"What most psychotherapists are doing now is to get people started on medication so the brain is calmed down," Higley said, "and then over time people can wean themselves off the medication, and the therapy becomes the principle treatment." Higley stresses, however, medications will often remain needed indefinitely.
Many at the highest level of psychiatry share concerns about casual overuse of medication. While the new policy push is to get early diagnosis and prevent psychosis, the methods to get there are intensely controversial.
The new diagnostic manual by the American Psychiatric Association, due out in May, has stirred a firefight in the profession. Allen Francis and Robert Spitzer, two luminaries in the field, warned in an open letter that new, looser diagnostic standards "could add tens of millions of newly diagnosed 'patients' — the majority of whom would likely be false positives subjected to the needless side effects and expense of treatment."
Saving the world
Medication is attractive, partly because it can sometimes work wonders, but also because reducing illness to a pathogen and hitting it with an antidote might allow everyone to go home. In contrast, the holistic approach Drake favors is very difficult to scale and requires deep reaches into private lives.
"We are a small agency, but we are a bold agency. We are trying to save the world," said Anne Mathews-Younes, a division director at the Substance Abuse and Mental Health Services Administration.
Much like Drake, Mathews sees mental health as wrapped up in all the deprivations or shocks that would jar an otherwise healthy life, tipping someone who is predisposed to depression or other dysfunction over the edge.
Mathews calls these environmental dangers "risks" and the positive alternative "protective factors." The idea is that many people are predisposed to tip into a mental disorder or addiction if certain environmental "triggers" occur. Avoiding or controlling these triggers is often all that is needed to avoid or control long-term problems.
"Poverty is a risk," Mathews said. "Family dysfunction is a risk. A lack of education is risk. We have a column where we say, if you have this many risk factors, it is very hard to be resilient and make it through life."
Mathews speaks of "targeting" such families, "getting in early" before problems develop. SAMSHA literature speaks of parenting classes and early childhood education, all under the rubric of encouraging mental health and controlling addiction.
"I'm not suggesting that drugs have no role at all," Mathews said, "but in many instances, a person with support can be in a very good position to judge what he or she needs. I have a lot of confidence in people's ability to make decisions for themselves."
And yet, to ensure the needed support, SAMSHA reaches to the most intimate household details of those at risk — a paradox with troubling economic implications for doing the job right.
Holding his own
Back in Rhode Island, Patrick Kennedy will soon be celebrating his two-year sobriety anniversary.
In the heady whirlwind of public life, first elected to office at 21, Kennedy never had a chance to get his feet on the ground. Power and pressure fed addiction and mental illness in feedback loops. Leaving Congress gave him the space he needed.
Kennedy and his future wife dated for over a year before tying the knot in the July 2011. "The good thing is that she got to see me when I wasn't well," he said.
But for two years now, she's seen the good side. Kennedy exercises every day, goes to bed early, eats well and is in much better physical condition. He also attends an hour-long 12-step addiction meeting every day. "Even on the road, I find one," he said. He engages in breathing exercises and has learned to anticipate when an episode is coming on and counter it.
The changes in lifestyle and strong family and social support have allowed him to live without medication for now. None of this was possible when he was in Congress.
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