Tag: diagnosis

Mental Health: Update

It’s been over six months since I got off my medication for depression (venlafaxine) and ADHD (methylphenidate), so I thought I should just provide an update. The immediate trigger for this post is that I’m reading Nassim Nicholas Taleb’s Antifragile, in which among other things he rants against excess medication, and explicitly picks on medication for depression and ADHD.

Overall, I must mention that I’ve managed pretty well these last six months. Yes, there are depressive bouts. Yes, there are times when I can’t concentrate and I get increasingly restless. Sometimes it is perhaps as bad as it used to be before I started seeing a psychiatrist. But it’s ok. The most important outcome of going to a psychiatrist for a year has been that I’ve gotten diagnosed.

You might have heard this in several places – that ninety percent (or maybe more, or less) of treatment of a disease is diagnosis. And in case of my mental health I find that to be absolutely true. Yes, I took medication for a year. Yes, it helped back then. Yes, as I’ve written before, having those medicines provided me the necessary stimulus to get myself out of the depths I’d gotten into over the last few years. However, I’m certain that I don’t need them any more. But the diagnosis helps.

Two years back my biggest concern was that I wasn’t able to explain my life. There was no story. I had done a lot of things that were seemingly disparate and there were a lot of things that I’d done which I would later regret. So I had a lot of regrets, and I would expend a lot of my idle processor time (in my head) dwelling on these regrets, and wondering why I did certain things the way I did, or why I took the decisions I took. Every time I tried to come up with an explanation for something, I would get the “but everyone deals with that, why can’t you” response.

The biggest advantage of having diagnosed is that it now all fits in. I now know why after getting into IIT with such a good rank I drifted away and completely lost interest. I now know why so many of my initial crushes didn’t work out (ADHD among other things makes you impulsive and blurt out things you aren’t supposed to). I now know why I chose to literally run away from my first job (that’s a long story in itself. Will save it for another day). And I precisely know why I went in and out of three more jobs in the five years after that.

Yes, I might be overfitting in some things (you can see that I’m doing that in the previous paragraph to explain why no relationships worked out). Nevertheless, after a long and ardous search for that one variable or set of variables that would explain a large part of who I am or what I did, when I all I found was noise, I think I’ve found the signal. Till I was close to thirty, I led my life without having fully understood myself. And trying to blame myself for being inferior to other people in certain ways, and constantly regretting my decisions. The diagnosis changed all that. Yes, after a discussion on a mailing list on ADHD some three years back I’d posited that I might have it. Yet, a formal diagnosis from a qualified psychiatrist helped.

So you may ask why I discontinued medication if I know that I have some problems. Two different reasons for the two medicines I was taking. As for Venlafaxine (which I used to take for anxiety and depression), I had a harrowing time in November of last year when I ran out of supplies of the drug and couldn’t find it in any store near my house for a couple of weeks. During this time I would feel weak, have a fever and feel extremely numb in the limbs, but had no clue why that was happening. Later, the psychiatrist told me that these were withdrawal symptoms for failing to take my drugs regularly. I panicked. i didn’t want to get addicted to mind-altering substances. More importantly, around this time I got the feeling that the drug wasn’t doing much help. I would still have the same old bouts of depression. The psychiatrist agreed that I had plateaued in response to the drug. So she recommended a rather slow taper off from the drug (to prevent withdrawal symptoms), which I followed and got off it.

Methylphenidate was useful, and wasn’t addictive (some literature has likened it to wearing spectacles. It affects you only when you’re taking it). Yet, I found that it changed me. Yes, I know that I’m attention deficit and possibly hyperactive, but I  refuse to believe now that it’s a ‘disorder’. The problem with the drug was that it was changing my mind. Yes, it made me concentrate so much better. Long strings of meetings when I would visit the client’s office were a breeze thanks to the drug. My concentration levels shot up. Yet,  I found that it had impaired my creative thinking. I’m extremely proud of my ability to connect disparate things, but I felt that this drug was impairing my ability to do so. I just wasn’t being myself. And I had found that on days when I would forget to take the drug  I would be more capable of creative non-linear thinking. And I figured that with the drug I wasn’t being myself.

So yes, I’ve been off the drugs for a while now and have adjusted to life with it. Yes there are days when I’m constantly fidgety and can’t concentrate to get work done. Yes, nowadays  work that takes long bouts of intense concentration gets delayed. But I’m back to being myself. And I’m back to being good at what I thought I was always good at – big picture thinking and making disparate connections.

Yes, one important factor that has helped me to deal with my condition (no, it’s NOT a disorder) is my work. As a freelance management consultant who mostly works from home (and visits client once every couple of weeks)  I can set my own pace. If i’m feeling particularly fidgety some day, I can take a break till I’m doing better. I don’t have daily or sub-daily deadlines to bother me (this was my biggest issue with most of my jobs). More importantly there’s no one looking over my shoulder to see what I’m doing, so I can freely switch between my work screen and twitter. And trust me, this helps. Immensely.

