Things picked up yesterday and today with a whole bunch of donations by PayPal and mail bringing the total so far to $835. Thanks so much for your contributions and for improving my weekend.
The goal for the fundraiser is $2,500, so it's one-third of the way there. Hope you are all having a fine weekend.
Another $55 came in yesterday, bringing the total to $175. I know there are a few things headed my way via snail mail. I won't count them till they get here though. The overall goal for this fundraiser is $2,500, and I'd be lying if I didn't tell that I wish things would pick up.
Most everyone compliments me on this site and tells me what a fine service it is. Well, the truth is that this service relies upon your contributions to keep it going because there simply isn't an advertising model--yet--to support work like this. Maybe someday. But everything about how the media works in this country and how it's funded is undergoing a sea change. From what I hear, several big newspapers have scaled back their health coverage significantly and that means mental health will get less and less specialized attention. That's why I'd argue sites like this and readers like you are important.
What's odd to me is that this sluggish response is going on when this site is setting readership records. I don't want to sound like a braggart, but in May I have already eclipsed this site's former monthly visits record and have also passed a goal I had set for this site back at the end of December of clearing 25,000 visits in a one-month period at some point during the year. I figured it wouldn't happen until October, since it represented close to a 50 percent growth rate. It actually happened yesterday. Yes, I will buy myself a beer.
My point is that there are lots and lots of regular and semi-regular readers of this site--on the order of 10,000 plus 6,000 or so occasional looky-loos--and I need you guys to step up to the plate and help keep this site charging forward. Otherwise, I can go find something else to do with my time.
As usual, the PayPal button is on the right and if you prefer snail mail, drop me an email and I'll shoot you a mailing address.
Thanks for your support.
There was an interesting and odd article on MSN Health yesterday. Interesting because it examined the question of why different people have such wildly different responses to anti-depressants--everything from the classic "better than well" response to no response to violence and suicide. Peter Kramer of Listening to Prozac fame makes an appearance in the article which I'll untangle in a second. The response/non-response issue is one of the most ticklish and important questions in all of medicine, especially since anti-depressants are the most prescribed class of drugs in America. It's a question that the article tries to sort out, but unfortunately researchers haven't hit upon anything less than a suite of answers, so the article does end up tasting like an interesting bowl of mush by its end.
Still, it is an important question and one I'd personally love to know the answer to someday. Just for fun. Why, for example, did 10 mgs of Lexapro work so-so for me yet when I went off the drug about six months later, suffered from rebound depression and, then, went back on the drug at the same dose, it damn near exploded my heart and had me so agitated I couldn't think? Why did 20 mgs of Prozac initially work quite well for me, then later make me feel stony, then wash out altogether and then at higher doses damn near cost me my life? I don't even pretend to know the answer or answers, although my broad hunch is that it's got something to do with small strips of genetic code that some people have and some people don't. Just a guess though. Researchers have not been able to come up with a consistent, replicable set of answers to date.
Anyhow, the article references the Kirsch paper from PLoS which appeared in February and asserted that several anti-depressants were no effective than placebo based upon their approval studies that were submitted to the FDA, but remained unpublished. If I were writing the piece I would've referenced as well the Turner paper in the New England Journal of Medicine from January which reached the conclusion that non-publication of FDA approval studies with negative results for all 12 "modern" anti-depressants had led to an incredible overstatement of anti-depressant efficacy by pharma companies. In my mind, it was more damaging than the Kirsch paper since it looked at the entire class of anti-depressants.
Ever since, some researchers have gone out of their way to defend and attempt to rehabilitate anti-depressants in the media (i.e., the recent Fred Goodwin program on "The Infinite Mind" radio show), operating on what one presumes is the assumption that legitimate researchers and clinicians like Kirsch and Turner are trying to scare people off their meds. No one I know of has spoken out more on this issue than Kramer.
He first took a swing at the Turner paper on Slate back in January. Later, he defended anti-depressants again on Slate as he set about attacking Charles Barber's Comfortably Numb, in which Barber had aimed several shots at Kramer for Listening to Prozac wherein case studies of seven of Kramer's patients had all of America rushing to doctors to get their serotonin back in "balance." Perhaps, Kramer defends anti-depressants so aggressively because he has so much to answer for. In his book, for example, he's completely dismissive of the idea that SSRIs can be linked to incidents of violence. He's even defended anti-depressant efficacy to me personally and there he was yesterday in the MSN Health piece.
"Two other complications are noted by psychiatrist Peter Kramer, author of Listening to Prozac. First, early data-—of the kind included in the meta-analysis which found antidepressants no better than placebo—-often fails to show results for drugs that later prove very effective. 'We have medications that show effectiveness in post-stroke depression, in the elderly with multiple brain lesions, in people with chronic, intractable depression. Why do they only not work in the early trials?' he asks."Second, people get excellent care in clinical trials, which makes the placebo effect especially strong. This means it’s harder to show a difference, even if a drug works well. 'We may be losing effective substances, not approving ineffective ones,' Kramer notes."
I wonder what anti-depressants Kramer thinks are going unapproved. I cannot think of a single anti-depressant, submitted to the FDA for approval, that has been rejected in recent years. That strikes me as a baseless statement on Kramer's part and makes me wonder exactly who the hell is editing articles like this at MSN Health. It's one of those things a judicious editor would've cut.
When I interviewed Kramer for an article a few months back, he admitted that the Turner paper in the New England Journal of Medicine injured the reputation of anti-depressants, but then proceeded to criticize how clinical trials were done and told me that there were studies showing that anti-depressants worked 80 percent of the time. I asked what studies. He told me studies of anti-depressants in post-stroke depression. I was tempted to say "Whatever," but I respect Kramer too much as a writer and thinker on these issues to be dismissive. All the same, his point was moot. We were discussing anti-depressant use culture-wide not in small cohorts. I almost quoted him on this point in my article just to show the nearly-religious degree people will go to to defend anti-depressants, but I figured it was too much of a sidebar to the main point. I suppose I should've asked him what response placebo got in the same trial, so I could get a sense of what effect size he was talking about. Oh, well, it was a more hurried conversation than I would've wished for.
Still, I must begin to wonder how Kramer can use post-stroke depression to justify the efficacy of anti-depressants in non-post-stroke depression. I suspect they are entirely different animals. Perhaps, he'll write about this on his blog someday soon and enlighten us all. I'd really like to know how post-stoke depression resembles garden variety major depression and why the experiences of those patients should speak to how I--and maybe you--care for myself. It's ironic that last week Kramer's blog entry on the bipolar child article in Newsweek was entitled "Not The Politics, The Experience." It would seem that Kramer is not as open to the experiences of millions of Americans, Brits and others who've had rotten experiences on these drugs as he should be, preferring instead the politics.
I must admit that back when I first read Kramer's book in 1993 it was when I was beginning to have some serious problems with Prozac. I went to his book looking for answers and became enthralled with the response his seven patients had to the drug. I so wanted to be like them. But I never was. I stayed on the drug several months more, at increasingly higher doses until I experienced such suicidality on the drug that my then-doctor switched me to Paxil. Fifteen years later and after many bad experiences with anti-depressants, I will never take an anti-depressant again in my life absent a gun at my head and a court order in my face. And I'll appeal the court order.
I know however that anti-depressants work well for some people and I congratulate those lucky few.
Here's a startling report from New South Wales, one of Australia's states, where the Daily Telegraph reports that children as young as two-years-old are being given Ritalin. Keep in mind that Australia is nowhere near as populous as the US and that these figures only represent kids in part of the public health system.
"Figures obtained by The Daily Telegraph reveal 311 children in NSW aged five and under depend on controversial medication, including 58 four-year-olds and 13 three-year-olds....As well as the three and four-year-olds, there are 240 five-year-olds on subsidised ADHD drugs in NSW. There are 6692 6- to 10-year-olds, 9006 11- to 15-year-old and 2584 16- to 18-year-olds."The figures follow the State Government's ADHD review which found there was no overprescribing of drugs."
Governments generally think this sort of thing represents no problem. The kids of course are getting a range of ADHD drugs, not just Ritalin.
One child psychiatrist was critical of the situation:
"But child psychiatrist Jon Jureidini said he was disappointed at the number of preschoolers on the list. 'I would be confident that they (the drugs) are being inappropriately used in most cases of preschool children,' Dr Jureidini said. 'ADHD is not a good explanation for putting these children on drugs. I have seen children of that age displaying very disturbed behaviour but it is usually a medical problem or significant family circumstances that are undermining their well-being.'"
I'm sure someone will box my ears for saying this, but two-years-old is simply way too young for a child to receive medications like these--even though it goes on in the US and UK--much less a diagnosis of ADHD. At two, children are barely able to walk. How the hell are they getting diagnosed at such a tender age?
Well, this is an interesting story in the Providence Journal today.
"A brain disorder drove historian Edward Renehan Jr. to record an album with folk legend Pete Seeger, work with New York publishers and write six books, including one on the Kennedys, the author says."But that same illness –– diagnosed last year as bipolar disorder –– may have pushed Renehan to steal and sell rare letters written by George Washington and Abraham Lincoln, a federal crime that could send him to jail or force him to pay up to $250,000 in fines."
Obviously, the letter were incredibly valuable.
I never quite know what to make of cases like this one. I know plenty of people with bipolar disorder who have experienced full-blown mania and they haven't stolen a thing. That said, Renehan has no previous criminal record, so one assumes something goofy went on here.
Still, blaming things on bipolar disorder is kind of a weak defense, in my opinion.
Another war is hell item: suicides among Army personnel were up last year to 108 deaths, an increase of six over 2006. One-fourth of the suicides occurred in Iraq.
