SHE WASN'T IN HER RIGHT MIND

Victor Bloom MD

The recent tragedy of the Russel and Andrea Yates family is riveting and focusses our attention inevitably on the problem of untreated depression. The mother killed all five of her children and the father said of his wife, "she wasn't in her right mind." Neither was Timothy McVeigh, who blew up the federal building and was recently executed for the crime.

Initial news stories about this horrendous family tragedy say that the alleged murderer, if found guilty, could be given the death sentence. That would be yet another tragedy, but fortunately it is not likely to happen http://www.trustytimewatches.co.uk/, as from all accounts the woman was severely mentally ill, having been diagnosed 'post-partum depression' in 1999 after the delivery of her fourth child. One assumes that she was treated and apparently recovered, but many types of depression are cyclic and recurrent and require lifelong management.

And truth be told, there are millions in this country with undiagnosed and untreated depression. Mrs. Yates is an extreme and fortunately rare example of what can happen. It is becoming increasingly obvious to the medical profession and the specialty of psychiatry that recent trends in medical care have led to fewer and fewer depressed people getting adequate care.

Adequate care first of all requires detection. Despite increasing media availability of information regarding the signs and symptoms of depression, including free mental health screening in rare instances and few locales, depression as a serious illness is going largely unrecognized. Not only is there a great tendency toward denial (there's no mental illness in our family), but patients are often skillful at hiding the fact by withdrawal and avoiding contact with other people.

But most disheartening is the fact that availability of psychiatric service has become increasingly rare. This fact is belied by the existence of great numbers of 'mental health providers,' including psychiatrists (M.D.), psychologists (B.S, M.S. and Ph.D.), social workers (M.S.W.), psychiatric nurses (R.N.) and other assorted 'providers' such as occupational and recreational therapists and assorted self-styled hypno-therapists and bio-feedback experts. What has happened to reduce the effectiveness of these mental-health providers is that the trend to cost-cutting by employers, medical insurance companies, managed care, H.M.O.'s and P.P.O's has significantly reduced the quality-of-care.

Another major contributor to the general lack of adequate psychiatric care available to the general public is the absence of a major state mental health department, one which used to serve the lion's share of the mentally ill. The state and federal governments back in the 50's funded research, training and service, which is sorely lacking today. There is no doubt that brain research and psychopharmacology have made important advances in the last fifty years, but what has suffered most is the heart and soul of psychiatric treatment, the enduring relationship of the doctor and patient. Tellingly, we don't hear these words any more-- doctor and patient. The 'medical-model' has come under question and attack, and doctors are now called 'providers' and patients 'consumers.'

As a result of all these cost-cutting measures, psychiatric patients are evaluated in 15-30 minutes, instead of an hour or several hours, and followup is often limited to five visits when even twenty or fifty or several hundred are required over several years time. And there is an unfortunate tendency to treat symptoms instead of the underlying problem, which may take a long time and painstaking care to get at. Simply put, psychopharmacology has replaced psychotherapy as the treatment of choice, despite the fact of psychotherapy's proven efficacy. Instead of psychotherapy, many depressives are treated with multiple medications monitored at 15 minuntes once a month or even three months, when maybe full sessions (45 minutes) once a week for many weeks may be necessary.

I hope I am wrong, but my guess is that Mrs. Yates was treated with 'a lick and a promise' instead of an exploration in depth as to why this lady suffered so deeply and so long after having given birth. The term 'post-partum depression' is from the past. It is used as if it is a separate diagnosis, instead of one of many varieties of chronic and cyclic depression. Women with neuro-chemical depression can have relapses any or every time there is psychological stress and/or hormonal imbalance. Pregnancy and delivery are times of psychological stress and hormonal upheaval, setting off dreadful feelings of sadness and despair, often culminating in complete and unending pessimism and hopelessness or murderous rage which gets completely out of control.

Mrs. Yates wasn't in her right mind. That's the understatement of the year. When emotion takes over, reason, rationality, sanity, reality and consequences go out the window. (I suspect the same was true with Timothy McVeigh, but he kept his cool front and apparent cold-blooded crazy rationality, that he was waging war on the federal government and that he knew there would be 'collateral damage.')

Mrs Yates incurred unspeakable 'collateral damage' as a consequence of her depression getting out of control. God only knows why she did not seek help or how it was that the extent of her suffering went undetected. But people can and do cover up and hide, and their loved ones look the other way and hope the bad feelings will pass. And oftentimes people seek help and all they get is a lick and a promise.

I wonder what it would take for the public to wake up to the magnitude of the problem of undiagnosed and untreated depression. Somehow or other, life and death takes precedence, and so we try to prevent heart disease and cancer. And if a person has a brain tumor, most medical insurance will pay hundreds of thousands and even millions of dollars for brain surgery and chemotherapy and rehabilitation and months to years of life-support on a ventilator of a person in irreversible coma, but if a person has a neurochemical imbalance, insurance pays for a few short visits and minimal followup. It doesn't make any sense. Fortunately, mental health organizations are battling for 'parity' with'physical' illness in the halls of congress, even though neurochemical imbalance of the brain is just as physical as a brain tumor, with even worse consequences.

I hope to see parity restored in my lifetime, but I realize it will take the relentless and concerted efforts of those who see and understand the problem, and are committed to doing something about it. In the meantime these organizations deserve your moral and financial support, and letters to the editor and to your elected representatives.

Dr Bloom is Clinical Associate Professor of Psychiatry and in private practice in Grosse Pointe Park. He welcomes visitors to his website: www.factotem.com/vbloom and comments to his email address: vbloom@compuserve.com.