Volume 41 Number 57
                 Produced: Thu Dec 25  8:40:04 US/Eastern 2003

Subjects Discussed In This Issue: 

Medication and Shidduch (3)
         [Jeanette Friedman, Anonymous_2, Rise Goldstein]


From: <FriedmanJ@...> (Jeanette Friedman)
Date: Tue, 23 Dec 2003 08:54:03 EST
Subject: Re: Medication and Shidduch

When it comes to psychotropic medication, the onus lies on both sides of
the fence. Women are also required to disclose medical information. In
fact, I told my kids that the most important thing they have to do is
discuss medical history.  This is not a joke. Many times, if the people
really care about each other, the shidduch will proceed. After all, no
one is perfect. Bi-polar disease, depression, and other mental diseases
have been brought to us simply because of our Ashkenazic heritage, along
with breast cancer, colon cancer and glaucoma, Tay Sachs and
Gaucher's. People need to know that Down's Syndrome is not genetic, and
there are all kinds of things out there, on both sides of every family
and every human that predispose people for physical and mental
conditions. Full disclosure is required at all times.

I would be much more concerned if someone is deliberately trying to hide
a medical condition than coping with it. After all, many of us married
folks are on all sorts of medications for all sorts of conditions,
ranging from breast cancer to migraines to other "hereditary"
conditions. The issue is making sure that we take care of our kids and
raise them to be good, productive loving Jews.

Jeanette Friedman

From: Anonymous_2
Date: Tue, 23 Dec 2003 06:01:53 -0500
Subject: Medication and Shidduch

> If there is one prejudice in our community that no one likes to talk
>about it is the prejudice that exists regarding frum people on
>psychotropic medication who face tremendous hurdles in shiduchim because
>of this.

It's worse then stated.  I know for a fact that there are parents who
refused to allow their children to be medicated lest it harm the shiduch
prospects of an older sibling.  So much for not using the appropriate

From: Rise Goldstein <rbgoldstein@...>
Date: Tue, 23 Dec 2003 07:14:27 -0800
Subject: Medication and Shidduch

An anonymous poster wrote:

> >There are people who take medicine for emotional and psychological
> >problems. [...] Perhaps the abusive husband was on medicine,
> >shouldn't people know that?

> If there is one prejudice in our community that no one likes to talk
> about it is the prejudice that exists regarding frum people on
> psychotropic medication who face tremendous hurdles in shiduchim
> because of this.

First I want to point out that at least *I* understood the particular
material to which the poster appears to be responding to be related
specifically to cases of abusive husbands whose abuse related to a
condition for which they took medication--not the issue of spouses on
psychotropic medications generally.

Having said that, and as a research scientist who has published a number
of studies about various facets of mental illness, despite a range of
considerations grounded in the clinical realities of serious mental
disorders, I cannot disagree that we have a serious problem with what is
at best very questionably grounded prejudices about the suitability for
shidduchim of utilizers of psychotropic medications, anyone who's seen a
therapist, etc., etc.

> I take medicine for a mild bipolar disorder, which I successfully
> manage.

NOTE: In what I'm about to say I make no assumptions about the specific
poster here, but am only commenting in a general sense on a phenomenon
that concerns me.

One way in which the stigma rears its ugly head seems to me to be in the
felt need for individuals affected by such conditions to describe them
as "mild" and "well" or "successfully" managed.  I'm not presuming to
doubt this particular individual's assessment of his own condition.  In
the professional jargon of my field, this might translate to a diagnosis
of Bipolar II disorder (i.e., episodes of depression and episodes of
"only" hypomania, which is defined as elevated or irritable mood plus
increases in certain types of goal-directed activity of insufficient
severity to require psychiatric hospitalization), or cyclothymia
(frequent oscillations between mild depressive symptoms and hypomania),
rather than Bipolar I disorder (i.e., episodes of full-blown major
depression plus episodes of full-blown mania).  However, in our world,
everyone I've seen with a significant medical condition seems to
describe it as "mild" and easily controlled by medication or other
"routine" measures, whether or not it actually is.

I would also point out that even conditions that are "mild" currently,
may not stay that way.  Again, I mean to cause no further pain to the
poster, whose anguish is palpable.  However, the scientific evidence
from studying large cohorts of patients with major mood disorders,
including bipolar, is that, especially in cases with onsets in
childhood, adolescence, or very early adulthood, the conditions are more
clinically severe, difficult to treat, and characterized by more
unpredictable course than cases with onsets later into adulthood.

Obviously, anybody can develop a devastating medical condition at any
time, including individuals ostensibly "perfectly healthy" when they get
married.  As I've said before, excluding someone from consideration
based solely on a diagnosis is wrong, but at the same time, there are
real and legitimate issues to be grappled with when someone is already
known to have a serious condition, even if it is "mild" currently.


> But the discrimination that exists against people with mental health
> issues is a sham. If every frum person would march down say Ave. J. in
> Flatbush, Brooklyn, once a year people would be shocked as too how
> many of us are out there. [...]

Quite so.  If we include all the specific phobias (e.g., of dental
visits, or lehavdil of animals), then about 40% of all Americans will
meet criteria for at least one mental disorder, not including most
personality disorders, in their lifetimes.  If we add on a criterion of
clinically significant impairment in occupational or social role
performance, this percentage drops to somewhere in the range of 25% to
30%, but the lifetime prevalence is still very large.  Some of these
conditions pose more challenges to marriage than others.

