Just because it's obligatory and vaguely amusing, here are some of the posts that generated the most hits on my blog this year. Thanks to all of you for reading and for your support. Happy New Year.
Love American Style: Web 2.0 And Narcissism
Damn did this piss off some people.
My little dust-up with some suicide survivors.
Zyprexa, Seroquel And Risperdal Really Do Suck
Just one of many posts this year on the poor performance of atypical antipsychotics.
Lilly Downplays Risks Of Zyprexa, Busted By The Times
The year closed with many questions about Zyprexa, Eli Lilly and a researcher who works for Lilly and Harvard at the same time.
People keep finding this post, which tells me that Cymbalta is pretty popular these days and that a fair amount of people have questions about it.
Seroquel For Bipolar Disorder And Oh So Much More
'Nuff said.
Those are a few of the hits for 2006. I wrote 121,500 words in this blog during the year. It'll be interesting to see what next year is like.
I've recently gotten a butt load of comments on my various rambling on Web 2.0, some positive, some negative, in the last few days. Here's one that was interesting enough to me to reproduce (with a couple of minor deletions) and address some of the commenter's points:
"1. I got your narcissist point, the framing of the self issue, and I will definitely use it (and the great "Pornography of the self") in my own papers, with due reference to you; as all academic types, I focused on errors. You made my day, though."
Thanks.
"2. Design. Simple is design. Your blog is canonical design at its purest. Tell those who disagree to choose the font and size and fancy features they love in the settings of their own browser. 'Empowering the user' they call it."
My basic approach has been that I want this site to resemble a page coming out of a typewriter back in the days of manuals and electrics and courier fonts. I plan on sticking with my basic design on this site, plus a few tweaks in the New Year. If anyone knows MT 3.2 semi-well and wants to help me tweak my individual entry archive code so that it more nearly resembles the main page, I'd be much obliged. But all the various trackbacks and internal references in that code intimidate me too much to go tinker without some advice. I'd also like to screw with the fonts setting in my CSS.
"3. Federated-Media is your David against Mountain View Goliath. Check it out."
I just did. Thanks. Looks interesting. The fact that Batelle is involved tells me a lot. In a good way. The loss of The Industry Standard was more significant than people realize.
"4. Copying "FOIA" fifty times. I've found it: Select All; Copy; Paste, paste, paste. . . Select all five copies and Copy those; Paste, paste. . . Done! I had to google that acronym! I'm really sorry bloggers don't have the needed journalists rights in certain semi-dictatorial states, while they need it."
Ha ha, good one. I actually meant 50 different FOIAs of course. The secret with public records requests is that you've got to know where the interesting documents to request are in the first place, then you have to know the law really well to keep the government from not complying. And, any citizen has the right to do public records requests, be they blogger, reporter or neighborhood crank.
"5. Congratulations for leaving your job for ethical issues: I haven't seen many journalists do that here --- and I'm sensitive to those issues."
Thanks. Principles are utterly useless if you don't act upon them.
During my rant on the Web 2.0, Google and narcissism the other day, I briefly noted that there are positive aspects to the social networking gang bang that has become the Net. Last New Year's Eve, as I prepared to head off into an evening of debauchery, I checked in on one of the mental health groups on MySpace. As an older bipolar who has gotten to the other side, I think it's my duty, for lack of a better term, to occasionally point out to younger folks with mental illness that they too can make it if they play the game intelligently--instead of being played by the game--and never give up. They sure aren't going to hear such talk from docs, researchers, social workers and the other hobgoblins of the mental health system.
Anyway, a teen was in the group and had just posted to he was going to kill himself. I responded. He responded. He emailed me directly, telling me that his folks were gone for the night, didn't care about him much anyway, and that he was going to wack himself as soon as he worked up the courage. I pointed out to him that if he killed himself at 17-years-old, then he'd never have a chance for his life to be better. I had been in roughly the same spot at his age, my life has worked out fairly acceptably and perhaps he might want to think through what he was doing. And so on. This went on for, oh, about three-and-a-half hours. At the end, he assured me that he was OK, squared away and so on.
By, then, it was 10.30 p.m. and I was emotionally drained. So I didn't go out at all that New Year's Eve, as I couldn't imagine what I could possibly say to anyone that night.
I am not sure if such experiences are what the propagandists of the Web 2.0 had in mind when they started rolling out their virtual community-building who-ha and extolled the technology's virtues for changing the world of man, but there you have it. And I suppose it does take a village, especially when parents have no fucking idea what their kids are up to and have, at best, a distant relationship with their offspring. That's not a criticism of parents, it's context for what is a central frustration of mine with the mental health world. As a society, we are doing a rotten job of running our own families (mainly because many parents don't have the time or the knowledge to run their families well) and that makes parents complete suckers for medicating the hell out of their kids in order to resolve their behavioral issues. It likely makes parents suckers for medicating themselves. And so on.
Oh, yes: the 17-year-old is now in college.
Phil Lawrence, a documentary filmmaker, is making a documentary about his struggles both taking and getting off of Paxil, which he was given for anxiety. As part of the film, he went to the recent FDA hearing in Washington, D.C. on adding further black-box warnings about suicide risks and suicidality to anti-depressants. Here's a blog entry on the hearing:
"My heart was pounding – I was about to witness one of the processes that makes our country great. Unfortunately, once the hearings got underway, I was no longer intimidated or in awe. I was just disappointed. I wanted to believe that this type of public debate was going to reveal some kind of truth - or provide answers to some of the issues at hand. It had every opportunity to be a reaffirming moment for me – especially to prove that there is some value and credibility in the way our system works. Sadly, that was not the case. In my opinion, it came off as a show - nothing more than a media event designed to give the FDA a boost in public opinion – which is timely considering that FDA reform is likely just around the corner. It was almost comical watching these public officials posturing for the cameras."
Read the rest. Having covered many other public hearings over the years, I am not surprised by Lawrence's reaction. Hearings tend to be a bit more productive on the local level. All politics being local, once you have hearings like these on a national level, little seems to ever come of them. I'll leave it to readers to speculate upon the reasons for that. At the hearing an FDA advisory panel recommended that black box warnings be expanded to cover young adults up to 25 years old. They declined to recommend that the warnings include anyone over the age of 24. How something like Paxil would suddenly go from being a problem to no problem in such a short span beats the hell out of me. Paxil caused me loads of problems as 31 and 32-year-old, including ones that the FDA is expected to issue a ruling on fairly soon.
In other news, Lawrence is two letters shy of a pretty decent first name.
First, thanks to whomever at reddit.com for linking to my ramblings about narcissism, the Web 2.0 and Google yesterday. Many hits as a result. I am more flattered that Nic Carr linked to the post from Rough Type. I also am flattered by others with small blogs who linked to my work as well. There were also many amusing comments left over at reddit.com, which you can read here. Also many comments here on the post itself.
Most commenters missed my global point that the Web 2.0 is essentially creating a mirror world in which narcissists can play in a weird context-free universe and that Google itself also does a fine job of creating its own context-free universe while stripping much revenue away from the mainstream media without adding any real value to the equation. And gets really rich in the process while newspapers are forced to cut staffs and do less reporting with those who are left. But whatever. It's all good 'cuz a bunch of bloggers will fill the gap. Oh sure you will. Gte back to me when you've done your 50th FOIA and then we'll talk.
As a note for those who inferred that I am a bitter unemployed reporter chased from my job by the almighty power of Web 2.0 and Google. You are wrong. I resigned my job in November for reasons of journalistic ethics, pure and simple. Some Seattle blogs noted this (here and here and here). For myself, I have chosen not to comment much beyond this and this. I suppose if I were a true blogger, I would've posted about it in filmic detail because it is all about You. Or the You that is me. But that would've accomplished What? Ugh, maybe another day.
For the few of you who bitched out my blog's clunky design, duly noted. Offer suggestions. Send me code. Make me more like the "I'm a Mac" guy.
For those who suggested that I bite the bullet and paste-up some Adwords, thanks for your thoughts. I wrestle with the fact that I don't think I can successfully control the content of those ads and I just don't know whether I ought to hew to my Libertarian/free market of ideas leanings and let whatever contextual ad run that Lord Google brings my way, or whether I ought to continue to lean on my outmoded reporter way of thinking and have deep reservations about letting ads appear on my site connected with products and treatment modalities for mental health about which I am deeply skeptical. I think I would lose my lunch if somehow an ad for Zyprexa or Seroquel popped up next to one of my posts, right after I had just commented critically upon a study involving said drugs, or the marketing tactics of said drugs' manufacturers.
If someone knows how I can resolve those competing problems, let me know. Otherwise, I may just let a coin toss make the call for me. Which somehow seems to me a most emblematic way to resolve the matter in the context-free world of Google and Web 2.0.
I will likely post tomorrow on one of the most positive experiences I've had in the whole social networking/Web 2.0/we are all one even though we are apart paradigm. It's got it all--teen angst, suicide, absent parents and a happy resolution. Get your minds out of the gutter people.
Last week, I noted that The Last Psychiatrist had posted some brilliant thoughts on narcissism being at the root of many mental health problems in our culture. He's also gone after the whole murder-suicide syndrome before in a similarly intelligent fashion. He's one of the few people in the mental health world these days who's actually bold enough to call stupid behavior stupid behavior. Which is smart.
My point, if I have one, is that we spend so much time in the mental health world blaming our brains, our biochemistry, access to health care and so on for people being depressed or manic (schizophrenia is excused from this conversation) when we really need to be examining ourselves. Meaning our selfs and what we do with them. Some of this is a bit hard to talk about, partly because I am reluctant to put too much emphasis on my own psychological goods when we are supposed to be a culture of consensus these days--you know, everyone feeling the same and grouped around the same loose norm. I am also reluctant to pound the keyboard too much, as well, because we don't even have an agreed upon language and semiotics and such for these discussions in our technologically advanced society. God help anyone who tries to be too individual and act smart, because you could be oppressing someone else. Gasp.
