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 in all forms of mental illness and how useless such a goal is for patients. Yes, it's a laudable public health goal, but within the limits of current technologies and practices does not seem to be achievable for many patients. If complete symptom remission is your polestar, then that could spell all sorts of practical problems for patients, as I noted two years ago:
"I think there's a certain power to be gained from the admission that complete symptom remission is a false god and that what we really ought to be doing is getting symptom remission where we can and letting people live where we cannot instead of pounding them to death with meds and wasting billions in the process."
The trouble is that many psych docs have gotten in the habit of reasoning that if Prozac doesn't work, for example, and a patient doesn't have symptom remission on Celexa, then they need to put the patient on multiple anti-depressants (the argument goes that if you bomb the brain's serotonin receptors from slightly different "angles" then you'll cover the problem) or perhaps an anti-psychotic plus an anti-depressant (ick).
That's part of what the Brown researchers pick up on in their letter:
"Advocating for 'more complex regimens' even earlier in the treatment algorithm may cause more harm than good. Very few studies have assessed either the safety or the effectiveness of complex polypharmacy trials. Polypharmacy increases the likelihood of side effects, drug interactions, cost increases, and noncompliance. Polypharmacy, nonetheless, is becoming more commonly used in routine clinical practice, presumably in part because of the setting of remission as the goal of treatment. Focusing too much on symptom remission in treatment-resistant patients may aggravate an already difficult-to-manage illness. Patients may feel even more discouraged if they do not respond to complex treatment trials. Such discouragement may lead to noncompliance with treatment. The STAR*D trials reported substantial rates of attrition despite the extra staffing, attention, patient education, and free care usually associated with clinical trials."
Not only is the practice of polypharmacy a concern for the researchers, so is the idea that all symptoms must be remitted:
"There is ample evidence to show that patients who continue to experience residual symptoms of depression are at higher risk for multiple adverse outcomes. Such findings are used to justify the push for remission. The correlation of adverse outcomes with residual symptoms, however, does not prove causation. Persistence of depressive symptoms in spite of optimal treatment may be an indicator rather than a cause of a form of depression that is not likely to respond to treatments currently available. The idea that there are some patients with a form of depression that is not responsive to available treatments is consistent with our current nosology, which groups together many different types of depression."
I think it's safe to conclude that there are forms of bipolar disorder and schizophrenia, for example, that are unremittable and where doctors have got to start asking themselves why pound the patient to death with meds when we ought to be asking how they can live decent lives with what they've got. Those are perhaps trickier questions with those two disorders, but I'm sure most of you know what I am getting at.
What's deeply ironic about this challenge coming from researchers at Brown University is that the school is also home to Peter Kramer, the bestselling author of Listening to Prozac and Against Depression who is very much of the full symptom remission crowd. As the Brown researchers note, eschewing polypharmacy and complete symptom remission creates an obvious question:
"What should be the goals of antidepressant treatment? One goal should be to achieve the greatest symptomatic relief possible, with the recognition and acknowledgment that this may not mean remission for a significant minority of depressed patients. For these patients, in particular, more attainable goals may be to improve their quality of life and psychosocial functioning in spite of persisting depressive symptoms."There are ways to help patients manage their persistent illness more effectively. Disease-management programs for chronic and remitting/relapsing illnesses are available that help patients focus on improving their psychosocial functioning and quality of life in the face of persisting symptoms. Pharmacologic treatment and disease management are not mutually exclusive. Ongoing medication and psychosocial treatment trials should be pursued concurrently in order to engender hope, since some patients may benefit over time or take longer to achieve remission. Clinicians should also feel comfortable, however, to address with patients the reality that they are suffering from a chronic illness. We can do a great deal of good by facilitating more effective coping strategies rather than promising something that we cannot deliver."
While I'm not sure what role meds should have in what I'll call unremittable depression (I think that choice best rests with the patient), I admire the honesty of the researchers and their practicality. I'm not so sure I buy their argument that doctors have a huge role to play in helping patients achieve a reasonable level of psychosocial functioning. Isn't that what social workers and counselors are for? Isn't it something for the individual to work out on their own?
Quibbles aside, I think the initial letter opens up a huge can of worms for doctors who treat depression. Into the breach steps John Rush with his reply.
"Since STAR*D did not evaluate all available treatments for depression, we cannot conclude that the 33% who did not reach remission after four treatment steps would not have benefited from other medications, psychotherapies, or somatic treatments."
Oh, really? The differences between Celexa and Lexapro, for example, are so slim as to be almost meaningless, as they are between many SSRIs. Rush's bit of posturing is scientifically correct but in the real world is nonsense. So is another assertion of his.
"[T]he decision to scale back the goals of treatment to less than remission seems unwise until at least four treatment attempts. On the other hand, some patients may well be unable to reach and sustain remission. Clinicians must decide when to no longer pursue remission as the goal of treatment by making further treatment changes. However, patients who partially benefit from medication may further improve their well-being and quality of life when psychosocial interventions or other rehabilitative efforts are put in place. On the other hand, given the undisputed advantage of remission, both functionally and prognostically continued efforts may well be worthwhile in selected patients. The decision to switch from remission to improved quality of life should be a collaborative one between patient and doctor."
It's nice of Rush to admit that there are people who may have unremittable depression and that alternative strategies may be required. But why the emphasis on doctors--and by doctors Rush means psychiatrists--deciding when treatment has failed? Whose bodies and lives are we talking about here anyway? Who appointed doctors emperors of our lives and souls and depressions? No one. Would you trust someone to tell you how to live your life psychosocially whose offers of treatment have already proven to miserable failures? Not if you are smart.
Rush concludes his reply thus:
"Whether "more complex regimens" (i.e., medication combinations) are more burdensome, risky, or effective is an empirical question that deserves study. Many psychiatrists now use combination medications, but few controlled trials have actually evaluated this practice. Some studies do suggest better efficacy and little additional side-effect burden for selected combinations. Whole sale polypharmacy is not to be recommended. Carefully conducted randomized trials pitting monotherapy against drug combinations are needed to directly assess whether both acute and longer-term outcomes can be enhanced without undue patient burden."
Nice that he doesn't support wholesale polypharmacy, but his insistence upon further empirical trials to investigate medication combinations is a bit silly. We already have plenty of real world evidence that such polypharmacy is fraught with risk and offers few results.
I'm glad to see that some researchers are willing to be honest about the practical problems faced by a significant group of patients with depression. However, that does leave a big question on the table: how much depression is acceptable for a patient? Is there a scale that can properly measure this? Does one simply not shoot for as low a result on the Ham-D scale, for example?
