Multiple press accounts report that pop star Britney Spears was hospitalized earlier today on a 72-hour hold at UCLA. With all the alleged medical care she's been getting for bipolar disorder, one wonders why she's spinning out so hard that she needs to be hospitalized. Or are the meds just not working for her?
News is out today that Eli Lilly has been subpoenaed for documents relating to the marketing of Zyprexa by a federal grand jury in Pennsylvania. Clearly, the feds are turning up the heat on Lilly as settlement talks with the drug maker continue.
Meanwhile, the media continues to cover Lilly's Zyprexa settlement talks. WSJ's Health Blog has some news. So does Fierce Pharma. And so does damn near every other news outlet. Glad to see Lilly's claims that it did nothing wrong in handling the drug are falling on deaf ears.
Jack Friday at PharmaGossip makes the excellent point that within 24 hours Lilly has engaged in some jaw-dropping hypocrisy. A couple of days ago Lilly's incoming CEO tells the WSJ Health Blog that Big Pharma is unfairly targeted and at the same time is holding settlement talks with the feds and states to halt legal claims against the company over all the illegal marketing it did for Zyprexa. Apparently, the new CEO has a future as a comedian.
That's the word from the New York Times yesterday. To whit, that Lilly and the Department of Justice and Lilly and the many states preparing to sue the company are in settlement talks. A settlement with both groups would absolve Lilly of all civil actions by the feds and the states concerning a slew of accusations around the company's handling of its atypical anti-psychotic Zyprexa. The settlement could result in Lilly paying more than $1 billion to the feds and the states--which would be a record fine for illegal marketing--and apparently Lilly is under some time pressure to get a deal done. (A slighty different Times account appeared today.)
A lawsuit brought by the State of Alaska against the company is slated for trial in March. With that outcome much in doubt, Lilly likely would prefer to have whatever verdict comes out of that suit not affect negotiations with the feds and other states. It's not clear to me how many states would be covered under this settlement. Ten have already sued the company individually, a suit is in the offing by Arkansas, and 25 or so states' AG's offices have been mulling filing a multistate action against Lilly.
According to the Times, Lilly may agree to plead guilty to a misdemeanor criminal charge as part of the agreement. Perhaps, the crafters of the agreement could require some Lilly executives to do community service in lieu of jail--you know, like sterilizing dialysis machines and serving food to the homeless. Other press coverage from the Wall Street Journal and Pharmalot.
Neither Lilly nor the feds would confirm the settlement talks.
If Lilly gets to walk away from its Zyprexa nightmare for $1 billion or so, then I'd say it's getting out cheap, especially given that the company has already settled about 30,000 individual cases for about $1.3 billion. You have to assume that if Lilly is getting off this cheaply--and still being allowed to sell its drug through Medicaid and Medicare programs which are federally-funded--then whatever agreement comes out of the talks could well contain provisions under which Lilly would foot the bill for continuing care of people who developed diabetes as a result of taking the drug so that the states and feds don't have to pick up their long term Medicaid bills.
What remains unclear is how many of the states such as Montana and Utah which have sued Lilly might be covered under this agreement or whether their cases would continue. What's also unclear is whether all the 25 states in the multistate combine would agree to the terms or whether big states like California might go after Lilly on their own.
In other words, much remains to be determined. And, if the cases settle, does that mean Lilly's lawyers are going to stop cruising my website and its collection of the infamous Zyprexa documents?
What also remains to be determined is what effect these cases and settlements might have on the legal environment around lawsuits against J&J/Janssen over Risperdal and AstraZeneca over Seroquel which have been brought by individuals and states.
Stay Tuned.
Over the past year, several readers have pointed me to the writing of Tom Wootton, who is author of The Depression Advantage (2007) and The Bipolar Advantage (2005). He certainly has different ideas about how to address depression than does the rest of the Western world and I recently interviewed him via email about his bold claim that depression is an advantage.
Depression is an advantage. What are you talking about?
How we choose to look at our experiences in life and how we react to them determines whether it is an advantage or a disadvantage. Depression is a very painful state that has a very real chance of killing you. Most people would say that it is the worst thing that ever happened to them. A few have chosen to use it as a catalyst that changed their lives while they gained power over it.
It is not the hardships we face that matter, it is what we become as a result of facing them. Some of the greatest people in history have said that depression is what made them great. The Depression Advantage is about facing our condition while accepting the possibility that we might gain from it instead of trying to hide from the experience. Avoidance leads to a diminished life where we live in fear that some day depression will return and we will not be able to handle it. When we learn from it we find that we gain power over it and it does not affect us the same as it used to.
Our first depression seemed impossible to survive, but as we experience deeper states we find that the level that first seemed impossible can now be managed very well. We can even help others because we understand it and can empathize with them. At least in lower levels, we gain an advantage over depression instead of it having the advantage over us. Taken to the extreme, Saint John of the Cross said that it was his "Dark Night of the Soul" that made him a saint.
Your book dips into religion and faith without really swimming in them per se. What is their role in recovery?
The Depression Advantage is about spiritual growth and the role that depression can play in it. Spiritual growth is not the same as religion or faith. Blind religion and faith can keep us from learning the spiritual lessons that are available to us. My previous book offended some people because I was open about my spiritual crisis. At the time it triggered me to hear fundamentalists claim that Jesus would cure me. I am now at best an agnostic, but if I did believe in God, why would he cure my depression when he let so many of his saints go through worse? According to Saint Teresa of Avila, she was given her pain because it helped her to see God.
Depression has four different elements; physical, mental, emotional, and spiritual. The book goes into detail about the different kinds of pain and how they affect us. Seventy percent of us have a physical pain associated with depression. We all know about the mental and emotional pain, but we all have spiritual pain too. The spiritual component is what makes us question why this is happening and to search for meaning in our experiences.
The process of introspection--looking within for understanding--is a spiritual process. It leads to insight that has the power to change our behavior and how we react to circumstances. The ultimate spiritual challenge is to change our behavior so that no circumstance can make us act other than the best we are capable of. Every religion has people they refer to as saints, sages, or other terms of endearment. The saints themselves say that we all have the capacity to be like them. Saint Francis was in extreme pain until his last breath, yet acted "saintly" to the end. Kind of blows a hole in the theory that depression is to be avoided or that faith is going to remove it.
You see medications as serving what role in fighting depression?
For people who are outside of a range that they can handle, drugs can be an effective tool to help lessen the symptoms. Unfortunately, too many people are on dosages that turn them into zombies. A new trend in the psychiatric community is to talk about an integrated approach, meaning combining drugs and therapy. Drugs and therapy should be seen as one part of a much bigger integrated approach. Some day it will be criminal to give people psychiatric drugs without the therapeutic supervision needed to make sure it is working to keep them in a range that works.
Some people prefer to be against the whole psychiatric industry. While I share many of their concerns, I prefer to try to change them from within by offering steps in the right direction. I speak to medical groups and challenge them to lower the dosages as we do the hard work to get our lives under control. My ideas have been met with great acceptance and have lead to some great strides in the right direction.
We are about to launch a pilot program that combines physical health, mind skills, life planning and coaching, relationship counseling, spiritual counseling, psychotherapy, and peer support during a six month program. Almost every component is lead by an M.D. or Ph.D., leaders in their respective fields. It treats the physical, mental, emotional, spiritual, relationships, and career aspects of one's life as an integrated whole. (More information on this at the end of the interview.)
You kind of turn the idea of "curing" depression on its head. Instead of eliminating it you seem fascinated by depression and its power and its ability to force deeper states of awareness. What's up with that?
We will never learn anything be refusing to even examine it. The more we avoid depression the more power we give it. The common misconception is that if we can avoid having depression for a long time we are cured. We are never cured as long as there is the possibility that it may return and we will have no control over it. With understanding we can be "cured" in the real sense. I still get deeply depressed, but find great insight in the experience and have learned to function in it. There is a whole chapter on redefining functionality in the book, but it is off the main topic of your question.
I have always been fascinated with the mystical experience and the myriad ways that it was triggered in people. Some people have them spontaneously as I have throughout my life, but my diagnosis as bipolar made me question the legitimacy of them. How do we know they are not just delusion? For thousands of years, people have explored every way imaginable that would help to create such a state. I spent my life practicing many of the techniques to varying degrees of success, but it was facing depression that made me realize that the greatest method for me was the one I was avoiding.
When I started researching for the book I found many examples of people who had pain way worse than I ever did, yet chose to find meaning in it. They were looked up to as the greatest people the culture had ever produced. Their greatness was not in some kind of mystical state. Their greatness was in how they acted and how people felt in their presence. If facing depression helps me to become more aware and to change my actions then it is the best thing that ever happened to me. In the final analysis, the only valid criteria for anyone who says they have a handle on their mental condition is how they act. Everything else is truly delusional. A new trend is to talk about mindfulness as a solution. I think it is a great tool, but unless it leads to actfulness, what good is it to be more aware that you are acting badly?
We all have the same capacity to turn depression into greatness, but it takes a tremendous effort. Doing the hard work to get a handle on this condition is the hardest thing you will ever do, except for one thing - not doing it. By avoiding the condition instead of facing it we suffer needlessly for the rest of our lives. Even if we don't get to some hypothetical level of awareness, facing it will give us power over it and lessen the pain. More importantly it might even help us to change the way we treat others.
If you read the clinical literature, people with bipolar disorder and depression are supposed to be doomed. Do you buy that?
Many people are sold the idea that they need to accept a diminished life. They are so attached to their illness that they get upset if anyone says they can do something about it. They use their condition as an excuse to not have to change their behavior and justify everything as a result of some unproven "chemical imbalance." By refusing to buy into the diminished life concept, we have the strength and ability to rise above our circumstances. When we finally figure out that feeling sorry for ourselves does not lead to anything but more pain, we have taken the first step toward turning our condition into our advantage.
