You've probably heard by now that an American-born Muslim—not a very devout one from what I have read—shot up the Jewish Federation's offices in Seattle on Friday afternoon. He killed one and wounded six others, all women, after vocally complaining about the current battle between Israel and Hezbollah. He also mouthed off about the US's support of Israel. He is 30 years old.
Late last night, one of our local stations had the man's family lawyer on TV and he was quoted as saying that the man, Haq, had bipolar disorder, had been wrestling with it for 10 years. He also said the man was on medication. He's been away from the family haunts in Richland, Wash. for a few weeks, so we ought to know at some point whether he was actually on meds at the time of the shooting.
The whole event is beyond tragic—and I'll let the rest of the media do their job there. It'll be interesting to see what the media does with the fact that he has bipolar disorder. I'll be watching very closely.
Over the years, I've seen a lot of murderers and, seperately, a lot of psychotic and deranged people. When Haq was marched into court over the weekend what struck me was how calm and composed and there he seemed. He didn't look the least bit deranged (ie, the smiling Ted Bundy type) or have the beaten down look of the recently psychotic. That's a long way of saying that I am not necessarily buying the bipolar/murderer/commiter of hate crime logic that I am sure will be advanced by some. I wonder what my homies at the Treatment Advocacy Center will make of this shooting. It doesn't look like it will fit their mentally-ill person/not getting treatment/goes nuts with a gun storyline.
What's interesting, too, is that two new papers on schizophrenia came out on Friday. One them was authored by Jeff Swanson, who wrote the recent paper on violence among schizophrenics taken from the CATIE study. This paper was then twisted to its own ends by the folks at TAC. I'm sure they will have fun with these two papers as well. I haven't gotten a full copy of either. But in an accompanying editorial, one mental health researcher says that the studies establish, once again, that the public's perception of the mentally ill as violence-prone is overblown.
Two other thoughts: if Haq was indeed on meds, then that answer scares me more than if he weren't. Also, prosecutors are mulling whether to charge this man with a capital crime. The death penalty is rarely sought in Washingtion State, even less often in King County, where Seattle is located. King County Prosecuting Attorney Norm Maleng hasn't sought it recently even with cop killers and serial murderer Gary Ridgway. Whatever degree of murder Haq is charged with, whatever penalty is sought, will carry with it a hate crime enhancement, deservedly so. His defense team will float an insanity defense. At this point, I would not buy that defense.
Stay tuned.
I wrote the other day about a suicide in my neighborhood. Since then I have learned that two more people have jumped from the same tower in the last year. One died. One fell through the plastic lid on a dumpster and survived. I have no idea whether this goes on at other housing facilities for the long-term disabled, especially among the mentally-ill. But it sure makes me wonder. If this is not so uncommon elsewhere, I am not even sure what you would do to address it. Or if you should do anything.
I ran into the recent suicide's lover at a market yesterday. I didn't even know what to say and don't really know the guy, so I said nothing.
I did spend quite a bit of time talking with one of the building's other residents. He's 60 years old, a long-time schizophrenic, and has been taking Haldol for 21 years. He's been out of the hospital for decades. He was of course rattled by what had happened in his building. But he was rattled by what had gone on his building and was threatening to catch a train to Portland and try his hand at starting his life over there.
"Why?" I asked.
"I want a normal life," he said. "I want a girlfriend and a car and a job."
I listened to him talk like that for a time and then my bus came and I went to the office. The man's name is Mr. B. You'll hear more about him soon.
I was interviewing a doctor today on a subject removed from mental illness. A nice change. Towards the end of our chat, we got into a short sidebar about alternative treatments for cancer. He made the point that while he could see the usefulness of medical marijuana that he felt it was inappropriate medicine because it is smoked (not always, but most of the time). His argument was that we should do nothing to encourage smoking of any kind in this country because of what he deemed were unacceptable side effects.
I went into skeptic mode for a minute just to see where it would get me. But we give patients all kinds of medications that have unhealthy side effects every day, in some cases for long periods of time, I pointed out, so what's the problem? He asked me for an example of a med that caused patients all kinds of problems.
Zyprexa, I said. And pointed out what is known about deaths tied to its use, its diabetes-inducing ways and so on. He paused for a moment. Then he said, "On the whole, Zyprexa is therapeutic."
I let that bit of mythology go. He's an important doctor, an internist by training, who was a major muckety-muck at one of America's top 10 medical schools and is, now, head of research at one of the nation's largest HMOs. I am not naming him here, because we really didn't get to flesh out what he meant and because I want the guy to talk to me again. The guy is what's known as a thought leader.