Since I visit my clients once in 2-3 weeks I end up having lots of meetings during these visits. But I simply draw up on my energy reserves during those times and buckle down and concentrate. Yes, last two or three times after I’ve visited the client I haven’t got much work done for the following three or four days – since I’d be recuperating from that intense expense of mental energy – but again I’m okay with that.

I plan to write on this again in the near future after I finish reading antifragile. I find this to be a rather important concept for me given that I’m prone to making errors (I’ve now accepted that). I think I’ve already started designing my life along antifragile principles. But more on that in another post.

Meanwhile, some other posts I’d written earlier about my mental condition.
1. How ADHD is like being perennially doped
2. On the importance of admitting mental illness and going to a specialist
3. On anti-depressants being like an economic stimulus
4. On mental illness in elite colleges in India
5. On anxiety being like a computer virus
6. On how ADHD can sometimes be advantageous

The stigma about mental illness

It saddens me deeply every time I see someone rubbish mental illnesses as a fad, and as a wall behind which the mentally weak strive to hide. Having myself being affected negatively by delayed diagnosis and treatment thanks to prevailing orthodoxies, and having seen the kind of lift timely recognition and therapy can provide, it is frustrating to know that most of the world still attaches a stigma to any kind of mental illness.

Earlier today, someone I know reasonably well complained that she’s feeling way too depressed nowadays, and that she needs to seek a counselor. Knowing her, I know that this is a deeply informed decision, but before I can throw in my support, her mother interjects saying “all this therapy and counselling is bullshit. Just move in back with us and you’ll be fine”. I had half a mind to interject with “your similar stupid judgments not so long ago drastically delayed someone’s recovery, I know. So I don’t think your daughter should listen to you”. But not feeling particularly combative, I kept my opinion to myself.

Over the last few months, I’ve been trying to do my bit, though, to help clear the stigma of mental illness. I was talking to some aunts today and told them, “Look, there’s nothing wrong in being clinically depressed. It’s just unlucky. It’s like having diabetes”. They nodded, and seemed to understand. Perhaps using analogies like this one, where people can evaluate mental illness on par with an illness that they understand well, help.

The problem with mental illness, though, is that too few possible evangelists are “out” (while reading homosexual literature, I see several parallels between the difficulties faced by the sexually queer and the mentally ill). So many possible evangelists are involved in professions that sees “mental strength” as a necessary trait that they are afraid of jeopardizing their careers by “coming out”. The only solution, as I heard in an interview a couple of months back, is for this to be a gradual process. People with mental illness “coming out” is now a trickle, but if we sustain that trickle, perhaps it will become a flood sooner rather than later, and that might help erase the stigmas associated with this class of illnesses.

A couple of months back, I happened to listen to cricketer Iain O’Brien’s interview with The Cricket Couch, where he talked about his depression, and about why he “came out”. It was a truly inspirational talk, and there he mentioned about the trickle turning into a flood theme. He talked about Marcus Trescothick, who probably led the way among cricketers with mental illnesses “coming out”, and the effect that had on mentally ill sportspersons. He mentioned that his own coming out was a step in sustaining that trickle.

A month back, I read Trescothick’s autobiography, “Coming Back to Me“. That is again a story very simply written and well-told, and hopefully that helps educate the larger population about mental illness, and about the fact that it can strike just about anyone. In fact, Tresco makes an interesting point there that mental illness is more likely to affect the mentally stronger people, for being mentally strong, they try to fight against the tide that inhabits their mind, unaware of its presence, and in the process sink deeper into the illness. We surely need more such evangelists.

So today, on no particular occasion, I have decided to do my bit for mental illness evangelism, to make my little contribution to what is currently now a trickle and will hopefully turn into a flood. I suffer from more than one illness that gets categorized under the class of “mental illness”. For over six months now, I’ve been on anti-depressants, trying to combat my anxiety and depression. I also suffer from this condition called Attention Deficit Hyperactivity Disorder (ADHD) , but don’t take any medication for it.

For a while I was suffering from “second degree stigma”, and hence not “outed” myself, though in general I keep my affairs public. Because I’ve known that mental illness has stigma attached to it, I was afraid that outing myself might harm me both personally and professionally. However, I realize that by not sharing my story of incredible transformation in the past six months, I was doing a great disservice to the class of mental illness patients in general by not contributing to the trickle. Having convinced myself that I can work (for the first time in over six years I completed a couple of projects recently), and that I can work well despite my illness, I think it makes no sense holding this back any more. I thank Marcus Trescothick, Iain O’Brien, Freddie Flintoff, Lou Vincent et al for showing the way, and I think it’s my duty to join the band.

My psychiatrist informs me that I must have had ADHD for, like, forever, but lack of knowledge of the condition in India meant I was never diagnosed. Back in 2002, my parents took me to a psychiatrist because they thought I wasn’t performing up to my potential at IIT. I got administered the Rorschach Test and some questionnaires and was put on a mild dosage of sleeping pills, which I soon stopped taking without much impact. In hindsight, my ADHD should have been diagnosed then, and perhaps that might have helped me make better career choices than quitting four jobs in a bit over five years’ time.

