Friday, May 29, 2009

Breaking Down Personality

The story so far: We all want happiness and love and meaning in our lives. The people who have this tend to have positive emotions, an integrated personality, life satisfaction, and virtues (such as courage and wisdom). But to get there, we need to have a strong sense of self-awareness, we need to "know thyself."

Personality is adaptive and non-linear, and evolved from three basic systems: 1) Habit (non-rational, tied to basic emotions such as fear), 2) Propositions (rational, tied to secondary emotions such as empathy) 3) Narratives (rational and also self-aware, allows us to change).

The above is from a lecture last week at the American Psychiatric Association's annual meeting by leading personality expert Robert Cloninger MD, detailed in two blog posts (here and here).

Okay, let's break down personality. The slide you see below dates from Dr Cloninger's work in 1993. It breaks personality into two separate but interconnecting branches, temperament and character.

Temperament is about our habit systems (which roughly equates to the ancient Greek concept of the "four humors") namely:

  1. Harm avoidance - The fear system that mediates responding to punishment and pain.
  2. Novelty seeking - Looking for pleasure, which leads to rage when frustrated.
  3. Reward dependence - Allows us to be sensitive to social cues that in turn allows social intimacy.
  4. Persistence - Allows us to deal with expectations about whether we will get rewarded or not. We see it in very conscientious people.

But these traits don't stand alone. They're always interacting with the person's character, namely their view of who they are and how they relate to the rest of the world. You can describe these in terms of three cognitive sets: 1) Self-directedness, 2) cooperation, and 3) self-transcendence.

It's the communication between all these that allows us to say whether someone is healthy and in a state of well-being. This in turn influences your overall sense of who you are, which in turn allows you to shape the rest of your personality.

Thus, we have a model of mental self-government that allows us to regulate the competing urges from our basic biological drives.

Fine, but if our mental self-governance is closer to anarchy, can we impose order? If it's closer to autocracy, can we loosen the reins? In short, can we change?

Let's back up. Below is Dr Cloninger's "temperament cube," that he developed in 1987.

Don't worry. We will compassionately spare you the details. The gist of the model is the interplay between three of the four temperaments: novelty seeking (high and low), harm avoidance (high and low), and reward dependence (high and low).

Thus, someone with low harm avoidance tends to be carefree and risk-taking while those with high harm avoidance are characterized as anxious and pessimistic. Combine high harm avoidance with low novelty seeking and worlds collide.

Note, on the corners of the top we see the four Cluster B Axis II personality disorders, together with their prime descriptors, thus: histrionic (passionate), antisocial (adventurous), narcissistic (sensitive), and borderline (explosive).

The bottom corners produce another set of (opposite) extremes. Thus, the antithesis to someone with explosive borderline traits would be a methodical and obsessional individual. Fortunately, most of us don't cluster into the corners.

But life isn't that simple. This is where mental self-government and its three branches come in:

  1. Self-directedness equates to the executive branch that implements the rules and allows you to be responsible, purposeful, and resourceful.
  2. Cooperation equates to the legislative branch that gives you the rules to allow you to get along with other people, so you can be flexible, helpful, and compassionate.
  3. Self-transcendence (judiciary) gives you the flexibility to figure out when the rules apply and don't apply.

Voila, the "character cube."

The ones who seek help, Dr Cloninger said, tend to be schizotypal or depressed. Thus, if we look to the bottom corner of the cube, in Dr Cloninger's words: "I had a patient of mine describe this as, 'Life is hard, people are mean, and then you die.'"

This contrasts with those who hit the character trifecta with the Jungian prize of enlightenment and all the goodies that go with it. Those with the Freudian prize of being organized can take comfort in the fact that they can at least love and work.

Thus we see a spectrum from transcendence to psychopathology, with a lot of room in the middle, meaning there is no true separation between normal and abnormal personality.

In the slide below, the upper case letters (S,C,T) stand for high self-directedness, cooperation, and transcendence, while the lower case letters (s,c,t) stand for their polar opposites. Red is happiness, blue is sadness.

Take a look. If you're low in all three, you're really going to be depressed. And seeing that personality is fairly stable, you are likely to stay depressed. Not good.

But here's the good news: We can change, and change can occur fairly rapidly. Stay tuned ...