But let's put it this way: If you got 1,000 Zyprexa patients to testify before the FDA about the nasty effects of the drug, their opinions and experiences would be swept away in two minutes by a few sentences from this doctor. He's that big of a big shot.
Why aren't people like him listening to psych patients and being honest with what effectiveness studies are showing about Zyprexa and other pysch meds? Why hasn't the CATIE study sunk into the pronouncements of thought leaders? This isn't a minor question. Until people like him, in a position to truly influence the debate on health care in this country, get honest about what's up with meds, then we are fucked.
Or we are going to have to find another way to change the game without the help of him and his colleagues.
After an unsuccessful week of spinal taps and blood patches during which I could not receive anything beyond 800 mg ibuprofen for pain due to my recent withdrawal, I'm sort of back in the swing of things.
I had a rather lovely appointment with my pain management doc yesterday and, for once, I'm not being sarcastic.
He actually listened while we talked openly about current treatments, their side effects, which side effects were acceptable for the time being but unacceptable in the long term (like my loss of sex drive - with the shape I'm in, sex hasn't really been on the table for some months, much to my fiancee's dismay), and where we were going with this. He even got excited about the pain management aspects of yoga that I told him about and took some notes - he seems to be planning to contact my yoga instructor for more information. I'll take that as a win for the day.
I told him that, eventually, I don't want to be on any meds at all. And he told me he supports that 100%.
Of course, there is the meantime.
The meantime is that I'm still on 150 mg of Lyrica twice per day, 60 mg of Cymbalta per day, 2 to 4 mg of Zanaflex per day, and I've now added about 375 mg of Ultracet to the mix to manage momentary pain spikes. It's somewhat amusing to me that I think I've taken every medication that online pharmacies try to pitch via spam comments on blog entries.
The net result is less pain relief than I received from vicoprofen but, supposedly, without habituation. Everyone says I sound like I'm doing better, but I don't FEEL like I'm doing better. I feel more lucid - perhaps people mistake a lack of slurred speech for improvement in my condition - but there's a substantial difference between lucidity and improvement. Just because I can think and speak more clearly doesn't mean I'm in less pain or in better shape. In fact, the opposite is true.
Where vicoprofen allowed me to spend an hour or two at the computer to check news and read my normal bookmark list of blogs, I can now spend about 15 to 30 minutes. The same goes for things like sitting up to eat. My pain management doc's response was to use cognitive behavioral therapy. Do what you can, then go rest. If you can only drive for two hours but you have to go to Boston, drive for two hours, stop and then start the drive again. You'll be in the same pain when you get there as you are at home. It's good advice. The catch is that riding across town hurts. Sitting up for any extended period of time hurts. The solution I have at my disposal now is bed rest for 2 to 3 times the length of time I was sitting up. That really doesn't allow me to, you know, WORK.
Right now, I'm pinning my hopes on yoga and bio-feedback therapy, maybe some self-hypnosis, to manage the pain while we work toward a diagnosis. The yoga helps tremendously for flexibility and temporary pain relief. As a result of the yoga, my physical therapist and I switched up PT to focus more on stretching and flexibility with some trigger point activation massage at the end which also turned out to offer temporary pain relief.
Perhaps the best thing about how the PT and yoga routines have helped is that they do not require any sort of mobility - the PT is done on a bench with an athletic trainer stretching my legs for me. The yoga, when I'm in shape to do, is partly done standing up, but is mostly done laying down. The last time my instructor came over, I laid on my back for the first 20 to 30 minutes and she worked my legs and arms through the routine to get me limber enough to stand up. All of these things can be done, even to a limited extent, by someone who is even bed-ridden because of pain and they offer at least a temporary endorphin release and - for me anyway - feeling like I'm an agent in my own treatment, like I am not subject to the latest miracle drug spawned by Big Pharma.
I'm not sure how many patients need to feel that way, but recovery is NOT merely a matter of allowing doctors to do things to you. At some point, you have to stand up for yourself and get involved. After all, it is your body and all those medications do have side effects and some of those side effects can be permanently harmful if not deadly. Call me crazy, but I'll take yoga and breathing exercises over that any day.
And who knows? Perhaps yesterday's discussion will spark a brand new avenue of treatment options for my pain management doctor's patients. Perhaps they'll find that, regardless of their mobility, they can participate in yoga to some degree and find some amount of pain relief in it. Perhaps that in turn will lead to my doctor publishing a journal article with some amount of clinical and anecdotal evidence so that this idea can spread and benefit others. That's one of the good things about working with a doctor who is also a researcher and constantly looking for new advances - they tend to be a little more open about things.
So basically, I'm a little worse off that I was when I started this whole thing. My back is really starting to hurt now, so I'm back to bed for a couple of hours. Thank heavens for DVRs and DVD box sets.