"The short version of the Time article is that we as individuals have formed a community on the internet (YouTube, MySpace, Wikipedia, etc), and this community is starting to 'build a new kind of international understanding, not politician to politician... but person to person.' Ok, no. Wrong, wrong, wrong all over the place."
And:
"Being on YouTube, having a blog, having an iPod, being on MySpace-- all of these things are self-validating, they allow that illusion that is so important to narcissists: that we are the main characters in a movie. Not that we're the best, or the good guys, but the main characters. That everyone around us is supporting cast; the funny friend, the crazy ex, the neurotic mother, the egotistical date, etc."
What he's getting at is that this whole Web 2.0, social networking, virtual community business is essentially a pornography of the self—a projected, fictionalized self that is then worshipped by the slightly less-perfect self. Human existence has been this way to a degree once we became the leisure society (am I dabbling in Veblen here? I think so.), but with the Web 2.0 we are so much more willing to spread our selves and our self-infatuations around. If you don't believe me, cruise through MySpace—a house of mirrors if there ever was one—where we are all rock stars, hotties, vampires and gangstas with flava.
This state of affairs cannot be especially healthy for our souls, our psychology and, hell, our brains because none of it is real. But it sure is a successful approach to getting us to spend more time on the computer (oh, how I miss being able to write on a computer pre-Net, you have no idea). That's not good either. Because the way the Net is now with all of its "communities" and communes of information there are simply too many stimuli. And, I've seen so many instances of such stimuli winding people up in ways that result in human wreckage.
The computer, some of you may recall, was supposed to free us. We were supposed to have so many automated tasks and so on that we'd be done with work by 3 p.m. and off to the social club. Things haven't worked out this way at all. Not only do we do more work for more hours than we used to before the computer age, but even when we are not working per se, we have become slaves to our fictional selves on Web 2.0. I worry about people younger than me who have no idea what human communication and hanging out were like before the PCs and Macs turned into these hyper-communication tools. The Net has become our social club. In Seattle, any popular coffeehouse is filled with people who just sit at tables on their laptops and communicate with other fictional selves on the Net instead of doing the least bit of the communication and interaction—positive or negative—with people sitting five feet away. All those people, all that weird isolation. Zombies.
This yearning we've got nowadays to be actualized through an idealized self that isn't real at all, but that everyone thinks is real!, is pervasive and so deeply-enmeshed in our culture and who we are that I don't even need to cite my sources—and to the point where Time magazine, as you no doubt know, has dubbed it all a social good, a flowering of democracy, and named the You of the Web 2.0 as its "Person of the Year." (Apparently, reality took the year off—or is meta-reality, watered-down and flattened, the new reality?) I think that the social networking, YouTubery and such has its place and its uses (duh!). But the problem with it is that when real people (the flesh and blood ones) learn that they are nothing close to their hyper-idealized selves (and they will find out), then look out. Depression. Anxiety. Here come the SSRIs. This culture we have created makes us suckers for the quick fix—or, tragically, the quick end—because we are so desperate to see ourselves and our new next best friends in our perfect false world that we will take anything to get back to that sweet spot of self-actualization. We will do anything, except for the psychological grunt work that is truly required for any anti-depressant to be worth a shit in the first place.
Consider Google and depression. Google is allegedly the big ass library of mankind, wisdom of the ages—all of it ranked by relevance, or more properly popularity (meaning clicks and links, fundamentally, an "American Idol" of knowledge). Because Google knows what's relevant and wise. Google "depression." Right now. First up: depression.com. A Glaxo website intended to point you to Wellbutrin XR. A couple of NIMH reference pages. Depression screening tests. Et cetera. Mankind has known and experienced melancholia and depression, and had a language for it, for a really long time. And this is the best Google can do? Depression.com? Oy vey. Which leads me to another point.
The Web 2.0 and the Net in general have been disasters for my profession, which is print journalism—a vastly different beast from broadcast journalism such as TV and NPR which are too often news presentation packaged as real reporting. Newspapers are dying. Talented people are being forced into public relations work. In Seattle, the speculation is that we will lose one of our two daily newspapers in the next year or so. The sad fact is that no one will care too much because no one knows the difference anymore between intelligent reporting and regurgitated information repeated endlessly in little echoes around the Net by people who have no fucking idea what they are talking about (this may be true of me sometimes, as well) and would have no idea how to hold the government or big corporations accountable if their lives depended on it.
I got into a huge argument at a bar with a self-proclaimed genius from Google earlier this year. He saw me writing on a legal pad, thought it was "quaint" and came over to inquire. I accused him and his company of doing little more than creating a series of algorithms to push original content around from portal to portal to website to website so that Google could basically hustle ads and revenue from each spot and make themselves rich while paying absolutely nothing for the original content on which they were making themselves rich. He told me that I was ever so wrong and that Google and Web 2.0 would be making original content creators—er, reporters—such as myself very happy at some point.
I pointed out to him that I hadn't seen more than a 3 percent raise in 5 years. Then I asked him how much he made. He declined to tell me. At that point, a Web 2.0 creature would crumple and link to some report on the Net—which they have no way of knowing the validity of—purporting to show how much one of these algorithm assholes actually makes. Within five minutes, I had cracked the genius and he 'fessed up that he made $210,000 a year. At the time, I made one-fifth of that (I make nothing now of course, but hey I am on Web 2.0, so I like totally rock!).
I told him that he either needed to buy me a shot of Remy (he could afford to upgrade my Maker's Mark) or he could get the hell away from my table. He didn't come back. Pussy.
And that, fair readers, is so emblematic of the Web 2.0 world. These people produce things that look all glossy and flashy and informative and so on. But when it comes down to it, they've got no balls, no passion and no soul. And, the fact that I am saying so on a blog on the Net is so ironic that I cannot stop choking. Because computers, you see, haven't freed me at all. They have made me a very cranky slave. One who will probably have to start running Google Adwords thingys on here soon—as soon as I can figure out how to filter out the stealth pharma ads and ads from ambulance-chasing Zyprexa personal injury lawyers.
Now, I must head off to check my Google and Technorati stats.
There's a lot of news in this post. Happy reading.
An anonymous tipster pointed me to something called "zyprexakills." Apparently, it is a response by the netroots to the court order forcing Jim Gottstein, a lawyer in Alaska, to return various marketing documents concerning Zyprexa, which may or may not have established that Eli Lilly was encouraging its sales reps to downplay the risks associated with Zyprexa and press doctors to prescribe it for off-label uses. I haven't reached any conclusions. I haven't seen the documents. Sounds like the internist in the post below this has reached some conclusions based upon his experiences, though. But I have seen the New York Times articles based on the documents and I know Alex Berenson to be a bad ass reporter. Speaking of bad ass, here's what the zyprexakills site has to say for itself:
"Eli Lilly’s motion to suppress the evidence has been denied by an inter-galactic court of appeals. Justice will be served over HTTP. As we speak, the slick marketing plans drawn up by the smartest boys in the drug dealing business are propagating across the Internet."
Inter-galatic court of appeals? Oh my. I'm not even sure I know what that means. Thank you, anonymous tipster.
Speaking of tipsters, it amuses the hell out of me that there aren't more sales reps turned whistleblower out there. Maybe all those cheerleaders turned pharma sales reps didn't learn to blow...a whistle. Now, why would anyone need to blow the whistle on a pharma company? Right now, there are lawsuits against Johnson & Johnson/Janssen/et al in Texas concerning Risperdal (as I noted here, recently) and a lawsuit in federal court in Florida against AstraZeneca over Seroquel and there are still proceedings involving Zyprexa. And, now, there is news that Bristol Myers-Squibb, makers of Abilify, has agreed to a settlement of $499 million with the federal government to defer prosecution relating to allegations it overcharged the government for drugs and promoted medicines for unapproved uses. It is not clear to me specifically what BMS drugs were involved. U.S. investigators in Massachusetts also were examining promotion of the Abilify schizophrenia drug and "other current and divested products" for unapproved, or off-label, uses, said Bristol-Myers spokesman Jeffrey MacDonald, in the above linked article.
Given all these proceedings, to date, very little has come out in the way of evidence in these cases, despite very substantial accusations. (FYI: Corporations like to settle cases and get judges to seal documents and put lawyers under gag orders.) As a reporter that tells me that either the accusations are without merit (and the corporations are settling some of these cases because it's fun) or that people in positions to know are ignoring the fact that Risperdal, Seroquel, Abilify and Zyprexa are taken by on the order of 6 million to 10 million Americans (that's my guesstimate), and that these atypical Americans have an absolute right to know the substance of the evidence involved in accusations concerning the medications they take, but these people in a position to know are keeping their lips zipped all the same. The revenue for the four drugs I just mentioned is about $9 billion a year.
Well, well, well. An internist in New York steps up to the plate and writes openly about how an Eli Lilly sales rep tried to coax him into prescribing Zyprexa:
"Sitting across from my desk on the small blue couch, the Eli Lilly rep tried to convince me that there was a good reason those boxes should be piled next to my coveted cholesterol drugs. She said that I was likely seeing bipolar patients, as well as demented patients who were agitated....But I told the rep that I hadn't prescribed the drug, that I had sent Anne to a psychiatrist who had prescribed it. Bipolar disorder and agitated dementia (for which Zyprexa is sometimes used off-label) are in a psychiatrist or a neurologist's domain.
I mentioned that most of the psychiatrists I knew used milder and better-tolerated mood-stabilizing drugs such as Depakote for bipolar disorder, that they didn't rely on the more powerful and side-effect-plagued Zyprexa as a mainstay of treatment. And neurologists had told me that antipsychotics such as Zyprexa are often over-prescribed for dementia and are not indicated if the patient is relatively calm.
When the drug rep persisted in trying to persuade me to prescribe the drug, I grew angry. Raising my voice, I accused her of trying to jeopardize patient care.