Thursday, May 28, 2009

Who the Hell Are We and What Does That Have To Do With Our Recovery?

Picking up from where we left off:

It turns out the most consistent way of recognizing that someone is in a state of well-being is how well they've been able to express self-directedness, cooperation, and self-transcendence in their lives.

This translates into meaningful work, mutually caring relationships, and a sense of what's really important beyond out individual needs.

So says personality and well-being expert Robert Cloninger MD of Washington University (St Louis). Dr Cloninger was addressing a packed house at the American Psychiatric Association's annual meeting last week in San Francisco. I was in the audience as a journalist.

Medications are useful in getting us to stable, Dr Cloninger advised, and in putting us in a position to get started. Then the real journey begins. It all starts with knowing ourselves, having a sense of growth and self-awareness.

So who the hell are we?

Well, before we answer that question, we might first ask ourselves to define personality. Dr Cloninger's simple explanation: "It's the way we learn and adapt." Let's amplify that: "It's the self plus the internal and external forces that pull on the self."

Key features of personality, Dr Cloninger said, include:

  • It's dynamic, and non-linear. "Get over the idea that it's fixed and written in stone."
  • It is psychobiological, which includes the body, the analytical mind, and the intuitive and creative mind.
  • It is organized. There is a basic design in all human beings that allow us understand and to communicate with each other.
  • It is personal. Adaptive processes occur within the individual. We tend to get sidetracked comparing the differences between people, which is wrong. If we want to motivate someone, we need to figure out what is going on within them, what counts to them.
  • It is idiographic. We are each unique.

Here's a key fact we tend to overlook: We have evolved over millions of years, and with it three major systems of learning and memory.

  1. Habits and skills learning: Reptiles have this nailed. This is based on the quantitative strength of our synaptic connections. It is prelogical, not rational, and subjectively linked to basic emotions such as fear and anger and ambition. These habit systems demand instant gratification and tend to get in conflict with each other.
  2. Semantic learning of facts and propositions: Mammals rule in this department. It is contingently logical and rational in a hierarchical sense, and is associated with secondary emotions such as empathy. Propositions bring order to the chaos of the demands of our basic emotions, but is not self-aware.
  3. Intuitions and narratives: A uniquely human trait, the recognition that we are writing our own story. At once, we talking about pre-verbal and intuitive, rational and self-aware, modular rather than hierarchical. Here's the pay-off: "It gives us flexibility about the future. We can change. We can have hope. We can be creative and do things we've never done in the past and surprise everybody."

Ah, now we're getting somewhere. We've just gotten past the Table of Contents. Now we can begin to check out our Owner's Manual in earnest. Think of the slide below as a sneak preview.

Trust me, "Know Thyself" is where recovery starts, and Dr Cloninger is the leading authority. Much more to come ...

Wednesday, May 27, 2009

What the Hell is Well-being, Anyway, and Why Is It So GD Important?

Good title for a talk? Psychiatry tends to veer toward wonky titles, such as: "Developing a Positive Psychiatry of the Person."

Okay, let's go with that. Last week in San Francisco, at the American Psychiatric Association's annual meeting, I heard Robert Cloninger MD of Washington University (St Louis) deliver the type of lecture that justifies his reputation as a pioneer in that strange field that we simultaneously know everything and nothing about: personality and well-being.

"Well-being is the universal wish of human beings," Dr Cloninger opened. "We all want happiness, love, and a meaning of life that is greater than our individual self."

Obviously, this is something that you can't get in a pill, and therein lies the problem with our treatments. Response to acute (initial phase) treatment, whether with meds or talking therapy, is only moderate, and drop-outs, relapses, and recurrences are high.

But if clinicians are smart, Dr Cloninger went on to say, they will attend to what people want in life and build therapeutic alliances around that. On the other hand: "Getting people to do things they don't want to do doesn't work well."

There are four converging ways to measure well-being, Dr Cloninger told his audience:

  1. Emotions: Namely positive ones, ie being happy.
  2. Personality: It turns out that positive emotions relates to maturity in character. People who have a well-integrated personality also turn out to be happy.
  3. Life satisfaction: People who are content with their lives don't have a lot of complaints.
  4. Virtues: People who have them (courage, justice, moderation, honor, wisdom, patience, love, hope, and faith) also tend to be happy, mature, and satisfied with life. Reframing a goal to work on developing courage, for instance, may produce a better outcome than figuring out what to do with an anxiety disorder.

