The Noonday Demon

by Solomon, Andrew

  369 The six Nobel winners who spoke before Congress in the testimony mentioned here appeared before an annual hearing of the House Subcommittee on Labor, Health and Human Services, and Education, in the early 1990s. Representative John Porter, among others, has described the event in several oral interviews.

  369 The figure that over 75 percent of health plans in the United States offer less coverage for mental health than for any other kind of physical health is from Jeffrey Buck et al., “Behavioral Health Benefits in Employer-Sponsored Health Plans, 1997,” Health Affairs 18, no. 2 (1999).

  371 The numbers for my own illness break down as follows: sixteen visits to the psychopharmacologist at $250 per visit; fifty visits to the psychiatrist (approximately three hours per week) at $200 per hour; and bills for medications that add up to at least $3,500 per year.

  371 The statistics regarding the financial costs of depression in the workplace come from Robert Hirschfeld et al., “The National Depressive and Manic-Depressive Association Consensus Statement on the Undertreatment of Depression,” Journal of the American Medical Association 277, no. 4 (1997): 335.

  371 The Mental Health Parity Act of 1996 took effect January 1, 1998.

  372 The statistic that four hundred thousand people fall off the insurance registers for every 1 percent increase in the cost is quoted in a letter from John F. Sheils, Vice President of the Lewin Group, Inc. to Richard Smith, Vice President of Public Policy and Research, American Association of Health Plans, November 17, 1997. Naturally this estimate will vary depending upon “the health policy being analyzed.” The letter was provided to me by the Lewin Group, Inc.

  372 The economic consequences of insurance parity are extremely complicated and rely on variables too diverse to be reflected in any one study. While many experts seem to agree that insurance parity will raise total insurance costs less than 1 percent—this statistic is quoted regularly in the professional and popular presses—various studies have found other numbers. The Rand Corporation Study found that equalizing annual limits would “increase costs by only about one dollar per employee.” A report by the National Advisory Mental Health Council’s Interim Report on Parity Costs found a number of possibilities—from decreases of 0.2 percent to increases of less than 1 percent. In a Lewin Group study of New Hampshire insurance providers, no cost increases were found. For more information on these various studies, see NAMI’s Web site at www.nami.org/pressroom/costfact.html.

  372 The figure on overall added costs for first year of parity is in Robert Pear, “Insurance Plans Skirt Requirement on Mental Health,” New York Times, December 26, 1998.

  373 That over a thousand homicides in 1998 were attributable to people with mental illness is stated in Dr. E. Fuller Torrey and Mary Zdanowicz, “Why Deinstitutionalization Turned Deadly,” Wall Street Journal, August 4, 1998.

  373 The extent of the discrepancy between the proportion of the mentally ill who are dangerous and the media coverage of those people is reported in “Depression: The Spirit of the Age,” The Economist, December 19, 1998, page 116.

  374 The recent study at MIT that showed that people who have major depression and lose work abilities can return to previous norms on medication is Ernst Berndt et al., “Workplace performance effects from chronic depression and its treatment,” Journal of Health Economics 17, no. 5 (1998).

  374 The two studies showing that supported employment for the mentally ill is the most economically beneficial way of dealing with them are E. S. Rogers et al., “A benefit-cost analysis of a supported employment model for persons with psychiatric disabilities,” Evaluation and Program Planning 18, no. 2 (1995), and R. E. Clark et al., “A cost-effectiveness comparison of supported employment and rehabilitation day treatment,” Administration and Policy in Mental Health 24, no. 1 (1996).

  376 The McCarran-Ferguson Act was passed in 1945. Dr. Scott Harrington, in his “The History of Federal Involvement in Insurance Regulation,” quotes the act as stating “that no act of Congress ‘shall be construed to invalidate, impair, or supersede’ any state law enacted for the purpose of regulating or taxing insurance.” This paper is in Optional Federal Chartering of Insurance, edited by Peter Wallison.

