The M-Word

When my grandfather, born in 1900, got cancer in his middle age, it was still the “C-word”.  I didn’t know what was going on until many years later when I was an adult.  Cancer was not talked about.  It was in hushed whispers.  And yet yesterday there was a whole section in the New York Times about breast cancer and there were sexy ads, cartoons and lots of pink.  I LOVE pink.  We all know what pink means.  And my girlfriends who have lived with, and outlived, their cancer, in no small part it is due to this huge paradigm shift.  There is now no judgement.   So we can prevent it, early-diagnose it, talk about it, understand it.  We rally and walk.  There is education, support and healing.  With or without cure.

Twenty-plus years ago, shortly after fluoxetine (aka Prozac) entered the pharmaceutical market, I was first given the diagnosis of depression and prescribed this medication.  I was very hesitant about taking it.  However, a very kind and wise physician said to me: “if you were a diabetic you would take your insulin, wouldn’t you?”  I gave it a try.   It may have saved my life, it certainly greatly altered it.  Initially, my feelings were similar to when I was twelve and first got eyeglasses.  “The trees have leaves!”  Of course I knew the trees had leaves, I just didn’t know “normal” people could see them, and in such vivid detail.  “Oh, this is how it feels to want to get out of bed in the morning!  To feel this thing people call ‘happy’.”  Part of you has known this hasn’t felt quite right – the not-wanting to arise, the not-quite clutching “happy” – but you work your world around your normal.

Of course, rare was the time before the diagnosis or after that I told anyone what it was like for me to live with or through this disease.

As a recent patient said to me – after a long discussion about my impressions and diagnosis of his illness and working out the treatment options together – when I asked how he was feeling about this: “I feel overwhelmed.  And, relieved.”  It is both a weight-lifting and a heavy thing to realize what you carry has a name and possibly a form of respite.  After the thing you have worked your whole world around and have experienced from the inside has been given an identity and an identity outside of your own.  Suddenly you can step outside of it.  Hold it in your hand.  Look at it from different angles.  Shine a light on it.  Ask it questions.  And, not alone.  But.  You have to learn how to see and decide whether to look at it at all, maybe its not so sexy or easy on the eyes.   And you may have to relearn how to be.  How to get along with this thing that is not you but lives with you, inside you.  And you may wonder about how much of yourself, or of what you know, you are willing to let go, give up to (maybe) get something new that you don’t know or understand or necessarily trust.  And it is shifting.  Possibly a medication helps to some degree but then a side effect or risk suddenly does not seem worth it.  Or it doesn’t work any more.  Or interferes with another medication.  Or you want to get pregnant.  Or just want to feel like you don’t “need” it.  It’s overwhelming.  And you are just at the start of a huge learning curve with a lot of not-knowing ahead.

And on top of all that maybe it has a name like “mental”.  With all the visceral playground-teasing and spooky hospital-on-the-hill memories that rise up from your belly.  And the grown-up, top-down, hyper-intellectual ideals of mind over matter.  And still after all these years, it is kind of the “M-word”.

Today I am a psychiatrist, so I am as wise and kind of a physician as I can be as I treat others with, what we now call, mental illness.  I actually use the diabetes metaphor a lot.  People ask me: will I have this illness, will I need to take this medication, forever?  Like type II diabetes, a familiar and common-enough illness, I recommend for many patients both a medication and lifestyle change.  I suggest “hitting it as hard as we can”, using all the available and appropriate resources we can muster.   We know that in many cases psychotherapy can help as much as medication and in many other cases that both together help even more.  Often exercise, nutritional changes, volunteer work, spiritual support, improved relationships, meditation, all relieve anxiety and depressive symptoms.  Does this mean the illness will go away?  We can not predict.  Any more than we can with diabetes.  Some people take their Metformin, their insulin, exercise, change their diet, lose weight, take their fish oil, relieve their stressors.  And, still have diabetes.  Others can lose weight and lifestyle measures alone rid them of what can be a chronic and debilitating illness with ongoing secondary problems.  But hopefully, whatever the illness, and whether chronic or acute, patients somewhere inside all of this  can work to educate, accept, improve and heal, find a renewed empowerment and improved quality of life.  Whether the illness ever goes away or not.  Hopefully, in this process they can find a way to keep that now-named creature from defining, controlling or keeping them from their own purpose, growth and meaning.  No one deserves to get depression or bipolar or diabetes or cancer.  But the truth is we get the hand we are dealt.  How are you going to live with it?

It seems I spend a great deal of my time persuading some people into giving a medication a try so their hard work can be more efficient.  Often these are people who would prefer to rely on “natural” methods or still believe they “should” be able to “think” their way out of how they feel, as if the illness or even emotions were a weakness or character flaw or “mental” illness.  An illness of their mentality.  They would maybe want to avoid or deny it or exercise or exorcise it away.  And don’t get me wrong.  Many of these things actually work and often enough.  But sometimes they do not.  And then, I will spend another portion of my time trying to educate others that a pill alone will not necessarily “cure” them.  There is not magic, it is not an exact nor perfect science.  Whether it was flawed environment, negative thinking, poor coping, etc. that contributed to them presenting to me or not, having the help of a therapist, specialized support team, improved sleep or lifestyle will help them cope with what they now have – an illness – however they got there.  So I get to educate and support and love people as they come to me feeling broken and escort them over the threshold into realizing that no, they are not broken and yet, yes, there is not necessarily a pretty nor easy way out of what they actually are.  Human.  And, living with an illness.

Both the naming it and the name we call it matter.   We do not call diabetes an “endocrine illness” or a “maybe-if-you-ate-less-donuts-you-might-not-be-here illness”.

Many people have been working really hard for many years to de-stigmatize mental illness.  We can keep working to try to disconnect people’s minds’, hearts’ and guts’ reactions to this word – “mental”. Or. For the same reason some people do not like to be called a “female writer” or a “black actor”, but simply just “writer” or “actor”. While we may be proud we are female or of our race or ethnicity, it is not always comforting or comfortable to be pointed out as different, separate or “special” from the “norm”. Perhaps we can just drop the “mental”.  And call it what it is.  Depression.  Anxiety.  Bipolar disorder.  Schizophrenia.  Posttraumatic Stress Disorder.  An illness.  We need a paradigm shift. To move away from judgement.  So we can prevent it, early-diagnose it, talk about it, understand it.  We can rally and walk.  There is education, support and healing.  With or without cure.

Having now been on both sides of the desk – so to speak – I understand the great courage it takes for people to find their way to me.  To break their silence and wonder out loud “Is there something wrong with me?”  Not knowing what the answer will be or treatment recommendations may entail.  They are especially brave because of the stigma after all these years.  It is an honor and a privilege to be with people in the most vulnerable and intimate times of their lives.  It is as close to life as one can be.  Whether being born, dying or in pain.  Devastated, joyful, or scared.  I feel lucky to be a physician and be with people in this way no matter what name we give it.