What advantage was depression for you personally?
Depression is the best thing that ever happened to me. It gave me humility, insight, empathy, understanding of the complexity of life, made me stronger, and most importantly, helped me to change my behavior and become a better person. I spent a huge part of my life believing that the spiritual path was about obtaining higher states of consciousness and mystical experiences. It was depression that made me realize that it is only in our actions that we find spiritual growth. The following is from the conclusion of the Francis of Assisi chapter of The Depression Advantage:
"Although Saint Francis also had depression as a central part of his change into a saint, I have included his story because he is the greatest example of how we should act. Saint Francis is revered because he chose to act perfectly in all situations. If we could follow his example in even minor ways, the world would be a much better place.
"Many followers of both western and eastern philosophies speak of the duality of the world. This duality is seen by many to be the work of the devil, or to the eastern world, delusion. Disease and health, pain and pleasure, loss and gain—these are all examples of the opposites that hold together our false reality.
"I often hear the idea that once we attain enlightenment, we live in bliss. If bliss is defined as great joy, is that just one side of duality? I think something may have been lost in the translation of the original meaning.
"If enlightenment brings bliss, why were the saints in this book suffering until the end? I think it is because bliss does not mean happy, it means acceptance that everything is part of the same oneness: as I noted in the chapter "The Art of Seeing Depression:" 'It’s all milk.' Depression is just as much a part of bliss as any other state. Peace, love, and joy are naturally felt, even when you are also experiencing great pain. If you read what Saint Teresa, Saint John of the Cross, or Saint Francis had to say, it will become clear: bliss is not the opposite of duality, it includes duality as a subset.
"Picture two small circles next to each other. One is pleasure and the other is pain. The common concept is that we get to a point that is outside of them both and move to another circle where there is only peace, love, and joy. Bliss is incorrectly thought of as beyond the duality, a place where pleasure and pain do not exist.
"Now picture a larger circle with the pleasure and pain inside of it. Picture it with all conditions inside of it: pleasure, pain, gain, loss, happiness, sadness, health, illness, etc. If you focus on the big circle, you are in bliss, even though you are still experiencing some of the elements inside. If you lose the perspective of the big circle, you feel only the small circles, and the pain seems more intense.
"Some people think that the problem is that we have wrong thinking. They propose that we catch ourselves thinking sad thoughts and replace them with happy thoughts, as if that is going to change the picture. It is the same as focusing on the two small circles. We will never fully understand our condition until we begin to focus on the big circle and find meaning in our experiences. As long as you think that sad thoughts are an illness you will not find the advantage of your condition.
"The example of our saints is that they got to a point that they were in the same state of oneness no matter what happened to their body or mind. Saint Francis was in incredible pain at the end of his life, yet had the ability to keep focused on the big picture. It is not that he was somehow separate from his experiences; he experienced them just as you and I would. But since he was focusing on the big picture, he was in bliss. Bliss is the state that is not affected by the duality.
"As our saints grew in understanding, they still experienced the pain, but from the perspective of bliss it did not affect them as much. That is why Saint Teresa said: 'All these illnesses now bother me so little that I am often glad, thinking the Lord is served by something.'
"It takes the perspective of extreme pain for some of us to see the truth of bliss. The Depression Advantage is that we have the chance to understand something that few ever will."
Information on Wootton's integrative approach to depression can be found in the Success Center section of his bipolaradvantage.com website.
My interest in Britney as a performer and personality is zilch, but my interest in her as a human being and someone whom the entertainment media will no doubt paint as the face of bipolar disorder (I'd really prefer Axl Rose myself), especially in light of fresh reports that Spears is actively undergoing treatment for a diagnosis of bipolar disorder. At least, that's what TMZ.com claims. Good enough for them, good enough for me.
There are questions about how nicely the meds are working out for her.
"Sources tell slightly different stories about the efficacy of the medication. A friend says when Britney takes her medicine she is like 'a different person -- normal and sweet.' But she takes her meds for a while and then feels as if she can live without it -- so she stops taking them -- and her condition quickly deteriorates. But a professional tells TMZ flatly, 'The medication just isn't working.'"That same professional tells TMZ, 'She's really trying. Whether it works -- we'll have to see.' That person also says it's extremely frustrating when the media shows video of Britney out on the town acting crazy, adding, 'She has a disease. Sometimes when you see her she's in the middle of an episode. It's like mocking someone with Down Syndrome.'"
Hm, would this be a medical professional or some other professional like, maybe, an accountant? TMZ doesn't say.
But talking about this as a disease....Oh, well, looks like the fine entertainment media in this country may need a wee bit of education about the chemical imbalance theory and what it isn't.
A remarkable story in the New York Times today about a medical researcher who was also a peer reviewer for the New England Journal of Medicine. The researcher is named Steven Haffner of the University of Texas Health Science Center in San Antonio and he's a diabetes expert who, last year, was reviewing a study in advance of its publication concerning safety questions around the drug Avandia. The drug is made by GSK.
Allegedly, Haffner "faxed the article to the drug maker after agreeing to read it as part of the peer-review process." That's a huge no-no in the science world, and a massive ethical breach on the part of a researcher. So what would so inspire a diabetes expert to risk his reputation in such a manner?
Haffner told Nature:
"'Why I sent it is a mystery,” the quote says. “I don’t really understand it. I wasn’t feeling well. It was bad judgment.'"
Wasn't feeling well? The Times reports that Haffner has received $75,000 in consulting and speaking fees from GSK since 1999.
Sorry for the delayed posting today, but I got a new computer yesterday--um, a new to me iMac G4--and was up most of the night transferring files and whatnot. I'll be caught up dealing with some pesky Internet issues a while longer as well.
In the meantime, feast your eyes on this: Danny Carlat, known to most of you as author of the Carlat Psychiatry Reporter and author of the Dr. Drug Rep article from a few months ago, writes about turning down an offer from a law firm to be paid beaucoup bucks--$500 to $750 an hour--to author a report for a lawsuit against Eli Lilly. The suit is being brought by investors upset that all the bad news around Zyprexa cost them money in the stock market.
Year-end 2007 financial results are just out for Eli Lilly today and it looks like Lilly's sales remain unaffected by bad news and lawsuits and legal settlements around Zyprexa. Sales of the atypical anti-psychotic rose to $4.76 billion, a 9 percent increase over 2006. Meanwhile, Cymbalta sales rose to $2.1 billion, a 60 percent increase over 2006. In the anti-depressant's third full year on the market, it's turned into a blockbuster for Lilly.
But there's less cheery news on the Cymbalta front. Four cases of Cymbalta-induced suicidality were published in the new issue of the Journal of Clinical Psychopharmacology. You can read them here. The reports come from doctors at the University of Kansas School of Medicine. In one case, a patient being given Cymbalta for pain turned suicidal soon after taking the drug.
Cymbalta, like other anti-depressants, does carry a black box warning of drug-induced suicidality.
A series of studies in December's Journal of the American Academy of Child & Adolescent Psychiatry is suddenly getting some attention because it raises serious questions about how ADHD is treated in children and teens, how well treatment works, what really drives ADHD--and whether it makes sense to medicate kids at all. The studies are based upon a cohort of 188 Finnish teens--the research is led by a Brit and an American, the teens have been tracked for several years--considered to have probably or definite signs that the disorder will continue into adulthood.
What the studies--including a central piece of research--found was that for many youngsters diagnosed with ADHD the disorder ebbed away in their later teen years. I don't want to read too much into the studies yet since they are complicated even if their implications are fairly clear.
These studies have not gotten much press attention so far, aside from an article last week on Psych Central and a good article yesterday in the Los Angles Times. That's too bad, because their publication represents yet another brain shake for the world of psychiatry. I'll pinch from the LAT version, especially because one of the researchers said something quite remarkable.
"Researchers found it is the can't-sit-still kids -- the stereotype of the "ADHD generation" -- who are most likely to mature out of the disease. Among those with persistent ADHD, they also found, half have problems with cognitive skills that are key to success in adulthood, but half have no such deficits."And when researchers compare the findings from Finland to studies of Americans with ADHD, an even more intriguing discovery emerges: By the time they're in their late teens, those who receive drugs for attention problems seem to fare about the same as those who do not."
Basically, the kids who daydream more do worse in the long term versus kids who are a fidgety who do better in the long-term, regardless of their meds situation.
"'This begs the question: Are current treatments really leading to improved outcome over time?' wrote UCLA neuropsychologist Susan L. Smalley and co-author Dr. Marjo-Riitta Järvelin."
Sounds like the answer is no for a significant proportion of kids diagnosed with ADHD.
"In Finland, as in studies of U.S. populations, about half of older teens with persistent ADHD performed poorly on tests of short-term, or working memory, and in cognitive skills that are key to problem-solving, making plans and executing tasks. And in each group, roughly the same proportion of children 'mature out' of the disorder."Although about 60% of American children diagnosed with ADHD are medicated -- at least at some point -- for its symptoms, virtually no Finnish children are given medication. And yet, by the time they reach 16 to 18 years old, these two populations look very much the same.
"In an interview, Smalley stressed that the studies do not cast doubt on the short-term benefits a child with ADHD may get from a stimulant or other medication that treats the symptoms of the disorder. She cited recent studies showing that at the end of one year, children medicated for ADHD symptoms function better at home and school than those who get behavioral and cognitive therapy. But after three years, the difference between the two groups begins to wane."
Interestingly, the Finnish studies parallel conclusions from a set of American studies in November, showing that ADHD kids in the US do just fine over time. They also tie in with points Bruce Levine made yesterday about the pathologizing of teen defiance (sometimes diagnosed as ADHD).
