Am I sick?

“Do you think you are sick?”

My outpatient shrink asked me that at my first visit.

It’s an interesting question, loaded with potential implications.  I don’t view bipolar disorder as me.  It’s not a huge part of my life.  I just have a label.  A diagnosis.  And since it’s not manifesting itself in any way, I am not currently sick.  I just happen to take a pill every day to keep it away – almost as a preventative measure, rather than as a treatment.

Despite being diagnosed with bipolar 1 (the supposedly more “severe” version), I don’t always identify as someone with mental illness.  At least not on a day-to-day basis.  In the middle of an episode? Perhaps.  I think that’s why I have a hard time relating to many of the people on popular bipolar and depression forums such as Reddit, even though we have the same disease.  Some of that is certainly self-selection.  People who are more ill may be more likely to browse these forums for support, at least compared to people who are stable.

I think for some people, bipolar disorder is part of their identity.  In other words, the ups and downs are part of who they are.  In the arts professions, there is this thought that bipolar-ness contributes to their work, and that their creativity stems from this disorder.  I think this is a very valid point.

However, I feel the opposite.  I see my “manias/hypomanias” and “depressions” as manifestations of the illness, but when I’m euthymic, I consider myself well or not sick.  I know most doctors believe that bipolar disorder is a chronic illness, and that it can’t be cured – that it can only go into remission and requires maintenance medications for the rest of one’s life.  In other words, forever sick. With the huge caveat that I’m not a psychiatrist or psychologist, I’m not sure if I entirely subscribe to that.

Think about it.  Unipolar depression isn’t necessarily viewed as a chronic illness (though for some people it is and they do stay on anti-depressants forever).  We don’t know enough about the biology of depression and bipolar disorder to know if they are mechanistically on the same spectrum, but there is often genetic links based on family history or genome sequencing.  So what’s to say bipolar disorder is any different?  Most of us have more depressive episodes than manic episodes anyway.

So back to the doctor’s question – are you sick?  I wonder what the purpose or intent of the question was, and I wish I had thought to ask.  Was it to see how exactly how I viewed my illness? If it was a part of my identity?  Or was it to ask if I was currently sick and having symptoms? Or was it to determine if I have anosognosia and don’t believe I have bipolar disorder at all?

Regardless, I answered that although I have an illness I don’t see myself as sick and yes, I take my pills every day (or at least try to). I hope I got the point across 🙂

On guns and mental illness

It’s the anniversary of several mass shootings and with the most recent congressional baseball game incident, gun rights has come back into the news.

This topic has always frustrated me.  And here’s why.

The Pew Research Center recently did a survey and found that 89% of their respondents strongly or somewhat favored preventing the mentally ill from purchasing guns.  (link: http://www.pewsocialtrends.org/2017/06/22/americas-complex-relationship-with-guns/ )  In other words, most Americans are associating mental illness with gun violence.  And that simply is not true.

Those with mental illnesses are no more violent towards others than those without mental illness.  Certainly there is the issue of harm towards themselves, but that’s a different topic altogether.  Here we’re talking about people jumping on the “oh he was a wacko/crazy, or he was psychotic, or he had to be seriously mentally ill” bandwagon every time a mass shooting occurs.  Then they try to make laws restricting mentally ill people from buying guns.

Which mental illnesses?  I’m sure lots of people will say schizophrenia or bipolar disorder (due to how Hollywood depicts us), maybe depression, but what about ADHD/ADD, eating disorders, generalized anxiety disorder, autism spectrum disorders? They’re all in the DSM.  If we count every mental illness that is in the psychiatrists’ book, that encompasses way too much of the American population.  Some might say just ban people with “severe/serious mental illnesses” (SMI) from purchasing guns.  SMIs are defined by law anyway (I can rant about this all day too).

How exactly do they expect to check whether you have a “restricted” mental illness before selling the gun?  Demand a letter from a physician? So much for health privacy.  Apparently that only applies to those with real medical diseases.  Let’s perpetuate that stigma against mental illness, shall we?

