The King County Sheriff's Office--the big metro area around Seattle--yesterday named a panel of citizens to look into all manner of management screw-ups at the agency and recommend changes. Leading the panel will be Randy Revelle, former King County exec, former Seattle City Council member and openly bipolar. Why is that significant? 18 months ago, KCSO fired Dep. Angela Holland after she revealed that she had bipolar disorder, a story I reported in Seattle Weekly last year. She had done nothing wrong on the job, but she was canned while other cops went around acting crazy on the job--sticking a gun against a citizen's head over nothing in one case--as has been documented in the Seattle Post-Intelligencer, and these cops never had their stability or job performance questioned. How much does anyone want to bet that Revelle, who last year was instrumental in getting mental health insurance parity passed by the Washington State legislature, finds a way to insert something in the panel's final recommendations on cops and mental illness...and dumb decisions made by sheriffs to discriminate against them over nothing? Stay tuned.
I've posted a few times on the issue of forcing patients to take meds on pain of forced hospitalization--which is to say soft imprisonment--and yesterday the Wall Street Journal ran a series of letters responding to their earlier article on the subject. The Trouble with Spikol has posted the letters, which nicely illustrate the divisions on this issue. My view is that forced medication is an unacceptable intrusion on personal liberties, unethical (oh, so we can give you meds that hurt your body just because we say you need them?) and deeply paternalistic. It annoys me deeply that the nation's leading mental health advocacy group, NAMI, continues to argue for forced medication. As long as a patient has not committed acts of violence or other crimes (and both of those would need to be proven in a court of law not by presumption), then I am against forced medication. If the mentally ill do not have civil liberties and the right to determine what goes into their own bodies, then who does? The Constitution applies to the mentally ill, too. If they have committed violence or other crimes (again, as proven in a court of law), then medicate them. Aside from that, fuck this shit.
It sure looks like depression has become every researcher's favorite malady unto which to link many other maladies. Hardly a day goes by that I don't read some study asserting that depression can be linked to this or that. Here's a report on a Swiss study claiming that childhood depression--a very nebulous thing in my view--is at the root of asthma and obesity later in life. Maybe it's just me, but that's a wild claim. Obesity and asthma are far more complicated matters than simply saying "Looks like another case of childhood depression behind this." But I digress. Because here comes an American study claiming a link between women with depression and allergies. I report, you decide.
As I wrote a couple of weeks ago, news that there are now questions of heart safety attached to ADD drugs like Ritalin would get patients thinking twice about taking the meds. Here's an account of what's up out there in psych land. Isn't it funny though that the ever so studious New York Times only asks questions about psych meds like these and anti-depressants but has never even poked at issues patients run into with atypicals nor examined globally why psych meds work about 50 percent of the time?
If there's good news in this it's that docs are being pushed to screen their patients very hard for things like heart murmurs before starting them on ADD drugs. That should've been happening long ago, in my view, and it should be happening just as aggressively with other psych meds. But then insurance companies don't pay docs to do proper screenings in advance of handing out psych meds--hell, any meds--and that's just dumb. I wonder: If docs had screened some patients against known indicators of diabetic shock would the two dozens or so patients who died from taking Zyprexa still be alive?
There have been stories going around for over a decade about people doing crazy shit soon after being put on anti-depressants. I am talking violent things. This used to be most prominently whispered about Prozac and Paxil. Researchers have long claimed no connections between violence and anti-depressants and juries have never bought the "Prozac Defense." But these stories pop up often enough where you've got to think there's something dark and inexplicable here that needs to be understood and explained. So here's a sad story from a city 50 miles south of Seattle, where an 82-year-old man stabbed his wife of 60 years soon after starting on Wellbutrin. There is no record of previous violence in either the marriage or the man's life--in fact, the wife, who survived, is desperate to see him but the courts won't allow it because they are classifying the case as domestic violence. Whatever you make of side effects of meds, something screwy is up here and I hope it gets resolved before these poor folks get any older.
On a related front, we could really use some kind of reliable predictors of how people will react to psych meds, especially whether said meds will spin patients up and make them do crazy things. I know that's a naive point. But I am sick of running across cases like these and the benign silence of docs who refuse to take this nasty business seriously. I mean, have you ever heard of someone going psycho on Plavix? Patients have got to be monitored far more closely than is the current medical practice. It's as simple as that.