Two days ago, one of my neighbors jumped 11 stories from an apartment building three blocks from own apartment. He died, breaking a stone picnic table in the deal. The building houses well over 100 mentally-ill people, many of them disabled military veterans and the residents I spoke with yesterday were badly shaken. Apparently, the man had been released from a psych hospital a week ago. I'll defend anyone's right to kill themselves—we are masters of our own bodies and fates, after all—but it is a sad, and unncessary, dynamic that has a spillover effect on other people.
What's even sadder to me is that my neighborhood has lost one of its great characters. The man, who was tall, used to walk the streets wearing black leather pants and often led his lover, another man who wore a dress and a bell around his waist, by a leash. I always used to take this gay couple as proof that there truly is someone for everyone. Not anymore.
Here's a tragic story: two brothers, both on Lexapro, commit suicide. Now their family has sued the drug's maker, Forest. I'm not sure about Lexapro's track record with suicide and suicidality, but I wouldn't be suprised if it has the same degreee of problems a la Prozac and Paxil. I took Lexapro once upon a time for about 7 months. When I came off it, the back of my neck was buzzing and I had the shakes. Powerful stuff. So nothing would surprise me.
The headline means nothing. But it is a long-favorite phrase (name of a band taken from a Bukowski poem) and it is hotter than hell in Seattle and has been for three days. Over 95 each day. Some of you in other parts of the country may chuckle at that, but those temps are 15 to 20 degreees above average. And most homes in Seattle do not have air conditioning. Neither does my apartment. I had intended to get back to posting over the weekend. But the heat is making that impossible, and I am also enjoying my blog-free holiday and I am busy at the office.
But I'll be back to it, semi-regularly, soon. After all, the fabulous folks at the Treatment Advocacy Center are up to their usual rhetorical vomit and Fuller Torrey said some disagreeable things at the NAMI convention a few weeks back. So, um, yes, I'll get on that right soon. The man said that forced medication is not a civil liberties question.
Don't get me started.
Here's an interesting media account, wherein a researcher in Quebec claims to have found the gene responsible for depression—well, that's how the publication cast it—and that it has nothing to do with serotonin. One gene? Oh, sure.
What tells me that that this isn't regarded as a breakthrough in the medical community is that this is the only news account of the "discovery" that exists even though it appeared in a journal article two months ago.
But whatever.
Just a brief note to let you know that I won't be posting as much as in recent months. It's summer and I have worked my ass off on this site to the tune of 100 hours a month since last fall. Therefore, I need to nibble off smaller bites of the mental health world and get some time off.
I got an email at work the other day from a woman who had read an article of mine on psych meds. She is a newly diagnosed bipolar and said she had some questions. We spoke by phone a couple of days later. She wanted my advice on meds, because she said she had been through several psych docs recently and was confused. The typical story of insurance companies picking what doctors she can go to, doctors who spend no more than 15 minutes with her and prescribe her medications without telling her how they work, much less how to be a newly-dx'd bipolar (a pretty dicey time in one's life that M.D.s should be very concerned about, but often aren't) and what to expect and how to make it all work for you.
I told her I couldn't really offer her medical advice, but could give her my opinion that all bipolars need to be on a mood stabilizer of some kind, at a minimum. She told me her doctor had prescribed her Zyprexa a few days before. Nothing else? No, she said, he told me it was mood stabilizer. She added that she had never been hospitalized, and she sounded very stable and aware to me, so I mentioned to her that I found it a bit odd that her doctor had gone straight for the Zyprexa.
He had apparently given it to her right away during a very brief appointment. Had he asked if she or her family had a history of diabetes? No, she said. Do you or your family have a history of diabetes? I asked. Yes, she said.
You need to see another doctor, I told her. Then I pointed her to basic resources on the Internet that are at least honest about treating mental illness.
I hope she gets another doc because the one who gave her Zyprexa is incompetent. Not only because he didn't do due process and do a proper medical history on this woman before prescribing her something that can cause elevated blood sugars, among other side effects, but because he hit her with an atypical anti-psychotic as her first bipolar med when she wasn't even in bad enough shape to be hospitalized.
I am troubled by the trend among docs to very aggressively medicate patients right out of the box. Often a diagnosis of bipolar disorder leads to the immediate prescribing of atypical anti-psychotics—as their name implies, they are most properly meant for psychotic episodes—when in fact the patient's symptoms don't demand such heavy artillery. This is doubly true because of the profound side effects of these meds. (Obviously, the Rx ball game is quite a bit different for treating schizophrenia.)