"The overall toll was the highest in many years, and it was unclear when, if ever, it was previously that high. Immediately available Army records go back only to 1990 and the figure then was lower - at 102 - for that year as well as 1991."
More on this later, when a full report is released later today by the Army.
Eli Lilly today announced that it has submitted a supplemental new drug application to the FDA for Cymbalta, its newish blockbuster anti-depressant, for the treatment of chronic pain. The drug is already approved for treating depression and diabetic neuropathic pain, and racked up over $2 billion in sales last year, its third full year on the market.
The company did not announce results of chronic pain studies it was submitting to the FDA. Previously, some of Lilly's pain-treating claims for the drug have been challenged in academic papers as being wildly overstated. Personally, I don't know what to make of this new paradigm of anti-depressants to treat pain, except to say that I am fairly skeptical. But anything to keep the DEA happy in its attempt to keep doctors from using legitimate pain killers such as opiates and medical marijuana.
The first day of the fundraiser brought in $120, on the way to the goal of $2,500. Thanks for your contributions.
For those of you who didn't see the notice yesterday, I am doing another quarterly fundraiser to support the work I do on this site for the next few months. So if you have $5, $10, $25, or even $50 to give, I'd appreciate your support.
As before, there's a PayPal button on the right. Or if you prefer snail mail, send me an email and I'll send you a mailing address. Thanks.
Recently, Newsweek had a cover story on a young kid diagnosed with alleged bipolar disorder. I've already ripped the piece apart. I felt it failed to deal with the lack of evidence for the disorder in children and didn't even bother to quote critics within psychiatry of the controversial diagnosis. It lacked the level of balance I would've expected from the magazine.
My views, of course, are one thing. Those of psychiatrists are another thing entirely. Last week, Peter Breggin, a critic of much of current psychiatry who happens to be a psychiatrist, was a bit over the top when he wrote that psychiatry had declared "war" on the boy, Max. I understand his frustrations, but war is a bit much. Then he makes an extremely valuable point about what this boy, who's been on 38 different meds, and his parents will be up against:
"From now on, Max, his family and his doctors will almost certainly have to face an increasingly impossible dilemma common to children who are prescribed multiple psychiatric drugs for a period of years. When trying to withdraw these children from multiple psychiatric medications, they almost certainly go through severe withdrawal problems with extreme emotional instability and the risk of worsening violence and suicidality. In fact, we are told that an attempt to take Max off his medications resulted in his displaying hallucinations and delusions, which Newsweek attributes to his worsening condition and his need for drugs. The odds are overwhelming, instead, that he went through a severe withdrawal reaction. So it can be very difficult to withdraw children like Max from multiple psychiaric drugs, but if they are kept on drugs indefinitely, their brain, mind and overall condition is almost certain to deteriorate."
Regardless of what you make of the bp kids paradigm, Breggin is precisely right about withdrawal problems and that some of this kid's symptoms could well be generated by a reaction to medication withdrawal, or to the meds themselves. Maybe he magazine will do a follow up article someday.
I was intrigued by Peter Kramer's views on the article on his blog at Psychology Today. Kramer is of course the author of Listening to Prozac, which just passed its 15th Anniversary in print, a stunning accomplishment, regardless of what you think of the book (my views are mixed). Kramer, who globally seems to like the article, raises an interesting point:
"A note regarding diagnosis: Yes, the Newsweek text and headlines are pitched to an interest in bipolar disorder, but who knows what this kid has? Mary writes that Max’s secondary symptoms include hyperactivity, anxiety, obsessionality, attention deficits, dyslexia, and pronounced elements of oppositional-defiant disorder. A current movement in psychiatry favors “dimensional” diagnosis, cataloging scattered problems rather than grasping for syndromes. This trend can be taken too far, but especially in the case of children, whose disorders are often protean, the approach can signal an appropriate agnosticism."
His subtle point is that he thinks the magazine shouldn't have pushed the bipolar angle on this kid so hard because "who knows what this kid has." I wish the magazine had been a bit more sensible as well, given the many controversies in the field over this matter. It's clear that something is up with little boys like this, but what it is no one really seems to know with anything approaching certainty.
For those of you who want to read the thoughts of a defender of the disorder in kids, you can do no worse than John McManamy's post over at Health Central. He's been an extremely harsh critic of anyone who questions bipolar disorder in children, and his tone is often one of religious conviction. I've noticed that tone to be consistent in late-diagnosis bipolars, as McManamy is. You've got to wonder what's driving that.
Maybe he can take on Breggin and Kramer now.
Looking to counter the very bad publicity its very tricky stop smoking drug, Chantix, has received the last two weeks, Pfizer will roll out special ads in five big newspapers today, including the Wall Street Journal and New York Times. In the ads, according to Bloomberg, the company will emphasize the dangers of smoking and the benefits of Chantix. That sounds like a desperate strategy. But then the drug over the last two weeks has received a public health warning from the FDA, its use by pilots, air traffic controllers, truckers and bus drivers has been banned, so maybe this is to be expected. After all, sales in the first quarter were down by 30 percent for the drug. It'll be interesting to see its second quarter results.
And, it'll be interesting to see if Pfizer's ad has any effect at all.
This lovely bit of news from my native land:
"Pharmacies in California would be allowed to sell confidential patient prescription information to third-party marketing firms working for drug companies under a bill expected to be voted on Thursday by the state Senate."The legislation would allow pharmaceutical firms to send mailings directly to patients. Supporters of the proposal say the intent is to remind patients to take their medicine and order refills. But consumer privacy advocates are outraged."
Is there simply no quit in the sales tactics of the pharma companies? I doubt that too many adults need to be sent reminders to take their meds each day. It's time for "America's pharmaceutical research companies," as Montel Williams puts it, to get the hell out of peoples' private lives. They already know what our docs prescribe anyway. Enough is enough.
We ban drug dealers and users to keep them away from schools. Why would we let these drug pushers into our homes and medical records?
From today's war is hell department comes this discouraging article from the AP. New PTSD diagnoses among troops in Iraq were up 50 percent in 2007, some of it inevitably connected to last summer's "surge" in forces around Baghdad. What with troops seeing increased rotations into battle zones and lengthier deployments, I doubt this will get better any time soon.
Whatever the next President does about the war, we are going to be paying the price for all of this in our culture for a long time to come. I hope we can do better by this generation of troops than we did th Vietnam generation.
Earlier this month, a study came out asserting that bipolar disorder was being overdiagnosed. About 50 percent of the patients diagnosed with bipolar disorder in a study in Rhode Island turned out to have been wrongly diagnosed once they were put through an appropriate clinical interview. This study hasn't generated anything close to the press response I would've expected to date, but it did lead to this interesting blog post at Psychology Today by Nassir Ghaemi, a psychiatrist at Emory University, asserting that the methodology behind the Rhode Island study was flawed. You can read it for your self and see if you can understand what he's talking about. (here's what I also wrote earlier about the Rhode Island study.)
But the bigger question is of how this sort of thing is playing out in the America the rest of us live in. J. R. White at Brain Blogger offers his own account of himself and some co-workers being misdiagnosed with bipolar disorder and how it happened.
"Let me illustrate this [the sloppiness of some diagnosing] with a pretty 'funny' situation that happened a few years ago. I visited a mental health facility for the first time and was seen by someone we’ll call Wanda. She was not a doctor; she was working towards some certificate or degree and was being 'mentored' by a psychiatrist at the facility. Well, after talking to me she gave me a brand new diagnosis, one that had never even been suggested to me before. It was a type of low-level bipolar disorder and she prescribed medicine to treat it. Turns out I didn’t feel comfortable with this diagnosis and didn’t continue with her suggested treatment plan."I became friends with two people who worked at my company and had been seen by Wanda within the same time frame. (Since we all lived in the same part of town and had the same insurance company, this wasn’t too odd.) What was odd about it was that after talking we realized that all three of us had been given the exact same diagnosis. And, stranger yet, none of us believed in the diagnosis so we all three stayed away from the medication and promptly either found someone else to see or found other ways of coping with the anxiety/depression/mood swings."
That's some nice mentoring there by the psychiatrist. It's interesting and not a bit funny that this happened to three separate people in the same town with the same caregiver, one who was still in training. It's just as interesting to me that all three newly-minted bipolars turned their backs on the diagnosis and the treatment. Since White does offer any information to the contrary, I assume they are doing fine.
What's discouraging to me is that this situation is roughly what the researchers in Rhode Island highlighted in their paper. People presenting to docs with symptomologies that spoke of depression and a certain unsettled moodiness and they wind up getting diagnosed with either bipolar disorder 2 or bipolar disorder NOS (not otherwise specified), get prescribed meds, and, later, learn that they aren't bipolar at all.
From where I sit, this speaks to what a bad idea it was to rebrand manic-depression (which generally required full-blown mania for someone to get the diagnosis) as bipolar disorder in DSM-IV in 1994 and, then, create several subtypes of the disorder--BP1 (the old school manic depression), BP2, BP NOS and cyclothymia (which had always kind of been around as a proxy diagnosis). The non-BP1 subtypes are much softer forms of the disorder, somewhere between depression and BP1 on the mood continuum. Part of the idea of rebranding manic depression back then is that the name change would be magical and would lead to less social stigma for people diagnosed with the disorder versus the really intense stigma that greeted folks diagnosed with manic depression. I think we all know how that bit of wishful thinking has turned out.
Even more troubling is how a misdiagnosis of bipolar disorder can lead to many years of treatment with medications that aren't particularly kind to the human body. Any doctor or mental health worker who does not recognize that this is an appropriate concern should get out of the business of diagnosing--especially the casual diagnosing that seems to be afoot in the land--until they get their bearings straight.
