SO CRAZY IT JUST MIGHT WORK: TREATING PSYCHOSIS IN CANADIAN YOUTH

As we move out of the shelter of our childhoods, few of us make the
transition from dependence to independence without accumulating a few
neuroses along the way. Some people get addicted to candy, some start
smoking weed to get to sleep, while others find themselves struggling
with onsets of depression and anxiety.

Some of us, on the other hand, go crazy. Really crazy. Contrary to
what you might believe about the lines between sanity and insanity,
crossing from one to the other doesn't necessarily take much. What
many people don't know is that today, with the right help, it isn't
impossible to cross back.

Psychosis, defined as losing touch with reality to the point of
disabling your social and occupational functioning, is in fact far
from uncommon. Around three per cent of people will at one point in
their life have a full-blown psychotic episode, and the large
majority of these cases arise right around the time we start jumping
into the real world--during our late teens and early 20s. But the
extent to which psychosis is recognised in public circles, whether in
a stress management class or at a mental health fair, makes it seem
like students just don't get psychotic. We get stressed, we get
anxious, we get depressed, but hey, we don't go off the deep end--do we?

Dr Jekyll And MS Hyde

Sarah (whose name was changed for anonymity) studies science at UBC.
She's currently looking into potential supervisors for graduate
studies and trying to finish up the last year of her undergraduate
degree. She's a chic dresser with a relaxed smile and an easy laugh.
The normalcy of sitting down in a cafe and having coffee makes
breaching the subject of her psychosis a tad awkward. So we just jump
right into it.

Sarah was recently diagnosed with bipolar disorder--what used to be
called manic-depression. She was treated after suffering her first
manic episode, which she describes as a gradual acceleration of her
thinking over a number of weeks. Though she says she didn't realise
something was wrong until about a week before she was hospitalised,
the signs of a serious problem could not have been more clear.

By the time her partner and family managed to get her to the
hospital, Sarah had gone from being unusually talkative to being
agoraphobic, paranoid, unable to eat and unable to sleep. She was
chronically vomiting and compulsively writing all over her arms.
Riddled with paranoia, she was absolutely convinced--falsely--that
her father had abused her and that her partner was a rapist, ideas
that she screamed repeatedly to whoever would listen.

Even within the confines of the emergency psychiatric ward, she spent
her first few days cartwheeling down the hallways, singing at the top
of her lungs, trying to break into the nurse's office in the middle
of the night and attempting to sneak out the hospital windows.

How much of this does she actually remember? "At that point, not very
much," she said.

This is often an unfortunate, though perhaps merciful, consequence of
full-blown psychosis, especially of the manic kind--when it starts
getting really out of control, you black out. Between chemical
imbalances screwing up your brain and the psychiatric intervention of
highly potent sedatives, some patients wake up weeks after the start
of their episode alone in the psych ward completely unaware that for
the last several days, or even weeks, they'd been out of control.

Mulling over the experience while chewing on a rice krispie, Sarah is
resigned to the fact that for other people, this kind of behaviour
isn't all that easy to forget.

She knows about the perverse accusations she hurled against both her
partner and her father, in addition to the enormous amount of
distress she put her loved ones through. She knows about the
nonsensical ideas she plied on her friends and the conspiracy
theories she ranted at work. But there's nothing she can do except
laugh wryly at how socially irrevocable her behaviour may have been.

"I mean, what can I say? 'Hi sweetie, remember that time I screamed
at you and called you a rapist? Man, I'm so, so sorry about that. Whoops.'"

Now, months later, Sarah is one of many young people who survived the
unexpected upheaval of psychosis and has successfully regained her
grip on reality, as well as her station in life. Though at the start
of her treatment she had to take large cocktails of sedatives and
anti-psychotics to keep calm while her long-term medication took
effect, she is now only on maintenance doses of lithium to stabilise
her moods. Her mind is clear, her demeanour calm, her relationships
reasonably mended. She's now able to look back on it all while still
looking forward.

Crazy Is As Crazy Does

Since Ken Kesey's One Flew Over the Cuckoo's Nest and Susanna
Kaysen's Girl, Interrupted--popular fiction that harshly criticised
psychiatric practices in the '60s--it has become somewhat popular to
be skeptical of the line drawn between "normal" and "crazy." When
debating mental illness and medical intervention people often check
themselves and ask: "But what is 'normal,' really?"