As I mentioned the other day, I went out with the police the other night. The cops tried to talk homeless people into coming into emergency shelters because it was the coldest night of the year. With wind chill it was maybe 15 to 20 degrees, plenty cold by Seattle standards. And no weather to be sleeping out in. The homeless die on the streets all the time in this city, not in huge numbers but enough to where it bugs you just knowing about it. Not far from where I live, an old woman died in snowbank in a parking lot two years ago.
This was the first big push made by the city in years to keep people from dying in plain sight. The cop I rode with for 6 hours that night, a veteran of 27 years, said he was glad to see it. He knew the streets and where the homeless secret themselves at night.
I won't detail too much of what I saw, since I was doing this in a work-related capacity. But it's just staggering and humbling seeing what's up out there. Mentally-ill folks everywhere without even a proper shot at deciding whether or not they want to be floating around in the snake pit of the streets. President Bush says he wants to end homelessness in this country within 10 years. He took a key step in enacting his policy this month. He slashed the annual budgets for Medicaid--that's where health care comes from for the poor--and public housing, funding needed to build the housing in which to place the homeless. Cocksucker. But whatever. Clinton was just as big a fool on homelessness. Reagan was damn near the devil. But that's for another day.
All I am doing here is finding a long way to say that if America truly wants to end homelessness, then it needs to properly address mental illness in this society. About 50 percent of the homeless are estimated to have some kind of mental illness (no, I am not counting substance abuse here). That works out to about 1 million to 1.5 million people. I only wish I knew all the things could fix matters for that many people. I do know a few things, however.
We need to get treatment that works and is not life-reducing for patients, otherwise patients aren't too likely to stick with treatment. We need to end the moronic stigma around mental illness. We need to make grappling with mental illness as easy as grappling with a heart attack. We need to address this most acutely among men. They are the ones who end up offing themselves or living homeless on the streets in the greatest numbers by far.
Hunter S. Thompson killed himself a year ago today. I was disappointed and crushed and went to a bar soon after I heard the news that evening. I drank whisky and came to understand why he did it. He'd been an outsized literary hero (an all-too rare thing in America), a journalist who changed journalism, a comic genius with a pen and a very shrewd observer of human character. And, then, he wasn't anymore. By the late-1990s, HST had become a hack. He had been a huge influence on me when I was young--for me, he's right up there with Hemingway, Rilke, Carver, Rimbaud and Henry Miller. A crazy motherfucker who was seriously after the truth and intent on finding it on his own terms and sending energy off in 16 directions at once. He was also funnier than all those other writers put together.
But something died in Hunter years before he put a gun to his head and pulled the trigger. He'd stopped doing any truly original work and pumped out an occasional column for ESPN.com. This was not pleasant to watch. His letters and assorted writings came out in various collections. He still did crazy shit with guns and drugs that got him into the news. But he was done as Dr. Thompson and he knew it. The guy who'd once shouted "I hate to advocate drugs, alcohol, violence or insanity to anyone, but they've always worked for me" was quickly becoming a dried-up old man. To go from large gifts to utter literary silence had to be too much.
His suicide is one of the few perfectly rational acts (there is evidence that he planned the business) of self-destruction that I know of. It was like he'd earned the right to off himself. As a pal of his put it:
"He told me 25 years ago that he would feel real trapped if he didn't know that he could commit suicide at any moment. I don't know if that is brave or stupid or what, but it was inevitable. I think that the truth of what rings through all his writing is that he meant what he said. If that is entertainment to you, well, that's OK. If you think that it enlightened you, well, that's even better. If you wonder if he's gone to Heaven or Hell--rest assured he will check out them both, find out which one Richard Milhous Nixon went to--and go there. He could never stand being bored."
He bought the ticket, he took the ride. Mahalo, buddy. Have fun with Nixon.
I've mentioned before that researchers believe there is some kind of connection between circadian rhythms and bipolar disorder, that our internal clocks are somehow different from the rest of humanity's. I believe they are right--and so do these smarty-pantses who wrote this study in Science. They claim that they've isolated a protein receptor that drives human internal clocks. What's more, said receptor is sensitive to Lithium. It's basic research so it's years out from meaning anything very practical, but it's still very interesting.
I was out all night with Seattle police officers trying to get the homeless to come in from the cold and stay in emergency shelters for the night...cuz it's like really cold in Seattle this week. As a result, I am too drained to post. But the levels of obvious mental illness--untreated and unaddressed--among the homeless are staggering--and depressing. More later.