I am beginning to think we are seeing a decent body of evidence supporting the idea that we've gone a bit too far as a culture--and I am talking Western civilization, not just the US--in diagnosing disorders in kids and teens and making them and their parents feel like fools for not getting the kids on meds. In other words, we need to be a bit more flexible in our cultural assumptions of how children should be allowed to behave and how we expect them to develop. It's time to let kids be kids--and in particular it is time we let boys be boys again, as most of the ADHD diagnosing and medicating in this country at least is among boys.
Happily for me at least, Smalley agrees with my basic argument:
"'We need to step back and embrace neurodiversity, diversity in human behavior and try to work on ways to embrace and enhance being at the extreme, instead of only focusing on the deficits and disorder aspects of ADHD,' Smalley said."
Yes, we do. And while we're at with regards to ADHD, there are some other disorders--alleged or otherwise--that deserve a thorough rethinking. But I won't go there today. But, as Psych Central noted last week, this does sort of demand a new approach to treating ADHD.
I'm sure that these studies will generate as much controversy as did the studies last November, now that they are getting slightly wider attention. Can a Judith Warner column be far off in the New York Times? I see another round of the so-called Ritalin Wars a-comin.'
The studies didn't take up any questions around the use of anti-psychotics in treating ADHD in boys, which seems to be enjoying a creepy vogue in the US. I've written about this before here.
I'll have more on these studies as soon as I've been able to review them in their entirety.
It's nice to see the LAT out in front on one of these stories for a change. In the past, the paper has been a strong voice (particularly on the editorial page) for the "medicate 'em and forget 'em" paradigm of mental health care and I have given the paper hell over this. Lately, the paper seems to be doing a better job, amazing considering all the cost cutting and personnel insanity that the paper's new owners (and its most recent previous owners, the Tribune Company) have been enforcing upon what's a pretty good shop.
Bruce Levine, a clinical psychologist and writer, has an interesting article on Alternet today discussing his view that good old-fashioned teenage defiance has been medicalized and resulted in teens being doped-up in order to shut them up.
"Disruptive young people who are medicated with Ritalin, Adderall and other amphetamines routinely report that these drugs make them "care less" about their boredom, resentments and other negative emotions, thus making them more compliant and manageable. And so-called atypical antipsychotics such as Risperdal and Zyprexa -- powerful tranquilizing drugs -- are increasingly prescribed to disruptive young Americans, even though in most cases they are not displaying any psychotic symptoms. "
He's certainly right about how these drugs are used and their effects. It all gives new meaning to "teenage wasteland." Levine most directly links this dynamic with oppositional defiant disorder, an alleged mental illness that, among other symptoms, involves arguing with adults and refusing to follow adults' rules.
The problem with Levine's assertion is that it's not backed by any data. Is ODD diagnosed in teens more now than say 10 years ago? I suspect that it is, but I don't know. Certainly, much of the drugging of teens is tied to dramatic increases in the prevalence of bipolar disorder and ADHD in kids and teens, but I'm less clear about what percentage of teens is now taking meds due to a diagnosis of ODD. I'm sure it's much more than in 1995, for example, but absent a thorough academic study there's little data to point to on ODD.
And, are these diagnoses of ADHD and bipolar disorder the result of teen rebellion against stultifying environments--making them proxies for ODD in a way--or are they representative of genuinely disordered behavior? I suspect that Levine's views are close to the truth. By today's standards Jesus Christ would be diagnosed with some kind of mental illness and medicated into the ground. So would half the saints and ancient prophets. And, the punk rockers and goths? Goes without saying.
Levine has some fun with mental health professionals and how their own experiences and expectations shape how they interpret human behavior:
"When compliant M.D.s and Ph.D.s begin seeing noncompliant patients, many of these doctors become anxious, sometimes even ashamed of their own excessive compliance, and this anxiety and shame can be fuel for diseasing normal human reactions."
Yes, that sounds nice and objective and scientific. For some time, I've been criticizing doctors--especially psych researchers--who have set themselves up as behavioral and mood norms for Western culture. The funny thing is that many things doctors do in their training and careers strikes me as being so divorced from common human experience that one wonders who the screwballs truly are.
I mean if you are a teen stuck in a boring school, then not being defiant might be the greater sign of a problem.
Perhaps my views on this are shaded by my experiences as a one-time pharma rep, patient and reporter, but I've certainly seen oodles of behavior by docs that strikes me as containing the same kind of excesses which docs pick apart as signs of an illness in patients. If it's grandiosity and wildly expansive egos you want to see in our culture, then check out the self-love of surgeons and almost any researcher who's just published a study. I can assure you that they often view themselves as gods and goddesses and that skeptical questions about their work (as a reporter, I'm supposed to be asking those) are met with heavy doses of defiance. And so on.
Levine also lays some of the blame on Big Pharma:
"It would certainly be a dream of Big Pharma and those who favor an authoritarian society if every would-be Tom Paine -- or Crazy Horse, Tecumseh, Emma Goldman or Malcolm X -- were diagnosed as a youngster with mental illness and quieted with a lifelong regimen of chill pills. The question is: Has this dream become reality?"
Right now, it's not possible to say just how much this is a reality in American culture. I think many of us sense that something is going on out there--talk to anyone who works in a school system--but we are at a loss for hard data. For me, I'm not sure how much to blame the pharma companies. They are simply one set of actors in a dynamic that involves families, teens, doctors, therapists, schools, teachers, coaches, governments and so on.
What do you think?
Ever since Arkansas AG Dustin McDaniel filed suit against J&J/Janssen in November I've been trying to get someone at his office to discuss the lawsuit with me. The lawsuit alleges, among other things, that J&J/Janssen cooked its clinical trials of the atypical anti-psychotic Risperdal back in the early-1990s (basically not giving patients who'd been on Haldol enough time to let that drug clear their systems before putting them on Risperdal or a placebo). As a result, the AG alleges that the company knowingly put a defective drug on the market once it received FDA approval.
As I noted then, this is a gigantic accusation, an attack on the central premise that Risperdal and other atypicals have fewer side effects than older anti-psychotics. What's more, if the accusation is true, then the State of Arkansas has identified a huge public health problem given that millions of Americans (and millions more worldwide) take or have taken the drug, causing the deaths of over 1,000 people.
So I asked the AG's office to detail its evidence for those accusations. Did it have documents upon which to base its claims? Was an expert on the drug offering testimony to the effect that the drug was defective?
Basically the AG's office blew me off and, on Friday, finally told me it wouldn't discuss the case. The evidence, a spokesman told me, was covered under a court protective order. He didn't seem very impressed with the argument that the state has a responsibility to alert the public to a public health problem. Nor did he seem particularly interested in my request that the state make the documents publicly available in whatever settlement agreement eventually gets hashed out.
We'll see what happens at some point. My own hunch is that the AG's office has gotten its hands on documentary evidence or it would have never made the accusations in the lawsuit.
No word on when McDaniel's office will file suit against Eli Lilly and AstraZeneca. It will be interesting to see if they make similar accusations about Zyprexa and Seroquel.
For those of you not in the Seattle area (and that would be maybe 90 percent of you) this post might be meaningless, but nonetheless I wanted to let readers know about the status of the proposed suicide barrier for the Aurora Bridge in Seattle. Washington's Governor, Christine Gregoire, has asked the state's Legislature to fund initial design work on a barrier to the tune of $1.4 million. The bridge is currently the second worst suicide bridge in the US and, sadly, many jumpers are not hitting the water below but are crashing onto the land below, resulting in much trauma for people who work in the vicinity of the bridge.
I'm glad the state is moving forward on the project. Now the state and City of Seattle need to agree upon a design. From what I'm told, it sounds as if the state's Transportation Department is going to propose an ugly, chain link fence type of design. Total cost for design and construction is estimated to be $4.3 million. Here's the state's website on the barrier. I've written about the proposed barrier here and here. Sadly, the piece I wrote for Seattle magazine is no longer on the mag's website. Gone too are the fabulous pictures which accompanied the article.
The public will have a chance to weigh in on the design and other issues at the first of two scheduled public meetings on Wednesday, Jan. 30 at 6.30 p.m. at B.F. Day Elementary, 3921 Linden Ave N. in Fremont. If you have strong feelings about the barrier you might want to attend. A little bird tells me that one group of neighbors is going to oppose any barrier as being aesthetically unpleasing. Apparently, they think dead bodies look better.
A second meeting is scheduled for later in February.
I am at work on a long post about beating depression and it's not quite coming out of the typewriter the way I want yet. So for now I wanted to pass along various items of interest. With luck, I'll have the depression post up later today. Or maybe not.
An unsettling report on how authorities in Britain worry that some recent suicides may be connected with social networking sites. Why am I not surprised by this?
PBS does a program on the infamous lobotomist whose name I won't even mention, who among other places also plied his sick trade in the Seattle area back when.
CL Psych goes wild on bogus continuing medical education courses and has even more fun sticking pins in those commentators on matters pharma who defend the hiding of clinical trials data.
There's been a very odd turn in the case of Stephany at Soulful Sepulcher's daughter. The system now seems to be screwing things up in ways that I shake my head at.
Mind Hacks has a fascinating item about these idiots in cyberspace called griefers.
Apesma's Lament reports on a tally of the homeless surviving--somehow--outside of Seattle's shelter system that was conducted last night. Over 2,600 people living on the streets of one of the most affluent cities in the world. The word outrage comes to mind, and could be applied equally to a wildly erroneous article in today's Seattle Post-Intelligencer on how many shelter beds there are in the city.
Back to writing I go.
Eli Lilly just announced that it's settled another 900 lawsuits against the company over allegations of injuries involving its drug Zyprexa. By settling the company avoided going to trial on five of the cases, including one which was scheduled for next month. The company did not specify how much the 900 cases cost to settle, but it has already set aside on the order of $1.3 billion to cover previous settlements. Reportedly, another 1,100 cases against the company remain.