  376 The statistics on Clinton’s proposed budget for FY 2000 may be found on-line at the NIMH’s Web site at www.nimh.nih.gov/about/2000budget.cfm. According to the NIMH, the final budget for FY 2000 will not be settled until early 2001.

  376 That the Community Health Services Block Grant was increased by 24 percent is in NAMI E-News 99–74, February 2, 1999.

  378 National-level suggestions for mandatory tuberculosis treatment are issued by the Center for Disease Control’s Division of Tuberculosis Elimination’s Directly Observed Treatment (DOT) program. This program proposes weekly meetings with health care workers who deliver treatment and verify compliance with treatment protocols. For more on the Center for Disease Control’s recommendations, see: www.cdc.gov/nchstp/tb/faqs/qa.htm. While all fifty states recognize the DOT program, it is implemented at state and city levels according to local needs. In New York State, for example, mandatory tuberculosis treatment regulations are issued and enforced through the New York State Department of Health in conjunction with city and local governments. The New York State Department of Health stipulates a DOT program that provides for “directly observed administration of antituberculosis medications for people who are unwilling or unable to comply with prescribed drug plans.” For more, see www.health.state.ny.us/nysdoh/search/index.htm. In New York State, more than 80 percent of people with tuberculosis are put into a DOT program. In New York City, the Commissioner’s Orders for Adherence to Anti-TB Treatment states, “the Department of Health works with health care providers to facilitate patients’ adherence to anti-tuberculosis treatment and to protect the public health. Most individuals adhere to treatment when they are educated about tuberculosis and receive incentives or enablers, assistance with housing problems, enhanced social services, and home or field programs of directly observed therapy (DOT). However, if these measures seem likely to fail or have already failed, the Commissioner of Health is empowered by Section 11.47(d) of the New York City Health Code to issue any order deemed necessary to protect the public health.” See the New York City Department of Health’s website at www.ci.nyc.ny.us/html/doh/html/tb/tb5a.html for more information. For a statistical analysis of mandatory tuberculosis treatment in New York City, see Rose Gasner et al., “The Use of Legal Action in New York City to Ensure Treatment of Tuberculosis,” New England Journal of Medicine 340, no. 5, 1999.

  379 The ACLU position on involuntary treatment of those with mental disabilities may be found in Robert M. Levy and Leonard S. Rubinstein’s The Rights of People with Mental Disabilities, page 25.

  380 For more on Willowbook, see David and Sheila Rothman’s The Willowbrook Wars.

  381 The budget breakdown for mental health spending in the Veterans Administration is in the testimony of the American Psychiatric Association to the Department of Veterans Affairs, April 13, 2000, and can be found on the APA’s Web page at www.psych.org by clicking on “Public Policy and Advocacy,” and then “APA Testimony.”

  381 I have taken from Representative Marcy Kaptur the anecdotal evidence that psychiatric disturbances may be the most frequent among veterans.

  381 This statistic that 25 percent of veterans at VA hospitals suffer from mental illnesses is taken from the testimony of the American Psychiatric Association to the Department of Veterans Affairs, April 13, 2000, and can be found on the APA’s Web site at www.psych.org by clicking on “Public Policy and Advocacy,” and then “APA Testimony.”

  381 That more than half of all practicing physicians have had part of their education within the VA health-care system comes from the Veterans Administration Web site. They report: “The Veterans Administration currently is affiliated with 105 medical schools, 54 dental schools, and more than 1,140 other schools across the country. More than half of all practicing physicians in the United States have had
part of their professional education in the VA health-care system. Each year, approximately 100,000 health professionals receive training in VA medical centers.” From www.va.gov/About_VA/Orgs/vha/index.htm.

  386 Kevin Heldman’s piece is “7½2 Days,” published in City Limits, June/July 1998.

  387 Estimates of the percentage of patients with depressive disorders within state and county mental health facilities are taken from Joanne Atay et al., “Additions and Resident Patients at End of Year, State and County Mental Hospitals, by Age and Diagnosis, by State, United States, 1998,” published by the U.S. Department of Health and Human Services in May 2000. They report that affective disorders are the second most prevalent disorder among residents at 12.7 percent, page 53. For nonresidents this number increases to 22.7 percent, page 3.