What the hell happened to starting with a classic mood stabilizer alone? What the hell happened to medical conservatism? Using atypicals as a first-line approach with mild or moderate bipolar disorder is about like recommending open heart surgery for varicose veins.
This is a trend in psychiatry that has led to the over-medication of millions of Americans, some of them children and teens. It is a disservice to patients. I believe it is also a violation of the doctor's ethical responsibility to act in the best interests of their patients. But that's another story.
Not much to say today. In the last week I have lost a colleague/friend to retirement, my editor resigned and a friend of mine moved from Seattle. So, I ain't feeling so perky. Have a nice weekend.
I posted results from the latest round of the STAR*D trials yesterday, and then asked John McManamy, who has been tracking these issues religiously for a decade, what he thought. Here's his response:
"The third round STAR*D results are definitely major news. We clearly have to rethink antidepressant treatment strategy and we've got the study to prove it. If a patient has failed on two trials of antidepressants we're clearly looking at the falling over the edge of the cliff phenomenon where there is less than a one in five chance of success.The AJP editorial was the usual blather, but the study findings were not. A lot of the study authors (maybe all of them) get very good money from the pharmaceuticals, yet they came out with what amounts to an anti-antidepressant study.
Until we get the breakthrough genetic and biological discoveries, we have to work with what we've got. This means being smarter with our current meds and talking therapies. That's what STAR*D was designed for. STAR*D should be publishing results soon on talking therapy.
The flaw in the STAR*D study is they probably didn't anticipate such dismal results in round three. There should have been an option to switch these patients onto bipolar meds to see what happens. Yes, I know you have you're skeptical, but we're not going to have any real answers unless we put this to the test.
The leading bipolar experts—Goodwin, Akiskal, Ghaemi, and others—are telling us that a lot of so-called unipolar depressions have characteristics of bipolar depressions. This suggests treating these people as if they had bipolar, with mood stabilizers. The catch is we're not very good at treating people with bipolar depressions. We have a long way to go."
I'll have more to say about STAR*D soon. And keep in mind that the main results from STEP-BD, a similar study on treating bipolar disorder, will be out in the fall. And so far they are looking as dismal as the STAR*D ones.
Or more properly for giving Seroquel to a friend, whose speech became slurred and whose parents called the police, who then busted the friend. The charge? Corrupting another with drugs. This happened in West Virginia.
Some shit I simply cannot invent.
As I alluded to the other day, the third phase of results from the NIMH-sponsored STAR*D study of anti-depressants are out. The results aren't good, but neither are they a surprise. In phase I, all study patient took Celexa and 27.5 percent of patients experienced remission. Celexa is a prototypical SSRI, so for some of the patients who didn't get symptom remission from Celexa, it was off to two other non-SSRI anti-depressants--either taking the new meds alone or paired with Celexa. Here, in phase II, remission rates ran about 20 percent. In phase III, patients who didn't see results we given either Remeron or nortriptyline, an old tricyclic anti-depressant; neither med is an SSRI. Twelve percent has remission switching to Remeron, while 20 percent who switched to the (very cheap) tricyclic had symptom remission. Oh, yeah: in phase III the trial lasted for 14 weeks, which is pretty short.
You can interpret those numbers as you please. To me, they call into question just how wise it is to make patients go on the medication merry-go-round for long periods of time. It's nice to repeat the old mantra that "every patient is different, there will be a med that works for you, keep trying, there is hope." That's OK short-term thinking, but in the long-run it's meaningless.
I think docs have got to intervene earlier when patients tell them their meds aren't working and figure out if there isn't another way to skin the cat, so to speak. Whatever way that might be.
Interestingly, the STAR*D studies have not been well-covered by the American media, even though they implicitly ask some difficult questions about anti-depressants. Like: how many meds should a patient take before trying something else? But the American media isn't built for that kind of honesty and skepticism when it comes to medical procedures in general, much less with mental illnesses.
I don't find that kind of honesty in the lead editorial, which accompanies the study, in the the AJP. Instead, there is the usually hang-wringing and call for how other depression treatment modalities work in the long-term, such as atypicals. I can assure the editorial writer that they suck just as much as anti-depressants. Maybe even more. It's odd that he only asks about other medication treatment and not about psychological therapy. Typical horseshit.
OK, the 3rd, but still no one is likely reading this today or tomorrow. And, there are several important posts I want to do: the 3rd round results of the STAR*D study of anti-depressants just came out (bad news for anti-depressants, no suprise there) and Fuller Torrey opened his big mouth at the NAMI National convention (no surprise there, either) and we've got some of the details of that.
But I'll wait to get into those till later in the week, when I hope most of you are back from having a lovely 4th of July weekend. Have fun. Be well.