Researchers now claim that they have developed a mouse model of schizophrenia, which is to say they have genetically altered and cross-bred mice until they have one whose brain can mimic dopamine receptor imbalances. I've been listening to researchers explain how they have animal models of this and that ailment for the last 10 years. Sadly, very few cures and novel drug therapies that are seamless have resulted for a host of illnesses. So I'll stay in Missouri on this one. Besides, it assumes that genetics alone explain schizophrenia and I'm just not concvinced that tweaking receptors is on its own the answer. Part of it, sure, but not the whole ball of wax. I'll be happy to be proved wrong, however.
OK, it's 2006 and here we have a church pastor asserting that a mother cut up her child because of demons as opposed to, um, mental illness. Jesus. You read it and tell me.
It's no surprise that the other bipolar blogger/journalist and I would post about the same matter on roughly the same day. That would be about the ascendance of cognitive behavioral therapy (CBT). Here's Liz Spikol's post. Read it and visit her site often or put it in your newsreader.
Spurred by a news account, I noted yesterday that the world of psychotherapy and, to a lesser degree, psychology has, over the last generation, shifted away from being dominated by classic psychoanalysis to being the province of cognitive behavioral therapy. That shift, of course, has all kinds of implications for the ivory tower crowd, but in the regular world it's not nearly as meaningful as academics would like it to be. That's because most psych patients get their care through psychiatrists and GPs and take psychotropic medications, a paradigm shift that supplanted the psychotherapy-alone paradigm in the late-1980s. By far, that is the dominant paradigm in treating mental illness and bad feeling and behavior in American society. Why? That's the way Pharma companies, mental health advocates, policy makers and insurers want things to be. It's the consenus in charge, you might say. Patients, by and large, have little ability to go against this flow unless they happen to be rich, well-insured and can pay for psychotherapy out-of-pocket. So chit-chat about what's up and what's down in the world of psychology has very little bearing on how patients actually get their care.
The sad thing is I can't find any evidence that shifting from psychotherapy-alone to biological-based treatments has improved the game for patients with the kind of global impact that proponents of the psychopharmacological revolution claim.
So how does that make you feel?
For the last two decades there's been a vast generational shift taking place in psychology and psychotherapy. The shift is from traditional psychoanalysis--admittedly a very broad term--to cognitive behavioral therapy. The principal difference between the two is that the former focuses on understanding and working through the past and its traumas as a means to overcoming them (hence Freud's emphasis on childhood), while the latter essentially blows off the past and deals with changing current patterns of thinking. According to this article, the shift is nearly complete, at least in academic circles. Somewhere in Vienna, Sigmund Freud is rolling in his grave.
A bit of research that's been quietly batted about the media the past week--OK, it's hardly been covered--asserts that researchers at Yale University were able to track the course of bipolar disorder in the brains of children and teens. The results were presented as if researchers had never before realized that bipolar happened in teens and that this was a major breakthrough. Um, whatever. I guess it's researchers' and their press handlers' jobs to make every bit of research sound world-changing even when it's obvious to just about everyone else. The researchers claim, too, that the course of the disorder and brain changes are slowed by the use of mood stabilizers.
What galls me about the study is the following claim by one of the researchers: "Research to understand bipolar disorder in youths is especially important because of their high risk for suicide." That's an interesting point since the rate of teen suicide has thankfully dropped dramatically over the last decade (about a 35 percent drop), while it continues to rage in adult men at approximately twice the rate as among teens. (The female suicide rate is about one-fourth what it is among men.) But, then, that's the research funding game: paint whatever ailment as a threat to youth, regardless of its effects among others, and in come research grants and media attention.
I've been holding my tongue on the violence, controversy and whatnot about the publication of the Prophet Mohammed cartoons, but enough of that. You know the story of their appearance and subsequent public and media responses. Although I am tempted to say a pox on both their houses (extremist Muslims grossly overreacted, the Western media continued to post the cartoons, the extremists overreacted some more, etc.), I must lay the blame for this on the extremists. These are people who make extremist Christians and extremist Jews look like nursery-schoolers. They are killing people over cartoons? They demanded--as an imam did in Saudi Arabia--that Westerners be put them on trial for running the cartoons? Jesus H. Christ.
If Muslims want to move to countries in Western Europe and come to America, then there are certain things they are going to have to accept. This includes freedom of the press, association, thought and so on. If they have a problem with these freedoms, then they need to go back from whence they came. They have no cause to try and change our cultures to conform to theirs. Western cultures have worked pretty damn well for centuries. That's why the extremists and other, more peaceful Muslims moved to them in the first place, right? Hell, I remember thousands of Iranians moving to this country in the mid-1970s to escape the brutality of the Shah and I remember many thousands more making the same move to avoid the brutality of the Islamic Revolution in their homeland. America has worked out well for them. Their coreligionists ought to keep that in mind before freaking out over a batch of cartoons.