As the more perceptive of you might have already figured out by now, this “coming out” means that I’ll probably be writing more about mental illness on this blog. I know it might make some of you uncomfortable, but it is indeed part of my effort to make people more comfortable with dealing with mental illness, and to try and erase the stigma attached to the class of illnesses. If you are a sufferer, too, I encourage you to come out, and join this trickle. And help turn it into a flood.

The Trouble with Mental Illness

  • The “patient” has an incentive to overestimate the extent of his illness, since he can “get away” with certain things by claiming to be more sick than he is
  • People around the patient have an incentive to underestimate the extent of illness. They think the person is claiming illness only to extract sympathy and get away with things that would be otherwise not permissible
  • The second point here leads to internal conflict in the patient, as he can’t express himself fully (since others tend to underestimate). Feelings of self-doubt begin to creep in, and only make the problem worse
  • There are no laboratory tests in order to detect most kinds of “mental illness”. Diagnosis is “clinical” (eg. if 8 out of following 10 check boxes are ticked, patient suffers from XYZ). This leads to errors in diagnosis
  • The method of diagnosis also leads to a lot of people in believing that psychiatry is unscientific and some reduce it to quackery. So there is little the medical profession can do to help either the patient or people around him
  • That diagnosis is subjective means patients have incentive to claim they’re under-diagnosed and people around are incentivized to say they’re over-diagnosed
  • I don’t think the effect of a lot of medicines to cure mental illness have been studied very rigorously. There are various side effects (some cause you to sleep more, others cause you to sleep less, some cause impotence, others increase your mojo, and so on ), and these medicines are slow to act making it tough to figure out their efficacy.
  • There is a sort of stigma associated with admitting to mental illness. Even if one were to “come out” to people close to him/her, those people might dissuade the patient from “coming out” to a larger section of people
  • If you were to be brave and admit to mental illness, people are likely to regard you as a loser, and someone who gives up too soon. That’s the last thing you need! And again, the underestimate-overestimate bias kicks in.
  • Some recent studies, though, show a positive correlation between mental illness and leadership and being able to see the big picture. So there is some hope, at least.

Collateralized Death Obligations

When my mother died last Friday, the doctors at the hospital where she had been for three weeks didn’t have a diagnosis. When my father died two and a half years back, the hospital where he’d spent three months didn’t have a diagnosis. In both cases, there were several hypotheses, but none of them were even remotely confirmed. In both cases, there have been a large number of relatives who have brought up the topic of medical negligence. In my father’s case, some people wanted me to go to consumer court. This time round, I had signed several agreements with the hospital absolving them of all possible complications, etc.

The relationship between the doctor and the patient is extremely asymmetric. It is to do with the number of counterparties, and with the diversification. If you take a “medical case”, it represents only a small proportion of the doctor’s total responsibility – it is likely that at any given point of time he is seeing about a hundred patients, and each case takes only a small part of his mind space. On the other hand, the same case represents 100% for the patient, and his/her family. So say 1% on one side and 100% on the other, and you know where the problem is.

The medical profession works on averages. They usually give a treatment with “95% confidence”. I don’t know how they come up with such confidence limits, and whether they explicitly state it out, but it is a fact that no disease has a 100% sure shot cure. From the doctor’s point of view, if he is administering a 95% confidence treatment, he will be happy as long as his success rate is over that. The people for whom the treatment was unsuccessful are just “statistics”. After all, given the large number of patients a doctor sees, there is nothing better he can do.

The problem on the patient’s side is that it’s like Schrodinger’s measurement. Once a case has been handled, from the patient’s perspective it collapses to either 1 or 0. There is no concept of probabilistic success in his case. The process has either succeeded or it has failed. If it is the latter, it is simply due to his own bad luck. Of ending up on the wrong side of the doctor’s coin. On the other hand, given the laws of aggregation and large numbers, doctors can come up with a “success rate” (ok now I don’t kn0w why this suddenly reminds me of CDOs (collateralized debt obligations)).

There is a fair bit of randomness in the medical profession. Every visit to the doctor, every process, every course of treatment is like a toin coss. Probabilities vary from one process to another but nothing is risk-free. Some people might define high-confidence procedures as “risk-free” but they are essentially making the same mistakes as the people in investment banks who relied too much on VaR (value at risk). And when things go wrong, the doctor is the easiest to blame.

It is unfortunate that a number of coins have fallen wrong side up when I’ve tossed them. The consequences of this have been huge, and it is chilling to try and understand what a few toin cosses can do to you. The non-linearity of the whole situation is overwhelming, and depressing. But then this random aspect of the medical profession won’t go away too easily, and all you can hope for when someone close to you goes to the doctor is that the coin falls the right way.