The question is a valid one--cultural norms dictating irrational or
unacceptable thinking can range so widely they can be in complete
opposition to one another. One might assume that defining "normal
thoughts" in Western medicine would be an intrinsically difficult,
mercurial practice. Indeed, diagnosing mental illness is an ongoing
process, and changes in the Diagnostic and Statistical Manual of
Mental Disorders (DSM), now in its fourth edition, are constantly
being re-evaluated and updated.

Acute psychosis has always been one of the most easily
distinguishable syndromes in psychiatry, alongside major clinical
depression. But surprisingly, many people are not aware of what
behaviour is officially considered 'psychotic.'

According to the DSM-IV, acute psychosis is parsed into two types of
symptoms: positive symptoms--those aspects of the illness that
manifest themselves in addition to regular thoughts-- and negative
symptoms--those that cause a deficiency in normal behaviour.

Positive symptoms are those we often think of when we think of the
stereotypical psychotic: hallucinations (usually in the form of
hearing voices,) disorganised speech and behaviour, and delusions
(fixed, irrational, often paranoid, beliefs.) These symptoms are
usually pretty easy to spot. When your best friend starts answering
questions that were never asked a la Whoopi Goldberg in Ghost, or
tries to explain to you how their television is broadcasting their
thoughts to the world, assessing whether or not this behaviour is
"normal" isn't all that hard.

Negative symptoms can be much tougher to detect. These symptoms
simply denote the worsening of regular thinking: basically, during
the throes of psychosis your emotions can become blunted, your
intellectual capacity dulled, your sociability deadened.
Differentiating between the negative symptoms of psychosis and the
standard symptoms of a mood disorder like depression then becomes
extremely difficult.

Even harder and more crucial to recognise is the calm before the
storm--what is known as the prodromal stage of psychosis. This
preliminary phase of an episode is characterised by antisocial traits
including withdrawal from others, skipping school or work, anxiety,
reduced concentration and irritability. But any parent, teacher or
guidance counselor knows full well that these symptoms on their own
could be indicative of other stressors and illnesses, or could just
as well be part of the standard routine of an angst-ridden teen.

Admitting There's A Problem In Time

It's unfortunate that such a debilitating illness begins so
inconspicuously, because it's during the prodromal stage that
treatment is likely to be the most effective and the least stressful.
In fact, if treatment starts early enough, a person can avoid losing
their marbles altogether. Technically, an accurate diagnosis is
easier when a person is actively hallucinating or delusional, but
medical intervention at this point is often inevitably traumatic and
terrifying.

In Sarah's case, she was so far off the deep end by the time she got
real help she wouldn't trust anyone, not even her parents. She had to
be tricked into going to St. Paul's Hospital, was committed against
her will, and due to lastminute emergency circumstances, ended up
shuffled around to the eating disorders ward before she got stuck in
a kind of solitary confinement-- locked in an empty room with nothing
but a mattress on the floor. She has no recollection of those who
visited her during those first few weeks, partly because she was
forced to take so many drugs--Seroquel, Epival, Ativan, Clonazepam,
you name it--just so that she'd finally start sleeping again.

When asked if there's anything she wishes were different about her
experience getting treatment, she says she can't understand why she
hadn't been helped earlier on.

"People aren't aware [about psychosis] they don't know how to handle
it. But when your partner is throwing up, running around, not
sleeping, not making sense and calling you a rapist, isn't it time to
get some help?" According to Pam Campbell, counselor for the Fraser
Health Early Psychosis Intervention Program (EPI), this is the
problem standing in the way of easier, more effective treatment.
Combine a psychotic person's inability to assess their own condition
with the general public's ignorance of how the illness should be
dealt with, and you end up with patients coming to the hospital when
they've hit rock bottom, at which point drastic medical measures need
to be taen just to restore order, let alone get the patient back on their feet.

Because psychosis so strongly affects a person's perception of
reality, simply waiting for them to realise they need help isn't
always the best course of action.

Campbell put the situation in a commonsense perspective--one that
people who haven't dealt with mental illness might not think of: "If
you break your leg, your brain tells you your leg's broken but if
you're having difficulties with your brain, who's [going to] tell
your brain?" she asked.

"The longer you wait, the more ingrained [psychosis] becomes, so that
it can seem normal," said Campbell. "It's like, 'well, I've been
hearing voices for a year now, so it's kind of normal,' whereas if
you just started hearing voices [recently] you can definitely tell
it's not normal."