And so should the bozos at CNN and other mainstream media outlets, print and broadcast, who refuse to run the cartoons or pixelate them so that they don't offend Muslim sensibilities. OK, so while fanatic Muslims trash our culture, you guys just sit back and play along? That's bullshit. How do you figure your press freedoms will fare under sharia?
Thank god for the blogosphere. Speaking of which, the best tracking of this whole crazy matter can be found at michellemalkin.com or just do a Google search.
It must be a rotten week to be Pharma exec or doctor. As I posted yesterday, an FDA advisory panel recommended that black-box warnings be placed on ADHD drugs due to 25 cases of heart related deaths. (It's amusing that's the ever-cautious New York Times describes these as stimulants in its headline not as ADHD drugs.) And, two days ago came news that some anti-depressants have led to lung damage and death in infants whose mothers took the drugs during pregnancy. Although in both classes of drugs the numbers of deaths are small, the reports raise serious questions about their use in tens of millions of Americans. I don't envy psych docs and general practitioners who've been prescribing these for years suddenly being swamped with questions from worried patients. But that's the nature of the job.
Keep in mind that there are already black-box warnings required on all atypical antipsychotics owing to connections between them and diabetes, which had led to 23 reported deaths, and death in elderly patients with dementia. I wonder how long it will be before reports come forth of heart problems in patients taking Risperdal, an atypical antipsychtoic, which made my heart race and beat weirdly from time to time when I took the drug.
As much as I consider these reports small vindication of my drumbeat about problems with these meds, I am not happy to have my bitching confirmed. I'd prefer to be wrong, since this will limit treatment options in many cases. If you are a parent, would you now allow your kid to take Ritalin? Would you continue taking them if you are an adult?
Some of you know I have a day job as a reporter, and every so often one of my colleagues writes something that makes me proud and jealous in a "wish I'd written it" sort of way. So here's a smart article by Rick Anderson about a former journalist who is a terrorist suspect and apparently somewhat psychotic and she's locked away in a federal government psych hospital...and she happens to be related to Dubya's chief-of-staff Andrew Card. Fascinating stuff.
This is just out on the wires: The FDA will require Ritalin, Concerta, Adderall and other ADHD drugs to carry a black box warning about possible dangerous side effects. I noted a few months back that the FDA was heading in this direction. Now, the FDA has also admitted that as many as 25 deaths can be connected with these drugs. I'm glad they are taking some action--although the warning is little more than a warning, it's not a restriction--but what the hell took them so long?
Maybe you have to be a basic research geek to appreciate this, but a recent article states that bipolars see a decrease in mitochondrial function--which is to say the cellular energy systems are kerflooey--in the hippocampus of their brains. That's interesting. But, like I said, maybe you have to be a geek. I wonder if the researchers were measuring this activity during depressive or manic phases.
Then, I'll say very little. Here's an abstract to a just-published paper tracking the course of bipolar in children and teens. Surprise. It's pretty much like with adults, only more so. I fear, though, that like other recent studies on bipolar and youngins it's a prelude to another round of medicating the hell out of kids. Oh wait, they already are. I know it's working no better for them than it is for adults. And yet the researchers push ahead down the rathole of a paradigm that needs to die.
To offer some background on the 90 percent lifetime recurrence of symptoms in bipolar disorder, here's the orginal abstract from the journal article "Course of illness and maintenance treatments for patients with bipolar disorder." It was published in the Journal of Clinical Psychiatry in Jan. 1995. The paper was cited in the most recent STEP-BD article I posted about yesterday and a reader basically asked "Where the fuck did that number come from?" Great question.
What's interesting to me is that the paper (I have to pay to get even a lousy html copy) would've been submitted to the editorial board of CJP in 1994, so this paper would have been looking at data from other studies circa late-80s to early-90s, so it's no surprise that the authors focused on Lithium and anti-convulsants. That's because atypicals essentially didn't exist in clinical settings for bipolars at that point, and anti-depressants were just starting to be researched in bipolars.
The 90 percent lifetime figure is not mentioned in the abstract itself. But look at what is: within one year of an episode, 50 percent of bipolars had another episode. So the same thing I've been bitching about on this blog--altogether now, "psych meds work 50 percent of the time"--is what the authors were pointing to before the advent of all the schmancy, side-effecty, costly, new jack psych meds. We haven't made a hell of a lot of progress, have we?