I can't speak to how you'd measure such a thing scientifically, but then I find most of the depression rating scales unreliable to begin with. What I do know is that this is another instance where doctors ought to begin listening very closely to their patients instead of arrogantly assuming that all symptoms must be destroyed. I don't think the latter approach is healthy for real people who are the ones who should be making these real decisions.
The trouble is that I fear whatever answers might be hammered out to this question will be driven not by science or patient input, but by the same politics and power dynamics that have always won arguments about mental health treatment in the past. And that means the pharma companies and doctors will be in charge and patting one another on the back at the end of the day because, at bottom, they know they don't have to listen to patients and consumers because we have so little power. They'll find a way to tip their hats to the notion that we should have some input and then find a way to undercut our interests because doctors are simply so much smarter and more well-intentioned than the rest of mankind. So are drug companies.
Can't you tell? That's why current depression treatments are working so well already.
Bruce Levine, a clinical psychologist, has a fascinating piece on Alternet examining the the hypocrisy around which drugs are legal and illegal in our culture. The short story is that people go to jail or are pushed onto the streets for using drugs deemed illegal in America while tens of millions of Americans take drugs that are legal to create analogous feelings of no depression but which are in some ways just as destructive as the illegal drugs and have the same basic mechanism of action.
The differences between cocaine, meth and ADHD drugs in effect, mechanism and so on is not that great. Neither are the differences that great between Paxil, an SSRI anti-depressant, and marijuana--at least in why people seek out the drugs, regardless of whether they are getting said drugs from a pharmacy or a drug dealer. What's frustrating when you consider it is that Paxil is perfectly legal and pot is largely illegal and responsible for about 700,000 prison sentences a year in this country. Yet from 1998 to 2005, Paxil is linked to the deaths of 850 Americans while pot is linked to the deaths of no one. As far as I know, no one has gone to jail for Paxil use.
Everyone is going to have a slightly different set of reasons for why this this situation persists--racism, religion, law enforcement bias, cultural blindness, etc. Those are all legit in my book. But the larger core issue is along the lines of what Levine gets at: major corporations make billions of dollars off of legal drugs but would make much less money from what are currently illegal drugs (unless Lilly reformulated pot as a long-acting injection!) because they are mostly natural compounds and therefore unpatentable. The media is largely silent about this hypocrisy because it would be attacking the source of billions a year in advertising revenue, and so the song remains the same.
As Levine puts it:
"The illegal-psychiatric drug hypocrisy in the U.S. is an ugly triumph. It is a triumph of marketing over science. It is a triumph for pharmaceutical corporations and America's ever-growing prison-industrial complex. It is a triumph for those comfortably atop society who would rather Americans view their malaise as exclusively a medical rather than a social problem. And ultimately, it is a triumph of injustice and greed over human rights and a sane society."
I am certainly no defender of cocaine use (especially crack cocaine which makes some people crazier than powdered cocaine ever could), heroin and meth. At the shelter where I've been working, I see far too many examples of people who have been ripped apart by the use of these drugs and only have a small chance of ever getting their lives and health back. But to put them on the streets over it is far too big a price to force them to pay when they were largely taking these same drugs (well, at least initially) to address the same set of psychological ills for which people take legal drugs such as Prozac.
A week ago, I got an email from a reporter at the Washington Post asking about this site and we emailed back and forth a bit, and yesterday my site was featured in the paper's "Media Scan" column. You can read the blurb here, for which I thank the paper and the reporter more than I can get into.
I'll get back to more frequent posting than has been the pattern this week as soon I catch up on some sleep.
PBS' "Frontline" took on the controversies around the bipolar child paradigm and medicated children last night. I was at work and did not see the program, so I have no opinion of it. You can watch it online here. I'd do so myself but I worked until 11.30 p.m., had an awful shift at the shelter, and then had to deal with a whole crew of crack heads at a bus stop for 15 minutes before heading home. They harassed me and several other people at the stop and it was a rotten scene where I had to act tough when I was kind of freaked out. That's a long way of saying I'll have my own reaction to the show--assuming it merits one--up later today. I need to clear my head and unwind, and from what readers are already telling me, it sounds as though I'll need to be nice and calm when I watch the program.
Here's what you all are already saying about the program. If others want to email me their thoughts or leave them in comments, I'll add them to this thread. In addition, for those of you on the East Coast in particular, the producer of the "Frontline" piece will do a live chat on the Washington Post's website this morning at 11 a.m. EST. You can participate by going here. if you want to leave comments for the "Frontline" people, you can do it here.
Now to reader comments.
One reader commented:
"I watched the show. Am I over reacting to say it was a terrifying commercial for big pharma? I hope so. The evil premise was that even though these drugs cripple kids for life, and even though there are no diagnostic criteria for child bipolar, at least the children aren't "moody" any more. And of course the show pulled out the bogus study indicating that after the black box warning on ssri's kid suicide rates increased when that study has been proven false. Carlat was on which was good. Chang discredited him unfortunately and there was no criticism of Chang's idea of treating kids with no symptoms, none."I feel so sorry for the poor abused children profiled on the show all of whom have parents who plan to keep on drugging them. Atrocious...someone tell me this was good in some way, I had been hopeful."
Another's take:
"My take on it is not quite as pessimistic as the reader you've quoted above. I think the producer/investigator was and probably had to be rather subtle in her anti-drug and anti-psychiatry message to get it by the PBS "censors". Remember PBS has a lot of big pharma funding. Personally I thought she made a fool of Chang and some of the treating physicians she showed. Sure she didn't say it explicitly but the message was there. These guys were arrogantly and cavalierly playing with children's lives and had no idea what they were doing. I think that came across frankly pretty loud and clear. But then I am coming at it from my own very experienced background and it's possible that that wouldn't be the take home message if you were seeing it as a neophyte. One thing is obvious there is a rush to "pathologize" disruptive behavior and nowhere (in the show at least) was there any nod to how the parents or the circumstances (or the shocking diet in one case) of the poor kids' lives might be influencing their acting out. "
Another offered this:
"What people need to really hear that was said in that program, is that anti depressants were dropped in use by doctors via the blackbox warnings, and atypicals were replaced for use. This is what is happening now, with the use of Risperdal, Abilify, etc."The 2 boys shown in the program are quite alarming, one has permanent head and neck movements, which in my opinion look like a side effect from the Risperdal, and it's being called simply a tic.
"The young boy who sees Dr. Bacon has me the most alarmed, and I want to emphasize that one needs to watch the program and watch the doctor react to the mother/parents questioning of the medications their boy is taking after they watched the Rebecca Riley 60 minutes show. This doctor waved away any idea of therapy, due to him "not being able to get anything from it due to symptoms", and said the boy is 99% treatable with meds only.