Why is this important? Because many millions of people in this country, from the young to the middle-aged, have been diagnosed with one of the types of bipolar disorder in the last decade or so. They've been put on very aggressive medications, including antipsychotics which are being handed out like candy in our culture (how else would Seroquel be winding up as a street drug?). Some of those diagnoses are now clearly in doubt, and so are the treatments these people are taking, in many cases unnecessarily. That's why.
Just as I did in late February, I am asking readers to make a financial contribution to my work on this site. Your contribution of $5, $10, $25 or what you wish will help fund my work here--which I already subsidize through freelance work, of which there's never enough that pays well--and help me keep a roof over my head for the next couple of months. The February fundraiser brought in $2,500 and I'd appreciate your help in hitting that total again over the next two weeks. May has already been a record month for this site in terms of readers and visits. I appreciate the attention because it has been built over time without the aid of mentions in the mainstream media or via links from mega-blogs.
I think most of you already have an idea of just how many hours I put into this site each day, so I'd appreciate your support. As usual, the PayPal button is over on the right. If you prefer snail mail, shoot me an email and I'll pass along my mailing address.
Thanks for reading and supporting this site.
I'm just going to pass this along without comment.
"Children as young as eight may soon be able to use the antidepressant drug, Prozac, following a recommendation by the European Medicines Agency (EMEA)."Prozac (fluoxetine) is an SSRI (selective serotonin reuptake inhibitors). SSRIs are the most commonly prescribed class of antidepressant.
"The drug is authorised for the treatment of major depressive episodes, obsessive compulsive disorder and bulimia nervosa. Currently in Ireland, its use is not recommended in children and adolescents under the age of 18.
"However the European Medicines Agency has now said that Prozac should be considered in the treatment of children aged eight or older who suffer from moderate to severe depression and who do not respond to psychological therapy."
Most of you probably saw somewhere in the news yesterday that a new study (here's the pdf) is out asserting that adults with ADHD cost their employers 22 work days a year in lost productivity. The study asserts as well that the prevalence of ADHD in the 10 countries studied runs at 3.5 percent with men being the primary diagnosees. One of the study co-authors is Ronald Kessler, a psychiatrist and public health policy big shot at Harvard.
Then the study researchers went on to say some things that really played into my fears that some of the public health sorts in the mental health world would really love to create a nanny state where governmental and public health paternalism reign supreme and citizens obey their commandments. I'll come to all of that in a second.
There are plenty of reasons to not lend much credence to the findings of the study. First, any time Kessler gets a hold of a disorder, its prevalence is always underestimated and work days are being needlessly lost (I tend not to trust researchers who always issue the same cry). Not long ago, it was Kessler who cranked out a study asserting that 50 percent of Americans have a DSM condition, a fairly preposterous assertion that gives new meaning to "abnormal psychology." Second, this current study uses a self-reported survey method to pick apart folks' psychological health and job performance. It's not the most reliable arrow in the psych researcher's quiver. Third, this study was supported by a grant from Eli Lilly (see the disclosures at the end of the paper). Say no more.
What amused the hell out of me was watching the US and British press jump all over this study as if it contained buried treasure.
Health Day News: "Dr. David W. Goodman, director of the Adult Attention Deficit Disorder Center in Luthersville, Md., agreed that ADHD is an 'under-diagnosed and under-recognized psychiatric condition that causes a tremendous amount of disability in the work environment.'
"And while he supports the idea of screening workers for ADHD, Goodman, who is also an assistant professor of psychiatry at Johns Hopkins University, worries that "identifying workers with ADHD raises the possibility for discrimination.'"
WebMD: "'People with ADHD have more sick days and lower performance when they work,' Kessler tells WebMD. 'This is one of those hidden illnesses in the workplace.'"
And so it went through newspapers, wires and websites. Apparently, reporters don't read studies in their entirety and since I am a reporter that kind of bugs me. Why?
Right at the end of the paper, there was this assessment of the "policy implications" from the authors, which sent chills down my civil libertarian spine:
"The above results raise the question whether adult ADHD is a candidate for targeted workplace screening and treatment programs. Short screening scales that are both sensitive and specific for adult ADHD exist. It might be cost-effective from the employer perspective to implement workplace screening programs with such a scale to detect and provide treatment for workers with ADHD. The thinking here is that ADHD among workers has non-trivial prevalence, high impairment and a low rate of treatment, whereas cost-effective therapies exist that are related to improvements in some objective aspects of role performance. The obvious next step from a public health perspective, given these findings, is to evaluate the extent to which best-practices outreach and treatment would result in improvement in functioning that might have a positive return-on-investment for employers." (Emphasis mine.)
No, Dr. Kessler those kinds of policy implications just aren't where you should be taking your nanny state express. You are asking a question that's just stupid and you are poking into private realms that you shouldn't touch. If workers aren't super-productive at all times and it's OK with their bosses, then who cares? I've been watching researchers like Kessler wrap their medicate-the-masses arguments in the cloak of we're-helping-business-productivity for years. I'm growing tired of it.
But what worries me about studies like these--part of the WHO's World Mental Health Survey Initiative--is that they seem to have no boundaries. Because what Kessler is driving at is a universe where there would be ADHD screenings as part of pre-employment interviews and, maybe, to get a promotion. If you want the job, then you'll take Adderall. Then come the mandatory drug tests. If you aren't taking your Adderall, you get fired. If you think I am joking, I recall back when workplace drug testing became standard at some companies and they went looking for pot use among employees (some even test for alcohol). I thought for sure that the courts would never support such an intrusion into peoples' private lives, but they sure did. I worry about a similar dynamic erupting here as well. It creeps me out even more that the United Nations is somehow involved in this push.
For some reason, I am more concerned about this sort of intrusion into everyday Americans' lives than I am by the specter of discrimination against people with ADHD (I'm concerned about that too, but by comparison with what goes down for people with schizophrenia or bipolar disorder, it's not even in the same ball park).
Isn't America already the most (or second most) productive country in the world? Don't Americans already work more hours per week than just about any people on Earth? We're already working our butts off, the price of everything is going up dramatically, our wages are largely stagnant. Why do we need to perform even more? Who is this kind of policy wonk talk really serving? Workers? Eli Lilly? Harvard? Boeing?
I'm not sure I want to live in a world that the Ron Kesslers of the world imagine, where every little slip in performance becomes an occasion to be sent to the company psychologist.
What about you?
You know those "let's do a thought experiment" features that run in some mags and newspapers? There's an interesting one on Time's website this week and I suppose it made its way to the print edition as well. Does anyone read print editions anymore?
The question: "Should antidepressants ever be sold over the counter?" The fact that such a question is even being asked in such a way tells you a lot about where America is as a culture. Time isn't exactly an out-there publication posing questions that have little connection to day-to-day America. Their charge is to be thoroughly in touch with what's under the skin of the mainstream. So the question spooks me.
Answering the query is Josephine Johnston, associate for law and bioethics at the Hastings Center. I was intrigued by some of her answer:
"The trouble, I guess, is there's a lot of concern that if you start providing needed medicine to clinically depressed individuals over the counter, it will pretty quickly become a drug that's used much more like alcohol or some other kind of what we might call recreational drugs."
And discouraged by her apparent ignorance of what's up with anti-depressants:
"But if you take the libertarian argument, 'Why shouldn't people be free to treat their own problems?' then there is no good argument against it. Antidepressants are not that dangerous."
Not that dangerous? OK, how about risky and dangerous for some?
"Overall I can sort of see both sides, but, in the end, it's hard for me to go completely with free choice. I think the interesting thing about this thought experiment is that it doesn't feel very far-fetched. While you can't buy antidepressants over the counter now, it's pretty easy to get a prescription from your doctor."
No, I suppose none of this is very far-fetched at all.
Regardless of what you make of anti-depressants and how to treat depression, the larger question to me is, "Would you make a drug available over the counter that's not particularly effective for most people and which some people kill themselves on while others get hooked on it and still others go through the Jones of withdrawal?" If you answer "Yes," then you'd have a tough time making a case against the legalization of some other drugs.
Me? I'm not in favor of OTC anti-depressants. If their performance and safety were in line with aspirin or antibiotics, then I'd be fine with the idea. But they aren't and I'm not.
An interesting piece in today's New York Times on mindfulness meditation, which comes to us by way of Buddhism and likely comes in many flavors and forms. Ben Carey, the NYT's reporter on mental health issues, raises appropriate concerns about whether meditation is a fad or a legitimate treatment:
"It is catching the attention of talk therapists of all stripes, including academic researchers, Freudian analysts in private practice and skeptics who see all the hallmarks of another fad...."At workshops and conferences across the country, students, counselors and psychologists in private practice throng lectures on mindfulness. The National Institutes of Health is financing more than 50 studies testing mindfulness techniques, up from 3 in 2000, to help relieve stress, soothe addictive cravings, improve attention, lift despair and reduce hot flashes.
"Some proponents say Buddha’s arrival in psychotherapy signals a broader opening in the culture at large — a way to access deeper healing, a hidden path revealed.
"Yet so far, the evidence that mindfulness meditation helps relieve psychiatric symptoms is thin, and in some cases, it may make people worse, some studies suggest. Many researchers now worry that the enthusiasm for Buddhist practice will run so far ahead of the science that this promising psychological tool could turn into another fad.
"'I’m very open to the possibility that this approach could be effective, and it certainly should be studied,' said Scott Lilienfeld, a psychology professor at Emory. 'What concerns me is the hype, the talk about changing the world, this allure of the guru that the field of psychotherapy has a tendency to cultivate.'"