At that point, she said the company had given her a directive to reach out to as many internists as possible. The company felt that we internists as a group were underutilizing the drug, she said.
That's dangerous thinking, I replied. I told her that such persistence would no doubt lead to the drug being wrongly prescribed — that it would hurt patients. She seemed insulted by my charge, and left, and I gave all her sample boxes to Anne, the one patient I had who was clearly benefiting from the drug."
I keep threatening to tell about my days as a sales rep for a pharma company. I worked for Abbott Laboratories. One of these days, I'll get into it a bit more. For now read, Marc Siegel's piece, which is great. I congratulate him for his forthrightness. I wish a few psychiatrists would join him in such behavior, which I have heard is efficacious for patients, not to mention the free market of ideas in the health care world.
Gee, are these the same pharma companies who are somehow able to monitor how much a doc prescribes of each drug and sic their sales reps on ones who don't use the product to the degree or to the dosages that said pharma company would like? (BTW, many embarrassing typos in the post I just linked to. Sigh.)
In today's New York Times is a fascinating article about discrimination faced by diabetics in the workplace. I had no idea diabetics were discriminated against, but it sure sounds like a lot of the same crap people go through in the workplace who have depression and bipolar disorder and anxiety and so on. The article is a real eye-opener for me, and I strongly recommend that everyone read it. America can be so fucked-up.
Not to go all self-referential here, but two years ago I wrote this about the struggles faced by people with mental illness trying to normalize theirs lives and get jobs and such just like American society demands of us—and diabetics:
"Once, I decided to be honest with an employer about what was going on and what I was up against. This was in 1993, when I worked for San Diego City Schools. It was one of the stupidest things I've ever done. A month later, the district, at my boss' urging, declared me a threat to the students and tried to fire me. They had only their paranoid bureaucratic fantasies and ignorance about the illness for evidence. It took a year, but they got rid of me.We do far too much of that in this society. Our compassion stops where the workplace starts. We toss aside thoroughly decent people over this illness. That isn't right, nor is it smart. If things don't change, the implicit promises that we've dangled before people like Rodney [a man I profiled in the article], of a better life, are meaningless. The time is right to get over the stigma of mental illness. So many working Americans now take antidepressants that it's an open secret in companies large and small. I bet there isn't a company of more than 50 employees in the Seattle area where at least one person isn't taking psych meds.
So why does mental illness remain such a basis of discrimination? And why is it that people of power, money, and privilege who take psych meds (you know who you are) can, in turn, ignore people like Rodney when they come looking for a job?
What are we so afraid of? We're afraid of taking a chance. What if something bad happens? Well, for that matter, what if something good happens? Something good can happen. It did for me. We can't know unless we try. And if we don't try, how can we expect people like Rodney to try?
Researchers keep talking about a cure for mental illness. They say that in the future Rodney will be able to take a pill once a day and kiss his mental illness goodbye, with no side effects. Others pin their hopes on gene therapy. Some of them say it will be within a decade.
That would be nice, but in light of previous cures, I'm not holding my breath. But I do think it's reasonable to hope for a time when America accepts people who have had the misfortune of a chronic mental illness as full-blown members of society. A day when someone like Rodney Plamondon can get a job without hiding the fact that a piece of his life is missing. For Rodney and me, it would be the best revenge."
Looks like there are some diabetics who'd like a similar revenge.
Just as I thought I was going to drift off for a few days, the New York Times has yet another revelation:
"The original results showed that patients on Zyprexa, Lilly’s pill for schizophrenia, were 3.5 times as likely to experience high blood sugar levels as those taking a placebo, according to a February 2000 memo sent to top Lilly scientists....But the results that Lilly eventually provided to doctors until at least late 2001 were very different. Those results indicated that patients taking Zyprexa were only slightly more likely to suffer high blood sugar as those taking a placebo, or an inactive pill."
How many more legs does this story have? It's now obvious why the court ordered the Alaska lawyer to return the documents from the Zyprexa class-action suit to the loving arms of court seal: it's simply not good for the American people to know a major corporation's dirty secrets, regardless of whatever health problems they might create.
More to come, I am sure.
I am taking a day or so off here. My reasons: I have written far too much on here lately; and, if I ever have to use the trade name for olanzapine again, I will scream; plus, I need some time off.
Meantime, check out my lovely post below about NAMI and Risperdal's new homey. As well, please check out this amazing post by the psych resident known as Intueri. It's about psych meds not being everything. And, then, she has two other fabulous posts here and here. One is, um, harder than the other.
And, The Last Psychiatrist has a blazing attack on post-modern American narcissism and how it's a driver of many mood problems, and how Time magazine is a joke. The good doctor from wherever he's from slaughters so much cultural horse shit in one post that I am jealous.
Also, your reading will not be complete unless you check this from CL Psych. It's about how the FDA may have cooked its data for the recent hearings on anti-depressants. Did 'ya ever get the feeling that the FDA works for Big Pharma?
In addition, CL Psych and I both find this whole J&J/Janssen/Risperdal/TMAP/TIMA business damn interesting. Sounds like we'll both be back on the topic sometime after Christmas. Nice to see that he's agreeing with some of my off-the-cuff ramblings on TMAP/TIMA from the other day.
One final bit. Thanks to Kevin, M.D. for linking to my who-ha on the Golden Threesome of Harvard, Eli Lilly and...Zuh...Zuh...Zyprexa. If only porn were so dirty.
Some days it's like shooting fish in a barrel around here. Johnson & Johnson just announced a new formulation of Risperdal (OK, it's really a slight chemical riff on the risperidone molecule) called Invega. Thank god, they didn't name it Inpinto. Anyhow, it's an extended release daily tab.
Now, read this press release for something really amazing. The executive director of NAMI National is quoted in the press release. To whit:
"We are pleased that innovative delivery technologies are being applied to new treatments for schizophrenia," said Michael J. Fitzpatrick, MSW, Executive Director, National Alliance on Mental Illness (NAMI). "New and efficacious treatment options, like INVEGA, provide significant opportunities for more people with schizophrenia to manage their disease as they work with their treatment teams to live more fulfilling and productive lives."
Now, what the hell is the ED of NAMI doing in a company press release much less mouthing the product name in all-caps? When I last talked with Fitzpatrick about two years ago, he assured me that NAMI National had really cut back on its pharma habit. So this is just disappointing.
And, about Invega, a researcher is quoted as saying:
"At the recommended dose of 6 mg per day, INVEGA had a tolerability profile that was similar to placebo."
I don't even think that's possible--an atypical anti-psychotic that's just like taking a placebo. It was a six-week trial. Whatever, dude.
Just another motherfucking day for Dre, as the saying goes.
In an editorial yesterday, the New York Times called for Congressional hearings on the many allegations surrounding Zyprexa, among other things. As is CL Psych, I am dubious of what a Congressional hearing would achieve, aside from allowing Congresswo/men to bluster, liberals to whine about corporate power and so on. I am not interested in seeing off-label use of drugs restricted, but I am interested in seeing Big Pharma not marketing drugs for off-label use. Off-label use is best left in the hands of ethical physicians and informed patients.
There were also loads of letters to the Times over the paper's Zyprexa revelations. As well, the lawyer who made the incriminating documents available to the paper is now under a special court order to return the documents and to urge the Times to do the same. Which it won't, I'm sure. I get very tired of courts sealing much of the evidence in product liability suits, but whatever. Reducing the public's ability to know how drugs are developed, tested and marketed must be the law or something.
Prevention has always been the goal of the psychcopharmacological revolution. Preventing relapses of mania, psychosis and depression, be they full-blown on sub-syndromal, is claimed as the chief good of the revolution and is certainly part and parcel of pharma advertising.
At the center of many studies, prospective or not, on assessing preventing relapses and, indeed, of preventing first occurrences has been Mauricio Tohen. He's a professor of psychiatry at Harvard and, at the same time, an employee of Eli Lilly, makers of Zyprexa among other psych meds. Tohen is variously described in Lilly documents as "Lilly Research Fellow and Leader of the Zyprexa Product Team" or as a "distinguished scientist." He is also described in at least one paper as a "major shareholder" of Eli Lilly. It is rare that any of his scientific papers note his stock ownership.
As I noted yesterday, he is a thought leader in the world of psychiatry, especially in regards to schizophrenia and bipolar disorder. He has published 435 papers and key findings are cited by by as many as 80-plus other papers. Tohen has vast influence in the psych world.
I appreciate his dedication to research on prevention, but I have my qualms about his research motivations playing out while he sits on an academic faculty and works for a major pharmaceutical corporation in which he owns many shares of stock and whose products he designs studies for and authors papers on. That's conflict of interest, straight, no-chaser.
Anyhow, let's take a look at two recent prevention studies in which Tohen was involved, since they are illustrative of many of the issues around that particular ideology. The first is controversial, the second damn interesting.
In the first, which I posted on in May, researchers at Yale gave Zyprexa to teens deemed to be at-risk of developing psychosis but who'd never had an episode. Tohen was a co-author of the study. As I noted at the time:
"Study authors concluded that the drug didn't prevent psychosis, but perhaps only delayed its onset. But they couldn't--or wouldn't--say for sure whether that alleged delaying (a few months, tops) was the result of some patients taking the drug and getting a benefit from it. But, then, only 16 percent of the patients who took the drug received a benefit at all....But, then, Eli Lilly paid for the study, so what do you expect the docs to say? You know what's coming. They called for further studies to bear out their findings. Why do these guys always act like the jury is still out on both a drug and class of medication that have been widely-discredited?"
In terms of prevention, the study failed. It also raised serious questions among other researchers about the study's ethics. From a letter to the American Journal of Psychiatry in October, written by a clinical professor at Oregon Health Sciences University:
"In addition to the patients’ average weight gain of 19 lbs, I am concerned with what other biopsychosocial repercussions there were for these young men and women after they were placed on the neuroleptic, without a clear indication, for a year. Isn’t our first and foremost obligation to 'do no harm'?"