What's interesting is that in recent months Lilly has claimed that it would aggressively defend itself in court against further claims. So why is it settling now? Perhaps those leaked Zyprexa documents--which Lilly claims are skewed and not representative of company behaviors--contain more truth than the company cares to acknowledge.
Pardon my really sarcastic attitude for a moment, but how the hell else does one properly reply to the inanity of federal regulatory agencies when it is pressed right in your face. Yet again.
OK. Strange as this might sound, the FDA is now officially entering the real world and is now requiring that detailed suicide and suicidality assessments be completed by companies and researchers trialing new drugs. Amazingly enough, the laziest (or the most hamstrung) agency in Washington, D.C. never required them before despite decades of evidence that some drugs caused these problems in both clinical trials and after approval. And it's not only some psych meds that have caused these reactions in people. Pfizer's stop smoking drug Chantix did, and so have cholesterol drugs and pain killers and so. Why the agency wasn't requiring a detailed assessment before is either the result of some truly amazing lobbying work by Big Pharma of of sheer stupidity on the FDA's part.
Here's the weird part though: the FDA didn't announce this new policy publicly because so much of what the FDA does is kept under wraps to protect industry instead of the public whom it's sworn to serve. Because why would regular old citizens give two hoots about what the taxpayer funded agency might or might not be doing to ensure the safety of the nation's food and drug supply? Anyway, the New York Times caught wind of this and has an interesting article on how this all came to pass.
Here's three more interesting bits: one, not all new drugs will be required to undergo the assessments; two, the FDA, if the article is to be believed (and I know the reporter involved, so I believe it), finally realized suicides and suicidality connected to drugs were a substantial issue in 2004, around the time of the hearings on suicide risks associated with anti-depressants; and, three, the suicide assessment instrument is remarkably basic, something clinicians and social workers have been using for decades, and researchers quoted in the article act as if it's the Rosetta Stone.
While I'm sure there will still be plenty of wiggle room for pharma companies to keep drugs from being assessed, this is better than nothing I suppose. But why the FDA didn't act as if this was a bigger issue in, say, 1993 is far beyond my small mind. There were five years of reports of suicidality attached to Prozac use at that point. Possibly, if the FDA had acted in the public interest then, me and people like me could've been saved some serious problems.
Anyhow, I want to offer sincere congratulations to David Healy and the many patients, and family members of anti-depressant-induced suicides for having forced the FDA to have those hearings in 2004--and for staying on the issue in the years since. Without their unselfish efforts, I doubt the FDA and the media would have ever paid much attention to the matter.
BTW, I am looking forward to the Drug Wonks post declaring that these new assessments are unnecessary, that they add too much cost to the research process and harm innocent pharma companies, and that they violate free market principles. I expect that post shortly.
A few weeks ago, I noted some news around the Judge Rotenberg Educational Center in Massachusetts. It's a "school" funded by the state where some of the most behaviorally-disturbed youngsters you can imagine are sent and where the treatment protocol doesn't involve medication but the application of electrical shocks to the youths' skin.
Now, thanks to the Boston Globe, details are emerging of just how barbarous a place this school is and how poorly the place is run.
The short story is that electric shocks given to patients are supposed to be approved by parents and a court--a process that surely short circuits the rights of teenagers to their own physical liberty--but last summer a former patient of the center placed a prank call to employees and convinced them to apply dozens of electrical shocks to two patients. Apparently, these patients were doing well--whatever that might mean under the school's bizarre rules--and hadn't been shocked in several months.
But the center, according to the paper, has employees who are poorly trained, including some who don't speak English well, and they were duped by the prank caller, who is now the subject of a criminal investigation.
Here are some details of what happened to a 19-year-old man:
"After the hoax call came in at about 2 a.m. Aug. 26, according to the report, Dumas's son told staff numerous times that they were violating his shock treatment protocol and suggested that the caller may be a prankster. At one point, he said, "Get on the phone and find out what is going on. . . ." The 77 shocks he received were, in part, based on his unwillingness to passively receive the shocks."The account in the report was based on videotapes of the incident from Rotenberg's surveillance cameras, which were shown to investigators before school officials destroyed the tapes in early October.
"Investigators found that a half-hour standoff occurred in the hallway, with Dumas's son at one end and the rest of the staff at the other end, including Bartholomew George, a rookie employee who was in phone contact with the caller and initiated the shocks. Soon after that, Dumas's son took out the batteries of his shock device, holding them out like weapons, the report said.
"But after that, the staff tied Dumas's son to a board, restraining all four limbs. The teenager, resigned to his fate, said, "Let them know I'm being compliant."
"During the next hour, he received dozens of rapid-fire shocks to his abdomen and limbs, which in fact violated his treatment plan. At one point, he complained, "Mister, I can't breathe."
"On tape, the staff recounted the reasons for different shocks, including swearing, verbal threats, and noncompliance. Of the two power levels of shock treatments used by the school, Dumas's son received the most powerful each time, school officials have said."
I would think this incident ought to be enough to get this kind of practice stopped because it is just rife for abuse. What's also confusing to me is that a 19-year-old would still be detained by the state at such a school and not be given anything close to due process rights.
Even more puzzling is that for the last year our country has been engaged in a heated debate about what methods can and cannot be used to obtain intelligence from terrorism suspects. Many Americans of every political stripe have taken a strong stance against torture being practiced by American military and intelligence personnel--even Sen. John McCain inveighed against waterboarding--and yet here it is being practiced in our own country against our own citizens who are guilty of very little but difficult behavior. The Rotenberg Center is America's own little Abu Ghraib.
Why are Americans more concerned about the rights of terrorists than of youths locked away in a veritable bug house in Massachusetts?
Via Psych Central.
That's the conclusion of two separate studies in this month's American Journal of Psychiatry (here's the editorial describing the studies). As much as I've poked fun in the past of the idea that cat feces could unleash a parasite that could infect a pregnant woman or child and later lead to the development of schizophrenia, I must admit to being somewhat impressed by the latest study showing just such a link. It remains unclear to me, if the theory is true, what percentage of cases of schizophrenia could be traced back to the parasite (the hazard ratio in the AJP study is 1.24), but it's becoming much clearer that there is a link.
I'm not sure what that does--or doesn't do--to various chemical imbalance theories of schizophrenia, or to the arguments of those who feel that childhood abuse gives rise to schizophrenia, or to the assertions of those (like the feds) who insist that marijuana causes schizophrenia, but there you have it.
Separately, a study of Swedish public health data found:
"There was a slightly increased risk of nonaffective psychotic illness associated with viral CNS infections, as well as schizophrenia. There was no evidence of increased risk in relation to bacterial infections. When divided into specific agents, exposures to mumps virus or cytomegalovirus were associated with subsequent psychoses."
Fascinating. While it's nice, however, that we might be getting some answers as to where slightly elevated risks of the later development of psychosis might reside, I wonder if we'll ever really find out and come to grips with why schizophrenia and psychosis occur and what we should do about it, if anything. Because the way the game is being played now--and the "scientific" assumptions that underpin it--is not working at all.
I was intrigued by a paper in this month's Archives of General Psychiatry, which may have been the final nail in the coffin for the mercury-preservatives-cause-autism theory--assuming that the 2004 Institute of Medicine report on vaccines and autism didn't get the job done. In it, researchers with California's Department of Health pound data from the state's Department of Developmental Services and come to the conclusion that since mercury was phased out of childhood vaccines--its use is as a preservative called thimerosal--from 1999 to 2001 cases of autism in California's youngsters has sadly not decreased, as you might expect if mercury were the culprit. In fact, the prevalence of autism increased.
From the study: "The estimated prevalence per 1000 live births for children aged 3 years increased from 0.3 for children born in 1993 (and reported by the DDS in 1996) to 1.3 for children born in 2003 (and reported by the DDS in 2006)."
That's a 430 percent increase in cases reported to the state, an alarming increase. So if autism isn't caused by thimerosal, then what caused the explosion in cases of autism in the US? Much as with the vast increase in cases of alleged bipolar disorder in children (another can of worms entirely) over a similar time period, the experts really don't have any firm answers. And it would be really nice if we could start getting some clarity on these issues (obviously I am ignoring the fact that psych researchers are deeply divided over the existence of bipolar disorder in kids). Because something happened in America and to its children in the 1990s. And it ain't good.
For some reason, I just don't buy the argument that "we've gotten so much better at doing diagnoses and people are so much more aware and educated on mental disorders" as an explanation for what's happened.
Does anyone know?
According to the New York Times, actor Heath Ledger was found dead this afternoon in the apartment of actress Mary-Kate Olsen in New York. Ledger was 28-years-old and his body was found amidst a scattering of pills. Ledger is best known for his starring role in "Brokeback Mountain."
UPDATE: Early this evening, one press outlet reported that NYPD is now calling Ledger's death an accident, apparently an overdose of sleeping pills to blame. The actor was also reportedly suffering from pneumonia. I'm not sure that an overdose of sleeping pills is any prettier or any less sad than a suicide, but there you have it.
An autopsy will be performed tomorrow.
There is a surprising report just out, claiming that over half of the women who committed suicide in Sweden in 2006 had filled a prescription for an anti-depressant within 180 days prior to their deaths. That works out to 52 percent among women who had committed suicide. Among men 33 percent had filled a prescription for anti-depressants 180 days prior to their deaths.
That's not particularly good news for defenders of the faith in psychiatry, who claim that anti-depressants are a suicide prevention technology. Such a claim is often the basis for pharmaceutical advertising and for the exhortations of advocacy groups.
There are, of course, weaknesses in the data. Filling a prescription for an anti-depressant within 180 days before a suicide does not mean that the anti-depressant caused the suicide, and it does not mean that a particular person was taking a drug at the time they committed suicide. They might have stopped taking a drug 179 days before their death.
What's more, the common response in the US on the anti-depressant/suicide question that "these are troubled people, so of course they were on an anti-depressant when they killed themselves" could no doubt be used in this case.