Here's the abstract pinched from PubMed:
BACKGROUND: Both naturalistic studies and treatment research on bipolar disorder are reviewed to describe its clinical course, the need for maintenance therapy, the efficacy of current pharmacologic prophylaxis, and the empirical basis for more comprehensive approaches to treatment.
METHOD: Articles were identified through computerized literature searches and from bibliographies of published studies, review articles, and textbooks.
RESULTS: Bipolar disorder is marked by multiple relapses and recurrences, as well as significant interepisode psychopathology. Within 1 year of recovery from a mood episode, half of all patients will have suffered a second episode. Various clinical and demographic variables have been investigated as risk factors for recurrence. Although lithium represents the single greatest advance in the treatment of this disease, it is clear that a substantial number of patients fail lithium prophylaxis, including those with a high frequency of prior episodes, mixed (dysphoric) mania, comorbid personality disturbance, and rapid cycling. The foremost pharmacologic alternatives to lithium are the anticonvulsants carbamazepine and valproate. Increased recognition of the psychosocial sequelae of bipolar disorder and the limitations of pharmacotherapy alone have led to the investigation of psychosocial interventions. These preliminary studies are small in number and of poor quality for the most part, but have nevertheless yielded positive findings.
CONCLUSION: Although lithium often fails to meet the clearly established need for prophylactic treatment, there is little evidence from rigorous clinical trials to support the wide-spread use of anticonvulsants in maintenance therapy. Treatment research should further examine these medications and the use of psychosocial treatments as adjuvants to pharmacotherapy.
The Trouble with Spikol has a fine round-up of Medicaid and Medicare cuts that will go down ugly for low-income and indigent Americans with mental illness. Bush's budget=tax cuts for the rich, the streets for the poor.
A reader commented that he didn't believe the assertion by researchers, contained in the post before this, that bipolars have a 90 percent chance of symptom recurrence during their lives. The interesting thing is that the researchers even attributed that figure to another scientific study that made that assertion. Now what exactly is driving the 90 percent recurrence...heroin use? Natural recurrence? Who knows? But in my 17 years as a bipolar who's talked with and interviewed hundreds of people with the disorder, I have met only one person who claims that they had an episode, took meds and have never had an episode since. Kinda stunning, eh?
As I mentioned the other day, important information from the STEP-BD study came out Feb. 1 via two papers published in the American Journal of Psychiatry. The study has important implications for bipolars. I just wish I could figure out what they were. That's only partly a joke.
The basic story is that STEP-BD (go look up the acronym 'cuz I am not typing that kluge out) was funded by NIMH and looked at how patients with bipolar disorder (I and II and a few NOSers) responded to "guideline-based treatment." The study lasted over five years. Four thousand-plus patients were tracked two years at a time. Although the main paper here doesn't delineate which meds were used and rate them against one another, NIMH has said elsewhere that the study was principally focused on the use of mood stabilizers and anti-depressants with some use of atypical antipsychotics. The study also allowed the use of psychosocial treatments, i.e., talk therapy and cognitive behavioral therapy.
In the last couple of years, there have been several interim reports from the STEP-BD study. But in "Predictors of Recurrence in Bipolar Disorder: Primary Outcomes from STEP-BD," the main paper to which I referred, researchers make their first global statements about just how often patients relapse/have symptoms return and how often patients recover/have symptoms remit. Which is to say that it provides a good picture of outcomes for patients over time. That's what matters, right?
The news isn't great for current guideline-based practices. Here are some excerpts from the study:
"Only slightly more than half of the participants (58.5 percent) who were symptomatic at study entry achieved recovery during up to two years of follow-up. Furthermore, 48.5 percent of the participants experienced recurrence during up to two years of follow-up."
Recovery is defined by the study as two or fewer syndromal symptoms of mania, hypomania or depression being present for at least 8 weeks. As you know, those three aspects of bipolar have many symptoms, but having only two of them qualifies you as recovered (meaning you are still sub-syndromal and having serious problems but you are vastly more stable than during an episode). Recurrence, or relapse if you prefer, meant that a patient had an episode that hit each symptom of mania, hypomania or depression.