"When that mom described the child's morning anxiety getting to school, the doctor said they could "get through the morning" or he could give him Xanax. Basically they left with an increase of other meds he was on, and defeated the purpose of the parents concern. When the doctor handed the mom a Trileptal rx, all he told them was to watch for nausea and sleeping all day.
"This is what happens in these appointments. The parents are basically trusting a doctor, and if you pay close attention to Dr.Bacon, you will see how it's meds on top of meds and more meds.
"I could see the mother's hesistant look on her face when she questioned the meds, and was glad to hear her decline the Xanax. When a person like her is in a doctor's office [and I mean this nicely]the doctor rules the roost. She clearly is learning from her gut instinct and I have a feeling she will get a little more pushy now.
"The fact that Dr. Joseph Biederman refuses all media interviews is an example of an evil axis, at work, and I feel the program exposed quite much about how we got into that evil pit.
"Dr. Carlat had one snippet that said, "You don't know who to trust.", and I believe he has that right, especially since he is in the process of repaying his "debt to society" for selling Effexor via speaking engagements, and now he's doing "counter" talks for free.
"What is alarming and what made me the most upset, due to being a parent who sat in doc offices from 1999 until present, was that the same ease of rx is being dosed out, TODAY, and to younger children, and now more and more anti psychotics are being used, it is an alarming situation.
"The reporter questioned the FDA spokesman regarding why there isn't a black box on antipsychotics, which are more dangerous in side effects than anti depressants, and he stated because all of the data is only about "demented elderly".
"Lack of data, doctors pushing pills to parents like they are aspirin. That mother had no information given to her about what Trileptal is, does or any side effects except for nausea and fatigue.
"If anyone was watching with a certain view point say, pharma, or parents drugging their kids, go watch it again and pay attention to Dr. Bacon, he is clearly riding the axis of evil."
Let's hear what the rest of you think.
Twenty years after the Prozac revolution took hold in America with all of its remarkable promises of cures for scientifically-determined mental health diagnoses through recalibrating human brain chemistry with drugs that offered few if any side effects, I am literally stunned at how divided people who care about these issues remain on basic issues such as the chemical imbalance theory of mental illness, diagnoses of conditions and the treatment of these conditions. That's bad news from where I sit because I view the evidence base as being so corrupted that it's not to be trusted and am puzzled that people keep aggressively defending its precepts.
But it's good news that people are obviously passionate about these issues, even where their critiques are largely off-base. Which is a long way of saying recent posts of mine have generated a lot of comments over on Daily Kos and have led to some readers over there dubbing me the equivalent of Tom Cruise and L. Ron Hubbard (but not Michel Foucault, I'm so hurt) while at this site some in the anti-psychiatry camp have styled me as a kind of frontman for psychiatry and pharmaceutical companies.
Most of the kicking and screaming has been over on Kos and if you are amused by such things, you read them here. Meanwhile, an anonymous reader from Australia chided me on this site for apparently being a pro-psychiatry ideologue.
"I suppose you are gonna censor my 'malicious comment' phil. Wake up to yourself phil. You're an ideologue for pseudoscience with a half baked commitment to human rights and safe drugs."
I almost never censor comments and approved his or hers and, then, left this comment of my own.
"and what's your commitment to schizophrenics who are homeless? when you get off your lazy ass and do some work on that front, i'll respect you. until then, stick in in your ear."
Oh, and my name is Philip, not Phil.
Of course, he's been back to comment since and call me out for being a bogus human rights activist. Seriously. You can read that bit of illogic here. He also claims schizophrenia doesn't exist. I wish that were true (that's not to say that all diagnoses of schizophrenia are accurate, or that the disorder is a lifelong affliction. I've seen enough cases that argue against that).
What amuses me greatly is that as I--and the critical neutrality I advocate--were being parsed on the 'Net, I was actually working my butt off at a homeless shelter. I've not written much about it because I'm not ready to.
Because where would you start?
Now, I have to start heading to work. I am picking up a shift that opened all of a sudden 'cuz I could sure use the money.
If anyone wants some fun, go on over to Daily Kos and check out the responses to my post on the PBS show on alleged bipolar disorder in kids. If you are a registered commenter there, comment away. Someone is implying that I am Tom Cruise. It goes from there. Remarkable given how measured I thought my posting was. You can find the thread here.
Anyway, sorry for the light load of posts today. I worked last night and am working a swing shift today, so I really cannot focus on writing to the degree I'd like/
OK, I will never be your Britney Spears HQ, but I should note that after her much-reported meltdown last week rumors are flying all over the place that the white trash pop star has bipolar disorder or is suffering from postpartum depression. She was apparently in a psych unit for 36 hours and was discharged--so she's not that crazy--and was visited by Dr. Phil and her family is apparently troubled by her early release. Spears went off and partied, so she's apparently in some level of denial.
What troubles me about the whole Spears saga is that she is hounded by the press. They follow her on motor scooters a la Princess Di and so on. You have to wonder if that's not going to contribute to a real life train wreck. But of course that's what the entertainment press--if you can call them the press--wants. Anna Nicole is dead. Bring us the head of Britney.
What troubles me further is that if she's genuinely bipolar, then she will become the face for the disorder in about two seconds, and will do a lot of damage to people with the disorder who lead decent, ordinary lives.
Just an advance note to let readers know that on Tuesday evening PBS' "Frontline" will take on the controversies around alleged bipolar disorder in children. Looks as though the show might be interesting to judge from PBS press release because the head of NIMH is tossing cold water on the bipolar child paradigm.
"'What’s not really clear is whether many of the kids who are called bipolar have anything that’s related to this very well-studied disorder in adults,' says Thomas Insel, the director of the National Institute for Mental Health. 'It’s not clear that people with that adult illness started with what we’re now calling bipolar in children. Nor is it clear that the kids who have this disorder are going to grow up to have what we used to call manic-depressive illness in adulthood.'"
But, of course, different researchers have different views, in one case clinging mightily to the unproven prevention model:
"'The theory is that if you get in early, before the first full mood episode, then perhaps we can delay the onset to full mania,' says Dr. Kiki Chang of Stanford University. 'And if that’s the case, perhaps finding the right medication early on can protect a brain so that these children never do progress to full bipolar disorder.'"
Clearly, there is a huge split in mental health circles over bipolar disorder in children. One side is very right, one side is very wrong. One hopes this gets sorted out soon.
Check your local listings for air times in your area.