But, still, these Swedish numbers are perhaps the best population-based entre we've got into the ticklish question of whether anti-depressants induce suicidality. Taking these numbers at face value, you'd have to say that there is an unsettling connection of some kind. But, keep in mind, that 48 percent of women who committed suicide didn't have a prescription for an anti-depressant either. Is that the more telling metric? I simply don't know.
What I do know is that anti-depressants sure aren't the rock solid anti-suicide technology we've been told they are. Some people with depression respond very powerfully to the drugs, others see little effect, still others appear to worsen and others seem to have tragic responses to the drugs themselves. While the evidence on suicide and anti-depressant use in the US is mixed (some studies say yes, others say no), it's certainly eye-opening to see this Swedish data, courtesy of that country's unique reporting methods (ones that don't exist in the US nationwide).
My own thinking is that there is a definite problem here, but one that doesn't offer simple answers. If you can assert that untreated depression is linked to suicide and can assert at the same time that anti-depressant use is linked to some suicides, then what do you do about treating depression? Do you treat it or not? And, what do you treat it with?
The mystery deepens.
First, thanks to all of you for your kind thoughts regarding my six-month anniversary of being off-meds. I happened to put the same post up on Daily Kos and got several fascinating replies, including this one from Paul Minot, a psychiatrist from Maine. I'm reproducing his reply, mostly in full, with his permission. You can read the others here.
"Bipolar disorder isn't actually a disease."It's a collection of signs and symptoms lumped together in a diagnostic classification that has no basis or assumption of causation. There is no known neurochemical abnormality associated with "bipolar disorder", and patients with this diagnosis certainly have a plethora of different problems, all lumped together in one convenient/dumb diagnostic classification.
"The expansion of the definition of bipolar disorder over the past two decades is simply a "rebranding" of post-traumatic stress disorder, impulse control disorders, personality disorders, and other problems into a pseudoscientific trashcan diagnosis, to provide an FDA-approved "indication" for the prescription and marketing of anticonvulsants and other medications to treat this "illness". I know this because I myself am a psychiatrist, actively treating bipolar disorder and prescribing these medications. I think prescribing these medications is reasonably safe and often helpful, but trumping up fictitious diagnoses and deluding people into thinking that they have a lifelong illness without a firm grounding in scientific fact is ridiculous, and unethical. Your own experience isn't miraculous, it just verifies that much of contemporary psychiatric diagnosis is a bunch of malarkey.
"You're very fortunate to have the psychiatrist you do, one that apparently hasn't fallen for our own bullshit. Good luck to you.
Minot is right that I am fortunate to have the doc I have. Minot authors the Candid Psychiatrist website and has several interesting posts there--for example, one discussing psychiatrists as enforcers of the social order as opposed to being doctors per se.
Anyway, I've not encountered this much honesty in the psych world this side of Loren Mosher and David Healy in ages and it was refreshing to hear a psych doc call BS on the huge expansion of the classification of bipolar disorder. This is an expansion of the disorder that continues today what with the new DSM-V on the horizon and much talk in psych circles of expanding bipolar disorder even further into a very soft bipolar disorder type 3 and the creation of an official child bipolar disorder in the DSM. I've written about my frustrations with the so-called subthreshold bipolar disorder here. I've written about the bipolar child paradigm so much that I won't bother linking to any one piece.
In fact, I'll make a prediction: when the DSM-V comes out it will contain a BP3 and a child bipolar disorder. I've talked to some in the psych research world who are utterly convinced that this will happen and that it will help people. I think these moves are twin disasters, but that's my opinion.
As I noted last May:
"If this strikes you as unimportant, perhaps you don't understand how all the dots connect around bipolar disorder the last few years. Zyprexa, Rebecca Riley, the bipolar child controversy, Seroquel declared the bipolar pill, class action lawsuits, multi-billion dollar settlements, researchers cooking research, black box warnings, calls for more outpatient commitment and so on. All of those bits connect with bipolar disorder in our culture and are evidence of the weaknesses--and dangers--of current treatment paradigms for bipolar disorder. And yet we have researchers, one cabinet level department (HHS), two private foundations and many pharmaceutical companies who would like to double or triple the number of Americans who must be convinced they have bipolar disorder, be instructed that it is a lifetime illness and be pressured to take medications that have a less than 50 percent chance of doing much for you and anywhere from a 30 percent to 50 percent chance of causing you an injury (I'm done with sugar coating it by calling injuries "side effects"). Forget about the usual criticism that this is all a naked land grab by pharma companies and researchers looking to line their pockets."It's darker than that. What we've got going on here is the norming of America--a big happy party wherein Americans are forced to have their behaviors, thoughts, impulses and expressions grouped around a carefully-controlled norm."
Which brings me to Minot's point of just how wildly expansive definitions of bipolar disorder have become. I cannot offer you quite the comprehensive overview of how manic-depression--aka bipolar disorder--had softened pre-DSM-IV (1994) that I'd like to. My understanding is that what we now call bipolar disorder was well understood in the medical literature going back to the 1800s (and further of course to the Greeks) and all the way through DSM-III (in effect from 1980 to 1994) had as its central underpinning that a patient had to be wildly out of touch with reality (ie, delusional) and manic off their butts for an entire week in order for a diagnosis to be made. That changed in 1994 with the introduction of bipolar disorder type 2, which allowed for a diagnosis to be made when only hypomanic symptoms were present (there was no change to the requirements for depressive symptoms as I recall).
I was diagnosed under the DSM-III (technically, DSM-III-R after 1987) in 1989. As I recall, I was not manic off my butt, but instead was dealing with something that, in retrospect, smelled more like BP2 than BP1. So how I ended up with a diagnosis of manic-depression (later to become bipolar disorder type 1) is a bit beyond me. I cannot account for this and it troubles me greatly because what if I were simply dealing with a mess of PTSD and impulse control problems, as Minot suggests, as opposed to a full-blown case of mania and depression? How would I explain the last two decades or so of my life to myself? How would I understand my future? How can I shake the label of bipolar disorder when the psychiatric profession refuses to undiagnose people who do well? How do I apologize to my body for all the years of psych meds?
It's because of questions such as these that linger 18 years later that I think the psychiatric profession needs to do a fair amount of soul searching when it comes to bipolar disorder. I doubt that too many researchers who shape the DSM and clinical research will bother. But i think this continual softening of bipolar disorder is out of line. Can the profession show replicated evidence of how BP3 (or SBD, as it's now called) patients have their lives dramatically improved by being diagnosed with the disorder and medicated? I'm not talking about these meaningless three-week studies that the industry favors (that's meaningful for talking about treating acute mania but not about much else in the context of bipolar disorder), but long-term naturalistic studies. I think we already know from the results of STEP-BD what the answers will be (hint: not really good). Absent positive real world evidence (as opposed to anecdote), why would docs continue to demand that bipolar disorder be expanded? Can some researcher delineate the impairment caused by BP3? Can they establish that this cannot be more effectively treated through therapy or by a short term course (ie, a few days) of benzos?
I also think the profession needs to be careful what it asks for when it comes to the bipolar child. The psych industry is fairly well divided on the question of whether the diagnosis even truly exists in kids (but the power centers at Harvard and Columbia think that it does), so it would seem appropriate that the writers of the DSM and the alleged key opinion leaders of psychiatry create a mechanism whereby someone diagnosed with child bipolar disorder at say five-years-old could later be undiagnosed at, say, 15-years-old. That seems like a sensible trade-off. It would also make sense to apply undiagnosing criteria to teen and adult flavors of the disorder, especially if the industry is going to push for this continual softening.
And, I think my own case ought to be a bit of a nudge to them as well. Because if their diagnostic criteria were as locked down and scientific as they claim then I wouldn't have so many questions and they would have far more answers that worked for large numbers of people. And I have questions.
What if I was basically just going through a bad patch of life with personality issues run amok? Must I pay for it forever? Why do doctors get to decide that I will never be well or never be redemmed? Isn't that my business and not theirs? It's my life after all, not theirs, and last time I checked I wasn't violating the social order in any way. So what gives?
Is bipolar disorder as cockeyed and ginned-up as Minot believes? Or are he and I utter fools?
I don't have an answer. Do you?
Not that anyone cares, but yesterday marked my six-month anniversary of going off-meds for bipolar disorder. After 18 years of taking meds consistently, my psychiatrist figured I might do well off-meds, so he suggested that I give it a whirl. So I have, since I've earned the right.
What's stunning to me is that I remain virtually without symptoms, even of depression--and that's just not supposed to be happening here, especially since I am under massive amounts of stress, personally and professionally. Not according to the medical literature I've read. The course for bipolars who go off-meds is supposed to be highly predictable--they wind up in big trouble and either die or spend time in a psych unit or what have you. And of course they wind up back on meds after wreaking havoc on the Western world. They never get better or do just fine off-meds.
But, then, maybe the unbiased researchers who write the medical literature never talk to or examine people like me. OK, I know they don't.
So what is going on here? Was I a bad diagnosis back in 1989? Did meds somehow cure me while messing me up at the same time? Did therapy cure me? (Um, no since I haven't seen a therapist since the early 1990s.) Did I cure me? Or does bipolar disorder just burn out over time? I am leaning towards the latter two possibilities, but I'm not sure how to explain this except to say that's what seems to be going on.
I just don't have any reference points to go on. Everyone from Kay Redfield Jamison on down says I am supposed to be a train wreck waiting to happen, but I'm not. That's both encouraging and disconcerting all at once.
On a positive note, I ran into a friend of mine last night who commented that I was finally losing weight in my face. He's gay and notices these things I guess, but he's right. Atypicals and meds in general really puffed my face up and it's been difficult to lose that puffiness. I'm glad it's ebbing away. Or at least that my friends think it is.
Thoughts?