The letter led to this response from the lead author, but you can bet it was cleared with Tohen (Lilly paid for the study):
"Prevention is a new concept to psychiatry. We are used to functioning as post hoc diagnosticians and interventionists. Prevention interventions are common in other medical specialties and, by definition, they involve prescribing active treatments to a mixture of true positive and false positive persons. The clearest example is cholesterol lowering pharmacotherapy. As prevention, the strategy treats risk (high cholesterol) not disorder (coronary heart disease), and the vast majority of those treated are false positives."
I, too, have major questions about the ethics of giving teens, children and adults psych meds before they are clearly indicated. Here's why: days after that exchange of letters in October, John McManamy passed along the following:
"Last night, I was at a gala NAMI fundraiser in DC. BMS was picking up the tab. The Pres or VP of BMS Neuroscience [Bristol Myers Squibb] got up to say his perfunctory two or three words, which turned out to be a shameless promotion for Abilify. Among other things, he mentioned psychiatric meds in the context of prevention. He specifically used as an example of patients who have never had a heart attack taking heart meds. One guess what he was driving at?If we were talking about an illness we actually knew something about, in a population with a very high risk probability of onset, with drugs that were predictably effective and tolerable then the conversation would be a lot different."
I agree with John wholeheartedly, but then I guess such amusing arrogance coupled with commercial interests and advocacy is what you should expect from NAMI and Big Pharma these days. The sad truth of mental illness is that there will always be relapses and recurrences of symptoms. Which brings me to the second Tohen paper.
In July 2005, Tohen was lead author (along with Harvard's Gary Sachs, Case Wetsern's Joe Calabrese, UBC's Lakshmi Yatham and Texas's Charles Bowden, all major authors of bipolar disorder papers as well as folks who are heavily involved in deciding what bipolar disorder and its subtypes are) of a 12-month study of Zyprexa vs. Lithium in maintenance treatment of bipolar disorder. In essence, Tohen was testing whether Zyprexa was a mood stabilizer and whether it or Lithium could prevent relapses.
The study found that relapses occurred in 30 percent of Zyprexa treated patients and in 38.8 percent of Lithium treated patients. That strikes me as fairly prototypical of what most bipolars, especially those with bipolar 1, would see in the course of a year. It also strikes me that there was no essential difference between the two drugs in their preventative abilities. An 8 percent difference in the real world ain't shit.
Tohen reasoned differently:
"The noninferiority of olanzapine relative to lithium (primary objective) in preventing relapse/recurrence was met, since the lower limit of the 95% confidence interval on the 8.8% risk difference (–0.1% to 17.8%) exceeded the predefined noninferiority margin (–7.3%)....These results suggest that olanzapine was significantly more effective than lithium in preventing manic and mixed episode relapse/recurrence in patients acutely stabilized with olanzapine and lithium cotreatment."
That's a stretch, especially since the paper does not note in any fashion Tohen's major shareholder status with Lilly. He does give a rather tangled statistical justification for his assertion in the paper and the stats-jock readers of this site are encouraged to review it.
As I noted above, relapses will always happen for almost anyone with a mental illness. As tasty a goal as prevention might sound to patients and as profitable as it might be for pharma companies, it is time for the mental health world to stop making that our collective polestar. Docs have been slapping patients with meds since the 1940s and researching newer ones along the way, yet nothing has changed no matter how bold the initial evidence might seem for a particular medication or class of drugs. I am not arguing that we give up, but that we spend our resources and efforts on more important and more easily-reachable goals.
The key is to keeping patients alive and in harnessing their human determination to move on with their lives and co-exist with their relapses. That strikes me as a more useful--and noble--goal than expecting patients to take meds that give them all manner of metabolic complaints, don't work especially well and cost hundreds of dollars a month.
I was poking around Google Scholar and PubMed as is my wont, and ran into something interesting. Mauricio Tohen, an MD and DPh, is listed as author on numerous research papers investigating Zyprexa. Tohen is a major thought leader in the psych research world. He is listed as an author on 435 papers in his career--apparently, the man has no social life--and that includes 39 papers since January 2004. I admire his industry.
In addition, his papers on bipolar disorder, schizophrenia and the use of Zyprexa are cited by one of the largest number of fellow researchers that I have ever seen. In some cases, a paper will have been cited by more than 80 other papers. That's vast influence. He's also the doctor who designs many of the Zyprexa studies (see below).
I give Tohen the title of Dr. Zyprexa or, perhaps, Lord Atypical. At the same time, Tohen is a faculty member at Harvard School of Medicine and works for Eli Lilly in Indianapolis, Ind. Lilly makes Zyprexa. Zyprexa has kind of been in the news of late.
The Harvard/Lilly cross-alliance is an interesting arrangement, one confirmed by looking at Harvard's online phone directory and papers on which he's listed as being Harvard's man in I-Town. In 2003, Tohen told "Special Topics": "Six years ago I joined Lilly Research Laboratories as an investigator, in order to design the studies addressing the use of olanzapine in bipolar disorder. In collaboration with a number of experts in bipolar disorder around the world, I am currently involved in a number of clinical trials that will determine the risks and benefits of the use of olanzapine in the different phases of bipolar disorder."
So, Tohen has been at Lilly since 1997, almost 10 years by now. Why is someone on an academic faculty working at a pharma company and designing studies on Zyprexa and then turning around and co-authoring papers with other prominent researchers, including Harvard's Gary Sachs and Joseph Biderman? Why was he saying in 2003 that he would still need to "determine the risks" of using Zyprexa in bipolar disorder when as early as 1999 he was writing in other papers that Zyprexa was associated with lots of weight gain? Sure, some of those studies were done on schizophrenics, but many were done on bipolars as well. You cannot make the argument that weight gain in schizophrenics wouldn't likely correlate with weight gain in bipolars. In fact, I was told as much by one the CATIE investigators last year. The risks of weight gain and its various consequences were well-known by 2003, as one of the recent New York Times articles traces various marketing memos about weight gain back to 1999.
Two things: one, click on the extended entry link to see a selection of papers Tohen has authored while working for Lilly, Harvard or both; and, two, come back later today when I will have another post on Tohen. We start with some non-Zyprexa papers.
"1995: Is clozapine a mood stabilizer?" He was asking about atypicals as mood stabilizers in 1995. QUOTE: "CONCLUSION: Clozapine monotherapy is an effective mood stabilizer, reducing both the number of affective episodes and rehospitalizations in patients with severe refractory bipolar illness."
Why, yes, yes it is. Assuming you can get past the white-count issues and the death issues.
"1996: Risperidone in the treatment of mania." QUOTE: "Further studies need to be conducted."
And, they were.
1997:"Risperidone in the elderly: a pharmacoepidemiologic study." QUOTE: "Risperidone appeared to be effective and may be safe for many elderly psychiatric patients with comorbid medical conditions provided that doses are low and increased slowly. Particular caution is advised in the presence of cardiovascular disease or cotreatment with other psychotropic agents."
How could it be safe when the study states: "Adverse events occurred in 32% of the patients (36% of those discontinued). These adverse events included hypotension (29%) or symptomatic orthostasis (10%), cardiac arrest (1.6%) with fatality (0.8%), and extrapyramidal effects (11%) or delirium (1.6%)."
1997: "Clinical risk following abrupt and gradual withdrawal of maintenance neuroleptic treatment." QUOTE: "Most patients who remained stable for 6 months continued to do so for long periods without medication, indicating clinical heterogeneity."
In other words, psychiatry isn't one size fits all, even in schizophrenia. Makes you wonder about the TIMA, doesn't it? It's not clear which meds were used in this meta-study.
1998: "Clinical predictors of acute response with olanzapine in psychotic mood disorders." QUOTE: "Olanzapine may be a useful alternative or adjunctive treatment for patients with bipolar disorder." AND: "METHOD: In a naturalistic setting, by reviewing medical records, we assessed response to olanzapine and factors associated with response to olanzapine in 150 consecutive patients newly treated with the drug at a nonprofit academic psychiatric hospital."
That hospital? I bet it was McLean. Tohen was working for Lilly at this point.
1998:"Antipsychotic agents and bipolar disorder." QUOTE: "The focus is on neuroleptic drugs, the atypical antipsychotic drugs (risperidone and clozapine), and two (sic) fo the new atypical antipsychotic drugs that were recently approved."
Fo' Shizzle.
1999: "Olanzapine Versus Haloperidol Treatment in First-Episode Psychosis" QUOTE: "In patients experiencing first-episode psychosis, olanzapine had a risk-benefit profile significantly superior to that of haloperidol. The study results suggest that novel antipsychotic agents such as olanzapine should be considered as a preferred option in first-episode psychosis, on the basis of both safety and efficacy advantages."
OK, someone on Lilly's payroll can say this ("preferred option") in a paper he co-authors with Jeff Lieberman (main PI of CATIE study)? Has Lieberman's tune changed?
2000: "Efficacy of Olanzapine in Acute Bipolar Mania" QUOTE: "Olanzapine-treated patients had a statistically significant greater mean (± SD) weight gain than placebo-treated patients (2.1 ± 2.8 vs 0.45 ± 2.3 kg, respectively)."
2001: "A Prospective Open-Label Treatment Trial of Olanzapine Monotherapy in Children and Adolescents with Bipolar Disorder." QUOTE: "Body weight increased significantly over the study (5.0 ± 2.3 kg, p < 0.001)."
Joe Biderman, the child psychiatrist at Harvard is a co-author on this study. He sits on the advisory board of the Child and Adolescent Bipolar Foundation. The study concludes that "Open-label olanzapine treatment was efficacious and well tolerated in the treatment of acute mania in youths with bipolar disorder. Future placebo-controlled, double-blind studies are warranted." One child in the study was five-years-old. A five-year-old with mania? Average weight gain of 10 pounds?