It's no surprise to me that meditation is gaining so much attention: CBT can be pretty rigid stuff while Buddhist approaches change in the hands of each practitioner, and, besides, the Zen has the reputation of being damn cool (I've heard the sex is better too). The trouble I've noticed with meditation over the years is that most people simply cannot get to that deep place of transcendence that you've got to get to in order to justify it as a treatment. That said, I know people for whom this sort of thing has been profoundly healing and life changing. So if it works for you, congratulations. If it doesn't, move onto something else.
I think Carey was smart to point to concerns that the use of meditation in psychotherapy could be racing ahead of the evidence. But, whatever, it's free country. Sure would be nice to see some more large-scale controlled studies.
I'm just as concerned as the prof I quoted above when it comes to possible guruism is the psych world (not that our culture's chemical gods are particularly helpful either). But maybe that's because the social history of my native land, California, is littered with hundreds of sleazy stories of gurus, many of them Buddha-based, run amok and I've bumped into my share of human wreckage from such groups over the years. My experience dealing with quasi-religious groups around certain gurus over the years--both in California and Washington State, where I wrote about one cult--is that people are turning to such outlets to salve their distress over being human in a complex culture at a complex time in human history and that many of them in the "personal growth" movement--as it was called once--were huge suckers for cult leaders. You do remember the Hale-Bopp comet suicide cult?
I'm certainly not saying that's the way meditation psychotherapy gets practiced. One just worries that it could be.
I really don't know what other headline to put on this Archives of Internal Medicine paper that came out yesterday from researchers showing that patients with dementia face a risk of death or other serious event at more than 3 times the rate of other elderly with dementia who don't get an antipsychotic. Given that recent studies (such as CATIE or this British study from January or this Dutch study from March) have found that giving antipsychotics to such patients is less effective than placebo, you've got to wonder what the rationale continues to be for pressing these meds on the elderly. I can kind of understand this in select cases, but as a standard of practice I cannot understand this medical approach. It's not playing out well clinically at all.
Of course, allegations of off-label marketing of second generation antipsychotics for use in the elderly is at the heart of several states' lawsuits against makers of these drugs. Strangely, that bit of context and the CATIE results didn't find their way into this piece in the Washington Post by Health Day News, which I guess is becoming part of the paper's health reporting team, itself the reported victim of a major shakeup coming out of the paper's recent buyouts cum layoffs.
Anyway, the reporter offered this:
"However, the problems underlying the need for such medications, behavioral problems such as aggression and agitation, are very real, and the alternatives to antipsychotics are limited, the researchers added."'A misreading of the findings would be we don't need to do something for these nursing home residents,' said study author Dr. Gary J. Kennedy, head of geriatric psychiatry for Montefiore Medical Center in New York City.
"Many experts feel behavioral interventions should be tried first and antipsychotics used as a last resort, 'when the behavior or the psychiatric symptoms are really out of control and causing complete distress not only for the person suffering from Alzheimer's, but for caregivers all around them,' said Maria Carrillo, director of medical and scientific affairs at the Alzheimer's Association in Chicago. 'It's important to work these things out with the physician and, of course, do follow-up very closely together, so you can make sure these antipsychotics are having the effect you want and, if not, discontinue them immediately.'"
The study was broken down into two main groups--those living in the community and those in nursing homes--and three subgroups--those getting no antipsychotics, those getting second generation antipsychotics and those getting first generation antipsychotics. The study was based upon the medical records of about 43,000 patients with dementia between 1997 and 2004.
Dementia patients who lived in the community and got a second generation antipsychotic were 3.2 times more likely to die or be hospitalized than patients who got no antipsychotic. With a first generation antipsychotic the rate jumped to 3.8 times. And the deaths and hospitalizations were occurring within 30 days of getting the drugs. That's just shocking to me.
As for nursing home patients with dementia, the rates of deaths or serious problems were 1.9 times for the newer drugs and 2.4 times for the older ones.
These findings simply amaze me. A reader who shot me an email last night posed an interesting irony:
"I can't help wondering how parents who strongly advocate for their children (including adult children) to take antipsychotics, view second generation anti-psychotics as miracle drugs, use extortion to achieve medication compliance, or insist on injectable anti-psychotics would feel if they realized that they face a future which might involve these very medications."
Anyone care to take a crack at that?
Separately, what with continued scientific evidence of health consequences for elderly patients getting antipsychotics, you've got to wonder what the health consequences are for people diagnosed with schizophrenia and bipolar disorder and why there is not more of a hew and cry on that front. We already know that antipsychotic use shortens the lifespan of people with schizophrenia. I don't know of similar evidence for people with bipolar disorder, but I'd be surprised if the evidence were appreciably different. What's interesting is that dementia patients generally get these drugs at lower doses than schizophrenics and bipolars. All of this also makes you wonder what outcomes will be like for patients who will get Seroquel for depression under its forthcoming FDA approval.
Or am I wondering too much here?
Troubling news just keeps rolling on Chantix, the stop smoking drug, which was last week banned for use by pilots and air traffic controllers by the FAA and was also banned for use by commercial bus and trucks drivers due to the recent warnings about erratic behavior caused by this drug.
Now, the Los Angeles Times reports about a Louisiana man who, two days after starting the drug, had his eyes roll back in his head while he was driving his truck with a woman. Then he steered the truck right into a bayou and the pair likely came close to losing their lives.
The LAT also reports that there were some very quiet advisories issued to docs by Pfizer last summer about problems with the drug. Apparently, plenty of docs either didn't read the warnings or blew them off as a trivial "it'll never happen in my practice" thing. Even the FDA thinks that's a problem:
"But such admonitions apparently didn't get much notice from busy doctors. Even some government transportation agencies missed them."The Federal Aviation Administration continued, until last week, to list the drug as approved for pilots. The federal truck safety agency was also unaware of the risk.
"'That is a problem,' said Janet Woodcock, head of the FDA's drug evaluation center, adding that her office needs to find ways to communicate safety information more effectively."
Do you think?
Meanwhile, the blog Fat Jewish Guy reports that Chantix has been making him utterly nutso after three days on the drug:
"OK, so today was a little better."Yes, my skin was crawling, but at least there were no violent thoughts.
"I’m lying.
"When I was on the phone with Pfizer, I definitely wanted to kill the snarky guy on the phone with me."
How strange that a drug being pressed upon patients by doctors to address a public health problem is turning into a public health health problem. Where have we heard of this before? SSRIs anyone?
Out of Britain comes this interesting survey from OnMedica.com. Keep in mind that it's just a survey:
"Almost half of doctors are reconsidering prescribing selective serotonin reuptake inhibitors to patients with depression after research found that they were not as effective as expected."Of the 490 doctors questioned by OnMedica, 44% said they would consider other treatments to SSRIs because of doubts over their effectiveness."
Survey or not, that's still telling and likely a big shift in doctor attitudes in the last few years. It'd be interesting to see where American docs line up on this issue. The rethink is coming because of studies published in the New England Journal of Medicine and PLoS in recent months showing that the efficacy of anti-depressants isn't anywhere near what the public and docs have been told by pharma companies over the years.
I've also written about the NEJM study in Willamette Week.
Read it and gasp. From upstate New York:
"Chittenango Middle School arrested for selling prescription drugs to students. On May 8th, school officials found pills, including Chantix and anti-anxiety medicine, in the possession of some students who were selling and giving out pills to other students."State Police arrested a 12 year-old juvenile Sullivan for 3 counts of Criminal Sale of a Controlled Substance in or near school grounds, a Class B Felony and 3 counts of Endangering the Welfare of a Child , a Class A Misdemeanor.
"He has been released into the custody of his parents and to appear Madison County Family Court.
"State Police say more arrests could be coming.
Where the hell did a 12-year-old get his or her hands on Chantix and Xanax or Ativan? Had to be the parents. People have clearly got to start locking up the meds. And why the hell would kids so young be handing psych meds around in the school yard? Have they heard they can get high?
Whatever happened to the days when the bad kids stuck with cigarettes and weed?
I'll be out of town doing some outside work much of today after about Noon PDT. I think Puckett may handle comment approval in my stead, but if not it'll be evening before I am back at the computer.
BTW, it's Memorial Day weekend, so I hope you all have a nice holiday, unless you aren't in the US in which case have a nice weekend.
Last month I wrote about British health officials seeking to ban certain food colorings over alleged connections to ADHD in kids. Now, WebMD.com reports that some US researchers are taking a look at the additive/ADHD connection elsewhere.
"In a newly published editorial appearing in BMJ, pediatrics professor Andrew Kemp, MD, of the University of Sydney, called for removal of food additives from the diet to be part of standard initial treatment for kids with attention deficit hyperactivity disorder (ADHD)...."Kemp tells WebMD that practitioners have largely ignored the clinical evidence suggesting that dietary modification improves ADHD symptoms in some children.
"'Clearly it doesn't work for everybody, but very few treatments do,' he says. '(Dietary modification) is certainly something that parents who want to avoid drugs could try for a month or six weeks.'"
As a first line approach to dealing with ADHD this makes sense, although elimination diets, as they are known, have been around since the 1970s and met with varying levels of success. And cold water has been thrown on the link between additives and ADHD before.
WebMD.com cites recent CDC stats on the prevalence of ADHD among American kiddos: "In the United States, 4.7 million children, including 9.5% of boys and 5.9% of girls, have ever been diagnosed with ADHD, according to the latest statistics from the CDC."
Ten percent of boys and 6 percent of girls? That's a remarkably high number of kids and certainly points to the need to figure out what is going on, regardless of whether additives are source of the problem. British researchers have estimated that about 30 percent of all ADHD cases can be tied to issues with additives. If true, there are 1.5 million or so kids in this country who could be affected.
