It was a gut hunch. Except that it's never that simple. So here's how the more complicated part went. It involves the word monotherapy.
I have been on Lamictal alone since last August, when I walked away from atypicals as an adjunctive med. That blue pill has been in my mix of meds since the spring of 2004. And it's been the best monotherapy for bipolar disorder for me since, well, since I don't know when. And monotherapy is a whole lot better than polypharmacy. I'd rather take 1 pill a day than 4 or 5. My body likes it better and so does my head.
Of course, I am a lot better now--more experienced with this shit really--than I was during my early days with Lithium (1989-90) and Depakote (1997). Both of those worked okay as monotherapies, but then I needed to add other meds in the mix to address depression and scattered psychoses. My body didn't like that and neither did my head.
Going Lamictal-only last summer was a move born of frustration and disgust with the poor performance and wicked side effects of Seroquel and Geodon. I have ranted about Seroquel's effects on my self elsewhere--suffice to say it dumbed me down and there was still sporadic symptom breakthrough (nothing major, we are talking fine points here). When I went off Seroquel last July, I switched to Geodon, searching for a way to bite off that edge that comes with bipolar disorder--for some of us--that you'd rather not have around. Geodon made me crazy. It was like taking speed.
So I dropped the Geodon one day last August. I didn't even consult my doc on that. I'd told him previously that if Geodon didn't work, I'd ditch it faster than a phone call from a publicist. And I did. When I went to see him about 10 days later, he asked what I wanted to do. I always had the option of trying something else, after all. I told him I was doing well enough where I wanted to roll with Lamictal and see what happened.
Excepting a few bumpy patches, things have been very good. Yesterday, I went to a press conference following a police shooting the night before where the cops killed a young man--early indications are that this guy was plum crazy--who'd run along the sidewalk with a .38. He raised the gun at the cops and two cops unloaded on him. After the television crews packed up and left, I stood around and talked with a deputy police chief about the uptick of cops running up against folks with behavioral health issues. Last evening, I went and covered a commission probing the sheriff's department and, later, followed the sheriff out onto the sidewalk and asked her annoying questions.
I ain't broke, so there's nothing to fix. And that's the story of my gut hunch.
I hope everyone else can get this lucky. I hope my luck holds for me.
The following is a boring exercise in population statistics. But it has a pay-off.
What's the norm for bipolars in the mental health world? I asked the head of psychiatry at a big HMO one day last year. We were talking about how things were in the world of bipolars and medications and treatment and results. And I began asking questions I never had before because this particular doctor can access a vast database on psych patients going back to 1994. If he didn't have precise numbers, he was willing to make educated estimates. For example: What percentage of patients get diagnosed, stick with treatment and have good long-term results? He estimated that it was much less than 50 percent--somewhere closer to 33 percent. Hang onto that 33 percent for a second.
What's more he said that, in his experience, only 50 percent of diagnosed bipolars came close to complying with treatment. That means, if his numbers are legit, that on the order of 50 percent of all diagnosed bipolars don't get treatment at all. His estimate is that only about 50 percent of all people who have the disorder get diagnosed at all.
Of the 50 percent who got diagnosed maybe 50 percent--again, this is an on the order of estimate--of them stick with treatment most the time. That means that there are a ton of bipolars out--perhaps as much as 75 percent of the population of bipolars--who are either off-meds and treatment altogether or who are going back and forth with what the docs like to call compliance. The doctor agreed with me that about 25 percent of all bipolars his HMO had data on--and there are about 20,000 bipolars in this HMO at any one time--consistently stuck with treatment.
Twenty-five percent of the 50 percent who get diagnosed--roughly 13 percent of all bipolars get diagnosed and are consistent with treatment and meds and so on. I'm not sure I believe that number as an absolute. So let's be nice and assume it's 20 percent.
Remember that 33 percent? Thirty-three percent of all bipolars get diagnosed, stick with treatment and have good results. So, apply that 33 percent to the 13 percent to 20 percent above: about 4 percent to 7 percent of all bipolars, diagnosed or not, wind up with the kind of results that we are told we are striving for by having people get diagnosed and stick with treatment in the first place. And, just for giggles, let me boost that final number to 10 percent. We weren't talking full symptom remission here. We were just talking about having things work well enough to where your life wasn't thrown off-track every two months--kind of a precondition for having your life progress at all when you are grappling with a mental illness.
That's a number I don't want to believe at all: that 10 percent of the roughly 6 million to 9 million bipolars in the American population--I'm using 2 percent to 3 percent of the total population, kids included, as my base--are realizing something approaching the rhetorical and scientific promises of the psychopharmacological revolution. Fewer than 1 million people. (For the record, I consider the NIMH's estimate of 2.2 million adult bipolars to be out of date--it's from 1992--and diagnoses and prevalence estimates have become more aggressive since then.)
We walked through the numbers that way and both the doctor and I were a bit stunned at what it meant--not many people at all, ok a small fraction, are getting good results. At that point, I asked him about my situation just to test that number in a more anecdotal way. My deal is that I have almost perfectly med compliant for 17 years--98.6 percent of the time--and have after many years of struggle had positive results in my life. That's the only place where results matter, after all.
So how common was my experience? I asked. "You are very rare," he answered.
I am still shocked by that bit of casual statistics. Because I am supposed to be the norm we are all expecting as a result of diagnosis and treatment. Mental health treatment is commonly spoken of by researchers, clinicians, drug companies and advocates as being hope-filled. There is hope, as the good folks at NAMI put it.
I am clearly nowhere near the norm. The universe of those who justify all the hope hype is far too small to be remotely acceptable. Even if you took the pollyannish view and said, "Well, we just need to get everyone diagnosed and sticking with treatment all the time," (a noble, but illogical goal) then you might get to maybe 30 percent of all bipolars having great experiences--and I think I am being wildly optimistic there.
It makes me bitter, at times, to consider that I am one of the lucky ones. I earned my luck to be sure. But a .100 batting average will get you sent to the minor leagues. And we all keep claiming that we are getting major league performance.
And that's why I don't use the word hope very often. At least not as things stand now.
And, yet, tonight I told a friend of mine, a bipolar of perhaps two years experience, that she's got to stick with treatment. She said that meds were making her feel as though her personality had been stripped from her. I know, I told her. But the only way to find out if you'll be lucky is to find out.
Oregon man attempts suicide with nail gun. Meth heads are just stupid.
Schizophrenia gene found. Uh huh, sure it was, along with the other 99 alleged genetic ties to schizophrenia.
Connecticut to not license lawyers with depression. And bipolar disorder. And schizophrenia. Fuck these assholes at the state bar. I have a hunch that the Bazelon people will run them over just like they did New York when it tried to deny a schizophrenic admission to its bar. Besides, I actually know lawyers with bipolar disorder.
My little dust-up with a group of suicide survivors over the weekend has gotten me thinking how we use the term survivor in the mental health world. The suicide survivors don't think I am one of them, despite
overcoming serious bipolar disorder and suicidality myself. Apparently, that's just not traumatic enough for them.
Anyway, the term survivor comes in 3 different flavors in the mental health world. There are survivors of suicide: not necessarily mentally-ill themselves, they have lost a family member, lover, friend, etc. to suicide OR they are mentally-ill themselves and have survived suicide atttempts, suicidality and so on. There are consumer/survivors: a catchall term that describes patients in some form of recovery from mental illness. And, there are psychiatric survivors: the most politically-charged of the survivor
groups, they are former psych patients who've typically had awful experiences with mental health care and as a result have rejected psychiatry and most standard definitions of mental illness.
I am not a big fan of balkanizing survivordom this way. We are all fundamentally in the same struggle and differentiating ourselves this way dilutes both the term survivor and whatever power (arguably, damn little) that attaches to it. But everyone likes to see their own trauma as being more special than someone else's. I have no idea why that is, except I suppose it gives people an identity to hang onto.
But you sure don't see cancer survivors dividing amongst themselves this way. The yellow Livestrong bracelet covers all cancers.
