.2010.11.022

J. A. Barnes. “Durkheim’s Division of Labour in Society.” Man, vol. 1, no. 2, [Wiley, Royal Anthropological Institute of Great Britain and Ireland], 1966, pp. 158–75, https://doi.org/10.2307/2796343.

“Psychiatric Drugs Do More Harm Than Good, Says Expert”. The Guardian, 2021, https://www.theguardian.com/society/2015/may/12/psychiatric-drugs-more-harm-than-good-expert.

“Myth of the Antipsychotic.” The Guardian, Guardian News and Media, 2 Mar. 2008, https://www.theguardian.com/commentisfree/2008/mar/02/mythoftheantipsychotic.

Lv, Qinyu, and Zhenghui Yi. “Antipsychotic Drugs and Liver Injury.” Shanghai archives of psychiatry vol. 30,1 (2018): 47-51. doi:10.11919/j.issn.1002-0829.217090

Dafny, N., and G.C. Rosenfeld. ‘Neurobiology Of Drugs Abuse’, Conn’s Translational Neuroscience. Elsevier, 2017, pp. 715-722.

Davidson, Michael. “The debate regarding maintenance treatment with antipsychotic drugs in schizophrenia.” Dialogues in clinical neuroscience vol. 20,3 (2018): 215-221. doi:10.31887/DCNS.2018.20.3/mdavidson

Rabitte, Anne. ‘Ireland’s first report to the UN under the Convention on the Rights of Persons with Disabilities’, www.gov.ie, Department of Children, Equality, Disability, Integration and Youth, 03 Dec. 2020.

‘Mental Health Act: 2001. Irishstatutebook.ie, Office of the Attorney General. Dublin, Ireland’.