It's discouraging, but not surprising to regular readers, that about half the patients in this 858-patient study group did OK and about half didn't. That just further strengthens the argument I've been making in recent months that psych meds work about half the time. It also backs my assertion that for researchers to claim that complete symptom remission is possible is spreading false hope and to make total remission a polestar of the psychopharmacological paradigm is to chase a false god. When Pharma companies make similar claims, their propaganda approaches criminality. Both groups need to be held to higher standards of honesty and accuracy in their public and marketing pronouncements. More:
"Over 90 percent of patients with bipolar disorder experience recurrences during their lifetimes."
That is the wall patients are up against. You get better, you get worse, you get better, you get worse all over again--and that's just the way it is. Researchers are often deeply dishonest about this fact. Pharma companies are downright liars on the matter. So why is it that both groups, plus the national advocacy groups, spend so much time touting "guideline-based treatments" (i.e., psych meds) to the exclusion of literally everything else? Why is it that every time a state Legislature or Congress hears testimony on mental illness the drumbeat is for meds, meds, meds? Is it because that's "state of the art" and the only game in town? Or is everyone afraid to admit the uncomfortable truth that things aren't working as well as anyone would like? I guess it's kind of hard to walk up to a politician and ask them for X dollars and then tell them it's not going to work really well. But still....
What if someone read the following assessment from the paper at a Congressional hearing?
"These results demonstrate that mood episodes in bipolar disorder, and particularly depressive episodes, are prevalent and likely to recur in spite of guideline-based treatments....The finding that nearly half of study participants nonetheless suffered at least one recurrence during follow-up highlights the need for development of new interventions in bipolar disorder."
I am glad the paper's authors are being honest in the AJP. I am confused as to why some of them go back to slinging deeply skewed assertions in media aimed at the general public:
"They [patients] want to know the chance they'll get well. The chances are excellent." So said Gary Sachs, one the paper's authors and a "leading" researcher on bipolar disorder in a UPI wire story. Um, sure, Gary. Or maybe the reporter got it wrong (doubtful with a wire service).
I don't count a 50 percent chance at a "recovery" that lasts 8 weeks and still includes symptoms and full-blown recurrences as an "excellent" chance of getting well. Statistically, that's no better than flipping a coin and, honestly represented, is pretty damn ho-hum. But then researchers like Sachs are dependent for their funding on Pharma companies and policy makers, so they've got to keep everything positive when speaking to the media. When it comes to disinformation, they make the Pentagon look like children and the media look like suckers.
By the way, there is no discussion whatsoever in the paper of side-effects of guideline-based treatments. And it's side effects that make getting to that 50 percent "recovery" rate kind of dicey.
So what new interventions do the paper's authors recommend? None. As I mentioned earlier, the STEP-BD study isn't primarily focused on atypicals, which docs have been leaning on very hard the last few years, but after the study design was arrived at in the late-90s. But, then, we know atypicals aren't working so well either--and the side effects can be even dicier than with mood stabilizers and anti-depressants.
So what's a patient to do in this sea of mediocre performance and half-honesty? That's for another day.
Here's an article from the Salt Lake Tribune, claiming that depression among Latinos is caused by racism. The reporter offers no evidence of racism per se, but claims that Latinos aren't made to feel welcome in Utah and that that leads them down the slippery slope into depression. I won't even begin to poke at this nonsense--using the R word is the first default of activists when they cannot explain things any other way. But Utah isn't the most welcoming place to white outsiders either. When my family moved to Salt Lake City when I was 14, there was a lot of pressure for me, a non-Mormon, to fit in by becoming Mormon. This pressure often came from school officials. I kid you not. As nasty as that business can be, it sure as hell isn't at the root of depression. It's just ugly.
It's no secret that bipolar disorder is often misdiagnosed as unipolar depression. That puts patients in the bind of being half-treated and, as we well know, the consequences can be disastrous. Here's an article on the phenomenon alleging that 35 percent of bipolars are misdiagnosed for a decade and that 60 percent of bipolars are initially misdiagnosed as being depressed. That's a hell of a lot more than I thought, and if the numbers are true, then this is a big problem. It also argues for the American Psychiatric Association to alter some of the treatment guidelines for depression to include advice to docs to pay strict attention to depressed patients for signs of bipolar disorder.
It's of course a weakness of how psychiatry is done and how mental illnesses are diagnosed that's at the root of this. Diagnoses are made by patients self-reporting mood and behavioral symptoms. Quite often, patients will show at a doc's complaining of depression--it is very easy for even the biggest lout to recognize they are depressed--and not say a word about manicky symptoms. Why? Because they don't know any better, because there is far more stigma attached to bipolar disorder than to depression and because the heightened moods that come with the manic side feel damn good, desirable even, to patients with depression. What's more, I bet much of this misdiagnosing results from patients being treated by GPs and internists who just don't have the expertise to tease out bipolar symptoms.