  391 The figures for the mental health budget for Pennsylvania were supplied by the Mental Health Association of Southeastern Pennsylvania. I thank Susan Rogers of the Mental Health Association of Southeastern Pennsylvania for her tremendous effort in tracking down this and several other statistics.

  391 Regarding the effectiveness of community-based programs, one report declares that community services “are virtually always more effective than institutional services in terms of outcome” is reported in the Amici Curiae Brief for the October 1998 Supreme Court Case of Tommy Olmstead, Commissioner of the Department of Human Resources of the State of Georgia, et al., vs. L.C. and E.W., Each by Jonathan Zimring, as Guardian ad Litem and Next Friend, prepared by the National Mental Health Consumers’ Self-Help Clearinghouse et al., in support of respondents, page 24. This report cites numerous studies supporting their findings, two of which are especially pertinent: A. Kiesler, “Mental Hospitals and Alternative Care: Noninstitutionalization as Potential Public Policy for Mental Patients,” American Psychologist 349 (1982), and Paul Carling, “Major Mental Illness, Housing, and Supports,” American Psychologist, August 1990.

  393 Thomas Szasz’s views are expressed in his numerous writings. His books Cruel Compassion and Primary Values and Major Contentions are a good place to start.

  393 The story of the lawsuit against Thomas Szasz is told by Kay Jamison in Night Falls Fast, page 254.

  393 The op-ed on denying care to the mildly mentally ill is Sally L. Satel, “Mentally Ill or Just Feeling Sad?” New York Times, December 15, 1999.

  394 The education programs of the pharmaceutical industry run quite a range. At the annual meeting of the American Psychiatric Association (APA), industry-sponsored forums include presentations by some of the most prominent psychiatrists in the United States, many of whom have received independent research grants from pharmaceutical companies. Salesmen in the pharmaceutical industry often end up giving doctors the better part of their continuing education; their work keeps doctors up-to-date on available treatment, but their educative activities are, of course, biased.

  394 On the strategies of research and “intellectual property” see Jonathan Rees, “Patents and intellectual property: A salvation for patient-oriented research?” Lancet 356 (2000).

  397 The quotations from David Healey are from The Antidepressant Era, page 169.

  397 The suggestion that mood disorders affect a quarter of the world’s population is from Myrna Weissman et al., “Cross-National Epidemiology of Major Depression and Bipolar Disorder,” Journal of the American Medical Association 276, no. 4 (1996).

  398 These quotations from David Healy are from The Antidepressant Era, page 163.

  398 The idea of taking antidepressants off prescription is in Ibid., 256–65.

  398 That the SSRIs are not particularly fatal or dangerous even in overdose is indicated in J. T. Barbey and S. P. Roose, “SSRI safety in overdose,” Journal of Clinical Psychiatry 59, suppl. 15 (1998), in which they write, “Moderate overdoses—thirty times the common daily dose—are associated with minor or no symptoms.” Only at “very high doses—seventy-five times the common daily dose”—do more serious events occur, “including seizures, ECG changes, and decreased consciousness.”

  CHAPTER XI: EVOLUTION

  401 The quotations from Michael McGuire and Alfonso Troisi are from their book Darwinian Psychiatry, pages 150 and 157.

  403 The quotation from C. S. Sherrington I take from The Integrative Action of the Nervous System, page 22.

  403 C. U. M. Smith’s explanation of emotion and mood is in his article “Evolutionary Biology and Psychiatry,” British Journal of Psychiatry 162 (1993): 150.

  404 Jack Kahn’s astute observation is quoted from John Price, “Job’s Battle with God,” ASCAP 10, no. 12 (1997). For more information, see Jack Kahn’s Job’s Illness: Loss, Grief and Integration: A Psychological Interpretation.