Either way, I think we need better terminology in the mental health world because all of these terms have weaknesses. The term consumer/survivor, for example, is one promoted by the federal government's SAMSHA--and I just don't trust language being given to the mentally-ill by the government. Psychiatric survivor is far too confrontational. Suicide survivor seems to be an exclusive club. And so on.
But with the deep ideological divides in the mental health world, it's hard to expect that kind of cohesion. Everyone wants their agenda to prosper--from Fuller Torrey to David Oaks. I wonder if we could even agree on a rubber bracelet of our own (I know that NMHA's Mpower has some kind of braclet thingy) and especially what color it would be and what it would say. What is our Livestrong message?
Personally, I don't need the term survivor to feel good about myself. But it is out there, so I may as well use it. And so I will. Without qualification.
Since a few of you have asked, I decided not to walk away from meds. I'll post more on that later, but for now I am at work. But I'm flattered you guys asked. I hope you all are doing as well as me.
Last fall, I gave a talk on suicide and suicidality at the University of Washington's Bothell campus. The audience was a mix of families, advocates and patients, several of whom had lost loved ones to suicide. At one point, I was asked why I hadn't killed myself. My response was probably not too helpful since I answered that it was my own foolish ego that had kept me from an early end. I figured I had some things in life I wanted to try and get done and couldn't let myself end it with a knife.
Later, I described myself and my own mental illness with one word--bipolar. I know that for some in the mental health world describing yourself that way is becoming controversial. That we are not supposed to say so-and-so is a schizophrenic but that we should handle the matter with tongs and say that so-and-so is "a person afflicted with schizophrenia." Somehow there is supposed to be less stigma attached to that and it changes things from sounding like so-and-so's life is defined by schizophrenia to schizophrenia isn't them at all. I think that anyone who buys into that is kidding themselves (try living with any of the mental illnesses and then tell me what you'll call yourself) and perhaps trying to shield themselves from being implicated in a crime of some kind. Whatever.
When the talk ended, I spoke with some of the audience in the lobby. I was approached by one woman who came up to me and said, "You cannot use that word."
"What word?"
"Bipolar," she said. "My son was not bipolar. He was a person afflicted with bipolar disorder."
I told her that she had just used 6 words to accomplish what I could in 1 or 2, and that I would continue to do so.
She looked at me for a second and said, "Get with it." Then she slugged me in the shoulder.
As I mentioned yesterday, I got booted from a panel for AFSP/AAS's national conference here in Seattle this coming weekend. I was to be the moderator and as I usually do when asked to moderate, I emailed the participants a week out and asked what we ought to talk about. What I ran into was an eye-opener and the worst case of identity politics I've ever encountered in the mental health world.
I should not that all the panelists are what's called "survivors of suicide." That's a broad term that, as I understand it, covers families, friends, lovers, children and so on of people who kill themselves, as well as people who've attempted suicide and survived or been massive ideators. I fall into the attempted/ideator category. I'm not real big on the term survivor since it's part and parcel of victimology, but it's the term we've got for such things.
The first of the panelists, Thomas Joiner, wanted to read from his book. I thought that a bit odd since he'd be selling the book outside afterwards, but whatever. All the others wanted to spend the hour we had detailing their stories of survival. I asked if we might not want to discuss suicide in its broader context in American society since we are all trying to change that dynamic in this culture. I asked, too, if we shouldn't also discuss suicidality and patients who grapple with that reality every day.
NO, came back the answer. What's more, I was told by one of the panelists that I wasn't even a survivor myself. Apparently my own 17 years of fighting mental illness and going to the brink of suicide and somehow managing to get on with my life--sounds like survivordom to me--are nothing to them because my pain isn't their pain. My own thought is that maybe I am exactly who they should be listening to--hell, at least letting me ask them some questions--since it's generally a good idea in life to look for answer to people who are successful in whatever endeavor you might wish to know about. Why is this any different?
That's when shit got a bit nasty and I pointed out to the group that I sure as hell was a survivor and that I was very sick of the mental health movement, such as it is, being dominated by the parents and families of mentally ill people and suicides. As I told them, the rights and needs of patients get trampled on in that dynamic. And the family-led groups like the very powerful NAMI National are essentially wholly-owned subsidiaries of pharma companies. And, when the families get charged up and go talk to legislators and policy makers, it's always about how can we get more patients taking more meds. That's what their grief and anguish gets them--more meds that aren't working so swell jammed down the throats of more patients who end up becoming more screwed up. I am not overstating the case either. I have watched this "we are upset parents, listen to our pain, follow our lead, if only my child had stayed on their meds" prattle no in three states and watched it first hand in a couple of different legislatures.
There's only one problem: NAMI and all the families have been pounding on the "take meds, make meds accessible, end the shame" pulpit for 15 years or so now--and it hasn't worked. By any measure, the status of the mentally ill in this culture and, more importantly, the kind of productive results they have a right to as patients have not improved a bit. And that's by just about any index you care to use--suicide, unemployment, misery and so on.
Their methods are not working--and I am damn sorry to have to say that. I'm glad that families care. I am sorry they hurt. But if they think the answer to the riddle of mental illness in American culture is to get on stage with their grief--um, since when did anyone not know that suicide and mental illness suck?--and jam yet another generation of Americans full of psychotropics that beat their minds, bodies, spirits and souls to the ground without solving mental illness itself, then they are delusional. We've been doing it this way for years. And we are getting nowhere.
Does everyone just want to cry--or do they actually want to do something? Besides, there is so much pain to go around, why are we competing with one another on that score?
It's time someone said this shit, and I'll say more about the whole families thing now that I have finally opened my mouth. This weekend, I found out what the price of saying it is. And I am fine with that.
I'll go into the details later, but right now I am recovering after an attack of sorts from some fellow suicide survivors. I was to moderate a panel on suicide survival next weekend here in Seattle at the combined national conference of the Suicide Prevention Action Network and the American Association of Suicidology. By email, I asked panel members what we ought to discuss. And, then, all hell broke loose betwen some panel members and myself. This morning I was removed as the moderator. Not such a big deal since I wasn't getting paid, would've had to get up at 6 am on a Saturday, and I was doing it to be nice to two groups whose work I care about. But it was a big deal, too, in a way that alarms me and will likely concern some of you as well. I'll get into the minutiae later.
For now, suffice to say that there are very prominent people in the suicide survivors/mental health advocacy movement who have their heads firmly up their behinds. They think that only family members of suicides count as survivors--and that people who've survived suicide attempts and years of suicidality are not survivors and that people like me (and maybe you) don't have a place in the emerging movement to address the twin causes of suicide and mental health in America. They are wrong. And yet these are the very same sorts of people who have far too much power in shaping the debate and policy around mental health in our culture--and in ways that have major impacts on patients, whom they claim to serve, and on any of us who give a rat's ass about individual freedoms. It's nice to see everyone's agendas out in the open.
I'll get into this later. But, now, the Mariner's are down 2-0 in the second inning and it's the first truly gorgeous weekend day of spring. Other concerns are more pressing.
Yesterday, I noted a situation involving Washington State’s silly 25-foot rule. Under the state’s recently enacted Clean Indoor Air Act, it’s illegal for anyone to smoke within 25-feet of, well, basically anything in the state. What’s more, one tenant of the building I work in has raised such a ruckus with our building’s management about smokers obeying the 25-foot rule on the public sidewalk behind our building that the National Building’s management company put out a memo to tenants the other day, including my employer, that stated that there is no legal place to consume a legal product on the sidewalk behind the building and that smokers needed to find someplace else to go.
I knew this to be untrue (there are in fact several legal spots to do this), so I contacted the management company. The woman who penned the memo told me that the memo had been spurred by one building tenant—a lawyer whom she wouldn’t name—who has appointed himself the anti-smoking enforcer of Post Alley. This man has hassled me on two occasions in recent weeks for smoking on the sidewalk even though I was obeying the letter of the law. He has harassed others as well. Last week, he got in my face and began flipping me off. This alleged lawyer had complained to the management company.