Well-being has little to do with income. Rather, there is an association with heritable personality traits, plus with meaningful work, mutually caring friendships, and spiritual values. Dr Cloninger cited Ed Diener's pioneering work that showed while personal income in the US has dramatically increased from the 1930s to the present, life satisfaction has remained static.

Over this time period, we have seen the introduction of all our psych meds and all our manualized therapies. We know these things are helpful, Dr Cloninger said, but "why isn't it making a dent" in these statistics?

So what's the key to well-being? It all starts with self-awareness, Dr Cloninger advised.

Check out the name of this blog. Much more on Dr Cloninger to come ...

Tuesday, May 26, 2009

What Does the Tango Have To Do With Recovery?

As you know from reading this blog, last week I was in San Francisco attending the American Psychiatric Association's annual meeting as a journalist. What I didn't report was my biggest knock-me-over-with-a-feather moment. Allow me:

On Thursday morning, I listened to Dean Ornish MD of UCSF. Dr Ornish is a celebrity doctor and author known for promoting smart lifestyle choices as the key to good health. His recommendations are all grounded in rigorous research, much of it his own. For instance, in a 1998 study published in JAMA, Dr Ornish found that patients can not only stop the progression of heart disease through lifestyle management, but can actually reverse it.

In fact, smart lifestyle reliably works across a range of illnesses (including depression), and can often replace invasive and costly treatment (or at least make the treatment work better). The catch is you have to do it, and therein lies the problem. "What's sustainable," Dr Ornish said, "is not fear of dying but joy of living."

Hold that thought.

Dr Ornish is no stranger to depression, having experienced a severe episode that sidelined him from college. Loneliness and isolation, he said, increases mortality 3.7 times. Depressed individuals are more likely to over-eat, smoke, drink, and work too hard.

You would think that making a few simple changes would be easy, right?

"'Dean, you don't get it,'" his patients told him. "'These behaviors get us through the day.'"

Getting through the day anyway they could was more important to them than living to age 86. In essence, these people could see no benefit to giving up smoking if it meant losing their cigarette-smoking friends, especially if there was nothing to replace those friends.

Meanwhile, the research on the benefits of positive lifestyle kept mounting up. In one 2008 study published in PLoS (JA Dusek lead author), researchers found that the relaxation response in trained meditators switched off cancer-promoting genes.

Changing our lifestyle actually changes our genes, Dr Ornish pointed out. But who wants to change their lifestyle? What Dr Ornish finally figured out was that will power was a nonstarter for individuals, as was the motivation to live longer. "Who wants to live long if you're depressed?" he asked.

What works, he said, is joy, pleasure, freedom. Up went a slide of two tango-dancers - Dr Ornish and his wife. Doing the tango was part of Dr Ornish's exercise routine.

That's when the lightbulb went off: Yes, we need to lead disciplined lives, but we are doomed to failure unless we incorporate fun into our routines. On my website are numerous articles about the virtues of good diet, exercise, yoga, meditation, and so on. We know all this stuff works, but what good is any of it if we give up?

Then it occurred to me: None of my lifestyle routines are based on iron will. They all have enjoyment incorporated into them. For instance, my "exercise" is daily walks, water volleyball, and (off and on) dancing. My "diet" is based on my love of cooking, where anything I throw together is both tastier and healthier than restaurant food. My "stress-management" is all about building contemplative time-outs into my schedule. Even my "meditation" has a fun twist - I play (rather badly) the didgeridoo.

Then I flashed back to some of my recent blogs - a whole series on play, a bunch of home-made nature videos. Guess what? When it comes to fun, I am very compliant. My "fun" routines may not be as beneficial as "serious" routines, but they work much better by virtue of the fact that I stick to them.

In the words of Dr Ornish: "Doing the tango makes your brain grow ... Some of the things that are most fun are good for you."

Dang! Why didn't I think of that?

Monday, May 25, 2009

This Memorial Day ...