Many of you know that the FDA's psychopharmacologic drugs advisory committee is set to hold a hearing on Lilly's pending application for its two-week to four-week injection of Zyprexa on Feb. 6. The deadline for public testimony that the advisory committee must consider is Jan. 10 for oral testimony and Jan. 18 for written testimony. Lilly is seeking approval for the drug's use in schizophrenia where you can bet the company will make a big marketing push to steer doctors to use it instead of the commonly-used (and off-patent) Haldol.
The hearing will be held in Silver Spring, MD. It is important that people let the committee know their thoughts on this drug. What I gather from some press coverage and general talk is that the committee is only concerned about somnolence caused by the drug. I haven't seen results from clinical trials for this formulation of Zyprexa, but knowing Lilly's pattern I'd expect that the trials were of fairly short duration, perhaps four weeks. It's kind of hard for side effects of this drug to show up in four weeks, aside from somnolence which would be there from the get-go.
You can sign up to testify or submit written testimony to the FDA at: diem.ngo@fda.hhs.gov.
I hope people who submit written comments and testify make note of Zyprexa's well-known safety problems, particualrly in long-term use. This new injectable (there's actually a shorter-acting one already on the market) would almost exclusively be used in patients for the long-term (i.e., well beyond the scope of clinical trials) who've been deemed non-compliant with treatment much as Haldol injections, and to a lesser degree Risperdal Consta, are used today.
I know the FDA is largely restricted to approving a drug based upon clinical trials data for basic efficacy and safety, but this time out I think they need to think outside their usual limits and ask some difficult questions about how this drug would be used and whether Lilly has any long-term data on its safety and efficacy in, say, one-year-long trials. If Lilly cannot offer long-term data, I hope the committee recommends that the FDA proper not approve the drug absent long-term data.
That strikes me as the only fair way to approach this situation.
You read that headline correctly. A study out in The Lancet today asserts that among a group of 86 non-psychotic patients with low IQs given either Risperdal, Haldol or a placebo to stem their irritability and aggressive outbursts placebo outperformed the two anti-psychotics. Although the study involved a group of patients for whom I don't know their particular DSM diagnosis, this is major news, perhaps heralding the end of the common use of anti-psychotics in Western culture.
First, it completely overlaps with the results of the CATIE study of anti-psychotic use in the elderly where placebo beat anti-psychotics, as I reported in November. Second, it speaks loud and clear to the status of kids, especially young boys, with ADHD and bipolar disorder who are being given anti-psychotics to control aggressive behavior. Third, it speaks to the use of these drugs in adults with bipolar disorder who are mostly being given these drugs to quell agitation. Fourth, it clearly has implications for the treatment of people with autism (Autism Vox takes up some of those questions here). Fifth, it has important implications for the emerging paradigm of treating depression with anti-psychotics.
The New York Times has the most extensive coverage of the study so far and clearly gets that the implications of this study are vast:
"'This is a very significant finding by some very prominent psychiatrists'--one that directly challenges the status quo, said Johnny L. Matson, a professor of psychology at Louisiana State University in Baton Rouge, co-author of an editorial with the study in the journal Lancet."While it is unclear how much the study by itself will alter prescribing habits, 'the message to doctors should be, think twice about prescribing, go with lower doses and monitor side effects very carefully,' Dr. Matson continued, adding:
“'Or just don’t do it. We know that behavioral treatments can work very well with many patients.'"
So why did the patients do better with a placebo?
"Being in the study, with all the extra attention it brought, was itself what apparently made the difference, he [a study author] said."'These people tend to get so little company normally,' Dr. Tyrer said. 'They’re neglected, they tend to be pushed into the background, and this extra attention has a much bigger effect on them that it would on a person of more normal intelligence level.'"
I'll have more thoughts on this study later, but let me be clear that its findings cannot necessarily be extrapolated to the treatment of psychosis. But the study authors dropped this bomb at the end of their article:
"Antipsychotic drugs should no longer be regarded as an acceptable routine treatment for aggressive challenging behaviour in people with intellectual disability."
Permit me a moment of gloating, please. For over two years, this site has been committed to seeing a sea change in the widespread use of anti-psychotics in our culture because it was clear to me that they didn't work very well in treating either psychosis or aggression. What's more, I wrote a lengthy article in Seattle Weekly two years ago in which I attacked the use of anti-psychotics in bipolar disorder and the stupidity of doctors in going along for the ride in creating a $14 billion market for these drugs. A lot of people have criticized me very aggressively for my views and have questioned my intellectual abilities and psychological stability in the process.
To them, I say: I was right. You were wrong. And the evidence of just how wrong you have been keeps mounting in study after study. If you wish to debate this matter further, then let's find a time and a place to do so. And soon. There are children and vulnerable people being doped on these drugs each day in America and elsewhere and they merit our attention.
For patients, I would recommend that you make your doctor aware of this study. If they fail to take its findings into account in your treatment, then you need to find another doctor.
A reader of this blog threw down a huge gauntlet before NAMI National a few weeks ago, sending a letter to the National office that called the organization on a lot of its rhetoric and ideology. His name is Steven Morgan and he runs the Vermont Recovery website. If anyone wishes to correspond with him directly they can do so by email at stevenmorganjr@gmail.com. I am reproducing his letter here with his permission. Let me know what you think in comments please. Morgan did receive some responses from NAMI, but I am not at liberty to share them right now.
I am writing this letter as a plea for reconciliation amongst those of us who have psychiatric diagnoses, those of us who issue them, those of us who have family members with them, and those of us who work toward related policies. As we are all aware, there are multiple tensions that exist amongst differing organizations within the mental health world, but I truly believe that if we can all begin to have a compassionate conversation, we will find a healthy common ground between our sometimes conflicting ideologies.
I specifically wish to address NAMI.
NAMI does good work throughout the country. They have power and use it to push for more awareness and treatment of psychiatric disorders. Indeed, NAMI has the constituency and funding to invoke a lot of positive change in our communities, providers, and legislators. I respect the work that they do, and see their passion as a measure of their enormous care of, frustration with, and optimism towards the mental health system in general.
So, it is with respect for their efforts that I wish to challenge some of the fundamental assumptions that they promote, specifically about what "mental illness" is, and how it is best treated. I hope that by speaking from my heart, my plea comes off as an invitation for more dialogue around these important issues that are sometimes taken for granted.
I want to start off by sharing something that I wrote the other night. I should state briefly that I am an individual who was diagnosed with severe and persistent mental illness, struggled for many years to emerge, and now am healed and work in the mental health world.
This is what I wrote when reflecting upon my relationship to diagnosis and the popular information floating around about "mental illness":
When I believed that a chemical imbalance drove my everyday experience, I told myself, "I am Bipolar." When I learned that the chemical imbalance was only a part of me, I told other people, "I have Bipolar." When I discovered that a chemical imbalance has nothing to do with me, I realized, "I am Human."