2001: "Long-term olanzapine therapy in the treatment of bipolar I disorder: an open-label continuation phase study." QUOTE: "Forty-one percent of patients were maintained on olanzapine monotherapy. The most common treatment-emergent adverse events reported were somnolence (46.0%), depression (38.9%), and weight gain (36.3%)."
A 49-week continuation study. Of 113 patients, only 46 made it to the end. Similar to the Zyprexa drop out rate in the CATIE study.
2002: "Olanzapine Versus Divalproex in the Treatment of Acute Mania" QUOTE: "Significantly more weight gain and cases of dry mouth, increased appetite, and somnolence were reported with olanzapine, while more cases of nausea were reported with divalproex."
It's interesting that "54.4% of olanzapine-treated patients responded (>=50% reduction in Young Mania Rating Scale score), compared to 42.3% of divalproex-treated patients; 47.2% of olanzapine-treated patients had remission of mania symptoms (endpoint Young Mania Rating Scale <=12), compared to 34.1% of divalproex-treated patients." That's not particularly impressive response or remission considering that it was a 3-week study.
2003: "Olanzapine Versus Divalproex Sodium for the Treatment of Acute Mania and Maintenance of Remission: A 47-Week Study" QUOTE: "There were no significant differences between treatments in the rates of symptomatic mania remission over the 47 weeks (56.8% and 45.5%, respectively) and subsequent relapse into mania or depression (42.3% and 56.5%). Treatment-emergent adverse events occurring significantly more frequently during olanzapine treatment were somnolence, dry mouth, increased appetite, weight gain, akathisia, and high alanine aminotransferase levels; those for divalproex were nausea and nervousness."
A 47-week study.
2003: "Comparative Efficacy and Safety of Atypical and Conventional Antipsychotic Drugs in First-Episode Psychosis: A Randomized, Double-Blind Trial of Olanzapine Versus Haloperidol" QUOTE: "Olanzapine-treated patients experienced a lower rate of treatment-emergent parkinsonism and akathisia but had significantly more weight gain, compared with the haloperidol-treated patients."
Jeff Lieberman, the main PI on the CATIE study, is lead auhtor of this paper.
2003: "Randomized trial of olanzapine versus placebo in the symptomatic acute treatment of the schizophrenic prodrome."
QUOTE: "Olanzapine patients gained 9.9 lb versus.7 lb for placebo patients (p<.001). CONCLUSIONS: This short-term analysis suggests olanzapine is associated with significantly greater symptomatic improvement but significantly greater weight gain than is placebo in prodromal patients."
Ten pounds in 8 weeks?
2003: "A 12-Week, Double-blind Comparison of Olanzapine vs Haloperidol in the Treatment of Acute Mania." QUOTE: "These data suggest that olanzapine does not differ from haloperidol in achieving overall remission of bipolar mania. However, haloperidol carries a higher rate of extrapyramidal symptoms, whereas olanzapine is associated with weight gain."
That's stating the obvious.
2003: "The McLean-Harvard First-Episode Mania Study: Prediction of Recovery and First Recurrence." QUOTE: "Within 2–4 years of first lifetime hospitalization for mania, all but 2% of patients experienced syndromal recovery, but 28% remained symptomatic, only 43% achieved functional recovery, and 57% switched or had new illness episodes."
It is interesting that this study was cited by 32 different papers, including seven papers investigating Zyprexa. Three of the citations belong to Joe Calabrese, another big player in the bipolar research world, who's done many of the studies around Seroquel.
2004: "Relapse prevention in bipolar I disorder: 18-month comparison of olanzapine plus mood stabiliser v. mood stabiliser alone." QUOTE: "Patients taking olanzapine added to lithium or valproate experienced sustained symptomatic remission, but not syndromic remission, for longer than those receiving lithium or valproate monotherapy."
This paper has Joe Calabrese, Charles Bowden, Gary Sachs (Harvard) and Nassir Ghaemi (Harvard) listed as co-authors, all of them bipolar big shots, two of them from the same faculty of which Tohen is a member.
So if we weren't seeing syndrome remission, then why are these same docs still pushing for atypicals to be used as mood stabilizers?
More to come.
Eli Lilly issued a statement in response to today's article in the New York Times, which detailed how the company engaged in off-label marketing of Zyprexa. Read it for yourself. The article itself is here. One interesting point: Lilly says that 50 percent of mental health care in this country is delivered by primary care doctors. Thanks for confirming what other doctors have told me. It is utterly moronic that, as a culture, we have primary care doctors--generally way over-worked without time to properly keep up on developments in the psych world--making diagnoses of bipolar disorder, for example, which is very tricky to diagnose, and then being educated by Eli Lilly's sales force about meds. That's a recipe for disaster.
Liz Spikol makes the point that she holds doctors as responsible for the Zyprexa mess as she does Eli Lilly. I agree, although it looks like much of the blame must be placed on primary care doctors, who should be better educated about what they are prescribing to patients. It's ironic, too, that primary care doctors have become so loathe to prescribe pain killers for back spasms--under pressure from the DEA--but are so willing to prescribe powerful psychiatric drugs to adults, teens and, yes, children.
The State of Texas is now suing the maker of Risperdal, J&J/Janssen, for misrepresenting the "safety and effectiveness" of Risperdal to state officials and for "improperly" influencing the development of treatment protocols through "financial contributions." There's more:
"The companies pushed Risperdal in other states through paid consultants on expert panels, peer-to-peer marketing strategies and "administrative decisions made by a select few public officials," the lawsuit says. The companies sent an unnamed Texas official around the country as a spokesman for the drug, and they hired third-party contractors to conceal their control and funding of medical education programs, speakers' bureaus and clinical research that promoted the benefits and safety of Risperdal, the lawsuit says. The lawsuit says at least 17 states, including Texas, have implemented the protocol or are doing so."
Unless I miss my guess, the protocol would be the Texas Indication of Medication Algorithm (TIMA), which is influential in the psych world and which docs have always assured me was evidence-based and all so scientific. Sure it was.
If these assertions are proven at trial, I'd say that the TIMA is toast. Which makes me think J&J's lawyers will be talking settlement tout suite. Gee, I wonder what documents might come out of this case.
As well, I wonder if all the "there is hope" mental health advocates out there will now stop spreading the gospel about "oh, but it's evidence-based and doctors are working on exciting treatment algorithms" that they've been feeding the public, as well as myself, the last couple of years.
Psychiatry remains as much art as science. Patient care is more in the hands of the patient than it is of the doc.
As I suspected in my first posts (which I wrote Sunday afternoon), there would be more revelations forthcoming about Eli Lilly's behavior around Zyprexa. Here's one revelation from a second New York Times article:
"Eli Lilly encouraged primary care physicians to use Zyprexa, a powerful drug for schizophrenia and bipolar disorder, in patients who did not have either condition, according to internal Lilly marketing materials."
Read on, please.
According to Alex Berenson's article, Lilly instructed sales reps working with general practitioners and internists (and likely gerontologists) to push the drug's use in dementia, a condition for which it was not approved. Pushing off-label use is a no-no. As in illegal. But Pharma does it all the time, the wink-and-nod relationship that goes on between docs and sales reps every day. If Berenson's assertions prove out, then this is huge. I wonder his documents show about Lilly's behavior about the use of Zyprexa in treating bipolar disorder prior to the drug's approval for use in treating acute mania.
As I've noted before, other atypicals have also been used in dementia patients and there have been studies establishing a higher than normal death rate in patients using the drug. As well, AstraZeneca reps in the Seattle area have done a lot of winking-and-nodding as well with doctors in the area. In addition, I have to wonder how all these docs prescribing atypicals to kids got put onto the drugs in the first place. Not that a sales rep would ever do anything unethical. Cheerleaders stick to the dance routine!
Alex Berenson is my new favorite reporter.
On Saturday, Eli Lilly issued a statement responding to the New York Times article calling into question whether the company has been completely forthright about side-effects of Zyprexa:
"Said Steven Paul, M.D., Lilly's executive vice president of science and technology, 'We believe it is critical to physicians and patients that Lilly state some important and relevant facts about our lifesaving medication Zyprexa that are missing from the New York Times article'."
Read their press release for Eli Lilly's accounting of the situation. I take up various issues around the situation in the post following this one.
Three points. First, for the company to attack the release of these documents as "illegal" is lame. As far as I know, the lawyer who released them to the New York Times was not bound by any legal restrictions in sharing these documents with the public. But, perhaps, there is a fine legal point here that I am not aware of.
Second, if Eli Lilly is concerned about its documents and how they are being used in the media, then the company should flat out release all the documents in the class action case it settled in 2005. Let the public decide for itself.
Third, Dr. Paul stated the following in the release:
"[I]t (Zyprexa) has been used by more than 20 million people worldwide, and doctors continue to prescribe it to deal with some of the most terrible mental illnesses, such as schizophrenia and bipolar disorder." (Emphasis mine.)
Look, everyone knows that schizophrenia and bipolar disorder are not a party. But to continue to paint patients as somehow terrible for being diagnosed with a mental illness verges on hate speech, because it creates in our culture an unfounded belief that we are dangerous. At best, such talk is stupid, especially since it contains a value judgment. Why mental health advocates let corporations get away with such talk is beyond me. But then a lot of things are beyond me in the mental health world.
I have lived with bipolar disorder for over 17 years. I've done pretty well for myself--no thanks to Prozac, though--and resent having doctors, researchers and Big Pharma describe me and my condition as terrible. You guys just have no idea what human determination can do in the face of mental illness. But that's because you never study what makes people tick who do well. You ought to. You might be surprised.
And, Dr. Paul: you owe me an apology. You also owe it to millions of Americans diagnosed with schizophrenia and bipolar disorder.