I don't even know where to start with this one: on Jan. 11 a woman in Massachusetts walked into traffic on a freeway with her sister's two children in tow. They were run over by two cars and all three died. The case has been ruled a murder-suicide and while murder-suicide cases are always weird, this one is weirder than most.
The woman, named Michelle Thibault, was 39 years old and a mother of two. She had what one press account called a brief episode of mental illness last year. She didn't use drugs and went to church. Apparently, she was part of a large tight-knit family--not usually the spawning grounds for this sort of craziness.
Crazier still is that her sister is her twin. And why would she kill her sister's kids, but not her own? Even more, why would she kill anyone?
Some experts speculate that the act could've been spurred by weird family and twin-bonding issues, but I'm not sure I buy that.
This case has all sorts of questions and almost no answers, but I bet we'll hear more about it.
I need to catch you up with several interesting items I've run into over the last few days.
Intueri, a blog written by an actual psychiatrist, briefly reports of learning about an eight-month-old infant taking Zyprexa. Her post is tantalizingly slim on details, but one wonders what would cause a doc to place an infant on this drug.
Wired has a brief review of a book by a Yale psych doc, who argues that America is wildly over-medicated (someone from Yale argued this? Oh, wait till the kids at Skull & Bones find out), and that people need to set about reverse-engineering (e.g., hacking) their own psychological makeups. Gee, it's like I could've written it.
CL Psych slaughters the recent Risperdal for depression trial (told you it was bogus!) as does Health Care Renewal, which offers loving detail of the many, many conflicts of interest in its authorship. This nonsense that anti-psychotics are good for long-term depression treatment simply needs to be stopped.
John Grohol at Psych Central echoes my basic assertion the other day that complete symptom remission as a goal of depression treatment is a bridge too far.
A social service agency in Seattle is closing two of its homes for the mentally ill. This will put out about 100 people, King County has no idea how it will house these folks (there is no other housing, and hospitals are not an option), and I predict that some of these poor folks will end up on the street.
The kids over at Drug Wonks (or is that Drunk Wonks?) attempt to spin on behalf of Big Pharma's coverup of anti-depressant trials data.
A mentally-ill paraplegic man, who was dumped on the streets of Los Angeles last year by a hospital, sues the hospital for abuse. Good for him. It's one of the most appalling cases of mistreatment of the poor that I've heard of in this country in a long time, and his wasn't the only case in LA.
A psychiatrist declares Symbyax (the Zyprexa-Prozac combo pill) a "miracle pill." Unbelievable.
Gianni Kali continues her withdrawal from meds and is taking lots of vitamins, which seem to help.
Eli Lilly fired off a press release today, noting its objections to how it handled data in clinical trials of its anti-depressant Prozac. This all comes in response to the New York Times' coverage of the New England Journal of Medicine study of the other day which revealed that a number of negative studies for anti-depressants had gone unpublished, allowing manufacturers to make unjustifiably outsized claims about the effectiveness of their drugs. There's some coverage of Lilly's response here. And Lilly's press release is here.
Lilly claims:
"Not only was the Times' story inaccurate when it comes to Prozac -- the NEJM article didn't identify a single Prozac study as unpublished -- but it also likely created a strong false impression with readers that Lilly suppresses data."
Lilly is right that other drugs--Zoloft and Paxil among them--were more the beneficiaries of a false bounce than was Prozac, based upon the study, which I've previously written about here.
But as far as false impressions of data suppression go, I'm afraid it's Lilly using this moment to turn itself into something it wasn't until the very recent past. The press release notes:
"In December 2004, Lilly was widely recognized as the first pharmaceutical company to voluntarily launch a clinical trials registry, where we post the results of all Lilly sponsored registration clinical trials for all of our marketed products dating back to 1994, and all clinical trials for marketed products since December 2004."
Let's see: Prozac comes off-patent in 2001 and is no longer flashed before the public as in the 1990s when the company was repeatedly accused of hiding clinical trials data, accusations which I happen to believe are factual. Three years later in 2004, the company decides to become more transparent and then posts all the old studies to the web. It's nice that Lilly is playing catch-up, but that hardly absolves the company of its past behavior and the bad old days when Lilly suppressed data.
I'd say the company earned its reputation long ago.
Speaking of which, one of the charms of the Zyprexa documents is to read through them and listen to Lilly execs talk about how its sales force should never admit to a connection between cases of diabetes, explosive weight gain, hyperglycemia, pancreatitis and its star drug Zyprexa. Even more fun is when Japanese regulators slapped warning labels on the drug in 2002 and within months Lilly had its sales force in PCPs' office throughout America telling docs that the drug was safe as could be and should be pressed upon agitated women.
That's some nice transparency.
Bowing to reality, Pfizer today updated the label on its stop-smoking drug Chantix to reflect numerous reports of suicidal ideation, erratic behavior and depression associated with the drugs use. "Pfizer said Chantix users should be observed for 'serious neuropsychiatric symptoms, including changes in behavior, agitation, depressed mood, suicidal ideation and suicidal behavior,' according to MarketWatch. A company exec noted:
"'A causal association hasn't been established based on the data,' Ponni Subbiah, vice president of medical affairs at Pfizer, said in an interview. 'However, in some cases, an association could not be excluded.'"
Sounds pretty causal to me. In addition the company notes on its Chantix website that patients should tell their doctor of any previous mental health history before taking the drug. It was apparent from patient reports that some of those experiencing problems with Chantix had previously had a mental health diagnosis of some kind and reacted badly to anti-depressant treatment in the past.
Liz Spikol had an interesting post a couple of days ago, a reader letting her and others know that this year's NAMI National Convention will be held in Orlando, Fla. with all sort of opportunities to go to Disney World (the convention is usually held in Washington, D.C.). The convention is June 13 to June 16. Its theme is "Tomorrowland Today: Making Recovery Real."
Here's the program for the convention.
While I agree with NAMI's push on making recovery real and pressing for changes in how the mentally ill are treated in the criminal justice system, I really have to wonder how NAMI's general medication means recovery stance measures up against real world realities and studies that increasingly prove that Big Pharma--which funds NAMI National to the tune of about $6 million a year--has been lying every step of the way on how its drugs work and don't work for treating mental disorders. And, let's not forget about just how shattered and broken this nation's mental health system truly is, a subject I'll be taking up a bit more directly in the near future.
But, then, maybe there is some secret Tomorrowland NAMI hasn't let us in on yet.
One of Spikol's readers had his thoughts on NAMI's claims:
"Tomorrow has arrived!"'Improved treatments; new social supports for employment, housing, and a host of other services needed to sustain recovery; significant progress in the realm of criminal justice; widespread education efforts and a strong and vital consumer movement - these and other innovations are making possible what just a few years ago seemed unattainable for many persons will mental illness - recovery!'
"I guess I should go down to our county psychiatric hospital and tell the 300+ inpatients that they are no longer being discharged to the shelters but are actually being housed. Then I'll go over to the county jail and tell those on the psychiatric pods that they are receiving treatment beyond medication alone. Then I'll go stop by but one of our community mental health centers where eighty percent of the 2500 consumers in its outpatient division receive no treatment other than medication and tell them that that they are receiving improved treatments. Then I'll go down to the sheltered workshop which receives three hundred referrals a year yet but could only relate one individual's post program outcome and tell them that they are receiving new social supports for employment. Then I'll go national and call those who comprised the 34% increase in the number of individuals on SSI by virtue mental illness in the five years ending 2006 and tell them they might well be on the path to recovery. I guess I could but my peers and I have to live in the real world of Today Land."
Joe, I couldn't agree more. Although I know he's not describing Seattle's situation, he very well could be.
Fox News' Douglas Kennedy, who's been the lone national TV reporter going after the lies around SSRIs and other anti-depressants for several years, reports on yesterday's New England Journal of Medicine study reporting that pharma companies routinely left unpublished negative studies of SSRI efficacy, or twisted them into more positive studies. The effect was to boost the overall efficacy or effects sizes of the drugs artificially when their positive value against a placebo was on the order of 20 percent. I congratulate Kennedy and Fox News for staying on this story.
For the last few days, a video featuring Tom Cruise espousing his views on Scientology has been making the rounds of the 'Net and has been excerpted on TV as well. Problem is the video keeps getting yanked from YouTube. Now the nice folks at Gawker have gone and hosted it themselves. Like them, I consider the video newsworthy and here's a link to it.
Just a note to let you all know that I have been down with an awful cold/flu thing--basically a super bug I picked up at the shelter--for a few days. That's why I posted nothing yesterday. I feel better today, so I should be back to regular posts throughout the day. And, yes, I'll be answering those emails that have stacked up. Thanks for your patience.
An important study is out today in the New England Journal of Medicine pretty much confirming what many of us have been saying the 'Net for ages, which is that a whole slew of pharma companies hid data about negative results from anti-depressants from the public and doctors going all the way back to 1987. (Update: the full paper is now available on my site here.)
Press coverage of this study here and here, and CL Psych has a lengthy roundup of the news here. Companies could hide data because the FDA does not require that all clinical trials data that a company obtains on a drug be published or made publicly available. Some companies like Eli Lilly do now publish their data on a company website, but they only began the practice in 2004.
By mostly only publishing positive studies of anti-depressants (a few negative studies were published) companies were able to make inflated claims about the effects sizes of their drugs--i.e., how much a drug outperformed placebo. That's nice for them and their shareholders I'm sure, but it made it impossible for doctors and patients to evaluate just how good these drugs were or weren't. Perhaps just as important is that such non-publishing practices worked to coverup data on side effects from the drugs.
From the WSJ:
"A total of 74 studies involving a dozen antidepressants and 12,564 patients were registered with the FDA from 1987 through 2004. The FDA considered 38 of the studies to be positive. All but one of those studies was published, the researchers said."The other 36 were found to have negative or questionable results by the FDA. Most of those studies -- 22 out of 36 -- weren't published, the researchers found. Of the 14 that were published, the researchers said at least 11 of those studies mischaracterized the results and presented a negative study as positive."