I share these words with you as an illustration of how insight shaped my own journey towards wholeness and healing. Being diagnosed had the residual effect of transforming how I relate to the world and my experiences.
In the beginning, I sorted through the various phases of my past and tossed them into clinical categories, and it all seemed to make sense. I also began to see my everyday emotions and thoughts as the product of a chemical imbalance in my brain. My sense of self became infused with a deep uncertainty, and because I was at a loss for why I did not seem to fit into the world, I absorbed all of the literature and psychiatric declarations that I was in fact Bipolar.
After a couple of years, I slowly graduated my thinking to: "I have Bipolar," which was a product of learning about the principles of recovery and truly embracing the notion that my "mental illness" is a part of me, not the whole me. At that point, I learned about "managing my illness," and as a result, came to believe that my chemical imbalance was in fact treatable – especially through medications – though highly volatile if left to its natural course.
Throughout this time, I was a voracious reader of mental health material, but I had never explored the actual scientific literature from which the material claimed to emanate, nor had I read many alternative perspectives on "mental illness."
Then, one day, things changed. I met a man who had been diagnosed with schizophrenia, but no longer took medications. Moreover, he worked full time in a very challenging position, and was sharp, compassionate, and full of humanity. Certainly, he did not seem to be experiencing "symptoms," and he didn't seem to be "in remission" either. He seemed healed.
As things go, I began meeting more and more people who had experienced profound suffering in their lives – been traumatized, diagnosed, hospitalized repeatedly, stigmatized, and on and on. But these people were well now. And not just "stabilized." But "well" in the sense of having emerged from a dark void with wisdom, clarity, and deep compassion; "well" in the sense of working long and hard hours altruistically. And again, they were not taking medications.
Slowly, I started to investigate some of my long-held assumptions, and slowly, I started to wake up to a different reality, one in which I started using terms like "experiences" instead of "symptoms"; "trauma" instead of "disease"; "problems" instead of "illness"; and "neuroplasticity" instead of "chemical imbalance".
In my inquiry into the scientific literature, I was shocked to find that many of the messages that I had received about "mental illness" were in fact highly presumptuous, and in some cases, driven by economics. For example, the notion of a "chemical imbalance" is suspect and misleading, and certainly not supported by reliable science. In fact, in this month's Scientific American Mind – a pop-culture psychology magazine – you can read, "The imbalance to which the SSRI ads refer is a deficit of the neurotransmitter serotonin at receptor sites in the brain. Such advertising is misleading, however, and does not reflect scientific findings. There is no clear scientific evidence that neurotransmitter deficits cause depression or that there is an optimal "balance" of neurotransmitter levels in the brain."
There may be a million people saying that mental illness is caused by a chemical imbalance in the brain, but that doesn't make it true. The truth is, in the scientific research, there has never actually been a chemical imbalance observed or measured. It is all inferred, and the inference is based upon a dangerous line of reasoning: "there is a form of circular reasoning that goes: if SSRIs are helpful in alleviating depression, and if they do change the "chemical imbalance," then depression must be caused by that imbalance. Inferring causality from the success of a treatment is frequently a flawed endeavor: aspirin is effective for headaches, but no one would seriously claim that headaches are caused by a deficiency of aspirin."
As my awareness expanded, I started rethinking the notion of "mental illness" as "chronic" and "persistent". Certainly, what is called bipolar disorder and schizophrenia can show up for many years, but if you look at the research, you will find that a majority of individuals in longitudinal studies are shown to significantly improve or recover entirely, and many without medications. How can "schizophrenia" be "chronic" and "persistent" when there are so many people out there who have emerged from it entirely? In fact, doesn't the evidence suggest just the opposite, that the chances are, you'll recover (and not just "recover" in the sense of "illness management," but in the sense of having a satisfying life without psychiatric experiences)?
The link to trauma in the development of "mental illness" is even more shocking, with some studies indicating that over 90% of people diagnosed with SPMI having had experienced trauma. If this is the case, can we really say that "mental illness" is "just like diabetes," as if it were all a physical flaw, and a permanent one at that? If trauma in fact triggers "mental illness" in the brain, wouldn't it be more appropriate to say that the illness and the disease are trauma, and that the symptoms of the disease are the plastic brain changes that we see? My point here is that popular messages about "mental illness" have stripped it of its context, thereby making it a brain error, when in fact, the brain is highly malleable, and could be thought of as reflecting experience as much as creating it.
What's most surprising in the scientific literature is that which surrounds the use of medication. Let me be clear in saying that medication can be helpful to individuals, and that some individuals attribute medication to saving their lives. But, there is plenty of evidence suggesting that medication should not be used by all people, and that with some people, it may actually hinder recovery. Thus, if we are to make any statement about medication, we should say that it is a tool that some people find useful, and that some people don't. In an ideal world, the scientific literature would inform psychiatric practice, meaning that just because someone shows up on the sofa with "symptoms" of a "severe and persistent mental illness" doesn't mean that s/he will be given medicine. But have you ever heard of a psychiatrist choosing not to administer medication to someone diagnosed with schizophrenia?
I no longer identify myself with Bipolar, though others still do, as I was recently rejected to a Meditation Retreat based upon my past psychiatric history and the "risk" that they assumed I pose. I am not in denial; nor am I in remission. Like all people, I cannot say where I will be emotionally in a year, but I do believe that I will be able to handle whatever happens, for I am now learning how to be fully human, not just the manager of my brain chemicals.
In terms of NAMI, I am concerned with some of their positions on "mental illness", which seem to be highly medical and follow a line of reasoning that medication is fundamental. As a brief example of such material, here are some statements from their handout on Bipolar Disorder that I find troubling (I have offered my counterpoint to each):
1. "The greatest risk in bipolar disorder is not getting treatment, or refusing treatment because of lack of insight into, or inability to resist, the lure of mania."
a. This is untrue for many of us. Many of us have actually been hurt by treatment, or experience great benefits from what is labeled "mania." I once made a 14-song album in a month and played every instrument on it during a period of "mania." The "lack of insight" declaration is arrogant and assumes that doctors know best, as opposed to allowing for people who actually have these experiences to define whether or not they value them. Also, many people "refuse treatment" because they find the treatment harmful, not because of "lack of insight" or the "inability to resist, the lure of mania".
2. "Bipolar disorder is a complex medical illness of the brain."
a. This statement strips "Bipolar disorder" from its context. Nothing happens in a vacuum, especially human experiences. The brain responds to the environment by literally changing shape, so that trauma actually physically alters the brain. If this is so, how can we call "Bipolar disorder" a "complex medical illness of the brain" as opposed to a reaction to trauma? Personally, I have found "Bipolar disorder" to be a "Spiritual Journey" more than anything else, and I know of many, many other individuals who share the same opinion. We would like our voices to be included in this ongoing dialogue, not to be told what we have or are, especially given the lack of scientific evidence.