The woman at the management company agreed with me that there are, in fact, places to legally smoke on the sidewalk behind the building. She also agreed with me that the company had no legal enforcement authority on the public sidewalk abutting the building. She told me that her company had put out the memo in order to mollify the single tenant who had complained which would, in her reasoning, prevent the company from being strung up on legal charges for not doing due diligence on informing building tenants about the law.
I asked her to identify the tenant, since I wished to contact him to ask him to stop harassing me and other smokers for complying with the law. She declined to identify him. So I asked her to pass him a message: that I would file a restraining order against this John Doe if he harassed me again.
I point this all out because days before the 25-foot rule went into effect last December, various local officials told me that there would be no situations pitting non-smokers against smokers over the rule. I was fairly certain that they were wrong. I based my opinion on local internet chatter in which virulent non-smokers claimed that they would turn into citizen enforcers of the law. Some said they would pick fights with smokers. Others said they would wander the sidewalks with video cameras collecting evidence of smokers violating the 25-foot rule—a fairly easy thing to do in Seattle with its tightly-spaced buildings—and post the evidence on the net or turn it over to authorities.
But Roger Valdez, King County’s tobacco czar, told me that my worries were misplaced. So did other officials. Valdez told me that he had “compassion” for smokers and their situation—apparently public health officials have gone Buddhist—and that the county would not enforce the 25-foot rule unless smoke was drifting into an establishment (in a future post, I will examine how he lied to me about that). He said the intent of the law wasn’t to create an environment where smokers were harassed if they violated the 25 foot rule—again, a very easy thing to do in urban Seattle where I pay taxes—but to prevent smoke from entering buildings and harming workers. I got similar assurances from other public health types, including James Apa, a flack for Public Health/Seattle & King County.
As it turns out, they were wrong and I was right. I take zero pleasure in that fact.
What’s more, spring is just starting to break out in Seattle and more people are walking the streets and hanging out in front of coffee houses, prime turf for smokers. Already, I have detected an uptick in non-smokers openly hassling smokers throughout the city. This being passive-aggressive Seattle most of the encounters are more along the lines of tut-tutting and disparaging stares, but it’s clear to me that this law has empowered non-smokers to hassle smokers—a likely goal of the unidentified people who crafted the law last year—and in a few cases this has led me to cut off contact with people I know because of their support for this silly law.
They kicked me out of the bars. They pushed me 25 feet from building entrances. Fine. I won’t hang out with them. Iacta alea est, as the saying goes.
As for the unidentified enforcer of the 25-foot rule in Post Alley, he should keep on walking.
Last evening, I learned that the property management company, from which my employer—Seattle Weekly—leases its offices, has declared a smoking ban in an alley behind the building. That’s where employees from the Weekly and other building tenants take their smoke breaks. Most of them follow the provisions of the state’s new Clean Indoor Air Act, which requires among other things that smokers stay 25 feet away from the entrances to publicly-accessible buildings, windows that open from these buildings and air intakes from the same. The alley and the sidewalk are both public property. I can find no ordinances or other local laws that state otherwise.
When I smoke out there, I do so on the sidewalk 25 feet away from entrances to the building. Even though I think the law is nuts (the 25 foot rule is a “presumptive safe distance,” and there is no data to back it up), I have decided to join my fellow smokers and stay 25 feet from entrances until this silly law can either be overturned in court or amended by the legislature. What’s more, Roger Valdez, the chief enforcer of the smoking ban in King County, has twice told me that the standard of enforcement is whether or not smoke is actually entering a building. I know for fact that no smoke is entering the building through doors, windows or air vents. It’s kind of windy down there mere blocks from Puget Sound.
But, now, the property management company has decided that smokers complying with the law just isn’t good enough for them. My guess is that this action is being driven by one occupant in the building, who has twice harassed me for smoking, even though I was obeying the law. I don’t know this man’s name. He has refused to provide it to me when I have asked him to do so. Last week, he gave me the middle finger.
Today ought to be an interesting day since I was at home yesterday with a stomach problem. When I get to work, I will review the memo from the management company. Then I will go outside and smoke on the sidewalk in the alley--all while obeying the 25 foot rule. I trust my employer will remain mute on this issue unless it merits coverage in the pages of the paper.
This nonsense over the 25 foot rule needs to stop. I hope I don’t get arrested or fined in the process. I cannot afford a lawyer or court fines. But I also cannot afford not to stand up to this nanny state horseshit and Seattle's emerging culture of presumption. This is America, not Singapore.
This is one of those stories you just don't know what to do with. A Vancouver, Wash. dentist is being sentenced for murdering his estranged wife. He confessed to the murder, according to news accounts. According to testimony at his trial, he was a bipolar, possibly undiagnosed, but was only being given Wellbutrin and Serzone. Wellbutrin, like some other anti-depressants, is famous for flipping bipolars into mania. I have no idea whether it is a legitimate defense here, but it would seem to argue that the man's sentence reflect something other than first-degree murder, if it is true that he had that kind of reaction to one of the meds and was, in fact, psychotic at the time of the crime. If he wasn't psychotic, then first-degree murder it is.
The world of psych meds is tricky for all concerned, tragically so at times.
As I have pointed out numerous times, most research psychiatrists take money from drug companies. These days, ethical academic journals require them to reveal these conflicts of interest when researchers publish. Now comes news that is both shocking and, frankly, not so shocking: that 56 percent of the psych experts who put together the current version of the DSM had direct financial ties to the pharma industry and that this was not publicly revealed.
That is a fucking travesty, since the DSM constitues the basis of what a Chicago Tribune reporter estimates as a $35 billion market for anti-depressants, antipsychotics and mood stabilizers. The total does not include ADD/ADHD drugs which would take the total to about $40 billion, if not higher.
But the hell with the non-disclosures for a moment. Don't the 30 million to 60 million psych patients in this country deserve a health care system in which the bases of diagnoses are made independent of any conflicts with pharmaceutical companies? You bet they do. These researchers should be ashamed of themselves and so should the American Psychiatric Association, which publishes the DSM, for allowing this situation to persist. The APA promises that for the DSM's next revision in 2011 conflicts will be revealed. I have another suggestion: No one who receives a plug nickel from pharma companies should be allowed to particpate in any way in designing the DSM.
So help me figure something out. As I posted a way back, my psychiatrist has used the term “recovered” to describe my current state. I am dubious of such terms, as they imply the completion of a journey and I am never quite sure when a journey is truly over and another one is beginning. But I feel damn good these days—not in a euphoric sense, but in a very level and stable way. Aside from a couple of short-lived blips, I have been in great shape psychologically since last August when I kicked Geodon to the curb. I know how to manage the blippy episodes and have never found a med or combination of meds that prevent them 100 percent. Hell, not even 80 percent.
So my doctor and I are considering taking me off meds altogether—a rare day in psychiatry! He broached the possibility with me six weeks ago and, ever since, I have been turning the possibility over in my mind.
Can I make a go of it without meds? Or is this a foolish experiment? And: If I do well without meds, am I still bipolar? And would that make me the poster child for the psychopharmacological revolution, or not?
After all, I’ve taken 18 of the 30 psych meds available for bipolars over the years and have found almost all of them wanting either in efficacy or in side effects. But for 17 years, I have taken my meds without fail even when they were failing me. I am not exaggerating—even when Prozac and Seroquel were giving me grief, I took them and went to see my doctor and laid it out for him. My one experience without meds came three years ago and lasted for four months. Other than that, it’s been all-psychotropics, all-the-time.
But here I am, doing damn well—and crossing myself as I write that—and wondering what’s next. My feelings are neutral at this point. I am only taking Lamictal these days.
So if it were your life, your body and your soul, what would you do? Let me know soon. My appointment is on Thursday.
And, by the way, who the hell ever said I don’t post positive shit around here?
Read this. It ties in nicely--OK, not so nicely--with recent news on stress and depression. I feel for this poor fellow and hope he's able to bounce back at some point.