This Memorial Day:

Our men and women are returning from two wars. They have witnessed things and felt things that those of us who stayed home have no clue. Their brains have been overwhelmed, their psychic beings shaken to the core.

This Memorial Day:

Our soldiers may leave the battlefield, but they cannot leave their memories there. Very high percentages are returning home with PTSD, depression, and other mental illnesses. Even those without full-blown symptoms have issues to deal with. Others are ticking time bombs. Suicide will claim more of them than enemy gunfire. Many will attempt to cope by turning to alcohol and drugs.

This Memorial Day:

Many brave men and women have no clue what is about to happen to them. They served as heroes, but, like many who served in Vietnam, may wind up homeless. They may be remembered for their bravery, but we will cross the street to avoid them.

This Memorial Day:

It's not just about flags on graves. It's about serving the people who served our country.

This Memorial Day:

Resolve to do something tangible. Advocate. Donate. Get involved with one of the veteran's organizations. Get involved with a mental health group making an outreach to veterans. Do something. Then keep doing it.

This Memorial Day:

It's our turn now.

Sunday, May 24, 2009

New Imaging Studies Reveal Brains of Assholes

In a study about to be published in "Nature," researchers at the NIMH reveal the first-ever fMRI scans of assholes at work.

Said lead researcher Y Mee MD, PhD, "We've always known an asshole when we see one, but it never occurred to us to actually scan their brains. I mean, seriously, who would want to?"

Nevertheless, the researchers overcame their strong revulsion and recruited 10 assholes plus 10 control subjects.

"I mean - crap - I was ready to quit my job in the first five minutes of the study," said co-author I Hadinoff PhD. First the assholes filled out their intake forms completely wrong, then abused the staff when they had to fill them out again. Next, they kept pushing and shoving to be the first one into the MRI machine. But once in, they couldn't stop complaining.

This posed a special difficulty because study protocol required that first the assholes' brains be scanned while in a resting state.

"So here we are," said Dr Hadinoff, "having to be nice to these fucking assholes. No sooner do I get one calmed down than another one gets started, and next thing they're all setting each other off like mousetraps going off in a room."

One asshole lady complained that her no-good son-in-law refused to finish cleaning the leaves out of her gutter, as he had promised. A world-class therapist had to be called in to remind the individual that her son-in-law had fallen off the ladder while she was shaking it and had cracked nine vertebrae and would be a quadriplegic the rest of his life.

"But I'm on a fixed income," the woman retorted. "How the hell am I going to find affordable help?"

Said Dr Hadinoff: "You know that show where that guy does all those shit jobs? I'm on the short list for the Nobel Prize, but, believe me, I was ready to throw it all in and go to work standing up to my ears in cow shit. Seriously, anything had to be better than dealing with this shit."

Eventually, the researchers got the assholes settled down and were able to get images of their brains at rest. On close inspection, the scans revealed certain structural abnormalities to the posterior corpus rumpus section of the brain. (See image above.)

"It's uncanny," said Dr Y Mee. "It's as if their brains had 'asshole' written all over them."

Then the assholes were made to perform certain tasks while their brains were being scanned. In one task, the subjects were asked to imagine lying on a beach on a tropical island.

"What? I'm just supposed to lie there in the hot sun with all the mosquitoes and sandflies and who knows what?" was the typical response. "Screw you, I did that for my second honeymoon, and let me tell you, it wound up to be our first divorce."

In other tasks, the assholes were asked to imagine something good about a member of their family, any accomplishment they could be proud of, a waitress they were nice to, and something that went wrong that they were willing to accept responsibility for. They failed every task spectacularly.

As their brains were thus engaged, a certain part of the posterior corpus rumpus, known as the temporal anal cortex, lit up like a Christmas tree. (See image below.)

"It's amazing," said Dr Y Mee. "For the first time ever, we are looking into the mind of an asshole - and the last time, I can assure you. Believe me, after what we went through, no one in their right mind is going to want to try to replicate our findings."

The findings are expected to provide valuable insights into radio talk show hosts, Fox News commentators, and antipsychiatry bloggers.

Drs Y Mee and I Hadinoff are at present in intensive therapy. Their prognosis is poor to miserable.