Sarah remembers how, while actively psychotic, she too lost sight of
the shore, so to speak. As her mind spiraled out of control and she
became trapped in a maze of paranoia and dissociated thoughts, her
ability to do simple tasks, like reading, became impossible. But
terrifyingly enough, though she could see that written words were no
longer making sense to her, it never occurred to her to get
help--since she couldn't remember if she was ever able to read to begin with.

Campbell attributes these treatment delays in part to the abysmal
state of BC's Mental Health Act. Though technically reformed in
recent years, in her opinion, it still has a long way to go in terms
of helping people with mental illness.

Currently, medical professionals are legally permitted to force a
client to start treatment only if they are considered an "imminent"
risk to themselves or others at the point of intervention.

"You have to be at risk of killing yourself or someone else before
you can be legally held against your will," Campbell explained. "It's
pretty awful. I mean, we can see, because we're nurses, that people
aren't doing well, but basically there's nothing we can do to help."

"I had a client once who couldn't get help for four months because no
one would see her, no one could certify her, and she wasn't getting
out of bed--ever. She wasn't in danger, but she just wasn't getting
out of bed." she said. "That's not a life. She used to be a teacher,
the whole bit, but [at that point] she just thought that everybody at
work was talking about her."

In Ontario, legislative steps have been taken to give medical
professionals more power to make patients get treated, but even these
reforms were put in place after things had gotten way out of hand.
Brian's Law-- which gives doctors a marginal increase in the
enforcement of treatment for severely ill patients--was only
conceived after Brian Smith, a sportscaster from Ottawa, was shot and
killed in 1995 by a man with paranoid schizophrenia who refused treatment.

The law passed unanimously in 2000 to improve the province's Mental
Health Act, but one might argue it came too late. Though very few
people with psychosis ever pose a real physical danger to others, it
took a fatal gunshot and a high-profile victim to make the government
wake up and realise that mental health authorities might need a
little more authority to get people the help they need.

Cutting In: Early Intervention

The Fraser Health EPI, manned at the frontlines by nurses like
Campbell, is an initiative inspired by pro-active, successful
psychosis outreach organisations in other countries, like Australia's
well-funded Early Psychosis Prevention and Intervention Centre (EPPIC).

Their mandate isn't to force more people to take medication through
legal reform, but to increase awareness about what psychosis looks
like so both patients and loved ones can spot it early and come in
for help while things are still manageable.

It has been shown in psychiatric studies that the longer people are
psychotic, the more resistant they are to treatment in the long run.
This is largely due to the accumulation of bad habits like
self-medicating with street drugs and the degradation of social
support, which makes treating any mental illness much more difficult.

People with chronic, untreated psychosis can, in the worst-case
scenario, burn so many bridges in their day-to-day existence that
getting better doesn't just involve getting their heads straight, but
also picking up the pieces of their shattered lives. Many lose their
jobs, drop out of school, get hooked on drugs, alienate their friends
and even lose their homes before they get help.

Through educational outreach in schools, as well as faster access to
medical assessment and treatment, the EPI is trying to get young
people in the GVRD to get help before things get that bad.

By going through EPI, clients can get a psychiatric appointment
within two weeks, whereas waiting in line to see a qualified
psychiatrist through the conventional route can take up to several
months. Considering many people don't even think about getting help
until they're absolutely floundering, waiting this long just to be
diagnosed is practically an invitation for disaster.

Drugs, Drugs, Drugs: Some Are Good, Some Are Bad

UBC psychiatrist Bill MacEwan created the EPI program to start making
the treatment of youth psychosis a priority in our health system,
considering that successful recovery is so timesensitive. One of
their major initiatives is educating the public on the nature of
psychosis and making people understand what factors contribute to its
onset and what factors contribute to recovery. Interestingly enough,
drugs play a significant role in triggering both.

When it comes to psychosis, genetic predisposition, such as a family
history of schizophrenia, and trauma (physical or emotional) play a
large part in triggering a first episode. But MacEwan stresses that
in our current society, with the high prevalence of street drug use,
it's recreational drugs that can have the largest influence on
whether or not a young person becomes psychotic.

