Tuesday, October 12, 2010

Pass the salt. Tuesday, Oct. 12, 2010.

“I like it, I’m not gonna crack.” –Nirvana, “Lithium”

Does it sound a little Brave New World-y to you? Bioethicist Jacob M. Appel wants to put Lithium Carbonate in your drinking water.

Actually, Lithium Carbonate is an amazing little substance. It’s actually a salt, not too far removed from the salt on your dinner table, and it’s used to process metal oxide – but you probably know it best in its psychiatric applications, where it is the number one treatment for bipolar disorder.

Lithium’s way different from other medications used in psychiatry. It has an amazingly long history, having been first discovered effective against mania in 1871 (you read that right). In 1886, it was discovered to be effective against depression. It took a century for the FDA to approve it, though, and in the meantime, people were given exceedingly high doses that occasionally killed them. Oops.

But once doctors learned to administer it properly – and to test patients’ blood periodically to make sure there was no toxicity – they discovered something about Lithium that makes it different from every other psychiatric medication: it seems to have an anti-suicide effect.

It’s not just about relieving manic/depressive symptoms; meds like Lamictal and Zyprexa do that too. But Lithium is extra special. In study after study, patients taking Lithium are less likely to kill themselves than those on other meds. One study, for example, at the University of Cagliari in Sardinia, found that suicidal patients were eight times less likely to commit suicide if they took lithium – and that the pattern more than reversed itself if they stopped taking their meds.

But the best-known evidence is the data collected from 27 Texas counties between 1978 and 1987, which demonstrated that the incidence of suicide (as well as homicide and rape) were significantly lower in areas with naturally-occurring Lithium Carbonate in the water supply. Last year, there was a similar finding in Oita, Japan. The amount of Lithium in the water was quite small – much, much less than one would get taking tablets; the stabilizing effects were seen not only in people who are diagnosed bipolar, but among the general public; and no adverse health effects were reported.

So, says Appel, maybe we should put Lithium Carbonate in everybody’s drinking water, just like we add fluorine to prevent cavities.

Whoa! Whoa! Whoa! People were already freaking out about the fluoride. And don’t we keep reading about the dangers of traces of pharmaceuticals that are making their way into our water supply? On the other hand, fewer suicides, rapes and homicides might be a good thing…

I took Lithium for many years. I stopped taking it for several, and bad things happened. I’m back on it, and so far, so good. I don’t mind the blood tests – although every time I get one, I’m reminded that this salt is a drug – and a powerful one at that.

Somewhere in my bookshelf, I have “1984,” “Brave New World” and “This Perfect Day.” Let me read those again, and I’ll get back to you on the question of whether I think that my drug belongs in your drinking water. Okay?

Monday, October 11, 2010

Against our will. Monday, Oct. 11, 2010.

“I must be crazy to be in a loony bin like this.” –McMurphy, “One Flew Over the Cuckoo’s Nest”

Life had become a nightmare for Rebekkah. Her husband of 20 years was divorcing her, and was continuing a pattern of abuse. He was trying to get full custody of their 13-year-old daughter. And Rebekkah’s mother, who lived with the couple, had just passed away.

But the chaos going on in Rebekkah’s environment was nothing compared to what was going on inside her mind. I had been noticing Rebekkah’s decline over several months each Sunday she came to church – she was losing weight, looking unkempt and chain-smoking. But it wasn’t until she called and invited me to her apartment that I knew how bad things had gotten.

Grabbing her pack of Newports, Rebekkah ushered me out to the lawn where she whispered, “Be careful what you say. He can hear you.” “Who?” I asked. “My ex,” she said. “He’s got microphones in the trees and bushes. He’s very powerful. Last week I was late to an appointment at my lawyer’s because he called his connections to cause a traffic jam on the expressway! He knows everyone in town. He can do anything he wants.”

I suggested Rebekkah talk to a therapist. “He knows all the therapists,” she said. “He has contacted every one in town and told them about me. They try to give me pills, but he has put poison in them.”

Rebekkah’s mental and physical health continued to deteriorate. She began to forget where she lived, and would walk for miles in the wee hours in the winter cold, asking to sleep on friends’ and relatives’ couches. Her sister found her wandering in traffic, murmuring to herself. She was arrested twice for driving under the influence of Hydrocodone. And she began making references to suicide. A half-dozen people (including her daughter) came to me – as the minister’s wife – asking me to “DO SOMETHING.”

Finally one day after church, I did. I asked her to come with me in my car, where she could smoke and chat, and I drove her to the hospital. Of course, when we got there, she appeared quite lucid. She knew her name (Rebekkah), her race (black), the year (2007). “I’m not crazy,” she informed the staff. “My ex husband is telling people that I am, but I’m not.”

“What do you want us to do?” The doctor asked me (when it came out that Rebekkah lacked health insurance). “Can’t you just take her to your house and watch her?”

I explained that I worked full-time and had a family to care for, and Rebekkah needed round-the-clock attention to make sure she would not injure herself. I fought with the doctors and administrators for almost two hours. Finally I exploded. “If I take her home with me and she winds up dead,” I said, “It’s on this fucking hospital! And don’t even THINK there won’t be a lawsuit!”

Rebekkah was admitted – over her loud objections – for a “72-hour hold.” At the end of that time, her sister and I were asked to attend a meeting at the hospital, where we both presented testimony in favor of keeping Rebekkah there for a period of time.

Rebekkah was livid. “You’re turning against me,” she shouted at us. “My ex has gotten to you too! They’re feeding me poison pills in here! They want me dead. I’ll beat them to it!”

About two months later, my husband and I received a phone call from Rebekkah. She and her daughter had moved into a new apartment, and she was having a housewarming party. Rebekkah looked beautiful in her native African dress. Her hair was styled and her makeup was flawless. She talked about an upcoming voyage to her hometown in Africa, and not a word about hidden microphones. The old Rebekkah was back. “Thank you,” she said to me as she handed me an expensive bottle of wine. She didn’t have to say any more.

The decision of whether or not to hold someone in a psychiatric unit, or whether or not to require them to take medication, is a difficult one. I knew that Rebekkah was in a world-class facility; I was also very sure that she was likely to be injured or die without 24-hour care. But I had to risk her anger, and I had to take the chance that I was wrong.

I know a lot of people would still say I was wrong. But if I faced the decision again, I have no doubt what my choice would be. And I would hope that someone would do the same for me.