We'll see how this turns out.
The Federal Motor Carrier Safety Administration, which regulates commercial trucking and bus driver licenses interstate, today issued a warning about Chantix, the stop smoking drug which yesterday was the subject of a ban by the FAA. The warning advised medical examiners for the agency "to not qualify anyone currently using this medication for commercial motor vehicle licenses."
Looks like I wasn't wrong when I guessed yesterday that bus drivers could be next for a ban.
Tough week for Pfizer. I bet you they are hard at work on another version of this drug.
I've had a look at the report by the Institute for Safe Medication Practices that spurred yesterday's FAA ban on the use of Chantix, the stop smoking drug, by pilots and air traffic controllers and that report is a doozy. From Bloomberg:
"Among the psychological side effects reported to the FDA were 28 suicides, 41 cases of homicidal thinking, 224 reports of heart trouble, 525 reports of hostility or aggression, and 397 cases of possible psychosis. There were also 173 serious injuries, including traffic accidents often associated with unconsciousness, dizziness, muscle spasms, or mental confusion."
Last year, when I wrote that this drug was acting like a bad old SSRI, I was attacked for making the association. Now, it's apparent that the report, based on the FDA's adverse events database, backs my concerns about the drug. In its two years of market life, the drug has generated more than 3,000 reports to the FDA (of course, the public and docs are a bit more attuned to the fact that they can report problems with drugs to the FDA these days than they were a few years ago). In a 10-year period, Paxil generated about 8,000 adverse events reports. By comparison, Chantix is like the Son of Frankenstein. Of course, it's never 100 percent clear if a drug is responsible for problem X, but based upon the many accounts of Chantix users who've written to this site, I'd say the drug has the unique ability to make regular folks crazy. And, it says quite a bit that the FAA banned the drug's use. That's not an agency that's prone to overreaction.
The rolling set of warnings the FDA has placed on the drug and Pfizer's own warning label (in advance of what would've been an almost certain black box warning by the FDA) have knocked sales of the drug down by one-third and financial analysts have downgraded future sales for the drug as well.
"The new report prompted Sanford C. Bernstein & Co. analyst Tim Anderson to cut his sales estimates for the drug by 42 percent, to $758 million from $1.31 billion, in 2009 and by 60 percent, to $720 million from $1.82 billion, in 2015."
That's a whole bunch of change going down the sewer. I often bang on the behavior of pharmaceutical companies in relation to hiding problems or non-performance issues with their drugs, but in this case Pfizer gets high marks from me for its behavior and its willingness to be proactive while inevitably knowing that it was hurting itself on the revenue front. The first very public reports of problems with the drug came in from late-September through early November of last year. Only a few months later, the FDA had issued warnings and Pfizer had voluntarily stepped up to the plate and issued its own version of a black box warning (after spending a few months trying to blame some of the effects of the drug on the effects of quitting smoking). Compared with how Eli Lilly covered up known problems from the late-90s onward with Zyprexa and then spent two years negotiating terms of the FDA black box warning, insisting all along that the drug was no problem, this is about as ethical as it gets in the pharma world.
Then again, company officials likely knew that if they didn't respond, the FDA would force a black box down its throat, and the company would be sued into infinity by plaintiff's attorneys. It still might be for all I know.
It's a pity Lilly wasn't as upfront with Prozac and Zyprexa. Lives would've been spared. But then you could say the same about the companies that make Paxil and Zoloft and Effexor and, well, you get the picture.
So I just finished watching the PBS "Depression: Out Of The Shadows" special and it had its problems, which I'll get to, but overall it was not terrible, except when it came to ECT which I think the show gave a free pass to while almost completely ignoring CBT. I think the producers were a bit too unwilling to be adult about the problems with anti-depressants and meds in general, although the subject is broached and, then, quickly backed away from several times during the program (which you can catch during upcoming repeats). I also think the program engaged in at least some fallacies as well.
Marissa Miller at depression introspection live blogged the show last night and has a nice rundown of it up. And her own analysis.
Globally, however, I think the program was OK, as in B-minus/C-plus OK. That's probably because its "faces of depression" were mostly sympathetic characters and genuine humans who had to grapple with some dicey depression and addressed it the way they addressed it and had it work out the way that it's worked out and were fairly articulate about their own experiences, and the loss, grief and flat out human loss that is somehow tangled up in the blue that is Depression and is often its grave enabler. I give them credit for that. All of them. I must admit to feeling worried about some of them, since I have a fairly good sense of where they've been and where they are. But then maybe I walked away semi-happy because I am damn glad that the I who was once Them is now Me.
Poor Andrew Solomon is on Remeron, Wellbutrin, Zoloft, Zyprexa (for the anxiety, he said, that accompanies his depression) and a couple of other meds for Alzheimer's to help stave off weight gain and cognitive impairment from the meds plus two kinds of fish oil. "That's my morning," he jokes with the camera, as he doles out his pills. He also exercises with a personal trainer and has a kitchen that no one could ever be depressed in (OK, I exaggerate a bit there) and does weekly talk therapy, apparently with Richard Friedman, who writes for the New York Times along with being a psych doc. How could you not be concerned for someone with that much voodoo in his system? I know he's made some very adult choices, and one hopes he might be a in a position to make a choices in different directions as time goes on. He's kind of become a spokesman for Depression (yep, the capital letter kind) and I hope he gets to speak up for other solutions as his life goes on. He's certainly a thoughtful and articulate man.
Of course, it was rough watching the two teens and the former Bloods gang member, Dashaun, talk about their experiences. And there was a mother who'd had postpartum depression who's now on a low dose of some unidentified anti-depressant in preparation for having a second child. This is apparently to prevent another bout of depression.
That's one of many places where the show fell apart a bit for me, where I felt it wasn't being entirely honest with its audience. The proof for meds preventing future episodes of depression is fairly weak, at least by my yardstick, although I know there is a lucky crowd who eventually find the proper mix of meds and don't have depression anymore. Sadly, this is perhaps 30 percent of the people who take anti-depressants--and perhaps it's a bit higher--and I am kind of surprised that Tom Insel, the head of NIMH, didn't bring that up when he was on camera. He's certainly said something close to that publicly before. Anyway, I feel the show should've been more honest about this point.
I was also staggered by how much time the show spent on ECT and deep brain stimulation, an experimental technique. I understand that this was in the context of discussing refractory or treatment resistant major Depression, but to spend about 10 minutes on these two controversial procedures while almost no time was spent on talk therapy, except in snippets throughout the program, and CBT, which made about a 10-second appearance, is a bit beyond my sense of what's fair and judicious in what was basically a depression for the uninitiated sort of program. Where the hell were Aaron and Judith Beck? Where was Charles Barber, or someone like him? Nowhere.
I was a bit frustrated that the program basically said, "ECT got a bad rap because of 'One Flew Over The Cuckoo's Nest'" and then showed a clip of Jack Nicholson's face as he was getting forcibly zapped and then said, in effect, "It's not like that anymore." If it's not like "that" anymore, then why not show the face of the woman who was having ECT performed on her instead of her feet? Why not a spend a wee bit more time discussing the pitfalls of ECT?
ECT is not a harm free procedure for everyone and that's a fact. It's also a fact that I am biased on this issue. But if it's OK for PBS to be baised, then it's OK for me.
I was pleased that the show spent some time talking about fast-acting depression treatment, especially ketamine, although it ignored the similar research on MDMA and marijuana. I think all three of these drugs should be researched until their molecules have nothing left to give in search of fast-acting treatments because there is something special about these molecules that the extant research is trying to tell us. But then I've been saying that for three years. It's nice to see ketamine make a brief appearance as the club drug that could.
To its credit, the show did chip gently at the idea that meds don't work for everyone. In a segment where Philip Burguieres, vice chair of the Houston Texans football team, was talking on the phone with someone he openly said that meds never worked for him and agitated him, but it was half-drowned out by the narrator. But it was there. Emma, a teen who'd been so depressed she was sent to a hospital in a neighboring state, refused to give the unidentified anti-depressant she takes much credit for her recovery. Dashaun flat out refuses to take meds.
Another thing that knocked me over the head was the insistence throughout the program that Depression is a disease and a medical problem. I don't have to time to go into this kind of beatdown right now, because it's a "Yes, it is, No, it isn't" dichotomy. To its credit, the program didn't hype the chemical imbalance theory of Depression. By the standards of the last 20 years, that's progress.
The most ticklish of the fallacies that gnawed at me in the show was the claim that Depression (and depression) are more untreated than treated in our culture. The show offered no evidence to back this assertion and, from where I sit, its claim is nothing more than opinion. It's certainly no more defensible than my opinion that the crisis in depression (and Depression) treatment isn't a lack of treatment or of people getting treatment (be it meds of therapy), but a lack of medical treatments that work well without beating up the depressive or not working at all.
And, finally, I don't think the show did a careful job of pointing out that almost all of its patient faces were sufferers of very severe major Depression (most had required hospitalization), when the fact is that the faces of depression in American aren't even close to all being like that.
And that's healthy for all of us.
What did you think of the show? If others of you have written about it, let me know.
The FAA has banned the use of the stop smoking drug Chantix after numerous reports of erratic behavior associated with use of the drug that have resulted in a public health warning from the FDA. Pilots and air traffic controllers are banned from using the drug.
"FAA spokesman Les Dorr says the ban is effective immediately and that the agency was notifying unions representing pilots and controllers."The FAA decision comes a day after its officials were briefed on the side effects by the Institute for Safe Medication Practices.