What drugs were involved, you ask? Prozac, Paxil, Zoloft, Effexor, Cymbalta, Serzone, Remeron, Lexapro, Celexa, and Wellbutrin. In other words, pretty much every anti-depressant approved by the FDA since 1987.
By not publishing negative findings or by misrepresenting them, Zoloft's effects size was overstated by 64 percent and Paxil's was overstated by 40 percent, according to the study.
On a personal level, this practice by Big Pharma and the FDA's complicity in the same really infuriates me. Back in 1993, I was taking Prozac and went to my doctor complaining of agitation. He said there was no data to support such a problem with the drug, so the problem must be mine alone. He upped my dose from 40 mgs. a day to 60 mgs. a day at which point I began acting oddly and had repeated suicidal ideations. I asked my doctor again what was up. He said he'd checked in with Lilly (meaning the sales rep, of course) and was told that there were no similar problems reported with the drug, so it was basically my fault. He upped my dose of Prozac to 80 mgs. and I went utterly manic and lost my job as a result. I know that I am far from the only person who experienced a similar dynamic on Prozac and got similar answers from their docs. Some people ended up dead as a result.
Is it too late for me to go back and sue Lilly's pants off? Probably. Is it too late to hold them accountable? Never.
I wasn't quite sure what to expect after posting on men, women and narcissism earlier today. It was weirdly liberating to get some things off my chest that needed to be off of there (and for you curious sorts, I was holding back), but I was concerned that I might alienate a good number of readers in the process, which wasn't my intent.
Anyway, what's occurred is that the post has been hit (meaning read) by several hundred people already, but, so far, there have only been three comments. I appreciate those. But the lack of comments sort of tells me that I stumbled onto something that people just don't know what to make of--and that's simply the oddest feeling in the world for a writer. Did I make people so mad they won't say anything? Did I write something so inane that there's nothing to be said? One wonders.
It's a feeling made doubly odd because I am still running a fever and have no choice but to go to work in two hours. Yes, I need the money that badly.
Since, I'm unofficially declaring today a liberation day of sorts, I'll tell you all that I deleted my MySpace and Facebook accounts a while ago. I'd been on MySpace for three-and-a-half years, but it sure doesn't hold whatever charms it once did for me anymore, and Facebook never really caught my fancy. I think both sites are pretty much useless hubs for predators of kids and women, and places where people go to gush about their latest vacation or affair or whatever. That's what the Web 2.0 has given us? Awesome, dude.
It'll be interesting to see how many of my alleged friends even figure out that I'm gone and how many even know how to get a hold of me through other means. I bet it's two.
Kind of like with today's posting, I am doing a good job of leaving people speechless.
I'll be back to a vaguely normal posting cycle tomorrow, flu or cold willing.
I know I am going to anger a lot of my readers by writing this, but sometimes things have just got to be said. So here goes.
Richard Friedman, a Cornell psychiatrist, pens one of those weird opinion pieces that the New York Times runs from time to time in its Health section. I think these pieces are supposed to pass for a blend of commentary on the human condition and medical advice all at once. Not sure what you'd call the form.
Anyhow, today Friedman takes up the yawningly familiar subject of the midlife crisis, pointing out that perhaps there is nothing natural at all about the dynamic and pegging it as a convenient excuse for misbehavior. He writes of two men in their 40s, both accomplished who both ditched their wives under the panic of a midlife crisis.
"[Y}ou have to admit that 'I’m having a midlife crisis' sounds a lot better than 'I’m a narcissistic jerk having a meltdown.'"
The guys do smell like narcissistic jerks in Friedman's telling, but what stopped me in my tracks wasn't that the doctor blamed "our youth-obsessed culture" for this dynamic, but that he only singled out men for criticism.
Does Friedman not have any insight into how disastrously and selfishly women behave in relationships? Has he never seen women unaccountably walk from an LTR to pursue a flavor of the month and try to somehow recapture something they feared they'd lost in the process of having a normal relationship (the one they'd presumably wanted at some point)? Has he never read of women lying about who they are and what they want out of life in order to tie a man down only to do an about face once the relationship gets comfortable? Are men always the culprits in the easy mythology of sex, relationship and gender as told to America in the pages of the Times or on "Oprah?"
The reason I ask is that, in recent months, I have watched as women in LTRs with men I know have ended or sabotaged relationships because of the same loose dynamic as what Friedman calls a mythic midlife crisis. I'm talking grown women behaving narcissistically here. In one case, I know a woman whose partner has been raising her daughter from a previous marriage for five years, has been paying the rent and so on the whole time. Now, the woman is doing everything she can do to force him out of the relationship because she's apparently bored. Wow, there's some gratitude.
The others involving friends I won't get into because they are too Seattle-centric and could result in a permanent downgrading of my social status in town (modest as it is already).
But here's a recent example from my own life, offered with much trepidation. This woman I know and I had always had an attraction for one another over several years. Thing was she was in an LTR and when she made a pass at me one evening at a social engagement a few years ago, I made it clear to her that I don't mess around with other men's girlfriends. Bad karma and honor and all that. The guy she was in a relationship with was a classic narcissistic jerk of the musician variety (women always seem to tolerate musician jerks more than other jerks, I've noticed, except wealthy jerks, of course) and pretty much everyone who knew the pair felt she deserved far better.
So a year or so ago, the guy starts cheating on her and she catches him and kicks him out of the house. They'd had an open relationship in the past but at that point it was supposed to be closed. She waits six months and officially ends the relationship. Not long after she and I go out for drinks, a friendly get-together (not a date) and wind up later at my apartment. It's obvious she's damn interested in me and I am in her, but I've gotten a bit timid about the headlong rush into affairs and dating and such over the years (too many awful experiences and misjudged characters and wasted money), so I take things carefully and leave her to pass out on my couch (she was drunk and so was I). In the morning, we agree to get together over the weekend. The weekend comes and I call (and call) but she won't answer her phone or return messages. Monday comes and I decide to shoot her an email.
She answers the email that Monday night. Turns out she'd spent the entire weekend all bummed out and locked up in her house (so typically Seattle that I cannot get into it), and now she was on the road at a business conference. "Ah, didn't know about that," I write back. "Have fun."
She replies that she will and, in fact, since it's 11 p.m. she's going to go to a liquor store, buy a fifth of vodka and drag whatever guy she can find from the conference in the hotel bar back up to her room and fuck the beejesus out of them. I figure she's kidding, so I email her back: "Funny joke."
She emails me back that it's no joke and indeed she's been doing this kind of thing at out-of-town conferences for years, sometimes behind her ex's back, sometimes not. She's an attractive woman and I guess she can get away with it, although in her email she whines that she's just hit 40 and isn't feeling very attractive and men don't understand her and support her and so on. In other words, complete narcissism, midlife crisis BS. She writes that she hopes I understand. The subtext of her messages was: While I'm getting laid on the road, I want you to be ready for me when I get back to town and we can have some fun.
I quickly write her back that not only do I not understand, but that I don't want her contacting me ever again. Seriously. I cut her off just like that because why would I even remotely be interested in having such a manipulative character in my intimate life (believe me, I knew none of this about her before). Over the next three days she writes me several emails claiming that she now feels guilty and begging me to be friends with her again.
I don't even bother replying because there is nothing to say, except that women in my generation (that'd be Gen X, more or less) have turned out to be an epic disappointment from where I sit. I'm a long way from being a member of the Tom Leykis women hating/abusing club (I had to listen to his show once for an assignment. Dumbest show ever), but I've really found that I've had to back the hell off from the dating world the last two years because it is a disaster out there and, in my opinion, there are some very damaged women running about who think they own men. And this isn't even remotely the fault of men, as some feminist theory and the Dr. Friedmans of the world would lead you to believe.
They don't own this cowboy.
Two years ago, I ran into a woman I'd gone out with a few times while walking in the neighborhood one afternoon. I was very interested in her. Anyway, we're talking and she hits me up with the proverbial, "Can I tell you something?" When those words come out of a woman's mouth, they either spell ecstasy or doom for the guy on the other end of the conversation.
"Sure," I answer, already sensing that it wasn't going to be the ecstasy version.
"Look, I'll just be honest," she says. "I'm not interested in you romantically or sexually. Can we just be friends?"
"Ummmmm," I say, fishing for an answer. "You don't want to date me?"
"Right," she says.
"You don't want to have sex with me?"
"Right."
"Do you have any single friends you plan to hook me up with?"
"No, I don't. I'm sorry."
"Then your utility to me as a friend is extremely limited."
I knew how things would play out had I decided to be "friends." There would be a string of irregular meetings for coffee and drinks and such where she would sit there and cry to me about how whomever she was dating or fucking at the moment was an idiot, and I'd be expected to do the friendly thing and just sit there and take it. I've been there before, and didn't like it. So I just walked off, knowing full well that what I'd just said and done was likely very narcissistic (I'm sure Friedman and Oprah would say so), but if knowing what one wants out of another human is narcissism, then I plead guilty. Hell, I'm 45-years-old, as midlife as it gets, so perhaps I am entitled.
I could offer many, many more examples of women being idiots in relationships, and in the even-dicier pre-relationship period. But my main point here isn't that women are bad or evil or whatever, it's that they are as big a disappointment to men as men are to women.
And from what I understand of human psychology and the DSM, they are just as narcissistic.
Back to you Dr. Friedman.
The excellent Spiritual Recovery (connected to the Spiritual Emergency blog) has a lengthy post about the ugly question of censorship on mental health websites. Especially on forums, one would assume free thought can reign, but apparently that's not the case over at schizophrenia.com.