Don’t get me wrong.  I have absolutely no interest in owning a gun.  I live in the safest neighborhood in my city, but I can understand if people who do not have that luxury (or perhaps like to go hunting) would choose to buy one.

I think everyone who owns a gun should be properly trained, practice regularly at ranges, and pass annual safety tests.  However, I  will not deny someone who has no criminal history the right to purchase a gun simply for having an arbitrarily-defined group of medical diseases.  The ACLU and several other mental health and disability advocates agree with me, but the media and general population seems to have other ideas.  I’ll just leave you with this article from a couple months ago:

http://www.nationalreview.com/corner/444582/no-gop-did-not-just-repeal-background-check-system-or-give-guns-mentally-ill

 

Health insurance: coverage for mental illness?

The latest news surrounding ACA and AHCA got me thinking about this topic, but I’ll try to stick with health insurance issues and leave politics out of this post.

It shocks me how little we learn about health insurance and the American healthcare system in medical school.  Sure, we had a couple lectures covering general facts such as the lack of access to healthcare, how our country does not have a single payer system but maybe ought to, that Medicare is for the elderly, and Medicaid is for low-income women and children.  That’s great and all, but they never taught us anything practical that we could use to help our patients.  In fact, I didn’t even know what the terms deductible, copay, coinsurance, or balance billing even meant until I was diagnosed with bipolar disorder and had to navigate this:

VanDusen_Botanical_Garden_maze

I am very lucky to have student health insurance.  Some students may complain about how everyone must buy the plan (or have something equivalent), but I don’t think they realize just how well-covered we are.  Compared to the similarly-priced individual plans I found in our state’s marketplace/exchange, we have a ridiculously low deductible and out-of-pocket maximum.  If we use our hospital-affiliated student health clinic, all visits and labs are in-network and completely free.

But most importantly for me, our student plan has great mental health coverage.  Whether I seek a psychologist or psychiatrist in-network or out-of-network, I have the exact same copay and 100% coverage (at the adjusted fee determined by the insurance company of course).  That was literally a life-saver for me.  Maybe it was an intentional decision by our school, as depression, anxiety, and addiction often plague physicians and those of us still in training.

Brass_scales_with_flat_trays_balanced

This past year I also read about parity laws – which mandated that mental illness cannot be treated any differently from other “physical” illnesses.  The Mental Health Parity Act signed in 1996 by President Clinton required health insurance companies to charge the same copays and offer same benefits ($$-wise) for mental illnesses as any other medical illness.  Of course, these companies got around this in many different ways, so the Mental Health Parity and Addiction Equity Act (2008, George W. Bush) tried to close some of the loopholes, then the Affordable Care Act (2010, Obama) finally mandated that mental illness benefits must be included in every plan.

You’d think that would be enough laws to fix mental healthcare and provide services to everyone, right?  Unfortunately, there are plenty of reports and articles in the news stating that these laws are not being enforced.  There’s also a shortage of behavioral health providers overall.  Reimbursement rates for office visits are low, and coupled with the additional billing hassles and headaches, very few want to deal with insurance anyway.  My psychiatrist and psychologist both have agreements with our medical school to take our student health plans, even though they didn’t accept any others.

I think there are a couple points to take away from all this.

  • Our health insurance system is too complicated — everyone needs to be better educated and informed (including doctors!)
  • Although I have great mental health coverage, that is not true for many others.
  • Politicians can bicker over drafts and pass laws all day long, but it doesn’t mean those laws will actually be enforced or translate into what they intended.
  • Having insurance is different from having access to healthcare.

I don’t know how to solve our healthcare problems, but right now I have little faith in our current lawmakers’ abilities to fix them.

 

Images: (top) Vancouver Hedge Maze, By Stan Shebs, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=602013 (bottom) By Toby Hudson – Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=27707265