"A representative from Chantix maker Pfizer Inc. did not immediately comment Wednesday afternoon."
Hm, today pilots. Tomorrow bus drivers?
UPDATED: 1:48 p.m. PST with AZ's response.
Arkansas State AG Dustin McDaniel yesterday brought suit against AstraZeneca for illegal marketing and fraud, among other charges, in its sales of Seroquel to various agencies in the State. The suit, which somewhat echoes a lawsuit filed by McDaniel last fall against Janssen/J&J over its handling of Risperdal, another atypical antipsychotic, alleges that the company knew of risks associated with the use of the drug, primarily diabetes and weight gain, but did not properly warn physicians or the public. McDaniel alleges that the drug was unreasonably hazardous and dangerous.
Jim Minnick, a spokesman for AstraZeneca, responded to the suit in an email. "AstraZeneca denies the allegations brought by these lawyers. Seroquel has helped millions of people suffering from a variety of debilitating mental illnesses, and allowed them to lead meaningful lives. AstraZeneca will vigorously defend itself in this lawsuit."
The lawsuit is online here (1.5 MB .pdf).
There are several stinging accusations in the lawsuit, which primarily focuses on promotion of the drug for use in children and the elderly. Not that the state is ignoring accusations for how the drug may have been aimed at people diagnosed with schizophrenia.
"Seroquel's premarketing clinical trials did not support an assertion that it was less likely to cause extra pyramidal symptoms than traditional antipsychotics....Defendant's trials were designed to produce similar rates of EPS in patients sorted into placebo groups and those taking Seroquel."
And concerning diabetes and hyperglycemia:
"[T]hey implemented marketing strategies that blamed diabetes and hyperglycemia on the schizophrenic population at large rather than on Seroquel...despite the fact that defendant's own internal studies and adverse event data revealed that Seroquel increased the risk of diabetes, even among schizophrenics."
Among other things, the suit alleges that the company sought ghostwritten research and paid thought leaders to support AZ's marketing aims, that AZ failed to reveal material facts about hypotension and cataracts, that AZ knew the drug to be unreasonably hazardous and dangerous, that it illegally marketed Seroquel for use in children and elderly and for depression and other psychological conditions, that the company engaged in an "elaborate and clandestine promotion of Seroquel for non medically necessary uses," that AZ engaged in "illegal direct solicitation of physicians."
In addition to recovering costs of care for people who developed diabetes and other injuries, the state is seeking an injunction against AZ to stop its off label marketing of the drug.
I reported earlier today that the state had also sued Eli Lilly over Zyprexa. A spokesman for the AG tells me that that was an erroneous media report in Arkansas and that the state has not yet sued Lilly.
I'm just hearing now that Arkansas State AG Dustin McDaniel has filed suit against AstraZeneca claiming that the drugmaker pressed doctors to prescribe Seroquel even where it wasn't required. The state has previously sued the makers of Risperdal and Zyprexa.
More on this when I see the lawsuit itself.
Last week, Gianna Kali who authors Bipolar Blast brought an academic study to my attention that left me speechless. It's a paper by Martin Harrow, PhD, and Thomas H. Jobe, MD, both of the University of Illinois College of Medicine's psychiatry department, and was published last year in the Journal of Nervous and Mental Disease. Its subject is what were the outcomes for people diagnosed with schizophrenia at a Chicago area psychiatric hospital 15 years after their initial diagnosis and treatment. It also takes up the tricky question of who fared better, patients who took antipsychotics consistently or patients who didn't take antipsychotics at all.
The quick, untricky answer is that the people diagnosed with schizophrenia who didn't take antisychotics had better outcomes 15 years later than the patients who did take antipsychotics. Yes, you read that right.
Before I launch into a discussion of the paper, I wanted to offer a brief disclaimer since I know this is a very emotionally charged subject. I am not trying to make an argument that anyone should be off-meds or should be on-meds. I am not interested in having that fight. I'm also not going to fly off and declare the medical model of treating schizophrenia defunct (I've noted many times, however, that it does not work very well) and that schizophrenia doesn't exist. This isn't about that.
This is about yet another tantalizing piece of evidence in how alternatives to the standard medical model for treating schizophrenia have worked out. Unfortunately, the study group in the paper simply isn't large enough to draw the kind of broad conclusions that many of us would like to draw. It is nonetheless fascinating work and joins other studies that show outcomes for people diagnosed with schizophrenia can be better for patients who step outside of the standard medical model (for whatever reason). I am thinking in particular of the WHO study of outcomes for schizophrenics in developing nations as opposed to developed nations (much better outcomes in developing nations) and a 1988 paper by Courtenay Harding, which examined outcomes of people with schizophrenia who were deinstitutionalized in Vermont in the 1950s and were sent out into the community, many of them to medication free lives (they did better than counterparts in Maine). There are other examples in the literature, of course, but for now I'll leave it at that.
And, since this paper does discuss unmedicated schizophrenia, let's be clear that the people in this study group who succeeded sans meds fell into a relatively special cohort and it's pretty clear that they didn't go off-meds willy-nilly after walking outside the locked unit door. Please keep this in mind.
Now, onto the Harrow and Jobe paper. For some reason, I was not able to get a copy uploaded onto my site this morning. I'll fix this as soon as I can. (Paper is now online here.)
"Patients with schizophrenia who had removed themselves or been removed from antipsychotic medications showed significantly better global functioning and outcome than those still being treated with antipsychotics. Detailed analyses of those patients with schizophrenia on antipsychotic medications versus those not on medications at the 15-year follow-ups also were conducted. These analyses indicated that in addition to the significant differences in global functioning between these groups, 19 of the 23 schizophrenia patients (83 percent) with uniformly poor outcome at the 15-year follow-ups were on antipsychotic medications. The data on psychosis in Figure 1 show that at the 10-year follow-ups, 79 percent of the patients with schizophrenia on antipsychotics had psychotic activity, whereas 23 percent of those not on any medications had psychotic activity. Sixty-four percent of the schizophrenia patients treated with antipsychotic medications at the 15-year follow-ups had psychotic activity, whereas 28 percent of those not on any medications had signs of psychotic activity.
That data doesn't exactly offer much support to the generally-accepted notion that antipsychotics prevent psychosis and improve global functioning and that everyone diagnosed with schizophrenia should be on them at all times. But people diangosed with schizophrenia were not the only ones who came into the psych unit with psychosis. There were people with psychotic depression, bipolar disorder (the most aggressive kind, one assumes) and other psychotic disorders. The authors don't go into their experiences in much detail, but offer this global assessment:
"The results for the nonschizophrenia patients who had psychotic disorders at index hospitalization also showed very large significant differences; patients with other types of psychotic disorders not on any medications at the 15-year follow-ups showed better outcome than those on medications."
So it's almost the same story there: no meds means better outcomes. So why is there such a huge emphasis on all-meds, all-the-time in American's mental health system much less in the broader culture? The authors state:
"A certain number of schizophrenia patients who go off antipsychotic medications and relapse are quickly brought to the attention of psychiatrists and other mental health workers when they return for treatment and/or rehospitalization; these relapsing patients are the ones from whom opinions by some about the absolute necessity of continual antipsychotic medications for all patients with schizophrenia are formed."
In other words, if researchers and key opinion leaders and such never see other types of patients with schizophrenia, then their world view is very narrow, as is their research base and so is their opinion of what modalities should guide treatment. Keep in mind, that's the authors' opinion and since they are on the faculty at a major medical school, I'd say they may have a basis for their view.
Someone needs to get this paper into the hands of Fuller Torrey stat.
So why did some people with schizophrenia do well without meds? There's a discussion of this in the paper, but it basically boils down to two key factors: "the unmedicated patients were more likely to be more resilient patients with better prognostic potential, better developmental achievements, and more internal resources" as well as, here's number two, self-esteem. Internal resources and self-esteem can be nebulous terms and I wouldn't even begin to guess at how a clinician can apply them to a patient. Nonetheless, they are the classic you know 'em when you see 'ems. Developmental achievements would, I assume, relate to learning and language acquisition (did they graduate from high school? on time?).
Then the authors offer this:
"Recommendations regarding the use of medications at various phases of illness are often based on a risk-benefit analysis involving, as in many other areas of modern medicine, the probability of success rather than certainty. The current data identify a clear subgroup of schizophrenia patients not being treated, a number of whom experienced periods of recovery, with the data indicating that on average, those patients not on any medications at the 15-year follow-ups had significantly better current and previous global adjustment than those on antipsychotics. There also has been some indication that as our patient sample is getting older, there may be some tendency for improvement among schizophrenia patients. Our overall analysis indicates that many schizophrenia patients not on antipsychotic medications played some role themselves in the decision for them to stop taking medication and leave treatment at a relatively early phase of their posthospital course. Thus, most of the subgroup of schizophrenia patients not on any medications who were in a period of recovery at the 15-year follow-ups had been taken off or removed themselves from antipsychotic medications over 10 years earlier by the 2-year or 4.5-year follow-ups."
Although the study doesn't get into social service-y details such as housing and aftercare, the Vermont study mentioned above does (the study first came to my attention in Charles Barber's Comfortably Numb). I don't have access to the complete paper--thanks APA!--but there is an account of it in the American Psychological Association's Monitor from 2000. The basic story is that long after being released from the state hospital, about two-thirds of the patients were recovered, often without medication at all. Much of the credit for that is given to community integration.
I'm going to leave my assessment of the Harrow and Jobe paper at that for now. For me, it has a lot of personal significance. I have two relatively close friends who are diagnosed with schizophrenia. One currently sits in a psych unit, doped to the point of slurring her words, after her psychiatrist tried an "innovative" new medication regime with her and it had very bad outcomes. The other is a man in his 60s who's been on the injectable Haldol for two decades or more and often looks like a dead man walking. I'd like both of them to have better futures, no matter how they are won.