It's true, too, that bipolar is sometimes misdiagnosed as ADD and vice-versa. On the manic side of bipolar disorder, symptomology often mimics ADD.
Here's a real world example. A friend of mine was diagnosed in 2001 as having anxiety. She took the standard meds for that. Nothing worked and she was especially beset by constant insomnia. In 2003, she was re-diagnosed as being bipolar. She took the standard meds for the disorder along with large doses of Seroquel, largely to address her inability to sleep. Treatment for bipolar didn't work very well either, although her doc at the time kept loading her with so much Seroquel (and later Geodon and Abilify) that she could barely function. When she made public that she was bipolar, she lost her job, despite doing everything that the medical system and American society demanded of her. Last fall, she began seeing another psychiatrist, who soon re-diagnosed her as being ADD. That treatment is working for her, which is nice and surely indicative of the diagnosis dilemma. But she lost many thousands of dollars in the process and was entirely chased out of her profession to which she can never return. Lovely.
Some of you know that 3 years ago Jayson Blair was a very promising young reporter at the New York Times. Trouble was that Blair was fabricating portions of his news stories and openly plagarizing from other reporters to a degree that was breathtaking. He was busted in the Spring of 2003, in one of biggest journalism scandals of all time. Jayson had also been smoking crack and drinking like a mad dog. Soon after his firing, he was diagnosed as having bipolar disorder. The next year, he wrote a book about his downfall at the Times. It had mixed reviews and probably was treated with plenty of prejudice within the American media just because of the stain many felt Blair left on the profession. There have been worse scandals, in my mind.
Word has it that Blair is working on another book--gee, I guess getting a famous name for telling lies does pay!--and this one is to be about bipolar disorder and, from what I've read, will address his experiences with it. Blair's website does seem to trot the word Recovery out a great deal. That's the big prize in mental illness, for patients at any rate. It is an interesting term coming from someone who's been in the game not even 3 years. It's interesting, too, because the standard measure of recovery that's used in the psych biz is 50 percent of greater symptom remission. Fifty percent is better than nothing of course, but it's a bar a mouse could jump over. So I'll be interested to see how big a role recovery plays in his book.
A kind reader passed along a pointer to the bipolar-connection.com, a decent enough resource site and point-of-entry to all that is bipolar. The site is part of the HealthCentral.com family of websites, all of which are heavily tilted to Pharma's POV and run Pharma ads. Nothing evil in that per se. I'm just pointing it out. What make me shake my head a bit though is that one of HealthCentral.com's parent company's primary investors is the Carlyle Group. Didn't Dubya's daddy and a buncha his friends have a connection there? Why, yes, yes they did...or do. I wonder why they have their paw prints on this. Just wondering.
The bipolar-connection also launched a connected blog last fall, a month after my feeble venture took sail. It's called John's Bipolar Stories and is far more mainstream than anything I'll ever do. I'm guessing talk of suicidality, substance use, spending and sex sprees and the joys of hypomania won't be making an appearance there. Still, it's good that a bunch of us are out there.
The Pittsburg Steelers just beat my Seattle Seahawks 21-10 in Super Bowl XL. A ref made an awful call late in the second quarter giving Pittsburg a free touchdown. And Seattle lost a touchdown on a questionable penalty call. Whatever. We still lost. Good season though.
I was fairly sure I couldn't be the only journalist blogging on mental health issues, and I am not. The other is Liz Spikol. You can find her at The Trouble With Spikol. Her blog is prettier than mine and I am jealous. My blog started two months before hers!
She, too, is a member of the bipolar club and, like me, is a long-term member. Other than the two of us, that's it. Most of the other mental health blogs out there seem to be born out of a Pharma PR agency or written by patients who lost perspective on the show a long time ago. Liz and I are both interested in personal struggle flapdoodle, but spend much of our time dealing with broader mental health issues. Journalistic sidenote: She's the managing editor of the Philadelphia Weekly. Like the paper I report for, it's a so-called alt-weekly and it's cool that someone from the same journalistic realm is doing this as well. Daily newspaper types--as much as I love them--are a bit too tight-assed for talking about delicate matters. We are different beasts, or bigger fools. She tells me she has quite the tale to tell of an encounter with the Pharma industry. So, um, start typing Liz. I want to read that shit.