3. "While no one knows the exact cause of bipolar disorder, most scientists believe that bipolar disorder is likely caused by multiple factors that interact with each other to produce a chemical imbalance affecting certain parts of the brain."
a. Again, the "chemical imbalance" theory is highly manipulative of the science we do have. Furthermore, much of the research into such theories is actually paid for and sponsored by the pharmaceutical companies, creating an obvious conflict of interest. It should be noted that an actual chemical imbalance has never been observed.
4. "Bipolar disorder is a chronic condition, much like diabetes. Because periods of remission are sometimes complete, but are often complicated by persistent symptoms, bipolar illness requires preventive maintenance treatment as well as acute treatment, ongoing medication management, and close monitoring during periods of remission."
a. "Bipolar disorder" is nothing like diabetes. For one, "Bipolar disorder" is often not chronic or "everyday", as scientific studies show again and again. Second, "Bipolar disorder" is a highly subjective experience that is culturally defined, whereas diabetes is pretty much agreed upon around the world as a disease and as unwanted. Third, "Bipolar disorder" does not require ongoing medication management, as many of us do not take medications and are clear and well.
5. "Your management plan should include attention to lifestyle, stress management, supports, and also medication options."
a. This statement says that my management plan "should" include medication options. No, it may include medication options. This statement should be followed with information about the number of people who do not respond to medications or who prefer not to take them to allow for the reader to understand that he or she does not have to take medications to be well.
6. "While medication is one key element in successful treatment of bipolar disorder, psychotherapy, support groups, and education about the illness are also essential components of the treatment process."
a. The first part of this statement, that medication is "one key element" in successful treatment, is again presumptuous and declarative that medications are essential.
7. "The most useful psychotherapies generally focus on understanding the illness, learning how to cope with it, and changing ineffective patterns of thinking or interacting."
a. This is untrue for many of us. I went through 9 months of therapy with a man who intentionally did not use the term "Bipolar," and with whom I learned to successfully re-transcribe my experiences into meaningful ones as opposed to chemical ones. In fact, I just heard a recent study presented during a SAMHSA teleconference that "Illness Insight" may actually be detrimental to recovery, in that it often leads to self-stigmatization, which was certainly the case for me.
8. "The ideal course of research is to identify medication that, used alone or in combination, effectively prevents episodes and offers maximum periods of symptom-free maintenance coverage during periods of remission."
a. Where does this information come from? I think that the "ideal course of research" should be to find treatments that work, not just medication treatments. Unfortunately, so much money is given by pharmaceutical companies to research that there is little in the way of "alternative treatments," which many of us claim have been the most helpful.
9. "People living with bipolar disorder should remember, however, that the recovery they attain usually depends in large part on the medications they are taking and their other health and wellness strategies."
a. This is a presumptuous statement and does not reflect the majority of interactions I have with "recovered" individuals. Most of us would attribute the "recovery we attain" to things like meaning, spirituality/faith, employment, human connection, peer support, personal responsibility, and so on, the same mechanisms that bring all human beings peace and joy. In our recovery, medication may or may not be helpful, but many of us would not say that our recovery has depended in large part on it. I see that the second half of this statement says "other health and wellness strategies," but again, the wording indicates that medication belongs in a class by itself, as a fundamental cornerstone to healing.
Too often the rhetoric of passionate debates skips over solutions, thus, I have listed them here in an attempt to be proactive as opposed to just long-winded. Here are some of my proposed solutions:
1. NAMI consider changing some of its language.
a. I am specifically concerned about the use of medical language. No one has a perfect solution to getting the language surrounding mental health "just right." We must all be creative in this process. I have found a great way to start challenging my own medically- induced worldview is by refusing myself to use the word "symptoms." Being a worker in the mental health world, I have to communicate with others, so I have consequently started talking about thoughts, emotions, and behaviors just as they are – thoughts, emotions, and behaviors, as opposed to a detached and bland reductionism of human experiences to "symptoms" of an "illness." I find that by doing this, I am doing myself, whomever I'm speaking to, and certainly anyone I am describing, a huge service. Indeed, by describing specifics, I am more clearly communicating. I am also re-humanizing some of the experiences that people with psychiatric diagnoses have. By saying something like, "Dave says he is feeling scared" instead of "Dave is symptomatic" or "Dave is paranoid," I am changing the way in which my colleagues and I perceive and communicate about other peoples' life experiences. Some other great solutions that I have heard: people using the term "big emotions" and "huge feelings" to describe what are traditionally thought of as "symptoms." I myself say things like "really hyper" or "full of energy" instead of "manic," and "I am with sadness" or "I am feeling vulnerable" as opposed to "I am depressed."
b. Additionally, the term "mental illness" may want to be revisited. This is, of course, tricky and new territory, but there are many alternatives that people are using to compensate for "mental illness." I say "psychiatric experiences" – I feel that term is ambiguous enough to encapsulate the people who feel harmed by psychiatry itself – and talk about "individuals with psychiatric diagnoses" as opposed to "adults with mental illness." By saying "individuals with psychiatric diagnoses," I feel that I am not claiming that the individual "accepts" or is burdened by an "illness," but simply that s/he has been given a diagnosis, whatever s/he feels about it. In that sense, I think it differentiates the individual from the diagnosis and somewhat severs the assumed relationship. Other people say "adults with psychiatric disabilities" or "people diagnosed with psychiatric disorders" and so on. As for "mental illness" itself, there are some people who refer to it as "spiritual emergency" or "spiritual emergence," or terms as clear as "mental health issues" or "mental health problems."
i. Please consider revamping the repeated and emphatic use of "illness" to describe crises.
ii. Also, Shery Mead has written some excellent work on Worldview and Language: www.mentalhealthpeers.com
c. On a whole, NAMI may want to emphasize less on the brain and more on environmental and existential conditions that lead to psychiatric experiences. Of course, there could certainly be more material on the impact of trauma.
d. I personally feel that the comparisons between "mental illness" and "diabetes" or other physical diseases are flawed and not supported by science.
2. NAMI add conflicting opinions to its existing literature and Provider Education program.
a. I may be going out on a limb here, but wouldn't it be wonderful to read something like this (currently in the existing NAMI literature):
"While no one knows the exact cause of bipolar disorder, most scientists believe that bipolar disorder is likely caused by multiple factors that interact with each other to produce a chemical imbalance affecting certain parts of the brain."