I have several thoughts in light of Saturday's revelations in the New York Times that Eli Lilly, according to documents obtained by the paper, had been telling its sales reps to downplay risks of weight gain, boosted sugar levels and diabetes in patients using its star drug Zyprexa to treat schizophrenia and bipolar disorder. You should read the article here and draw your own conclusions. If Eli Lilly's corporate behavior in regards to Zyprexa is anything approaching its deceit around the side effects of Prozac (a point so well-documented that it's now practically common cultural knowledge), then I expect further revelations to come forth. I want to be careful in what I say, but the Times itself made a comparison between Zyprexa and Vioxx:
"As did similar documents disclosed by the drug maker Merck last year in response to lawsuits over its painkiller Vioxx, the Lilly documents offer an inside look at how a company marketed a drug while seeking to play down its side effects."
The documents that the Times got its hands on were made available to the paper by Jim Gottstein, an attorney in Alaska. The documents were available as a result of discovery proceedings in a class-action lawsuit alleging diabetes and other injuries (including deaths) connected with the use of Zyprexa. The case was settled last year for either $690 million or $750 million, depending on whose account you trust. The settlement forced Eli Lilly to take a loss for one quarter in 2005. The monies have not yet been distributed to plaintiffs and Eli Lilly's internal documents were unavailable to the public because a judge had ordered them sealed.
Gottstein was peripherally connected to the case and, in connection with another case he was working on, he got ahold of the documents. Since he was not a party to the class action suit, he was not bound by the court's seal. I know Gottstein a little bit and am confident in saying he felt morally compelled to ensure that the public knew about the company's behavior. He is owed many thanks.
In addition, I'd like to thank the Times for its recent coverage of mental health issues, especially those involving atypicals, and Alex Berenson for reporting Saturday's fine article. The NYT has been the only mainstream media outlet to comprehensively take up the issues around mental health and psych meds in a skeptical fashion. I hope that the paper will continue to do so.
At this point, the judge in the class action should unseal all documents in the case relating to Zyprexa's safety, efficacy and effectiveness, as well as any documents relating to clinical trials of the drug. In addition, the judge should unseal any and all other documents in the case. The FDA as well should release any and all documents concerning Zyprexa. So should any psych researchers who have done studies on Zyprexa. At this point, it would be unethical to do otherwise.
The public has a right to know the truth and to, then, draw its own conclusions about the drug and Lilly's behavior. I know I am just a little old patient (and an unemployed journalist with a blog), and that we are all supposed to go sit off in the corner and let Big Pharma, the FDA, researchers, the American Psychiatric Association, the federal government and mental health advocates decide how the mental health game will be played, defined, advertised, spun, justified and otherwise ginned-up, but there are millions of patients who take Zyprexa--as well as other chemically-similar atypical antipsychotics--and they have an absolute right to know the truth about Zyprexa and the other atypicals. My rough estimate of how many Americans take the atypicals is between 6 million and 10 million people. This includes over 1 million children.
Reportedly, there have been two dozen deaths associated with the use of Zyprexa and there have been reports of deaths and adverse events tied to the use of atypicals in children.
Regular readers know that I have been asking questions about the safety, efficacy, effectiveness and ethics of use of the atypical antipsychotics for over a year. In addition, I have been asking about how substantive the evidence was for doctors to jump the fence with these drugs and use them as a long-term treatment for bipolar disorder. I have also been asking questions about how studies on these drugs have been conducted as well as how the drugs are marketed.
I am trying my best to keep an open mind about these drugs, but at this point I have to say that their long-term use in bipolar disorder is not justified. If anyone wants to offer arguments countering that assertion, you know where to find me.
I think that their casual use in our culture is ethically problematic. I think that it is time to drop the "yes, we know atypicals are problematic, but they are the best option for schizophrenia" spin that is floated by doctors and mental health advocates. Being skeptical and honest in the face of strong evidence is hardly crossing the "oh, but we'll scare off people from being diagnosed, or seeking help, or taking their meds if we are honest" line that many doctors, researchers and mental health advocates employ as a justification for keeping their lips zipped when some of these same folks tell me privately that they agree with me.
What's more, the atypicals have not proven out as good replacements for the first-generation antipsychotics in treating schizophrenia--and that's not my opinion. It is an assertion backed by two non-Pharma funded, long-term studies, as well as other evidenece. The drugs' 8 to 20 times price differential as compared to the older antipsychotics is not justified by either the drugs' long-term performance or their side effect profiles. If someone would like to offer me evidence to counter any of my assertions, feel free.
For over a year, I have been pointing out that mental health advocates, the federal government, doctors and the American Psychiatric Association should demand that the prices of these drugs be radically-slashed. I have said that doctors have over-stepped their ethical boundaries in pressing their patients to use these drugs long-term for bipolar disorder. Why they continue to remain mute is beyond me. Why NAMI National continues to coddle these drugs and their makers is beyond me as well, given that the group is the so-called "Nation's voice on mental illness."
It is time for the mental health industry to start asking skeptical questions about these drugs, if they are to retain any shred of credibility. It is time, also, for clinicians and researchers to publicly share their thoughts about these drugs. I am sick and tired of docs hiding behind the curtain and wringing their hands over whether their "colleagues" will stab them in the back if they speak up. The medical profession has an ethical responsibility to be open and honest with patients.
When I began this blog in September 2005, I was criticized by some readers for being too skeptical about atypicals, especially where I was questioning their long-term use in bipolar disorder. As well, when I made similar points in a Seattle Weekly article a year ago, my reporting was challenged and one local psychiatrist went so far as to question my sanity. So did some of the paper's readers.
Based upon recent revelations about Zyprexa and other atypicals, I would say that not only was I on-point, but that I was restrained in whatever criticism I offered. As usual, if anyone would like to offer countervailing evidence, let me know about it.
From the lede of a New York Times article on Zyprexa:
"The drug maker Eli Lilly has engaged in a decade-long effort to play down the health risks of Zyprexa, its best-selling medication for schizophrenia, according to hundreds of internal Lilly documents and e-mail messages among top company managers."
Read the rest at the link above. This is major news. More later.
Depending on where you live, you may not give a rat's ass, but Western Washington (that's everything west of the Cascade Range) just came through one of the largest windstorms in our history. Wind gusts hit 69 MPH in the city last night, the highest speed ever clocked here. There were 100 MPH gusts north of the city. Power is out to one million people, including about half of Seattle. Businesses are closed, schools are closed and so on. Even the mighty Seattle Post-Intelligencer was unable to be printed or delivered. When a newspaper doesn't come out, well, that tells you a lot.
My neighborhood, Capitol Hill, has power and, to my amusement, people are driving in from other parts of town to get coffee and food. There's a very interesting social experiment going on right now, rather reminiscent of Tom Insel's classic monkeys and anxiety study in the 1980s. His experiment featured two groups of monkeys: one raised with the ability to control its environment, the other without control of its environment. They were then administered an anxiety producing drug. The monkeys who controlled their environment got pissy but otherwise fared well. The other group of monkeys cowered in fear in the corner.
Human behavior is playing out similarly. I watched people who were not of my 'hood lining up to get coffee a half-hour ago. They all seemed very panicked and quiet. They didn't tip the baristas. And, as others continued to pour in from neighborhoods without power, people were driving around frantically trying to find parking and blazing up side streets.
Ah, human behavior. And mental illness.
During the storm last night, I went out to one of my local bars, had a few beers with some friends and laughed at the storm. Not that it was funny. But it was.
As dubious as I am of the whole "bipolar child" paradigm, here's a very heartfelt blog post at The Huffington Post by an anonymous father of a bipolar daughter. Read it for yourselves. I post it because I do believe in a free market of ideas on psych issues, even when they run counter to mine. Hell, if Tom Cruise sends me an email, I'll post it!
My two thoughts on the piece: I really find it hard to swallow the whole "our child was different from the time she was born" rap that's in this piece and that you hear from advocates for bipolar kiddos, and, two, the Huffington Post could really use a proofreader. Then again, so could I sometimes.
In reading advance stories and following coverage of the hearing on anti-depressants, I was struck by what was said by Carolyn Robinowitz, president-elect of the American Psychiatric Association. She takes off next year. She told the Washington Times the following:
"The actual risk [for increasing suicidal tendencies in adults associated with SSRIs] is still to be determined," Dr. Robinowitz said in an interview yesterday. "But we know there is a 15 percent higher risk for suicide in patients with untreated depression, and we have seen a decline in suicides since SSRIs have been available. Black-box warning labels cause black-box panic, and we know the warnings currently on anti-depressant labels have interfered with many families being treated effectively [for depression] out of fear."
Um, Dr. Rabinowitz, hate to tell you this, but the actual risk is well known. No one can agree on its precise dimensions though. So what? The risk is still there.
As for the drop in suicides, it was about 10 percent over 25 years, which is not impressive with or without SSRIs. Unless she is referring to drops in two subgroups: teens and the elderly. Suicide still rages among men aged 25 to 64 at a rate of something like 17 per 100,000. SSRIs haven't done squat for that.
But, yes, depression is very serious and should be treated. But I would think that the APA should be very interested in consumers getting as much legitimate information as possible about medications they take. Then, they can make informed decisions. Or does this lessen docs' power as gate-keepers of information?
Either way, her statement is sure a far cry from past-president of the APA Steven Sharfstein's brilliant address to the APA convention in 2005.
"We allow an unacceptable rate of medical errors in our practice, even as we campaign for tort reform. We have let the biopsychosocial model become the bio-bio-bio model. As a profession we have neglected the uninsured, the poor, the needy, and the seriously and persistently mentally ill. We allow gross disparities in health care for racial and ethnic minorities even as we ask for better reimbursement."
You should read his speech in its entirety. Oh, and as was reported today, the rate of teen suicide actually nudged back up a bit in 2004. Which sucks. But the rate isn't anywhere near what it is in adult males.
I only have a little to say about yesterday's FDA advisory panel hearings on expanding black-box warnings on anti-depressants. The panel voted to recommend to the full agency that the warning of increased suicide risk/suicidality be expanded from its current application to children and adolescents to adults up to 25 years old. Here's one press account.