I am generally oppposed to the death penalty. It does not deter future murderers, is wildly expensive to implement and is morally problematic. But there's also the case that argues for such extreme measures. Say howdy to Zacharias Moussaoui. In this account of his sentencing proceeding comes news that he may be mentally-ill and was raised in an abusive, mentally-ill household. So what? I hope there is a special place in Hell for him because he is headed there and soon.
Meanwhile, financial analysts are all a-tremble over Eli Lilly's stock due to forecast decreases in sales of Zyprexa and Srattera. Live by the sword....
Scientists think they've identified a strong candidate gene for schizophrenia and are beginning to get an understanding of how it affects the brain. That's fascinating, but it doesn't mean squat for schizophrenics today since it would be a good 20 years until, should it be a valid theory, it turns into a fix. Until then, the state of the art isn't too promising for patients. Haven't we got something more workable and tolerable to offer schizophrenics in the meantime than Zyprexa and Risperdal? Can't we do the equivalent of the CATIE study on how schizophrenics who have gotten better got that way? Josh Nash didn't win that Nobel Prize because of Haldol, after all.
Ah, my good pal Maverick is back at it again.
Scientology better than Prozac. Better in which sense, Tom?
British psychiatrist bashes Tom Terrific. Yee-haw.
Tom to Katie's placenta: Hello, dinner. I have a hunch Katie will break the silent birth vow if that happens. Seriously, this boy needs some Seroquel and some humility.
Well, duh. And they have tentatively established this in rats. Not that animal models are such a great proxy for human maladies, but yeah stress does crazy things to people. And American society is sure a big old stress machine. Everyone do tai chi and get zen with yourself.
If there is one country the culture of which is weirdly and tragically bound up with suicide, it's Japan. About 30,000 people kill themselves in the island nation each year. At a population of about 130 million people, that makes their suicide rate approximately 2.5 times greater than ours in the US. Don't think that many of those fit stereotypes of dishonored businessmen and students leaping to their deaths. The country is home to internet-based suicide cults and has a relationship with the Ultimate Solution that I've never understood--not that our relationship is much better or easier to disentangle. The country is setting a modest and hopefully achieveable goal of cutting that rate by 15 percent in the next 10 years. No news on how they plan to pull that off.
Meanwhile, back in America, the federal goverment's goal of halving our suicide rate by 2010 is getting absolutely nowhere. Better luck to Japan.
Some you may know that Sen. Gordon Smith's son, Garrett, killed himself in 2003. The Oregon senator opened up about his loss on the Senate floor the following year, pushing the whole nasty silence around suicide aside in ways that few have ever done. Smith, a Republican, has written a book. Here's a link to it at Barnes & Noble. Good work, Gordo. My own feeble attempt at writing about suicide is here. In it, I was a bit critical of Smith's then-silence on his son's death. The senator rectified that 7 month's later to the benefit of us all.
I don't often find my gut hunches getting scientific backing, but here are some eggheads from Cambridge Uni. getting my back. I've long believed that people of high intelligence--in the raw IQ sense--do better over time with mental illnesses than less intellectually gifted sorts. These researchers don't pretend to know why, so let me help them out: people who start from a solid intellectual baseline before developing mental disorders have something to strive for. You'd be amazed how having a few powerful, animating life goals can get you through the worst of shit. I am not joking.
On occasion, the mainstream media is willing to step away from its aiding and abetting of the pill-pushing paradigm. Here's an example from Britain's The Independent. Like everything in the British media, it's deeply slanted. But whatever. Basic argument: patients are taking too many psych meds and getting too few results and now there is a push to have Britain's Nation Health System incorporate cognitive behavioral therapy into mental health treatment. Any port in a storm, I always say. Besides, it can't hurt you any more than Prozac or Seroquel or Zyprexa. Of course, the most robust evidence in favor of CBT and the like involves using it to address depression. Mania and psychosis are likely beyond its reach.
Most the time, I post about mental health matters that pique my skeptical nature. That's not hard to do since there is damn little good news on the psych front these days, aside from the small victories of silent individuals, and I am tired of trying to stay upbeat after watching 17 years of bullshit go down. That said, here's a nice upbeat piece on therapy dogs, which aren't be used just in nursing homes these days but in general hospital wards. I have never bumped into one of these animals at a psych unit, but I know one reader is committed to getting them into Western State Hospital down the road from Seattle about 40 miles. Based upon my visits to those wards, I'd say many of those poor patients could sure use a visit from a nice dog.
Back in my bad days in San Diego, I had a cat named Spider who saved my ass more than once. These days, my pals are named Katie and KC. Cats are therapeutic, too. But, yeah, I'd like a dog as well. Too bad my landlord isn't down for that. Send me your dog and cat stories--I'll post them.
This is just one of those stories that makes you go, "Huh?" Women with breast implants commit suicide twice as often as women who don't have boobs jobs. It's one of those questions of such little moment that you wonder who approved the damned study in the first place. But, as the reporter carefully notes, maybe something else is afoot that's more worthy of study:
"One recent study found that women who received cosmetic breast implants were more likely to have a history of psychiatric hospitalization than those who underwent other types of plastic surgery."
Just as I'd always suspected.
Officials in Australia have ordered cheerleaders to no longer wear midrif exposing costumes, allegeding that the very sight of a chisled tummy may cause eating disorders. Where are Mencken and Twain when we need them? Oh, hell, they'd likely be banned too.
Meanwhile, researchers discover that the effects of X--aka Ecstasy, aka MDMA--are intensified by music. No shit. And they argue further study is needed because X and music could lead to mental illness down the road. These people get paid for this shit? Why isn't the media the least bit skeptical when interviewing them? Are these soulless dweebs now accepted as the soothsayers of our time? (Credit: To The People.)
Once again, St. John's Wort fails to treat depression better than placebo in a study.
Swiss dcotor wants to open suicide clinics.
Sometimes, the world is so weird that you just don't know what to say. Happy Easter.
The Scotsman reports today that "Half of goths have tried suicide." The paper and the study they cite are clearly conflating actual suicide attempts and cutting, but whatever. If public health officials report it, then it must be the truth. So, let's ban the goths and Marilyn Manson and black clothes because public health officials--who know the human soul so much better than the rest of us!--will be able to link all of that with self-harm. Geez.
A reader offers the following in response to the earlier sad story of an Irish schizophrenic dying young and under mysterious circumstances:
"Misadventure . . .right!!!! There is seriously more to this story. I would like to know his family history regarding heart disease. As my medications continue to increase in not only in dosage but variety, I am constantly aware of how the handfull of pills I ingest daily (that have actually saved my life) may end up killing me in the end."
Any others taking psych meds have these kinds of concerns? I wonder all the time about what effects meds I have taken long-term may have done to my body, especially in the cases of Lithium (not so nice to kidneys over time), Risperdal (made my heart race and have odd rhythms) and Seroquel (nothing specific yet, but I have my concerns).
New Jersey's governor signed a bill into law yesterday requiring medical personnel to screen new mothers for depression and to counsel expectant mothers about depression. A nice, heartwarming law. But doctors and nurses weren't doing this before? Another example of legislating common sense.
This is just sad. A Mass. man, who doctors testify had paranoid schizophrenia, blows a high school friend away with a .223. Why did he have a gun? Why wasn't his family involved enough to know this was going on? Why did he slip through the cracks?
Then here's a case of a bipolar run amok, where the family tried to get their son some kind of treatment and the system failed them with disastrous results for everyone. Nice.
A sad, strange account of the death of a young schziophrenic in Cork, Ireland. Misadventure, eh?
According to the BBC, the suicide rate in England has dropped to a historic low of 8.5 suicides per 100,000 people. That's about a 15 percent drop from the mid-90s. It's not huge--and the article doesn't talk about what changed things that much--but it's progress. Meanwhile, here is the States, the suicide rate is still at about 10.5 per 100,000. That's virtually no change in the last 50 years. What's discouraging is that the feds' public health officials have a national goal of halving the suicide rate by 2010 to about 5.5 per 100,000. That'd work out to about 16,000 suicides a year, as opposed to the 30,000 to 32,000 people who kill themselves in this country each year. That goal has been in place since 1999. Shows you what public health officials know about human existence. The key question is what could we possibly do to cut that rate in half, or hell even by 25 percent? The usual argument that you get is that more people need mental health treatment and more meds, arguing that those who sucide have a mental illness in 90 percent to 95 percent of all cases. I am not convinced of that figure and I am not convinced that mental health treatment is the entire solution. It's part of the solution, of course. But, as tricky as it is to admit, there's something up in American culture and American souls that drives suicides in this country. What the fix is for that I just don't know.