Another thing: I am dead-dog-tired tonight and haven't been able to wrap my mind around anything complicated. I'll post more on the STEP-BD study when my brain returns. I did, however, read through the two studies I referenced yesterday. There is no reason to alter my initial conclusions.
Initial results from NIMH's long-term study of treating bipolar disorder--known as STEP-BD--are just out in the new issue of the American Journal of Psychiatry. I don't have access to the full-text versions of the related journal articles yet (I will soon enough), so for now let me offer these thoughts based upon abstracts of the articles:
Treatment of bipolar disorder with medications fails to offer symptom remission 48 percent of the time, according to this first-long term study of treating bipolar disorder according to "evidence-based" practices (translation: meds). Kind of calls into the question some of the psychopharmacological revolution, eh? This half-performance is a point I've been making for a long-time, and it's damn nice for the sages of psychiatry to get my back on this point. We'll see if the press picks up on this with the same intensity with which they glommed onto the results of last fall's CATIE study (my prediction: total silence will result). Not to be a pain or anything, but we've been aggressively diagnosing bipolar disorder and treating it with meds in a wholesale fashion for the last two decades, so why the hell did it take until 2006 to get a real-world, long-term study? Are our lives and our health care that meaningless?
Also, an AJP article from the STEP-BD study reports that for bipolars with depression (already taking a mood stabilizer and anti-depressant), Lamictal proved to be fairly useful while the atypical antipsychotic Risperdal was next to useless. Hmmm, I may have made a similar point elsewhere before, no?
I'll post more about the STEP-BD study as the articles become available to me in the coming days. Until then, I'll just say it's good to be right. Damn good.
I've posted before about the practice of outpatient commitment, or forced medication of the mentally ill outside of hospitals based upon the presumption that some people are too crazy--ok, psychotic--to be permitted to exercise their own free will. It's back in the news again thanks to an article in yesterday's Wall Street Journal (thanks to The Trouble with Spikol for posting the text), which offers a decent account of controversies around the practice.
Advocates for this approach--NAMI and the annoying E. Fuller Torrey--say that without forced medication some patients will commit violent acts and therefore they must take meds whether they like it or not. I am willing to accept that argument when applied to patients who have, as determined in a court of law, committed violent acts in the past and that those violent acts can be proven to be connected to said patients flying off their meds. If such patients wish to stay out of state hospitals and jail, then they should be participating in appropriate treatment--and requiring them to take meds seems a reasonable trade-off. But only under the above circumstances.
Other than that, forced medication is wrong and a violation of patient civil rights, especially that business about due process. Opponents such as the Bazelon Center say "No" to outpatient commitment altogether. I am on their side on this, principally because there is no proof that the mentally-ill commit acts of violence at a rate greater than the rest of the population (when they happen, the acts get massive media coverage as daily newspaper editors and television news directors are stupid like that). What's more, there's no proof that outpatient commitment works well, according to studies on the matter. And the meds that are forced on patients are typically antipsychotics--and I think everyone knows how I feel about those meds. Apply the Fuller Torrey logic to other classes of citizens: Should we tie all police officers' hands behind their backs when they go home because some of their colleagues commit domestic violence at a rate greater than other Americans? You know the answer to that.
If society is so convinced that the seriously psychotic among us are so, so dangerous, then get a court order and commit the patients in question to a hospital. And as for Fuller Torrey and NAMI, reread the Constitution and the Declaration of Independence and, then, go to hell.
You may have noticed that often one research study will say X while another study will say Y about treating depression. Part of that, of course, is tied in with the fact that researchers are working with different patient populations (ie, this group has underlying heart disease, that group smokes crack, etc.) and they are often asking slightly different research questions. At least, that's how docs will explain a day like this with three different assertions about depression treatment being released. One says that women who stop taking anti-depressants during depression wind up being depressed. Another says that depression treatment doesn't do diddly for patients with underlying diabetes. The last says that exercise beats depression and that, as a result, first-line treatment for mild to moderate depression should be exercise not meds.
The bottom line, however, is that the researchers are still treating depression with the same essential medication therapies and getting divergent results. You make of that whatever you want.
The most troubling of these studies is the one on pregnancy, which was being reported on network television. The study concludes that the longstanding practice of having women go off anti-depressants during pregnancy due to concerns over damage to a fetus is a bad idea (it doesn't address post-partum depression, if you were wondering). What was interesting, too, is that 27 percent of the women who stayed on anti-depressants during pregnancy wound up getting depressed.
So here we are 15 years or so into the psychopharmacological revolution and we are still getting hit with inconsistent results and contradictory assertions. Nice.