There's been a lot of advance press for this evening's PBS special, "Depression: Out Of The Shadows." NAMI, which is a sponsor of the show, has done a very good job of seeding the media with information about the show, which features a number of profiles of depression sufferers, including Andrew Solomon, author of the Noonday Demon, and an after show featuring Jane Pauley discussing depression research. There have been lots of advance print pieces on the show's airing, so I'm sure loads of people will be tuning in. It's not like depression is a small problem in the US and elsewhere.
Not everyone reviewing the show in advance is in love with its results:
"Opening with lonely cinematography and sad, minor-key music not unlike a Cymbalta ad, the documentary "Depression: Out of the Shadows" (CPTV, 9 p.m.) attempts an overview on what is actually various maladies, from bipolar disorder to postpartum depression, usually lumped under one name."A number of case studies are followed in the two-hour film, along with a glimpse of current treatment (in one, electroshock treatment is presented as a treatment that has gotten a bad rap; lobotomies don't get a similar resurrection).
"The show provides almost too much information. Even so, it's followed by a panel discussion, "Out of the Shadow" (CPTV, 9 p.m.), in which interviewer Jane Pauley dominates the discussion, speaking of her own bipolar disorder, diagnosed at age 50."
Electroshock? ECT? On PBS? Oh my. Here's a transcript of researcher Charles Nemeroff calling the procedure "the heavyweight champion."
I've poked through the show's website a bit--every show must have a website these days!--but it's not clear to me whether PBS is taking us all to a big old SSRI party or if there's going to be some emphasis on psychotherapies such as CBT. It's telling to me that the show's producers have lined up psychiatrists such as Charles Nemeroff and Tom Insel to participate, but where the heck are Aaron and Judith Beck? If you are doing a show on depression, it'd kind of make sense to include them.
Anyway, interviews with some of the depression sufferers are already posted here and you can read them for yourself. Apparently, one woman who will appear and who suffered from postpartum depression after her first child was born is now pregnant with a second child and is taking an anti-depressant. I hope to God it's not Paxil. I don't want to prejudge the show's tenor too much, but advance news that electroshock and pregnant women taking anti-depressants will be in the mix sure send shivers up my spine.
You can find out where the program airs in your area by using this handy schedule finder.
I'll have a report on the show tomorrow. Feel free to leave comments on it in the meantime, if you are viewing it in time zones ahead of mine.
I've complained on this site before about the odd phenomenon of Google searches for "seroquel snorting," "shooting seroquel" and the like coming to this site, principally because I have made stray mentions in the past of the drug's underground status as a drug of abuse. I think I was the first in the mental health blgosphere to write about Seroquel's misuse in this fashion in January 2007. And, the hits haven't let up since, sadly, because something is up in American society.
It's surely not AstraZeneca's fault, but its star antipsychotic is apparently becoming a new breed of hillbilly heroin, a la Oxycontin (which can also be crushed and snorted, or melted down and injected). The $4 billion a year in sales drug is set for FDA approval for depression and anxiety, meaning there will be even more of it out there to divert into underground uses. Lovely.
Last evening, however, I was visited by someone in the US looking for information on "seroquel 'date rape.'" Yes, the very concept is sickening, but I did a Google search myself using the term and found that Bipolar Chicks Blogging had had similar visits as well. Apparently, some very major criminals out there are using Seroquel as a drug to turn women--likely teens, given that that's the age group where the drug seems abused the most--into rape victims by slipping them a Seroquel. I have no idea if the perps are crushing the medication and mixing it into a drink or somehow slipping their victim the drug in pill form, but you can imagine the effect this sedating drug could have on someone. I can find no record of any arrests of anyone using the drug in this fashion.
Sadly, this is how "Roofies" or rohypnol gained infamy in the 1980s. As sick as I find all of this, I thought it was necessary to point out just how weirdly embedded antipsychotics are becoming in our culture and how they are being put to very sad uses. For those of you who bump into this post long after it's published, don't even think about doing what you are thinking about doing. Rape isn't just a crime. It can mess up its victims--female or male--for many, many years to come. So don't do it.
The fine folks at Bristol-Myers Squibb are running new TV ads for Abilify, its super-expensive, chock full of side effects atypical antipsychotics. I saw it air last night during "The Tonight Show." The new ad--which hasn't made its way to YouTube yet--is aimed at adult women with bipolar disorder who experience "racing thoughts" and bursts of energy. Once again, that sounds like symptoms of bipolar disorder 2 and hypomania, not the big old serious mania that folks are taught to fear. The ad is pretty much your typical Big Pharma "improve your lifestyle" ad and features a woman with curly hair wandering the cliffs in what's got to be Mendocino County. At the end of her wandering, she meets up with a vaguely handsome 30something man who gives the putative Abilify taker a welcoming hug. Then they go for a walk.
Abilify will get you acceptance from the opposite sex! It will also put you at risk for a whole raft of side effects which the voiceover trots out as the pair walk a long planked path toward the sea. Maybe they'll see Venus in the sea foam. Target marketing at its finest and aimed squarely at a class of potential users who, according to recent research, may actually be wrongly diagnosed with bipolar disorder at about a 50 percent rate.
You can view the ad on BMS's website for the drug. Just click on "view the TV spot."
I am simply beside myself that as a culture we are now advertising antipsychotics--the sledgehammers of psychiatry--on national TV. What could possibly be next?
Oh, wait: Abilify has been approved for use in children as young as 10. I see a play date at the beach advertisement in our future.
Yes, you read that correctly. State records in Minnesota--which requires public disclosure of payouts to docs---indicate that psychiatrists in the state have received $88 million in gifts, grants and fees from Big Pharma since 2002. This comes from the St. Paul Pioneer-Press, which is running a kickass series in the wake of a patient committing suicide in a clinical trial of Seroquel in 2004.
"The amounts aren't unusual, according to the payment records collected by the Minnesota Board of Pharmacy. The records, which were updated this month to include 2007 figures, show 167 Minnesota doctors who have received $100,000 or more since 2002. One in four psychiatrists has received funding from pharmaceutical companies, averaging about $50,000 over the six years."
I'm sure all of these docs diagnose disorders and prescribe drugs in a completely unbiased manner as a result. If the payments are this lofty in Minnesota, then you've got to wonder what they are in California and New York. But we don't know because those states don't require payments to be reported publicly. The two doctors in the Seroquel trial got $782,000 from pharma companies.
"A growing body of research suggests that drug company money has an influence on study outcomes. One analysis found that industry-funded research was four to five times more likely to produce positive outcomes for a paying company's drug than federally funded research. A report last year found that drug company-funded studies of cholesterol medications were much more likely to produce results that favored their own drugs as well."
This ugly little system needs to be stopped. It's not like psychiatrists are starving in the streets. The average American psych doc pulls in $180,000 a year already.
AstraZeneca, which makes Seroquel, offered this response to the paper:
"AstraZeneca declined to discuss documents from the case, but brand corporate affairs manager Abigail Baron said the company's financial arrangements with doctors are necessary to improve health through drug discovery."'That mission cannot be fulfilled," she said, 'without close partnership with those on the front lines of patient care and ... research.'"
I'd say the money AZ and others are throwing around buys them all kinds of partnership.
Yesterday, I noted that outgoing GlaxoSmithKline CEO JP Garnier had walked out on the BBC after facing tough questions over the company's handling of various accusations around Paxil (Seroxat in the UK). I'll let the audio speak for itself. It's about a six-minute exchange between the BBC's reporter and Garnier and it's well worth listening to a Big Pharma CEO defend his company and claim that it's been open and transparent with the public in its handling of allegations that Paxil caused suicidality (among other things) in patients, that the company knew what was going on from its own clinical trials, that the company then hid this information from regulators in the UK (and the US), that they hid this same information from the public and that many, many patients needlessly took an anti-depressant of limited efficacy that did all manner of rotten things to them and that they had a bitch of a time withdrawing from. Think I am joking? Go look at these photos of a newborn in an NICU in Seattle four years ago. The baby is withdrawing from effects of Paxil that was given to her mother while the child was in utero. Some Paxil users have never been able to get off the drug.
Keep these things in mind when listening to Garnier and the BBC do the hokey-pokey: People died from taking Paxil. There are over 800 reported deaths associated with the use of this drug in the FDA's adverse events database. There are over 8,900 other adverse events in the FDA's adverse events database associated with the use of this drug.
Here's the audio which someone has superimposed a few points upon. Garnier begins by answering questions about Glaxo's new avian flu vaccine, then the reporter begins pressing him on Paxil (Seroxat) at about the 4:50 mark. Scroll forward and hear the sound of one CEO who flunked his PR classes.
I haven't the faintest whom the BBC reporter is questioning Garnier, but he puts the boots to the evasive CEO in fine fashion. Thanks to my many British friends (you know who you are) for getting this radio moment online in listenable form. Are Americans as pissed off about this drug as are the Brits?
So new readers know my bias on Paxil, here's how I once described my short stay on this drug many years ago:
"When 80 mgs. of Prozac didn't fix what ailed me, my doctor dropped that in favor of Paxil and lowered my dose of Lithium. I am convinced that Prozac made me pretty damn suicidal, but Paxil was a whole other ball game. The shit gave me akathesia and spun me up. I wound up desperate and alone, sitting in my apartment night after night trying to figure out what the hell was going on with me. I didn't last long on Paxil. Even my sorry ass doctor figured it was not benefitting me so he took me off it, this at a time before the Paxil withdrawal syndrome business was acknowledged. Let me tell you: everything people say about how bad it is coming off of Paxil is true. Mostly, I felt like a dead lump as I was being weaned and had those lightning bolt zaps in my brain. Not pleasant. "
BTW, everyone knows there are loads of Paxil documents out there in the US and UK that have never seen the light of day. It's time that they did.