In this case a 4-year-old was diagnosed. Except in extreme cases, I am not buying that--and I sure as hell am not buying kindergartners on Zyprexa and Seroquel. And the mom in the article says this gives her her kid back? What kind of kid would that be? The article also reports that dx'ing of bipolar in kids is up 25 percent in 2 years and now affects an estimated 1 to 2 percent of American kids (12 and under, generally). That'd work out to be 1 million or more kids. I don't think America and its children have changed so radically in the last 10 years that all these kids are now suddenly bipolar. Researchers have changed diagnostic criteria. Hey, it's job security and it's what parents want, so who can blame them?
A fine article appeared in yesterday's Washington Post pointing out that, in multiple studies of atypical antipsychotics in schizophrenics, when Eli Lilly, say, sponsored a study pitting Zyprexa against Risperdal (made by Janssen/J&J) Zyprexa always came out ahead. And when J&J sponsored studies of Risperdal, then that drug was the winner. It's an article well worth reading. But it could've been improved in two small ways. One, by noting just how large the market is for atypicals--about $10 billion last year in the US, the fourth largest class of patented drugs in the country--and that 50 percent or more of the market for atypicals now comes from those with bipolar disorder, and there is very little independent/non-pharma data on the use of atypicals in treating bipolar disorder. That, too, sounds like news to me.
My good homie Tom Cruise will be interviewed by Diane Sawyer on ABC's "Primetime Live" on Friday. Don't watch it. And his new movie, "Mission Impossible 3," opens in May. Don't buy any tickets for it. The man is a negative force in American culture and should not be supported with your dollars. There is also an article on Cruise forthcoming in GQ. Meanwhile, here's a great Tom-dissing website, Tom Cruise Is Nuts. I feel the need for speed!
A Canadian doc says that by 2020 depression will be the second leading cause of disability worldwide. I'm not sure how he can predict that, but I bet the pharma companies are happy to hear it. Actually, you do hear that same assertion tossed around by others--it's a consensus opinion, so it must be right! Seriously, though, I have yet to read a cogent analysis of what's driving the depression dynamic. My vote goes for post-industrial sociocultural shifts in human living, as in an America where we push everyone to study their asses off and go to college and ring up loads of debt getting there, but when they graduate it's a job at Starbuck's or a boring accounting job or a moronic cubicle job of some kind. That's why you spent all that time reading Plato, right?
In other depression news:
Mass. Senator Goes Public With Depression. Cool. Funny thing: out here in Washington State I know several prominent figures who refuse to be public about having bipolar disorder or depression. Not cool.
UK Man To Stamp Out Friend's Depression. Cute.
MRI To Predict Depression Recovery From CBT. And they are recovering without medication? Very interesting.
George Clooney Gets Depressed Putting On The Pounds For Movie Role. Matt Damon says no one recognized George on the set and Clooney got all bummed out. Vanity, thy name is George Clooney.
The British group the Mental Health Foundation proclaims that Brits turn to alcohol to combat stress and depression. Um, no shit. I wonder when they will call for a ban on alcohol.
And, a London researcher claims that he can make early diagnoses of schizophrenia by way of a brain scan. If true, it's interesting. But, to maintain perspective, it'll take a long time to prove out--and won't change a thing about crappy antipsychotics.
Some studies are just too breathtaking to comment upon. Snoring parents cause snoring in children and ADHD. This one has gotten a lot of press attention, although no one in the press has pointed out just how out of control the conclusions of some researchers have gotten. Gee, I wonder if the makers of Ambien and Concerta funded this study?
For the last few years, I have felt a whole lot like Diogenes, minus the lamp, wandering around looking for an honest psych researcher who will admit openly just how dicey the evidence is supporting the use of psych meds. Researchers I have interviewed will cop to the sad state of affairs off-the-record, but are much more guarded in their on-the-record pronouncements and in publications. That makes the following all the more striking to me:
"Indeed, perhaps the most striking finding of a recent (2004) meta-analysis nof antidepressant therapy of bipolar affective disorder that spanned more than 40 years of research in all types of antidepressants (including tricyclic antidepressants [TCAs], older and newer selective monoamine oxidase inhibitors [MAOIs], diverse second-generation "heterocyclic" antidepressants, selective serotonin reuptake inhibitors [SSRIs], bupropion, and serotonin norepinephrine reuptake inhibitors [SNRIs]) was that there were a grand total of a mere 11 randomized controlled trials (RCTs) conducted to date. Of these, only 5 included a placebo-control group. The state of the evidence is, in a word, abysmal." (Emphasis mine.)
Making this statement (on Medscape, registration required) was Michael Thase, a psychiatry prof at Pitt's medical school. He was writing about anti-depressants and bipolar disorder, and more specifically bipolar depression. He's making a very important point for a few reasons: bipolars, when they are cycling, spend 3 times as long in depressive states as they do manic states; anti-depressants have been aggressively prescribed to bipolars for at least 15 years with spotty results; and, AstraZeneca is pushing like mad dogs to get Seroquel approved to treat bipolar depression.
So good for you, Mike. But why does he have to say this on Medscape as opposed to in the pages of something like AJP?
Speaking of problems with evidence base, one of two studies touting Zyprexa as a mood stabilizer--for the long-term maintenance of bipolar disorder!!!--shows that the med was about 50 percent effective at preventing relapses over a 48-week period. Relapses mind you, were the measure, not remission, which means Zyprexa likely remitted X percent of symptoms as opposed to nuking them altogether. Given the drug's high cost and tough effects on patients' bodies, I wonder if this study, paid for by Eli Lilly, impresses anyone?
A recent paper in AJP claimed that 4.4 percent of the US adult population has ADHD. I have no idea whether that's an accurate number. That figure was based on a community survey, a notoriously unreliable method of making absolute claims. Hell, you see claims that kids have ADHD at a rate of 16 percent, so anything goes I suppose. Anyway, part of the papers point was co-occurence with bipolar disorder. I haven't read the paper itself yet, so I don't know the precise overlap.
But yesterday, a doc put out a press release--an obvious sign of pimpery--claiming that the paper lent credence to his theories around COBAD and his book. COBAD is co-occuring bipolar attention deficit disorder. Wow, thanks doc. Now, we have a whole new diagnosis and it's co-bad.
Of course, there is some crossover between bipolar disorder and ADHD--I know enough people running around with both diagnosis to lend credence to that. To what degree, who knows? Funny thing is that a lot of these same people wind up taking 4 and 5 meds at a time and don't do very well at all. Also, I ran across a paper the other day claiming that there is much similarity between bipolar and schizophrenia on a structural level. Bipolar is the odd man in the middle--and once upon a time, schizophrenia and manic-depression were considered the same thing.
Anyway, the good doctor's PR move strikes me as yet another fine example of disease-mongering, as the Brits call it. But, then, plenty of docs and public health officials and advocates and school officials are guilty of that--the big nasty by-product of high-tech America.
Why are they in charge? Why do they have all the power in the conversation? Many have good intentions, yes. Many are also motivated by money. Let's face facts: mental illness is a huge industry.
A Reader Comments
I posted recently about the conflicts of interest inherent in mental health advocacy groups accepting funding from pharma companies. A reader replied with something so good I wanted to make sure you all saw it:
"CABF is a not for profit support/info online site www.bpkids.org They now have membership fees, though in the past did not. I long suspected them of receiving drug company money, per posts of mine years before the FDA announced the connection of antidepressants and suicidal ideation in kids, I was posting there, telling how my daughter while on Zoloft, or any other antidepressant only had suicidal thoughts when on an antidepressant.Most of the time my posts that were required to say "Im not a doctor, etc" were deleted, no explanations. Some members were banned from the site, for being part of what they called med-bashing, etc. We were telling real stories about our real kids and antidepressant use. Years went by, and we found out that they had to start taking membership fees per some drug companies pulling out funding support. We knew it all along. Money talks, it is all a business deal. It is disgusting, I totally agree."