In the case of bipolar disorder, the clinical nature of the condition
has considerable potential to engender a very bumpy ride in a
relationship over the course of years, even if it is well controlled:
"well controlled" usually doesn't equal "perfectly controlled," so
recurrent episodes, some of which are likely to be severe enough to
require hospitalization, have to be expected.  THEY MAY NOT HAPPEN, but
they are likely.

Then, too, there is a clinically significant genetic risk to offspring
of inheriting the condition.  Apart from the genetic risk to the
offspring, when the affected parent is symptomatic, his or her ability
to parent is going to be compromised, and family life is likely to
suffer considerably.  I didn't say this is irremediable, but it has to
be taken into account.

 From the side of the affected parent, there are also concerns about the
teratogenicity (potential to cause birth defects) of some antimanic
medications.  This is clearly of greatest concern for affected women,
but , even without conclusive evidence, some clinicians believe that not
only women trying to get pregnant, but also men trying to impregnate,
might do best to be off meds for several months before conception,
assuming that the clinical situation can possibly allow it.  Sometimes
the best guesses about the ability of the clinical situation to allow
medication-free intervals are wrong, with ghastly consequences.  As
well, bipolar disorder requires patients to regulate the daily rhythms
of their lives, e.g., in the area of sleeping and waking at regular and
predictable times and getting full nights of sleep, since sleep
deprivation is known to trigger manic episodes.  In frum families that
follow what seems to be becoming the universal norm of adding a new
offspring every year, the presence of large numbers of noisy, needy,
children poses a risk by contributing to serious sleep deprivation.  I
don't know of any way that one parent can effectively shield the other
from this enough of the time for the risk not to be present.

> [...]  Unless people can present statistics saying that occurrences of
> people on meds commonly stop their meds they shouldn't throw around
> such accusations.

Unfortunately, and I can cite any number of studies to bear this out, it
is extremely common for patients with chronic medical conditions *do*
stop, or at least play dangerously "fast and loose" with, their
medications.  The exact percentage who do this varies by medical
condition and by the research methodology used to assess medication
compliance (or, to use the more politically correct term, adherence).  I
will be glad to provide a bibliography to anyone who wishes one by
private e-mail.  Sometimes the noncompliance has to do with side effects
of the medicine (nausea, vomiting, diarrhea, weight gain or loss, etc.),
sometimes it has to do with the cost of the medicine, sometimes it
relates to the stigma of being seen taking pills, sometimes it relates
to the complexity of the dosing regimen (e.g., in HIV/AIDS "cocktails"),
and sometimes it is about other factors.

Regarding bipolar disorder, many patients stop their medications because
they find the elation of manic phases so pleasurable that they consider
being in a normal mood state to be a distinct "come-down" and feel logy,
groggy, etc., when they aren't manic.  For some of these folks, the
devastating consequences of out-of-control manic episodes aren't
sufficient to deter them from seeking the pleasurable aspects.

> > Perhaps the abusive husband was on medicine, shouldn't people know that?
> Perhaps the abuser is just an "achzor," an evil self centered person. It
> is wrong to assume that an abusive person is mentally ill and thereby
> tar all people with mental health disorders with the same brush.

I totally agree here.  The overwhelming majority of wife abuse has
*absolutely nothing* to do with mental illness in the husband.  I've
said it before and I'll say it again: the best evidence suggests that
husbands abuse because they can.  That is, the consequences, whether in
the frum world or in "mainstream" 21st-century western society, to the
abuser of abusing are insufficiently severe to deter the behavior.

> I am not saying people should marry people who can't get up in the
> morning or hold a job. I am saying people who take medication should
> not be assumed that they would stop taking their medication. I love my
> medication because it makes me stable and would stop if you paid me.

I assume the poster means, he *wouldn't* stop if someone paid him.
However, this poster is in a vanishingly small category among patients
with bipolar disorder.  *Most* patients *will* stop taking their
medications at some point, and, in the case of bipolar disorder, some
studies have suggested that if patients do this, their disorder becomes
more resistant both to the medications they've stopped, and to other
medications used to treat the condition.  There are basically no
reliable ways to predict which patients, whether with bipolar disorder
or with some other serious, chronic medical condition, will be
noncompliant with medications; even past compliance, or noncompliance,
is not a guarantee of future compliance or noncompliance.

> Much has been written as of late as too the need for a revamping of
> the shiduch system. Perhaps we should look at the way people who take
> psychotropic medication are marginalized from the system. I think it
> is time we start a discussion about this vital issue.

I couldn't agree more.  Despite the agonizing dilemmas posed by the real
and legitimate concerns I have raised, I repeat my earlier assertions
that to exclude someone from consideration for a shidduch based only on
a diagnostic label, valid though the diagnosis may be, is wrong.  Each
case has to be handled on its own merits, which our world doesn't seem
to be particularly proficient in doing these days.

One way of making it more feasible to do a reasoned, case-by-case
assessment, might be to allow a couple more time to get acquainted
before this issue must be raised.  Can anybody cite sources for why such
serious and potentially stigmatizing conditions have to be disclosed on
or before the third date?

Rise Goldstein (<rbgoldstein@...>)
Los Angeles, CA


End of Volume 41 Issue 57