My initial thoughts are that I am glad the warning is being expanded. But I think the panel is kidding itself--and disrespecting patients--to think that a patient using Paxil, say, suddenly becomes less at-risk when they hit 25 years old. We'll see how the FDA itself votes fairly soon.
I'll have further thoughts later today, especially concerning the president-elect of the American Psychiatric Association, who said some rather odd things yesterday.
A report out ahead of today's FDA hearings states that advocates are concerned that the potential of further black box warnings, which could come today, about suicidality connected with SSRIs could lead to reduced access to psych meds. Well, not be disrespectful of anyone, but it's time that the FDA called a spade a spade and directly addressed suicidality and SSRIs in patients young and old. Honesty is a great freedom we have in American society, and it is time for the FDA to face facts on SSRIs. We'll see what happens later today. Maybe the panel will blink and maybe they won't. I hope for the latter. Stay tuned.
I was busy with "the Other Project" all day yesterday, so I have little in the way of original material to post for the moment. For now, feast on this post and the one below.
Over the 15 months this blog has been running, I have come to love Google alerts for the interesting little tidbits of conversation and news about mental health that it brings to my inbox. For example, last night I got an alert about a very heated blogosphere cat fight about "racism is a mental illness." I'm not sure who posted what first, but it seems to have its antecedents here along with plenty of comments, and then spread here, and here, too. And, um, here also. Ah, the things the intelligensia will find to bust one another up over.
And, if an alert steers one of those contestants back over here, consider the following: Am I a racist if I don't vote for Barak Obama for president in 2008 and, therefore, mentally ill? If I don't vote for Hillary Clinton, am I a sexist and mentally ill? What meds are indicated if I am a mentally ill voter? Could we get an open-label research study going on that?
Joking aside, knowing AstraZeneca's penchant for trialing Seroquel on every possible DSM malady, I imagine they'd be happy to sponsor a study or two. And, then, use goofy computational methods to run the data so that we can then get this press release: "Racism is a serious mental illness," said Dr. Stephanie Blowchow, AstraZeneca director of social integration control. "And sufferers from the condition known as racism are symptomatic half their lives, according to the World Health Organization. But recent research at the Harvard School of Medicine indicates that 300 milligrams daily of SEROQUEL...." You know the rest.
Thank god, I am a Libertarian, who will return with something sensible to say tomorrow.
A new research report is out linking a "chronic cough" with depression. Sigh. As I've noted before, I am tired of researchers painting absolutely every human ailment in terms of depression, as they recently have with teenage acne. It's a trend that makes me wonder if, going to logical conclusions, researchers might now recommend treating a cold with Paxil which has an elevated suicide risk attached to it and, once the patient offs himself, proclaiming that the cough is cured.
And, since I am in a smart-assed mood, would that chronic cough be from a cold or smoking 'da chronic? In which case, Dr. Dre isn't a doctor at all. No, he's an evil rapper out to give Americans depression. And that coughing at the beginning of Black Sabbath's "Sweet Leaf?" It is obviously a cry for treatment with Cymbalta.
Howdy. I've been adding all manner of links to other useful blogs and Internet resources over the last day, and trying to shift links around to make the site more functional. And I stripped out the meds pics, because it looks a lot cleaner with just the Van Gogh. And Van Gogh is badass. I'll probably do more fiddling over the next few days as well. Let me know what you think.
Two young women, 20somethings both, killed themselves in Seattle last week. I didn't know either, but certainly know several of their friends and acquaintances in the loose confederation of artists, musicians, techies, waiters and late-night freethinkers with which I run. Suicide is such bullshit.
I didn't ask too many questions, because, as some of you know, I have written at-length on the topic before and that it's rough terrain for me to re-visit. The general picture I get, though, is of talent going down the toilet. That sucks, and it'll suck 31,000 times a year in this country.
What staggers me is that this country has been unable to do much about suicide for as long as anyone has tried to do anything about it. The annual rate of suicide in America runs at about 10.5 people per 100,000 residents. It has dropped about 5 percent to 10 percent in the last 50 years, despite untold billions of dollars being spent on psych research, psych meds, psychosocial treatments, health care, housing, telephone help lines and public health education campaigns. None of that has worked to much effect by any honest reckoning of the situation.
To give you an idea of just how ineffectual some well-meaning initiatives have been, check this out: in 1999, the federal government announced its goal of halving that rate by 2010. That would take it down to the rate od death attributable to AIDS/HIV to give you a comparison. The move was part of then-Surgeon-General David Satcher's call to action on mental illness in America, which begat the President's New Freedom Commission on Mental Health. The basic idea is that we would carve into--OK, bad metaphor--the suicide rate by way of advances in treatments, public recognition that mental illness was addressable/destimatization and public outreach efforts. In other words, your basic public health approach. Last time I checked, America's suicide rate hadn't budged aside from year-to-year fluctuations.
That's discouraging, of course. But it's also hopeful. The answers to addressing this problem are to be found outside of current methods. I only wish I knew what to replace them with that would be effective in a society-wide fashion.
My own thoughts went something like this:
"Suicide is most often the impulsive act of a desperate man. I can do a cage match with desperation, but the wild, mad, suicidal impulses truly horrify me. You can get to a point of desperately wanting to stick a gun in your mouth faster than you can read this sentence.Somehow, two things have reeled me in when I've been in that state of mind and being. First, the somewhat dopey principle that I could never do that to my parents, especially my mother. Second, a sense that even in the darkest of my dark moments, my life can't possibly end that way. I'm too interested in the world and human mechanics not to want to watch the parade. Albert Camus, who called suicide the only philosophical problem, had a similar explanation: 'In a man's attachment to life there is something stronger than all the ills in the world. The body's judgment is as good as the mind's, and the body shrinks from annihilation'. I'll buy that."
I am very sorry that those two young women weren't buying.
You can find the Freedom Commission's entire report here. It is fascinating reading, especially in light of how little progress has been made on addressing mental illness and suicide in America in the years since.
The fine folks at the Treatment Advocacy Center had a recent post with which I actually agree. Namely, that inmates in Florida with mental illness must be treated, as a court recently ordered the state. I think TAC is on shakier ground when it asserts that antipsychotics are not mind-controlling. Perhaps "controlling" is too strong a word--something like mind-leveling might capture it better--but there's no denying that the drugs do alter peoples' minds and behaviors, and, where they work, they do so in a predictable fashion. Sounds like control to me. But, then, control is a big buzz word among anti-psychiatry folks, so I understand why they jump on the word.
Taking the situation in prisons and jails together with antipsychotics, I think an interesting ethical and legal quandary arises when you consider how antipsychotics are used on inmates. What if Zyprexa--or Haldol for that matter--is messing up an inmate's cognition or making them put on 30 pounds and raising all manner of metabolic issues? How does the inmate get a prison doctor to listen to their concerns? Does the state have the right to force to make someone take a med that is screwing them up in order to maintain the inmate's mental status? Can you inflict injury--diabetes, say--upon someone in order to restore their competency for trial? Can you medicate a prisoner into sanity so that you can legally execute them for a crime? (OK, we know the answer to that one.)
I ask the above in a speculative fashion.
An article on the one-time New York Times reporter/serial plagarist was in yesterday's Boston Herald, noting that Blair had recently written for bp Hope. Blair, as some of you know, was diagnosed with bipolar disorder soon after the scandal about him stealing from other reporters--including a friend of mine from college who turned him in and got the ball rolling on the disclosure--came to light. I should note that the magazine is funded by pharma companies and refuses to publish articles that criticize meds by product or generic name. Stupid policy. Let's leave readers in the dark, shall we?
At times, I do feel sorry for Jayson. I've interviewed him before and he is quite smart. But I don't fancy his claim that bipolar disorder played a major role in his transgressions against journalism. I've been a reporter for a decade and have never found that bipolar disorder turned me into a liar or plagarist. In fact, it hasn't limited me at all. The most important bit of business with living with bipolar is knowing yourself and your limits, and not using the disorder as an excuse for bad character and dumb choices. To do so mocks the millions of Americans who get along quite well with this disorder, and do it without lying or stealing. And with far more nobility than Blair ever has.
The tasty irony for me is that I would've axe-murdered for a job at the Times, but they wouldn't consider me because I am white. Meanwhile, Jayson is a famous liar who's done a book and is rumored to be at work on another, while I quit my job last month because my paper's new editors felt it was a grand idea to publish fake news and dupe the public. Jayson has a job. I don't. Ah, life's parade of irony continues.
There was an Associated Press story the other day on how there's bright news on the atypicals front for drug makers (yes, but what about for the patients?). At the end, the AP business reporter noted that Bristol Myers-Squibb had just announced study results that "its antipsychotic drug, Abilify, delayed relapses in adults with Bipolar I Disorder for up to two years."
Interesting, I thought, and did some poking around, because that struck me as a lipstick-on-a-pig statement. Sure enough from a company press release:
"Of the 161 adults who entered the trial, 67 completed the 26-week phase (ABILIFY n=39, placebo n=28). Sixty-six adults entered the 74-week phase (ABILIFY n=39, placebo n=27). Of these adults, 30 discontinued due to various reasons (ABILIFY n=18, placebo n=12), 24 discontinued prematurely due to study termination (ABILIFY n=14, placebo n=10), and 12 completed the additional 74 weeks of treatment (ABILIFY n=7, placebo n=5). Such drop-out rates are common in long-term studies of people with Bipolar I Disorder."OK, so BMS is making this claim about Abilify based on results in 7 patients:
"Maintenance therapy with ABILIFY for nearly two years significantly delayed time to relapse in adults with Bipolar I Disorder who had a recent manic or mixed episode and were then stabilized with the medication for at least six weeks, according to findings published in a supplement to Neuropsychopharmacology."