CABF is the Child and Adolescent Bipolar Foundation, a group advocating for the diagnosis and treatment of bipolar disorder in youngsters. It's chilling to me that they were engaging in censorship. I hope other advocacy groups don't stoop to that level. BTW, CABF is still an arm of the pharma industry, listing Abbott Labs, GlaxoSmithKline, Janssen/J&J, Eli Lilly and Pfizer as contributors to the group. And you all know what drugs these companies make.
The AP reports that Seattle is the most educated city in America. Yeah, but are we smart? State pays for sex-change operations at $84,000.
Here's an interesting article from The Guardian, which summarizes recently-published papers by researchers in which they assert that pharma companies actively try to recruit normal people into thinking they have entirely abnormal conditions--restless legs syndrome, anyone?--which are best fixed with a pill. Such attempts by the pharma companies are, of course, legendary in the mental health world.
As fate would have it, this is one of those unusual moments when you don't have to take my word for what the papers say. They are published on the peer-reviewed Public Library of Science website and are free for you to access. Of particular interest to readers of this site will be the article by David Healy, the British doc I referred to last week who is pounding the pulpit about the over-selling of bipolar disorder. His assertions are tough medicine and I will discuss them later, but they are not too dissimilar from one's I made in a recent article of my own. You read. You decide.
In the past, I have rapped NAMI's knuckles for taking contributions from pharma companies. It's a big compromise when advocacy groups of any kind take money from private industry and then go out and beat the drum to help create a market for their contributors, directly or indirectly, all while being a tax-exempt non-profit. So now, DBSA notes on its website that it's gotten support from AstraZeneca, makers of Seroquel, for the group's "Sleepless in America" campaign. Sleep is, of course, a huge issue for bipolars, but that still does not remove an advocacy group's responsibility to do independent advocacy for the patients it says it represents--and taking money from pharma companies puts them in conflict with the people they are supposed to serve. That would be you and me.
We are not well-served when one America's major mental health advocacy groups essentially seeds the ground for bipolars to go marching into their docs with sleep problems and go marching back out with a scrip of Seroquel. Psych docs and GPs love handing out that nasty atypical antipsychotic as if it were Ambien. AZ is, of course, working overtime to convert Seroquel into a mood stabilizer akin to Lithium and Depakote.
What's more, DBSA also notes in the executive summary of its "The State of Depression in America" report that the report was supported by an educational grant from Wyeth Pharmaceuticals. Why would Wyeth want to help? The company makes Effexor.
Nami is also pounding on the sleep theme on its website in a bit reprinted from bp Magazine called "The Quest for Sleep." The magazine also takes money from pharma companies. Look at its website for proof.
I have never run into NMHA taking money from pharma companies.
Some of you could probably give a tinker's damn where advocacy groups get their money. But you should. Almost every pronouncement on treatment from NAMI National, for example, contains some kind of pro-meds message. Even when the organization makes statements about recent research results that indict meds, NAMI always spins things positively for its masters. Don't believe me? The group recently spun the results of the STAR-D research, which were very bad news for anti-depressants (and of course for patients), as being hope-filled. I kid you not. Why's that important? If you are a patient, then you'd expect that you can look to an advocacy group, which claims to serve you, as having your best interests at heart and to holding multi-billion dollar pharma companies accountable for the products they make.
But you cannot do that. And that is disgusting.
A reader posed the following about my earlier post:
"Is "distress" being used as a politically correct version of "illness" perhaps. -something to make results more accessible to patients while reducing stigma?"
I don't think it's illness per se. They are trying to measure something that appears to be far broader than diagnosed mental illness. I cannot find one of the FMD questionaires yet, but so far I can find this bit from the CDC:
"Since January 1993, the interviews have included four health-related quality-of-life (HRQOL) questions (4), including the following general mental health question: "Now thinking about your mental health, which includes stress, depression and problems with emotions, for how many days during the past 30 days was your mental health not good?" Persons who reported that their mental health was not good for greater than or equal to 14 of the preceding 30 days were defined as having FMD. This 14-day minimum period was selected because a similar period is often used by clinicians and clinical researchers as a marker for clinical depression and anxiety disorders, and a longer duration of reported symptoms is associated with a higher level of activity limitation."
Stress, depression and problems with emotions don't equal mental illness, so this FMD thing is little more than a proxy question. Also, what is "not good?" What's the measure of good mental health for one person versus another? The FMD numbers that are being floated around come as the result of a subjective question and are self-reported by respondents. So there's a heck of a lot of flux there.
One thing that is interesting to me is that if I can take the 14 percent number in NYC and the 9 percent number in Seattle/King County at face value, then I wonder what that means for the prevlance of mental illness numbers often floated by advocates that 25 percent of Americans have a diagnosable mental illness. Or does it mean anything at all? Either way, the two data sets certainly don't line up perfectly.
A series of public health reports have just been released by various local public health departments. New York City's report, according to the Times, pegs the rate of "frequent mental distress" at about 14 percent of the population. The US average is 10 percent. Seattle/King County comes in at about 9 percent, according the our local public health department. I'll poke into these reports more after I print them out. But what makes me a bit queasy already is this term frequent mental distress. It's not the same as mental illness, is it? I don't think so.
BTW, although this nebulous FMD rate is higher in New York than Seattle, don't assume that means Seattle is less messed up than New York City. Historically, Seattle's suicide rate far outpaces NYC's.
More to come.
I have no idea why this study caught my attention, but it did. It has to be one of the most-aptly titled journal articles I have seen in ages: "Surviving the Tornado of Mental Illness." Because that's what it all boils down in the end, isn't it? When going through hell, how do you keep going?
As usual, I can only access the abstract, but the core ideas are there in this Canadian study of what the authors call 90 "psychiatric survivors" (a controversial term within mental health advocacy) struggling to maintain housing while battling debilitating illnesses in a world where if you ain't working, for whatever reason, then you are fucked. The study concludes:
"Individual and team analyses of the transcripts [of interviews with patients] revealed that psychiatric survivors experienced three levels of upheaval, loss, and destruction, similar to the effects of a tornado: losing ground, struggling to survive, and gaining stability. Within each of these levels, five major themes were identified: living in fear, losing control of basic human rights, attempting to hold onto and create relationships, identifying supports and seeking services, and obtaining personal space and place. A caring community response, including adequate housing, income support, and community care, can help people rebuild their lives."
The study is obviously working from a population of people with severe and chronic mental illnesses--the sickest of the sick, who too often end up on the streets of major urban centers. Whatever you make of the call for income support--Canadians are a bit more comfortable with socialism than are Americans--it's been clear to me, like, forever that the prospect of losing one's housing and shelter is enough to make a strong man crazy and people who are in dicey shape slide right out to the streets. I'm not speculating there, of course. Maslow's hierarchy of needs scoped the situation out long ago.
There aren't enough good meds in the pharmacopeia nor enough caring hands in the community to help a patient who has no housing. And without shelter and basic food, there is no way for a patient to recover. So if we expect people to do what society expects in order to combat mental illness, then there simply has to be a level of housing available to those that many Americans--and Canadians, too, no doubt--despise as losers for the life.
Currently, the Bush Administration is doing what it can to claim it wants to solve the riddle of mental illness in American society and also says it wants to end homelessness. So why the hell are they cutting federal Medicaid funding--about 50 percent of which, by some estimates, funds mental health care for profoundly ill people--by billions of dollars and cutting hundreds of millions from public housing dollars that have been depleted for decades? How can we go in both directions at once? We cannot, of course. Not that there isn't already plenty of other hypocrisy to point to in the current administration. Just add this one to the list.