This is a very sad story from South Carolina. It speaks for itself.
"Back in February, Zach Langan, a 15-year-old scholar at Battery Creek High School chose to end his life by stepping in front of a cement truck traveling a busy highway. He left a note behind."Zach was four months into taking Lamictal, a drug prescribed to treat his seizures for Epilepsy. His dosage increased about a week before his death. Ironically, that's also when the Federal Drug Administration released serious warnings about 11 antiepileptic medications, including Lamictal. After an in-depth study, the FDA alerted health professionals about an increased risk of suicidal thoughts and behaviors in patients who take these drugs to treat epilepsy, bipolar disorder, migraine headaches and other conditions."
I wrote about these warnings when they came out in February. This same class of anti-seizure drugs is used by millions of Americans diagnosed with bipolar disorder. Most of the suicidality noise in the FDA's data seemed to relate to people being treated for a seizure disorder, but there was a slightly elevated risk of suicidality for people taking the drug for "mood stabilization.
Langan's mother offers this sad irony:
"'The only explanation I can find for the morning my son died is the medication,' she said."Four months shy of his death, the optimistic teen who shared dreams of one day becoming president started his treatment for epilepsy. His mother, a nurse, kept a close watch.
"'I actually did a lot of research on it. I didn't see anything about suicide in any of the research that I read. The first time that I became aware of it was a week before he died,' Langan said.
"That's when the FDA issued a warning citing a study where patients receiving antiepileptic drugs had approximately twice the risk of suicidal ideation compared to patients receiving placebo.
"'So I called him into the living room and I said, "Hey, Zach, I just heard this on TV." And he said, "I’m good Mom, I'm good." I said, "Okay honey, if anything changes, you need to tell me." But he never did,' Langan remembered."
Two doctors said:
"'There are definitely times when there are no signs that someone may be ready to commit suicide or about to commit suicide,' Dr. Shannon Drayton, Assistant Professor at MUSC said."Drayton, who works with students at the Medical University of South Carolina's Institute of Psychiatry called this a sticky issue.
"'Unfortunately, with Epilepsy, it's not something we have a cure for yet and so patients have to be treated,' Drayton said. 'And with all the medications, there are 11 that have the warning on them now and all of them eventually may have this warning. You know, there's really not a lot clinicians can do but educate their patients about the warning signs of suicide and risk factors.'"
"But Dr. Bryant Welch says one of the greatest risk factors is how patients often react to the warnings.
"'Yes, the medication will put some people at increased risk,' Welch said. 'But the problem is, there are a lot of people it will but at a decreased risk. So, it's not a reason not to use the medication. It's a reason to use the medication with greater awareness, and to stay in close contact with your doctor about any changes.'"
The FDA and GlaxoSmithKline, the drug's maker, responded after a fashion.
"Both the FDA and Lamictal's maker Glaxo-Smith-Kline refused our on-camera interview requests. But both wrote us their reaction to the study's findings."GSK said 'Our own analysis of clinical trial data with Lamictal showed a similar trend but the actual numbers were too small to draw conclusions.'
"An FDA spokesperson says, 'The FDA will work with manufacturers of marketed anti-epileptic drugs to include information about the increased risk of suicidal thoughts and behaviors in the labeling of these products.'"
Sad stuff.
Much has been made by Sen. Barack Obama's supporters of the fact that he stands for integrity, "new politics," "reform" and cannot be bought by any special interest. That may be so, but the new politics are sure beginning to look a bit like the old politics.
CNBC.com reports that Obama is numero uno among presidential candidates, current and former, in contributions received from pharmaceutical companies and health care companies at $636,000 through the end of April. Sen. Hillary Clinton is second at $568,000. Sen. John McCain has taken in $173,000.
If he's elected President, you have to wonder what health care reform would look like under Obama. You also have to wonder why an alleged reformer is taking in so much money from Big Pharma.
Via Pharmalot comes news that JP Garnier, the CEO of GlaxoSmithKline, walked out on a BBC radio show earlier today due to repeated questions about whether the company would release documents related to its handling of Paxil (Seroxat in the UK) and allegations that the company hid important side effect information from UK regulators, including data on suicidality. Garnier was on the program to discuss Glaxo's new avian flu vaccine and apparently wasn't expecting the Paxil questions. Good work by the BBC. You can hear the program here, but you need to go to the little iPlayer in the top left corner and scroll to 1:32:00 in the program to hear Garnier's interview. I suspect that the feed is only good for today, so listen while you can.
I wish the US press would push Glaxo as hard as the BBC has. Paxil has caused just as many, if not more, problems for patients in this country.
Garnier has previously blamed the press for all of Glaxo's troubles.
Two excellent articles in the St. Paul Pioneer-Press today examining the very ugly case of a young man who had a first episode of psychosis and was admitted to care by a doctor who basically shoehorned him into a study of Seroquel for treating schizophrenia. I won't even attempt to summarize much, so you should just read the pieces for yourself. I think there are serious questions about how the doctor may have manipulated the patient to keep him in the study even though he wasn't doing well on the drug. The patient, Dan Markingson, later committed suicide.
There are also serious questions about how the University of Minnesota's institutional review board performed.
All in all, a sad discouraging story and some excellent journalism. (Via Pharmalot.)
This is a sad story out of Fresno, Calif. On April 16, Jesus "Jesse" Carrizales, 17, who was supposedly taking Lexapro and one of a number of antipsychotics (Geodon, Risperdal or Seroquel) for depression attacked a campus police officer with a bat at his high school. After being knocked to the ground, the cop saw the teen winding up with the bat, so the cop shot the kid dead.
Now, what's come out of autopsy results is that Carrizales was likely taking far too much Lexapro to the point where the drug induced paranoia into the youngster. That's the opinion of the medical examiner's office. The entire story is tragic and you can read it here.
You can draw your own conclusions about what role Lexapro may have played in this tragedy. It's not clear if there were any antipsychotics in his blood at the time of his death.
Here's what the county coroner said:
"The autopsy showed Carrizales' blood had a "lethal level" of Lexapro....In general, "lethal level" means that in some people, that amount would kill them, [Coroner] Hadden said. A toxic level of Lexapro also could cause paranoia in some people, but not everyone. The drug's effect would depend on whether Carrizales had built up a tolerance to the antidepressant, Hadden said."
Here's what one psychiatrist said of the Lexapro connection:
"Dr. Barry Chaitin, chair of the department of psychiatry at the University of California at Irvine, said in general, Lexapro is 'pretty safe' even at high doses. The lack of antipsychotic medicine in Carrizales' system, however, is troubling -- those drugs are typically prescribed to help people cope with aggression, psychosis, hostility and hallucinations, he said."Carrizales' behavior is difficult to explain, said Chaitin. On one hand, Carrizales' family has said that the medication helped him become more sociable. But police say Carrizales sneaked up on Perry from behind and attacked the officer without provocation.
"'His conduct appears way out of the ordinary because the attack sounds premeditated,' Chaitin said. 'He must have had a misperception that the officer was a threat to him.'"
Back in 2003, my then-doctor had me restart a Lexapro prescription after being off the drug for four months. Within hours of taking the 10 mg. pill, I was so agitated and my heart was racing so fast that I literally thought I was going to die. I almost took myself to an ER to be monitored. Two days later, I took myself off the drug. Lexapro sure can be weird stuff.
The new issue of Newsweek has a cover story on a child who allegedly has bipolar disorder and, while it is an article filled with lots of detail and heart, it is also one of the worst pieces of journalism on the alleged disorder that I have ever seen. I'll return to the media criticism in a second.
The article concerns a boy named Max, who was diagnosed with bipolar disorder and hyperactivity when he was two. He's been on 38 different meds, including Zyprexa at two years old. He's been hospitalized. He's been in therapy (still is). He's made suicide attempts. His parents, seemingly educated and fairly normal, have tried everything. He even had an off-meds trial that lasted for one month (probably not long enough to assess things, but then I wasn't there). Their son is 10 years old now. He's not doing particularly well. There's an accompanying video which I cannot make myself watch.
It's a very sad and rough story to read. It takes place in the Boston area (why are so many of the stories about out of control kids centered in the Boston area?). And, yes, the kid's doctors come the realm of the Harvard bipolar child army. While I am critical of the bipolar child paradigm, it's very clear that there is something the matter with kids like Max. We're a generation now into diagnosing young children with serious mental illnesses and I don't think we have many answers for what's up. That's discouraging.
We'd all like answers, but my global hunch is that child bipolar disorder is not anything other than an intermediate explanation of what's going on. Maybe I'll be proven wrong someday.
Even more discouraging is the magazine's handling of the most controversial diagnosis in all of psychiatry and psychology. The author, Mary Carmichael, admits a few times in the piece that the diagnosis of bipolar disorder in kids is controversial and that some doctors feel it's overdiagnosed (since it doesn't even exist in the DSM, it's overdiagnosed by definition). However, Carmichael doesn't include a single quote from a single critic of the child bipolar disorder paradigm. These critics exist, have medical degrees, teach at major medical schools and are easy to find through the miracle of search engines. Why Carmichael didn't include any dissenting views is hard to understand. Why her editors at the mag didn't insist upon the same is beyond comprehension for a news magazine that is supposed to adhere, at least somewhat, to the basic journalistic principles of fairness. Unless the editors and Carmichael ha