Color me completely unconvinced. It embarrasses me when so many reporters buy the sizzle and don't really bother to look at the mechanics of these studies. There'd be much less hype of Pharma's products if that were the case. And, shit, even harried wire services business reporters have time to figure it out. BTW, Reuters, Street Insider and MSN Money all went with the same spin. Sigh.
I cannot locate that supplement to the journal, so for now, no link to it from me.
Here's a discouraging story involving a young man with bipolar disorder who allegedly murdered his parents last Wednesday in Spokane, Wash. According to media accounts, Bryan Kim was taking meds (whether it was contemporaneous with his alleged act remains to be seen), but stabbed his father and strangled his mother all the same after they told him he'd need to move out of the house by January 1. He'd reportedly been charged with assaulting and kidnapping them in the past.
I'll be interested to see more details in this case as they emerge. For now, I have one thought. If Kim was not psychotic at the time of his alleged deeds, then I hope he rots in prison for the rest of his life.
As usual, I am not asserting or hinting that meds made him do it, but I am fascinated that some in the mental health advocacy world act as if meds are an absolute buffer against bipolars and schizophrenics committing crazy, regrettable acts. It'll be interesting to see if TAC takes this one up, or if they benignly ignore it as they did with the bipolar who allegedly shot up the Jewish Federation in Seattle this summer. He was on meds at the time.
I am taking the day off to focus on other things. I'll be back on Monday with news of things like the Associated Press completely screwing up a study on Abilify. Ah, the AP. Where to begin?
Have a nice weekend.
It's not my standard practice to cop a bunch of someone else's text when linking to them, but when the subject is bipolar disorder and potential tolerance to anti-epileptic drugs (read: Depakote) and the blogger blogging is The Last Psychiatrist, well, I cannot help myself.
"If mania is a strictly biochemical dysfunction in the brain, shouldn't tolerance to its treatment occur? Don't we make patients worse by keeping them on the meds? Or at least harder to treat? And if it isn't strictly biochemical--if we're allowing that life happens--do we really believe that a fixed dose of an antieplieptic is going to prevent a negative response to a life event? And wait a second--doesn't mania spontaneously remit even without medication? Shouldn't we just, sort of, help nature along, or even get out of its way?I'm not saying not to treat--I'm saying not to overtreat.
A guy is on 1500mg Depakote today. What do you do when the patient relapses? Increase to 2000mg? Then what? When does it stop? When does it not result in polypharmacy?
Any reason--biochemical or epidemiological--why we should not be treating symptomatically rather than prophylactically? Anti-manics when you're manic, then stop them when you're better?
I know everyone thinks Osler helped write the DSM after finding the gene for psychiatry and Hippocrates is jealous because he's balding junior faculty, but perhaps we should go reread The Epidemics and rethink our principles."
I am taking things rather light today because I was working my butt off yesterday on the other project, code-named "The Other Project." But there is loads of news on the depression front, so herewith is your official depression round-up, including some actual big-time news.
The FDA released a report this week on suicides and suicidality connected to the use of anti-depressants. It concludes that anti-depressants present no risks for people older than 25, but that they present a greater risk for people younger than 25 (press account here). This has got to be the largest pooling of data on the matter ever by the FDA, as it incorporates 100,000 people who were in various clinical trials. The FDA is holding a hearing on December 13 to assess whether to place a black-box warning for suicidality in adults on prescriptions of anti-depressants. The warnings already exist for use in teens and children. This little back-and-forth has been going on for a decade, and I think it's time for the FDA to actually do its job and go for the warning. And, if they need me to fly in and shoot off my mouth, no problem. BTW, the agency chose to redact several pages of data in the public version of the report. That's bullshit and I hope there are reporters filing FOIAs over that.
The riskier in younger people conclusion, however, flies in the face of this study in last month's American Journal of Psychiatry, which found that suicides decreased among 5 to 14 year olds taking SSRIs versus those not taking the anti-depressants. Funny thing, though, is that that group is the second smallest suicide cohort of all (0 to 4 year olds are the smallest for obvious reasons), so it's not the most compelling study on the planet (editorial on the study). Besides, there probably weren't too many 5 to 14 year olds in the FDA's data pool. And just for fun, let me link once again to this study conducted right here in Rain City, which concluded that there is no increased risk of suicide with SSRI use.
The whole thing is an endless debate and that's why the FDA should step up and slap on the warning label. It's not like black-box warnings have hurt sales of atypicals. And, the FDA is supposed to be protecting the public's interests not the marketing campaigns of pharma companies.
In other news, postpartum depression is found to be more prevalent in mothers than previously thought. That's not good at all, but I get a little tired of researchers describing increased rates of this-and-that as a "public health problem" and an "epidemic." Those are scary words, typically used to pimp for more researcher money. And, no, I am not being mean to moms here, especially since the confounding fact is that there is now--or should I say, once again?--a group of obstetricians saying women should avoid Paxil before and during pregnancy due to risks of birth defects. So if postpartum depression is a "public health problem," then Paxil and pregnancy would be a public health epidemic. Sorry, couldn't resist.
Speaking of Paxil: more Paxil lawsuits. Wonder if the FDA is paying attention.
And, let's not forget: Lexapro is better than Cymbalta. I'm sure Andrew Solomon is smiling somewhere. A skeptical take on the Forest Labs sponsored study by CL Psych here.
In what strikes me as an important post, CL Psych, is calling into question how a recent study on Seroquel's use in bipolar disorder arrived at the degree of positive effects experienced by the research subjects. Or more properly how the researchers calculated those effects. If I am not incorrect, this study, known as BOLDER II, was the basis (or one of the bases) of Seroquel's recent FDA approval for bipolar depression (company press release here). That approval, in essence, now allows AstraZeneca to market Seroquel as a mood stabilizer. Or do a lot of nudging of clinicians such as one I wrote about recently.
For example, see the AstraZeneca website www.isitreallydepression.com. I have also recently noted that AZ is trialing Seroquel for several other DSM diagnoses, anxiety, depression (as opposed to bipolar depression), and PTSD among them. The company is also testing it in children as young as four-years-old.
I'll let CL Psych's post speak for itself. Except to say that the gist of his concern is that researchers used what s/he considers an unusual statistical method to calculate effects of taking the drug on depression. Prompted by that post and conversations with others who read this site, I emailed Dr. Michael Thase, a professor of psychiatry at Pitt, who was lead author on the study and asked him several questions about the stats.
Thase responded that he would check in with the project statistician and get back with me. Later, he suggested that I write a letter to the editor of the Journal of Clinical Psychopharmacology, and that the study team would respond there where people who read the original study can read his group's explanation. I appreciate Thase's prompt response. Sounds fine to me and in keeping with academic debate and so on. But i'll be surprised if the journal would take a letter from a patient seriously.
One concern of mine, however, is that results of the BOLDER II study have blasted all over the Internet. There are almost 700 references to it on the 'Net, including this one. Would an academic debate in the pages of the journal generate similar attention?
Heck, maybe it's time for these types of discussions to start happening online instead. Maybe next time.
I had planned on doing some other posts for today, but since a few readers have asked for it as in right now, here is my own personal self-help, self-awareness, stay-out-of-the-psych-unit, any-fucking-port-in-a-storm guide. I want to caution that this is a highly personal approach developed over 18 years--it probably only makes sense for me. My bipolar disorder isn't your bipolar disorder, and I am highly self-aware--an "expert patient" to use what's becoming a popular term. I prefer "bipolar OG," but whatever. I should stress that I am not addressing schziophrenia, psychoses and pacic attacks. Maybe another day. But, if this helps others as a starting point, then goodie. Adapt and improvise, people.
In no particular order:
1. Have a good relationship with yourself. Know yourself. You may also find this useful for life in general.
2. Have a good relationship with your doctor, therapist, counselor, etc. If you don't, get another one. And, remember, they work for us, not the other way around.
3. Have a good relationship with your family, lover, friends, booty call, whatever.
4. Have your finances squared away. Rich, poor or middle-class, it's imperative that you don't have financial worries hanging over your head. Money is one of the biggest triggers I know of. I have seen a sudden overdraft reduce people into the foulest depressions...over $50.
5. Have a good working knowledge of your moods, triggers and so on, as well as a good sense of the warning signs of an on-coming mood shift. For example, when I feel myself getting agitated and pissy, I know that I am about to head into some nasty depression. When I am suddenly smoking more than a pack a day, I know I am off for hypomania.
6. Act on your mood shifts before they act on you. I've gotten pretty good at heading off descents into depression, or at least into deep depression. I haven't had an actual DSM-approved manic episode in many years. Hypomania? Oh, I roll with that. But that's me.
You need to know what works for you. Here's what I do, and, yes, I realize that my methods are unconventional, but they are preferable to the alternative:
a. Realize that you don't have much time to work with. You must take action as soon as you recognize what's up. It is not time to fuck around and wonder if it'll pass. It might pass for a few hours, only to come on like an anaconda 6 hours later.
b. Eat. Food can shut down screwed-up moods faster than anything I know. It's not a cure, but it beats falling into crisis mode. And I am not talking good nutrition here. I will take an apple or, alternatively, reheated corned beef hash over an episode of depression any day. My research indicates that corned beef hash works longer than an apple!
c. Keep an emergency med on hand. This is something for people to work out with their individual docs, but you ought to be able to make a case to them that you know what you are doing and can be trusted with a small script of whatever to knock the bad stuff down. It beats having to call the doc in the middle of the night or go to an ER.
From the mid-90s through about 2000, I used to have a small bottle of Mellaril around. That's one of the old school antipsychotics that's fallen out of fashion. But 40 mgs. of Mellaril can knock down manic spins, rapid cycles and spirals into depression. It can help you sleep as well. Unless you are really manic, then you need to take other measures. But for heading things off, it's pretty good dope. You won't want to take it for more than a couple of days.
I think that Seroquel, in small doses, is now a pretty good substitute for Mellaril. At least for me. When I know I have no other choice, then 50 mgs. of Seroquel