A BBC account of the Canadian study of pregnant women taking SSRIs, which I posted about yesterday, reports that patients taking the meds had twice the likelihood of delivering babies stillborn as did a control group. I have no way of knowing if that relationship is statistically significant or just a weird coincidence, but it sure makes me raise my eyebrows. Stillbirth isn't one of thsoe side-effects that docs and regulators can explain away by saying, "Averages are not individuals. Nothing to worry about here. There is hope."
And yet here's an advocate, quoted by the BBC, saying:
"Whilst this study has found a correlation between SSRIs and pregnancy complications, it has in no way confirmed a clear causal effect between the two, so pregnant women should continue taking their medication as normal. Left untreated, the physical and psychological effects of depression can lead to problems during pregnancy. Sufferers of depression are far more likely to smoke, as well as lose their appetites and in extreme cases are more likely to attempt suicide, which can all have devastating effects on mother and baby."
Ah, I love how the health nannies always get in a dig against smoking, but refuse to acknowledge just how dicey taking SSRIs actually is. That's the kind of arrogance that ought to be in the criminal code. Why do reporters continue to quote these fools?
Funny that the stillbirth issue wasn't highlighted in other press accounts. I wish I could do this gig full-time so I could actually have time to call the study's authors and ask them about their data instead of just sitting here wondering.
The FDA yesterday approved the first ADHD drug for children to be delivered in patch form. The drug is called Daytrana and is a chemical cousin of Ritalin. Like that drug, it will come with a host of warnings. What puzzles me is that this med was initially denied approval by the FDA and then an agency panel reversed the denial. It also only underwent two small, short-lived clinical trials. That's a fairly clear sign that given its close kinship to Ritalin the only thing novel about Daytrana is its delivery mode. I recognize that FDA approval regulations are goofy and that America is taking an any-port-in-a-storm approach to psych meds, but when is our drug approval system going to ask the basic question, "Do we need another way to give kids Ritalin? Don't we already have enough problems with that drug? Why would this one be better because it's delivered by a patch?" Can we get some skepticism going in high places in this country?
It'll be interesting to see what patient experiences are like with this drug. I ain't holding my breath.
But for now, my beloved Seattle Mariners are in first place. Last night, they beat the Oakland A's, predicted by smart sportswriters to knock the Angel's off their throne. The team is hitting well and the pitching is tough. Tonight, Felix Hernandez takes the mound. I hope to go buy myself a ticket and watch him throw 92 MPH breaking balls and have fun doing so.
By mid-May, such enthusiasm ought to be replaced by the annual Mariners slide into the cellar. But, hell, this just may be the year. I wish.
In the last two days I have mentioned the explosion of the diagnosis of bipolar disorder, especially among children. It's hard to quantify just how much diagnosis has increased since there is no central index, so I hit upon one way to get a handle on the situation. How often have researchers used the term "bipolar disorder" or "manic-depression" (commonly used in research before the mid-1980s) in published papers since 1950, decade by decade? According to PubMed:
1950s--275
1960s--1,589
1970s--3,358
1980s--4,999
1990s--5,576
2000s--6,134 (through April 6, 2006)
So you can see that there has been a pronounced increase in research on bipolar in this decade (that's good, as a general rule), and it's safe to assume that there's a reasonably tight correlation between research and diagnosis in the real world. Researchers do go where the funding (oh wait, that would be objective interest) is after all.
Looking at the 2000s, year by year, gives us:
2000--879
2001--1,021
2002--1,044
2003--1,230
2004--1,323
2005--1,319
2006--239 (through April 6, 2006)
If this rate continues, we ought to wind up with about 11,000 to 12,000 articles by 2010, or a little more than twice the articles in the 1990s. That tells us a lot.
PubMed also allows you to break down publications by age groups under study. So how many of those articles were targeted at ages 0 to 18 years old?
1990s--1,048
2000s--1,208 (through April 6, 2006)
So we are likely to see a doubling of papers about bipolar disorder in children and teens by 2010. That also tells us a lot.
I'm not asserting that these papers are bullshit. What I am asserting is that there is a reason we are seeing such a jump in bipolar disorder diagnosis. Research drives diagnosis in the clinical world, perhaps more than real world prevalence drives research. Researchers are well-known for chasing funding.
One of these days, I'll break down all of these papers by medication because I have a hunch that the jumps in research and publications related to bipolar disorder have a strong correlation to new classes of medication being introduced, especially atypical antipsychotics. Yes, I am a skeptic. But you don't see gobs of papers and studies on Lithium lately, do you?
No, I am not warming up to a Tom Cruise joke there. As I posted two months ago, American researchers found serious respiratory problems in some infants whose mothers took SSRIs during pregnancy. Now, Canadian researchers--and, indeed, Health Canada itself--are now warning of other problems tied to anti-depressant use among offpsring of SSRI-taking moms. The Canadian study points to respiratory problems as well.
If I recall, a decade ago, SSRIs were considered contraindicated for use among pregnant women, especially Paxil, and among breast-feeding women. Pregnant women were routinely taken off SSRIs. Now, it appears a fair number of women have been taking these meds during pregnany, at least enough to inspire such studies of their use during pregnancy. Which begs a few questions. Are these women so depressed that they must continue to take an SSRI while pregnant? Or have their doctors gotten lazy? Are they taking these meds while pregnant with informed consent? What are the implications for treating post-partum depression, if any?
The troubling thing beyond the obvious here is that, compared to bipolar disorder and schizophrenia, depression is a more straightforward illness. It's sad that treating it properly is such a complicated business, especially for the patients who have to contend with the condition.
Over the past year, there's been some skepticism popping-up in psych circles about the increased rates of diagnoses of mental illnesses as well as about the performance of psych meds. Most of that skepticism seems to be coming from the UK. Last year, for example, a couple of docs published an article in Britain that utterly savaged treatments for depression. In this country, the skepticism is quieter and usually it's restricted to the pages of academic journals, where the skepticism is implied as opposed to be wide open. But docs are beginning to acknowledge that the state of the art in treating mental illness isn't very good. Anyone who doubts this ought to review the editorials which have accompanied the recent CATIE and STAR-D studies, for example. They should also read Ben Carey's recent articles in the New York Times, especially the one on some docs arguing that some schizophrenics can be treated without meds.
Something is afoot out there. No one is claiming that the brain as locus of mental illness paradigm is wrong--not even British critics claim that (Scientologists do, of course, but they are morons). There is enough anecdotal and direct evidence to support the bad brain paradigm. The evidence is much spottier, however, on treating brain-borne maladies with psych meds, as I have detailed elsewhere.
This skepticism hasn't trickled through to the media, sadly, which is still largely catching up with the decades-old idea that you can wholly treat mental illness with psych meds and that mental illness can be successfully treated at all. Policymakers, too, have only recently begun to embrace these ideas.
But I digress.
The most controversial talk in psych circles these days is about the prevalence of mental illnesses in society. Once again, the skepticism is coming from the UK. To me, the biggest question is about the prevalence or rate of bipolar disorder. For the last 15 years, it's been thought to run at about 1 percent of the adult population or a little over 2 million American adults (these are NIMH's numbers). Lately, though, you will see pharma companies claiming that the disorder afflicts as much as 5 percent of the population and some academics assert that it's 3 percent. The epidemiology of mental illness is very tricky for obvious reasons, and these estimates often skirt the prevalence of the illness in children and teens where the, um, prevalence of research is limited. But it's clear that bipolar disorder is being diagnosed at much higher rates than it was 10 to 15 years ago.
But is it mental illness that's driving these numbers? Is there that much bipolar disorder in America? Or is something else at work? I am asking such questions because rates of diagnosis have jumped dramatically in recent years and because the treatments for these disorders are not working as well as any of us would like. That leads me to wonder what the hell is going on here because if you look at the state of mental illness in America, the many assertions made about these illnesses don't always add up. And I am a reporter and this situation makes me skeptical.
So, too, do articles like this. It's an advance piece in the Sydney Morning Herald on a forthcoming conference in Australia centered on the issue of what conference organizers call "disease mongering." I'm sure the article--extensively quoting a British doc--will piss off many readers. But the central questions being asked are worth asking, no matter what conclusions any of us reach.