Followed by this (not currently in the existing NAMI literature)
"However, there are many other people, including individuals who have been diagnosed with bipolar disorder, who would claim otherwise, instead defining the cause as related to life experiences, spiritual crises, past trauma, or various cultural expectations."
In fact, my challenge to NAMI is to include as many "consumer" voices and opinions as those of scientists. That would allow for people who are reading the materials or taking the Provider Education course to be introduced to an array of models for understanding human experience, which in fact would be empowering to those many individuals who currently feel marginalized by the "brain disease" theories that they find disagreeable.
3. NAMI change their overall emphasis of medication in treatment.
a. First and foremost, NAMI could introduce statements such as "Medications do not work for everyone" and "Some people find recovery without medications" into the existing literature and dialogues. They could even back the statements up with current scientific research.
b. Also, please consider removing statements like "People living with bipolar disorder should remember, however, that the recovery they attain usually depends in large part on the medications they are taking and their other health and wellness strategies" that feel – to me – paternalistic, and that in my experience are not entirely true.
c. NAMI could consider some of the shifts of consciousness in medication use promoted by people like Pat Deegan ( www.patdeegan.com). I cannot justly speak for her, but she has basically introduced the concept of "using medication" as opposed to "taking medication." In this way, a person who is prescribed medication uses it as a tool as opposed to simply taking it passively. The emphasis for medication use is that it should be the person's choice, and that the person should feel empowered with it to help in his or her recovery, not ashamed or passive.
d. NAMI may want to revisit the use of literature from pharmaceutical companies that emphasizes the necessity of medication use. While much of this literature is seemingly helpful and useful, if the literature proclaims that medicine is a necessary component to recovery, then it is promoting a one-sided belief system that many of us see as damaging.
4. NAMI mention in its literature and at its meetings the scientific studies that demonstrate that a majority of individuals diagnosed with schizophrenia significantly improve or recover entirely, many without medications. I was very pleased with the two speakers at the recent NAMI-VT annual conference who cited Courtney Harding's work! These studies are powerful, scientific, and dramatically challenge our presumptions about the course and outcome of diagnoses such as schizophrenia. Here is a great place to start for some research and perspectives into the many faces of recovery: http://www.bu.edu/cpr/repository/ or check out this quick review of studies: http://www.power2u.org/evidence.html
5. NAMI consider promoting alternative treatments at conferences.
a. At the recent NAMI-VT conference, a representative for Abilify had a booth and handed out materials. I do not see the point in having a drug rep at an annual conference, but if NAMI wishes to have drug reps in the future, they would be doing a great service to the term "fair and balanced" by having reps from health clubs, alternative therapeutic communities (which, to NAMI VT's credit, there were some reps from Spring Lake Ranch, which I presume is "alternative," though I am not too familiar with them), naturopathic facilities, consumer/survivor/ex-patient organizations, local community interests, spiritual communities /organizations/facilities, and so on. It would be too idealistic to suggest having all of these types of peoples represented at every conference, but I think NAMI could at least consider having some other options available.
6. NAMI keep away from highly political and moral/ethical controversies such as involuntary treatment. I am writing this proposed solution strictly from my heart, though I can point to some rational reasons why NAMI would benefit from staying out of advocacy on involuntary treatment. The most obvious reason is that these issues are highly emotional and dear to many people who have in fact experienced things such as involuntary treatment. Thus, when NAMI gets involved, or promotes people who advocate for one side only, NAMI isolates a lot of people, and quite frankly, a lot of anger and resentment results. NAMI has a large constituency that makes it very powerful, and I ask that it please be mindful of this power when working on legislative levels. NAMI did not begin from people with psychiatric diagnoses, and while many of us are connected nowadays to NAMI, the organization still doesn't fully represent our many voices. Thus, while advocates at NAMI may see their work on issues such as involuntary treatment as kind and compassionate, they may find that the people for whom they are advocating actually strongly disagree with their positions and stances. It is so important to many of us who have experienced some of the uglier sides of mental health treatment that our voices are heard and respected, and that we are not unfairly represented by large organizations who may be making skewed though well-meaning presumptions.
I would like to end my list by saying that I am not by any means "the voice" for those of us who may have concerns with some of NAMI's messages/practices, nor do I feel hardly able to represent the many brilliant and beautiful solutions that people are offering as alternatives. In my proposed solutions here, I am simply offering the best list that I can think of on a given night, so I want to attest to the fact that is just my opinion! The best that we can all do is continue to research, ask questions, and listen to one another. I hope that others who have differing solutions will also either speak up or be engaged to be included in any process of reform.
Thank you for your time and consideration,
Steven Morgan
In response to my recent post on the new mental health screening program for kids on Medicaid in Massachusetts, CL Psych has his own thoughts.
"There is the black undercurrent of labeling developmentally relatively normal behavior as indicative of a mental disorder and sticking the kids on all sorts of psychotropic meds that (in many cases) have little data to support their use."But there is more to it than drugs. It's our culture. We've come to accept that there is an epidemic of autism, depression, anxiety, ADHD, bipolar disorder, and who knows what's next in our kids. While the drug industry certainly played a role in these developments, it says something about our culture that we are readily willing to buy into the idea that mental illness has spread like a plague throughout American society. Have we bought into these disorders hook, line, and sinker because:
* It abdicates parents of any responsibility for their children's behavior
* It lets kids off the hook for their behavior ("I couldn't help it -- I have ADHD")
* It adds yet more drama to the teen years ("Gina is, like, so moody. I bet she is, like, bipolar")
* It seems so scientific. We uncover yet more diagnoses with each edition of the DSM and we then think that we have a better understanding of human behavior.
"I'm not claiming that these are especially deep thoughts, but there is something about the interaction of science, marketing, and American culture that seems to have gone awry here."
I couldn't agree more. Our culture is indeed getting weird when the language of psychiatry and the DSM is the lingua franca of behavior and mood, and when states feel they have the inherent right to pry into the minds of children.
A reader kindly passed along at item from the Wall Street Journal's Health Blog (second item) about a drug developed by Addex that was designed to treat dental anxiety disorder. DAD is apparently one of many specific phobias that are covered by the DSM. The new drug failed its Phase 2 clinicals.
I've been well-versed in psychiatry, psychology and the DSM for two decades and it just staggers me that every so often I run into yet another "disorder" that strikes me as being a completely legitimate response to human experience. Some people utterly hate going to the dentist because once they get there a stranger is going to stick their hands in the patient's mouth and start drilling. Being anxiety-ridden about such an experience is well within the range of normal behavior. In fact, I think it might be a bit more abnormal for someone to not be anxious about having their teeth drilled.