  404 Anthony Stevens and John Price express their views in their book Evolutionary Psychiatry.

  404 On the orangutan as a loner, see Nancy Collinge’s Introduction to Primate Behavior, pages 102–4.

  404 On the basic principle of the alpha male, see Ibid., 143–57.

  404 A large amount of literature exists on the general matter of depression and rank societies. Leon Sloman et al., “Adaptive Function of Depression: Psychotherapeutic Implications,” American Journal of Psychotherapy 48, no. 3 (1994), is perhaps one of the first solid formulations of a coherent theory.

  405 John Birtchnell’s views are in his book How Humans Relate.

  405 Russell Gardner’s thoughts on altered dominance mechanisms in higher mammals are described in a variety of his publications. For the most comprehensive description of his ideas on depression and social interaction, see John Price et al., “The Social Competition Hypothesis of Depression,” British Journal of Psychiatry 164 (1994). For more focused discussions, see Russell Gardner, “Psychiatric Syndromes as Infrastructure for Intra-Specific Communication,” in Social Fabrics of the Mind, edited by M. R. A. Chance, and “Mechanisms in Manic-Depressive Disorder,” Archives of General Psychiatry 39 (1982).

  406 Tom Wehr on depression and sleep and energy-conservation strategy is in his “Reply to Healy, D., Waterhouse, J. M.: The circadian system and affective disorders: Clocks or rhythms,” Chronobiology International 7 (1990).

  406 Michael McGuire and Alfonso Troisi on the genome lag may be found in Darwinian Psychiatry, page 41.

  407 J. H. van den Berg’s book was originally published as Metabletica, a title I prefer. The ideas expressed here are developed throughout his text.

  408 On the difficulties of freedom, see Erich Fromm’s classic Escape from Freedom. Ernst Becker also has a pertinent discussion of freedom and its relationship to depression in The Denial of Death, beginning on page 213.

  408 The description of the boy whose family had moved and who hanged himself is in George Colt’s The Enigma of Suicide, page 50.

  408 The statistics on the number of goods in the produce section of the supermarket is taken from Regina Schrambling, “Attention Supermarket Shoppers!” Food and Wine, October 1995, page 93.

  409 The work of Paul J. Watson and Paul Andrews I have taken primarily from their unpublished manuscript “An Evolutionary Theory of Unipolar Depression as an Adaptation for Overcoming Constraints of the Social Niche.” A shortened version of this paper was published in ASCAP 11, no. 5 (1998), under the title “Niche Change Model of Depression.”

  410 The principle that low mood keeps people from overinvesting in excessively difficult strategies is expounded in Randolph Nesse, “Evolutionary Explanations of Emotions, “ Human Nature 1, no. 3 (1990). For his current ideas on depression and evolution, see his “Is Depression an Adaptation?” Archives of General Psychiatry 57, no. 1 (2000).

  410 The musician is described in Erica Goode, “Viewing Depression as a Tool for Survival,” New York Times, February 1, 2000.

  410 The idea of depression as a means of soliciting altruism is described in the work of Paul J. Watson and Paul Andrews. I have taken their ideas from their unpublished manuscripts “An Evolutionary Theory of Unipolar Depression as an Adaptation for Overcoming Constraints of
the Social Niche” and “Unipolar Depression and Human Social Life: An Evolutionary Analysis.”

  411 Edward Hagen’s views are presented in his article “The Defection Hypothesis of Depression: A Case Study,” ASCAP 11, no. 4 (1998).

  414 On the link between depression and interpersonal sensitivity, see K. Sakado et al., “The Association between the High Interpersonal Sensitivity Type of Personality and a Lifetime History of Depression in a Sample of Employed Japanese Adults,” Psychological Medicine 29, no. 5 (1999). On the relationship between depression and anxiety sensitivity, see Steven Taylor et al., “Anxiety Sensitivity and Depression: How Are They Related?” Journal of Abnormal Psychology 105, no. 3 (1996).