"People use marijuana, cocaine or methamphetamines and those can all
cause psychosis," he explained. "Usually what will happen is people
will experience paranoia or hallucinations or delusions while they're
intoxicated and when the drug goes out of them the symptoms will go
away. However, if you have a person who has a tendency, like if they
have schizophrenia in their [family background], their psychosis may linger."

The age at which you start using drugs also affects your
vulnerability to the illness, he said. "If you're 35 years old and
start smoking marijuana the chance of you getting a psychotic episode
that lasts longer is really low. But if you're 14 years old and
smoking marijuana there's interesting evidence that shows that that
may trigger psychosis and there's a higher chance that [it] will hang
around longer, and possibly turn into schizophrenia."

The reason for this is that the brains of fully-grown adults have
stopped growing and changing for the most part, while the brains of
adolescents are still developing, and don't stop until well into
their teen years, sometimes even longer. Tossing crystal meth or weed
into your brain circuitry while it's still fine-tuning is a very
risky game that can involve long-term consequences, depending on your
genetic predisposition.

Unfortunately, genetic backgrounds don't display psychotic
vulnerabilities very clearly. Unlike easily predictable, single-gene
disorders like Huntington's chorea, chronic psychosis is now thought
to be influenced by 20 genes or more. Basically, you could have 18 of
them and be highly susceptible at any given time, or you could have
two and need a pretty heavy nudge to push you over the edge. Drugs
like crystal meth or cocaine-laced, THC-rich weed pack a pretty big
punch, one that's often more than enough to do the job.

Wondering how vulnerable you might be? According to MacEwan, if
you've had a bad time with drugs in the past and are still using,
you're likely putting yourself at risk for a fall you probably aren't
ready for.

"There are people who will say 'I get paranoid whenever I smoke
[marijuana,]' or 'I get a little weird when I'm on it,'" he said.
"Those are the people who are much more prone to [psychosis.]"

Though MacEwan acknowledges the futility of telling youth these days
to "just say no to drugs," he still hopes people who have responded
negatively to drugs before will be honest with themselves and stop
using. Hopefully by doing so some kids will manage to skip around the
nightmare of psychosis and avoid being swallowed up by it altogether.

Cuckoo's Nest Misconceptions

Paradoxically, many people embrace illegal drugs they get off their
friends, but are incredibly distrustful of legal ones that doctors
give them to help with their illness. Campbell says that treating
clients who don't understand what they need can be so frustrating she
"just wants to shake them--but you have to be patient."

"It's like they need to experiment a little bit-- they need to figure
it out for themselves," she mused. "I think people have to just come
to that point, but some people never come to it, you know? We have
people who experiment with their medication all the time, always
changing the dose, and then they complain that it's not working it's
like, hello?"

Thankfully, it seems that as long as counselors show they want to
help, regardless of whether or not clients take the drugs, patients
eventually come around on their own.

Campbell reflected on a recent case: "We had one fellow who had
missed a few doses, smoked a bit of marijuana, and came back and
said, 'you know what? I can't do this anymore. I need to take
medication and I need to stop smoking.'"

Although some clients don't come back for a year or longer, the EPI's
approach is to let them go as they please and welcome them back with
open arms and no questions, if only to build trust. Once trust is
established, proper compliance to treatment can start and real
progress won't be far behind.

Drugs are only a small part of real treatment, anyway, Campbell said.
The right drugs simply manage the symptoms, while counseling and
long-term case management are usually needed to help clients learn to
live with the disorder, make good decisions, handle relapses and
generally take care of themselves.

"Medication isn't everything," Campbell reminds us. Indeed, according
to MacEwan, good social support can be the biggest factor driving a
rapid recovery. Which is exactly why programs like EPI and EPPIC have
been created.

Treatment for psychosis has come along way since the days of Ken
Kesey's Cuckoo's Nest, though most people outside of the psychiatric
community are unaware of this. Fifty years ago, the laws were such
that a person suffering psychosis would be branded permanently as
schizophrenic and be locked away in a mental institution for years,
even decades. Today, a better understanding of the illness has made
the treatment of psychosis, under the best circumstances, a practice
of patience and hope, with an uplifting record of successful recovery.

Contrary to stereotypes, people aren't 'just crazy.' They get sick,
and like most sick people, they have the capacity get better, even to
be cured. So one of the most important things that can be done now is
get this message out to those who are straining to hear it. From
there, with any luck, helping hands can reach out and pull them in
from the darkness of their disorders.