What SR ran into was that when they authored posts pointing to other theories of schizophrenia and so on was that they wound up with her posts edited by the moderator. You can read all the ins and outs of what happened here. I congratulate SR for calling them on their BS.
My own view of these things is that schizophrenia.com is a private entity, so the owners can do whatever the heck they want with posts, but they do need to be upfront about their policies and unwillingness to hear challenges to the standard orthodoxy on schizophrenia. Given how well that orthodoxy is working, I cannot understand why they would censor someone like SR whose thoughts are almost always reasonable and well articulated. Why wouldn't they want a multitude of views?
Do others have stories of similar experiences on other sites?
Anyway, my own policy here is that people can pretty much say whatever they want as long as they don't hector someone about their life or psychological condition. That's worked well enough that in almost two-and-a-half years, I have only had to ban two commenters. I don't care if people agree with me or other readers, they are welcome to their own thoughts and opinions.
So keep those comments coming.
There was an essay in the New York Times yesterday, written by Terri Cheney who apparently writes the "Modern Love" column for the paper. Cheney has a book on the way called Manic: A Memoir which means it's time for the interest-building advance essay in the Times. Cheney was a high school valedictorian who graduated from Vassar and went onto to become a big shot entertainment lawyer in LA. Also, she has bipolar disorder and apparently things weren't going so swell for her.
"I didn't tell anyone that I was going to Santa Fe to kill myself," she writes in the book, as noted on the publisher's website.
Santa Fe? How prosperous, how Los Angeles, how book worthy. OK, my usual snideness aside, Cheney's essay talks about rapid cycling bipolar disorder in terms of trying to have a romantic life--basically writing checks in her hypomanic self that her depressed self wouldn't let her cash. But there's hope. She ought to be on "Oprah" within days of her book's release.
"That was five years ago--five long years of ups and downs, of searching for just the right doctor and just the right dose. I’ve finally accepted that there is no cure for the chemical imbalance in my brain, any more than there is a cure for love. But there’s a little yellow pill I’m very fond of, and a pale blue one, and some pretty pink capsules, and a handful of other colors that have turned my life around. Under their influence, I’m a different person yet again, neither Madame Bovary nor Hester Prynne, but someone in between. I have moods, but they don’t send me spinning into an alternate persona."
Oh, please. Cure for love being a metaphor for a cure for bipolar disorder? That's nice and meaningless.
I'm always a bit concerned when I read these kind of first-person accounts because I think they give a very skewed message of what bipolar disorder is, how it is experienced and how one successfully grapples with it. It's all a big "I am really a fucking mess, look at how messed up I am and all the things I do that are abnormal, look at me, and I'm really, really smart and went to a top school, but I'm really confused about myself and am going nuts all over the place, look at me!, and all I needed to fix things are a whole bunch of pills. Look at me!" I'm exaggerating, of course, but ever since Prozac Nation (or is it Patty Duke?) there has been a long string of these types of memoirs. I know they make for good copy and publishers love publishing them and people like reading them, so on a certain level, whatever. Most of them are written by women (at least the ones I am familiar with mostly are) and that likely skews things in ways I don't care for either and a lot of them are written by Ivy League/Seven Sisters types. Nice and representative of America.
The trouble is they and the experiences they describe are not representative of bipolar disorder as a whole. For everyone who is taken apart by the disorder--or allows themselves to be taken apart--and surrenders to the wildness of it ("Let's go spend $100,000 we don't have"), there are many more people who actively work to make their lives better. Their stories never get told. I guess there's not enough sex and elitist preening in these humans for book publishers. So much for a free market of ideas.
By there is apparently a whole new set of bipolar and depression books just hitting store shelves. All of them written by women. Pardon me, but are agents and publishers having a hard time understanding that these two disorders affect men as well and that men also buy books? Anyway, here's a rundown on those books in the UK, including an obligatory advance essay by the author of one of the books. Why depression is described as a "new" plague facing women is beyond me. What's new about women and depression, or suicide and men for that matter?
The Cheney essay includes the almost-always obligatory bowing to the chemical imbalance theory. I should think that most editors at the Times are well aware by now that that theory is hardly rock solid science (I assume they read their own newspaper), so why don't they call writers on this sort of thing since the writer could never offer proof that their ills are driving by chemical imbalances? Beats the hell out of me. It's opinion and opinion is fine but it should be explained as such.
That said, I don't want to throw too many rocks at the author. They are entitled to their own explanations of things and to explain what's worked for them. They are not entitled to assume that what's worked for them will work for everyone else. That would be crazy.
In recent weeks, I've really had mental disorders and how widely varied are individual responses to standard treatments shoved into my face. But much of what I have encountered at the shelter has confirmed what I've known for a long time: some people who genuinely have schizophrenia, depression and bipolar disorder (these are fairly clear cut clinical cases) have it to completely different degrees, and for some of them meds are a very good answer while for others meds either don't work at all or are toxic to their bodies. By toxic I mean that the meds cannot be tolerated by the patients' bodies and as a result they cannot take meds consistently. I've spoken with several clients at the shelter who've been on a host of different meds and their response is virtually the same across all meds. That's frustrating as hell for them of course. These things are supposed to work, doctors press them to take them because they will work, the system makes them available to them because they will work, so they take them and they get sick and can't take them anymore.
I understood this dynamic before working at the shelter, but working there it is truly a visceral experience in a way that I wish more doctors and researchers would experience. I know they see it on the ER and psych unit end of things, but by then things are very out of control and the texture of what's going on day-to-day is lost.
I think that's led to the silly tautology bandied about by Fuller Torrey, his Treatment Advocacy Center and others in mental health circles that goes like this: the patient has a serious mental disorder; the patient must take meds at high doses to cure this disorder or the disorder will get worse; the patient doesn't take their meds because they claim that they make them sick or the patient is in denial about having a disorder; let's give this dynamic a fancy Greek name so it'll sound authoritative and scientific; we'll call it "agnosia"; these patients just don't know how beneficial treatment with meds is; they must be forced into taking meds because we know and they don't.
If only it were so simple in the real world.
As it is, I was at a small dinner party the other night and met the 70-something mother of a 40-something man with schizophrenia. She very much fit the NAMI parent model, which is fine, and was very happy that her son was on Risperdal Consta (that's the long-acting injectable). But, as we talked, it became apparent that she's quite honest about the state of the art in treating schizophrenia.
"I've always heard that the meds work for one-third of them, that for one-third the meds don't work at all, and that for another one-third they don't need the meds at all," she said. Remember she was talking about schizophrenia.
I have no idea how accurate those numbers might be, but I think they give a sense of just how wide open things are out there. I also sense that you could apply the same proportions to patients with bipolar disorder and depression. Meaning that fully two-thirds of people with these disorders either have horrible responses to standard treatments or don't need them in the first place. That's a lot of people, the majority of those diagnosed with mental illnesses. That's kind of important and yet the realities around how mental disorders affect people and are treated in various patients and the wild variations in how people respond or are killed by treatments simply are not addressed.
And that's why I get so damn frustrated by essays such as Cheney's. They get published in an important place and are assumed to speak for one and all, becoming the public proxies of how we all experience mental disorders and alleged mental disorders. But the world isn't flat like that.
It's round.
A friend of mine happened to be in town last night, so I was tied up with that. As a result, nothing original from me today.
Sadly, Stephany from Soulful Sepulcher's father was killed yesterday in a private plane crash in California. You can offer your condolences here.
CL Psych points out that the "Frontline" piece on the bipolar child paradigm once again trotted out false claims about SSRI prescription rates and suicides.
John Grohol at Psych Central goes after the use of anti-psychotics in our culture and how they impede relationships between human beings. And in a piece that was linked to by the New York Times, Grohol questions why anyone would lie to their therapist.
Gianna Kali continues to wrestle with withdrawing from meds. I continue to wish here luck.
I have an interview this afternoon which I must prepare for, so I'll be back to regular posting on Monday. Have a nice weekend.
There are problems with the commenting system on this site right now, as a result of an earlier glitch on my server. I am working with my hosting company to resolve this ASAP.
UPDATE: Looks like it all got fixed and things are back to normal.
There was a fascinating exchange of letters in this month's American Journal of Psychiatry concerning just how much depression doctors should accept in their patients and the implications of such decisions. What prompted the initial letter was the federally-funded STAR-D trial, which showed that current depression treatments--including some psychotherapies--are no where near as robust as doctors (and presumably patients) would like. What the trial showed, in short, was that various anti-depressants had anywhere from an 8 percent to 30 percent chance of success in remitting symptoms of depression.
That leaves a large subset of people who do not get relief using current therapies and that raises a host of practical issues for the mental health field. This situation affects millions of Americans.
Two other practical issue before I get to those: Both letter writers accept that STAR-D trialed drugs and therapies produced remission in 67 percent of people in the trial. That is wrong for two reasons: one, each arm of the trial was a discrete experiment, having no impact statistically on subsequent arms of STAR-D and to engage in additive probabilities the way these academics are is embarrassing. Two, the STAR-D trial, though the first long-term, real-world, independent study of depression treatment in this country, was still only a measure of how well people did in a snapshot in time. For instance, of the approximately 30 percent of people who took Celexa in the trial's first step and achieved remission of symptoms we have no idea how they are doing now, well after their comparatively short trial. Remission is hardly a static state because depression is simply too episodic a disorder. You can have no depressive symptoms for two years, say, on or off-meds and then suddenly have symptoms reappear later.
Those caveats aside, several psych researchers at Brown University wrote the AJP to offer commentary on an editorial by John Rush of the University of Texas. Rush's editorial on the STAR-D results appeared in the AJP last February. You can read it here.
What the researchers at Brown had issues with was the insistence of Rush and others that complete symptom remission is the appropriate goal of treatment. "It is not clear, however, that this recommendation is in the best interest of our patients," they write in their letter.
I've noted previously how obsessed the psych world is with complete symptom remission i