The doc asserts that rates of diagnosis of bipolar disorder have increased 50-fold in the last 20 years or so, from a classic rate of 0.10 percent to 5 percent. That's a hell of an assertion, but I am at least willing to accept a 5-fold increase from 1 percent to 5 percent, for the sake of argument. The doctor claims that the whole thing is being driven by pharma companies interested in creating a vast market for atypical antipsychotics like Zyprexa and Seroquel, especially by encouraging their long-term use as replacements for classic mood stabilizers like Lithium and Depakote. That's, of course, a very easy claim to make--blame big business, blame the capitalist. But, having worked as a sales rep for Abbott Laboratories once upon a time, I can say that pharma companies are very aggressive and will do anything to convince docs that a problem is much larger than was previously thought and that Product X is the perfect solution. That's what I was trained to do, although the market I worked was critical care monitoring not drug sales per se.
The doc's central assertion is that mental illness is being manufactured and created through hysteria.
I think the doctor is onto something because radical increases in diagnosis of bipolar disorder and intense marketing by pharma companies, public health organizations and advocacy groups should give rise to skepticism, if not outright suspicion. At a minimum, the right questions are being asked, regardless of the answers.
Even more interesting is that the finger is also being pointed at the media. The doctor asserts that the media is repeating what he calls lies and has failed, by implication, in its responsibility to ask skeptical questions, turning instead into a propaganda arm of public health do-gooders and, by extension, of pharma companies. I don't know if that necessarily a fair assertion, since the media can often be little more than the mirror held up to the society upon which it reports. But I, too, have questions about the media's role, good and bad, in all of this. I know through personal experience that asking skeptical questions about the state of the art in treating mental illness is liable to get you attacked and disregarded as a fool.
But a couple of years ago, based upon almost two decades as a patient and 6 years as a reporter, I started to ask some of these same questions, although with great timidity. I began asking them, as I have on this blog, because things don't seem to be working very well. And that always makes me scratch my head and wonder why that is the case. I have reached no firm conclusions myself. I just know that something is up.
However, there is much that argues that the good doctor is overstating his case. I'll take that up another day.
As I've noted before, some psych researchers are pushing very hard to diagnose and treat bipolar disorder among children. By children, I mean pre-adolescents not teens. I have seen studies claiming that you can diagnose the illness in 2-year-olds. That's of course very controversial within psych circles, principally because it's very hard to accept the presence of a long-term psych malady in children whose brains, bodies and souls are just beginning to develop. No matter what, there has been a huge spike in diagnosing the illness in kids and with a frequency akin to the mid-1990s, when it seemed that every third kid was being diagnosed as having ADD. And we all know how that worked out.
Here's an article on what's up with youngins and BP in Michigan.
I'm not bothered so much by diagnosing bipolar in kids--although I am plenty bothered by it--as I am by what it means: 6-year-olds getting stuffed with Zyprexa, for example, which is problematic enough for adults to handle/not handle. There was a huge jump in diagnosing BP in teens and tweens in the mid-1990s, too, and I have not seen convincing evidence that slapping them with loads of meds has helped their lives very much. (You can always make the case for mood stabilizers, of course, but antipsychotics? Um, try going through high school on those.) If you don't believe me, take a look at the bipolar groups on myspace.com, which are filled with 20somethings who were diagnosed with bipolar in the mid-1990s and are loaded on 4 and 5 meds--some on so many that they are taking meds to counteract the side effects of their psych meds--and are simply not doing very well.
We simply need to find a more intelligent way to address bipolar disorder in our society because the meds-alone paradigm is not providing the kind of results that any of us would like to see.
A fascinating story of intervening in a suicide attempt in Orem, Utah. Read it for yourself.
If there's one thing that will tell you a culture has real sociological problems, it's when you see bits of news like the suicide rate quadrupling in Ireland in 50 years. Ireland is a nation in great flux and has been since the 1980s especially, when it began a rapid transition from Western Europe's backwater to Western Europe's fastest growing economy. Shifts like that come with a lot of pressures, especially ones tied to conforming in the workplace (can drive anyone crazy) and financial achievement. Were the Irish people better off poor and backward? Is capitalism to blame? Who knows? But it's more than coincidental that suicide rates are jumping at the same time the country's economy is exploding.
A bit of caution: in this deeply Catholic country, it's likely that suicide wasn't accurately reported until recently and the overall number of suicides (about 450 to 500 people in a country of 4 million) is small enough to where a fluctuation of 50 people a year, say, can make a huge difference in the suicide rate. Caveats aside, the increased number of suicides puts the rate of suicide in that country a bit higher than the US (current US rate is about 10.5 deaths per 100,000 people).
I linked to a nice New York Times Magazine article the other day about a possible new direction in treatment for people with the most wicked form of depression. For the last several days it has been one of the most emailed articles on the Times' site, but it doesn't even crack the top 10 of that paper's most linked-to articles. Why's that important? It makes it clear that tons of people are interested in depression and an answer in a wilderness of half-assed solutions. But it also makes it clear that there's damn little original writing--ie, blogs--on mental health matters. Which is weird and leaves Liz Spikol and me as the main weirdos writing on mental illness in the blogosphere. And that's depressing.
Menopause leads to depression or at least that's what two studies out yesterday assert. That should come as no shock to anyone. It sure doesn't for me since I wrote an article 5 years ago about a researcher at the Oregon National Primate Research Center who had established that estrogen depletion in rhesus monkeys led to serotonin problems. Nice to see something I wrote about years ago turn into fact.
I keep threatening to do some kind of round-up on all the lousy news around psych meds. After all, in the last few weeks ADHD drugs have a new round of warnings recommended, due to their connections with heart problems, psychosis and suicidality. So serious were the assertions that they reached an FDA panel. We'll see soon exactly what they get down to there. As for anti-depressants, the STAR-D results of two weeks ago have made it clear that this class of drugs is effective 25 to 50 percent of the time at reducing symptoms and perhaps 25 percent of the time on remitting symptoms. The news on atypicals continues to be dodgy--second round results from the CATIE study, which I'll get into later, show that damn near the only thing that worked for the poor schizophrenics (and we are talking profoundly ill people in CATIE's study group) in the group and for whom the run of the mill APs didn't work well (74 percent discontinued taking them in the first round of the study) was to switch to clozopine, aka Clozaril. That's the first of theAPs, introduced in 1989 but never widely used because it has very nasty effects on patients' white cell counts, among other things.
So when your best option to limit zombieism with schizophrenics causes huge immune system problems, your best ADHD drugs are flat-out problematic and anti-depressants don't work well at all, then you've got to say that something is wrong with the current paradigm. What's more, the best long-term results for bipolars seem to be coming with good old-fashioned mood stabilizers--and the APs are having the same kind of effectiveness and livability issues as they are for schizophrenics.
So are we well and truly fucked? Sometimes, it sure seems the way. But those are further questions for another day.
Today's New York Times Magazine has an interesting, lengthy article on an experimental depression treatment--electrodes applied to a very specific brain region called Area 25--in Canada which seems to have nuked the depression of 8 of 12 patients for two years. That's encouraging--but a 67 percent success rate in a 12-person study isn't the end of depression treatment as we know it today. However, it may well lead to aggressively trialing this approach with patients to see where it might take us. Caveats: this is not the same as ECT and it is important to keep in mind that the 12 patients had depression in its most extreme form. What's more, it'd be kind of hard to do the usual 2,000 patient trial because everyone fitted with the electrodes would require brain surgery--and that's kind of intricate and expensive. But you never know. Read the article for more.
So this blog is a few days past its 6-month anniversary. I just note it for what it's worth. In that time, I have written 52,000 words--yeah, I counted--which works out to about 8,600 words a month. In essence, I just wrote a very scattered book-length MS. There will be many posts forthcoming on recent results of the CATIE study's second round, which were released yesterday, as well as a wrap-up of sorts on recent results from the STEP-BD and STAR-D studies and the FDA hearings on ADHD drugs.
For now, however, beer.