My further frustration with this drift to a disordered America is that the folks making up the rules are doctors. They are the norm of human behavior in the 21st Century and if we don't respond to human experiences in the same manner in which they do, if we don't follow their behavioral and health habits, then we are somehow sick and disordered and in need of treatment. Have these clowns ever heard of free will and individual choice? Did they skip that lecture in college? Have any of you spent significant social time with a doctor? I can assure you that they are among the most arrogant, money-grubbing, attention-seeking little idiots you'll ever encounter. Hm. Arrogant, money-grubbing, attention-seeking...sounds like a disorder to me.
I am aching for the day when some doc declares smoking cigarettes a form of insanity that requires involuntary hospitalization and forced medication. Or when some researcher pontificates that dislike of homosexuals is a mental disorder. Oh wait, that one already happened. (Note: I am not advocating dislike of homosexuals, just pointing out that it hardly passes muster as a mental illness.)
But to come back to DAD and Addex. How big a market could there possibly be for DAD? Wouldn't it make sense to take a Valium or something if you're scared of the dentist? Why do pharma companies invest tens of millions of dollars into research to treat non-disorders?
Because, as P.T. Barnum once noted, there's a sucker born every minute.
Gianna Kali, who writes the Bipolar Blast blog, has been slowly tapering down on her meds the last few months. Like me, she's run into awful problems coming off Lamictal. A longtime bipolar, she's written about her quest to be off "these poisons," as she calls them, at length. Now, she's taking the game a step further in order to get off her meds faster and is traveling to California to consult with an orthomolecular specialist.
"He was there 23 years ago when I was first diagnosed. If only I had known. And in line with maintaining responsibility for my health I won’t stop there and I won’t count on him being the answer. Also in line with being responsible, I need to do what I can to get back to functioning so I can be a productive member of society. I choose to heal. I choose to move forward and confront my 'trouble.'"I fear I may look like I’m grasping at straws to some, but instead I see this as dogged determination. I’m sure many people would have given up by now my journey is no joke. In the end it may be that I am the one who did all the work. That all this searching out others to help me will have been for not, but then again that makes no sense because I wouldn’t be doing this without all of you, my readers and all the people in my withdrawal groups who give me hope everyday as I see more and more people recover—as people come to me again and again and tell me their recovery stories. We are legion. I get help everyday from people and now I seek more help.
And yes we are all alone too. And must find the final answer within. I am moving in that direction. With great faith and hope."
I cannot even begin to wish her the best of luck. I have a hunch she'll get to where I am at these days. It will have little to do with orthomolecular cures (though those may help) and everything to do with human determination and personal responsibility. There is something deeply freeing about those two forces, but they are very hard to write about in an America where we've long ignored human psychology and willpower and desire as keys to recovery and turned the game of mood and feeling and behavior over to doctors who see us as neurotransmitters, glial cells and a big old biochemical soup.
For those readers who might be interested, I have been cross posting a few of my posts lately to Daily Kos, the juggernaut of prog-lib political websites. It's a good way to assess how a more general public responds to mental health issues and criticisms of our current mental health paradigm. What I am finding so far is a mixed bag of agreement, ignorance, introspection and name calling. It's already been strongly implied by some readers there that I am an anti-psychiatry type, a Scientologist, a right-wing Christian and a gun nut. Fun times.
Today, I posted my entry on mandatory mental health screening in the Bay State and it's led to some interesting comments. Feel free to join in the fun here.
As most readers know, Big Pharma is sure interested in having its anti-psychotics used for treating depression. While I cannot argue with the short-term use of atypicals for treating depression, I find it appalling that we could well have a situation in this country where people are taking two sets of unpredictable, dangerous drugs (anti-depressants and atypicals) for long-term use when real world experience would argue against the long-term use of these drugs. Anti-psychotics are not safe for long-term use, pure and simple. Doctors who have their patients on these drugs long-term are doing them a profound disservice.
Anyway, CL Psych has yet another post on the infamous ARISE study of Risperdal's use in depression. A psych doc wrote a letter to a journal challenging the study which led to an interesting exchange with the study's author. Well worth reading.
Meanwhile, AstraZeneca has filed two applications with the FDA to have Seroquel XR--the extended release version of its atypical anti-psychotic--approved for treating mania and bipolar depression. In a press release, the company claims that bipolar disorder affects 4 percent of American adults, a claim that is largely without support. NIMH pegs it at 2.2 percent.
But then America's pharmaceutical companies can say pretty much anything they want and get away with it.
The State of Massachusetts is embarking on what strikes me as an excessive social experiment. As of Jan. 1 annual checkups for about 500,000 kids and teens on the state's Medicaid program will have to include a mental health screening, regardless of whether there's a reason to suspect mental health issues in the patient or not, reports the Boston Globe. Doctors are required to do this with each patient, although parents and children are not legally required to comply. But then most people are utterly in thrall to doctors and I doubt many would tell their doctor to back off.
The paper also has an enthusiastic editorial supporting the program. That's kind of bizarre since the paper has been one of the best at reporting on just how screwed up mental health care for kids is and how dangerous some of the treatments are. Perhaps the paper's editorialists should re-read the paper's series on the Rebecca Riley case and the bipolar child paradigm.
One of the symptom checklists on the paper's website contains a stunning array of non-symptom symptoms: teases others, refuses to share, is fidgety, acts younger than others, daydreams too much, is afraid of new situations. And so on. Many of these symptoms are hardly indicative of abnormal behavior or psychology
Could someone please let me know what is the objective standard for daydreaming?
I object to this mandatory screening for a number of reasons:
1. It represents the kind of governmental intrusion into peoples' personal lives that Americans should be against.
2. The criteria for diagnosis is not objective. Asking a kid if they are having less fun is not likely to elicit a reliable response and is hardly a predictor of mental illness.
3. Pharmaceutical treatments for these conditions are not well-researched in children and their long-term effects are generally bad. With anti-depressants in particular there are significant risks of medication-induced suicidality and extreme agitation.
4. There is not good evidence that pharmaceutical treatments work well in treating these conditions--the usual 30 percent success rate hardly inspires confidence--and there is virtually no evidence that these medications prevent future episodes of a disorder. This is true in adults, teens and kids.
5. The whole screening paradigm is the brain child of the public health crowd and pharmaceutical companies, neither of whom are to be trusted.
6. Given that this is limited to Medicaid participants, it unfairly targets low-income families and ethnic minorities.
I hope parents in Massachusetts are smart enough to refuse to cooperate with doctors when they start breaking out these screening tests unless the parent wants their kid screened. It will be interesting to see where this program goes as the year goes on and if any resistance breaks out.
As for the Globe, I think the paper's editorial board is out to lunch on this one. What do readers think?
Via the AHRP Blog.