Friday, May 22, 2009

Judi Chamberlin is Dying, But She is Still Fighting Our Fight

Judi Chamberlin belongs to a generation of antipsychiatrists who got in the face of psychiatry and changed it. Equally, she helped shake patients out of their fatalistic mindset to one of feeling empowered. Judi, 64, is dying of COPD. Her insurer, UnitedHealthcare, has pulled the plug on her home hospice care.

Ironically, her insurer would be paying out far more money for back and forth visits to the hospital.

Judi has dedicated her life to fighting for the dignity of others. Now, she is fighting for her own dignity - the right to die in accord with her simple wishes. But her fight is never her own fight. It's always our fight as well.

Full story in the Boston Globe

Thursday, May 21, 2009

Tooting from San Francisco - V: Mental Health Break

I’m at the Cliff House perched over the Pacific Ocean, drinking coffee and watching where the seals are supposed to be on the rocks. I lived in San Fran for about a year back in the mid-70s, and this is where I enjoyed coming to for my mental health breaks.

This is mental health break time. The American Psychiatric Association’s annual meeting is in its last hours and I’ve called it a wrap. I heard some excellent presentations this morning, which I will get to at another time. I’ll be flying out in a few hours. Time to close this laptop and enjoy the view ...

Wednesday, May 20, 2009

Tooting from San Francisco - IV: Dang- This is Interesting!

This is my fourth day in San Francisco at the American Psychiatric Association’s annual meeting. To recap:

Morning: Time off.

1:00 PM: I’m back on the job, checking out the posters. “Deep Brain Stimulation [DBS] of the Ventral Capsule/Ventral Striatum for Treatment-Resistant Depression” reads the heading to a poster.

“That does it,” I tell the researcher in an accusatory tone. “Now you’ve really gone out and confused me.” Helen Mayberg and others have already been applying the same technique to Brodman area 25 in the anterior cingulate, and yesterday I was treated to an equivalent of a masters class on the topic.

Now I have to learn about another area of the brain? I hold my ground. I demand my masters class.

1:45: I’m early for a session on “me-too” medications. Frederick Goodwin is on the panel, and we greet each other warmly. This is the first time I’ve seen Dr Goodwin since the NY Times published an account that irresponsibly smeared him in relation to a show that aired on “The Infinite Mind,” which used to be run on NPR.

The NY TImes piece was a mugging, and clinicians who should know better such as physician blogger Dan Carlat and psychologist John Grohol of PsychCentral engaged in the equivalent of kicking Dr Goodwin in the face. Antipsychiatry bloggers such as Philip Dawdy of Furious Seasons predictably piled on without checking the facts.

To the best of my knowledge, I am the only blogger who defended Dr Goodwin. I wasn’t sticking my neck out. The facts were - and still are - on his side. I was very pleased to see Dr Goodwin in a chipper mood. We enjoyed a very pleasant conversation, then I took my seat in the audience.

The first speaker, William Carpenter of the University of Maryland, made the telling point that new meds development is held up by the prevailing single disease mindset (Dr Carpenter used “paradigm,” but I forgive him). For example, we tend to equate psychosis with schizophrenia. Psychosis, however, features in other illnesses and conditions. Individuals with schizophrenia, in the meantime, have a lot more to contend with than just psychosis.

For instance, avolition (lack of motivation) looms large in schizophrenia. Yet, there is no med for this, and there may never be one if drug companies have to run clinical trials based on old precepts. Suppose, for instance, a drug company tested an “avolition med” on a population of individuals with schizophrenia. But if only say one-third of those being tested had to contend with avolition, then, said Dr Carpenter, the trial would fail.

Ironically, such a cognition med may be efficacious across a whole range of disorders. Dr Carpenter informed his audience that the FDA is aware of the situation and is working to fast-track cognition meds (Google “MATRICS”).

Dr Goodwin pointed out that clinical trials do not reflect clinical practice. For instance, those with severe mania can’t get into trials as it is impossible to obtain from them “informed consent.”

Clinical trials are based on finding results that apply across large populations. This, combined with “hierarchies of evidence” (which devalue smaller studies and clinical experience) are forcing patients “into a one-size-fits-all straightjacket.”

Here’s where the danger lies, according to Dr Goodwin: Treatment guidelines based on unrealistic clinical trials (but which are at the top of the evidence hierarchy) create uniform menus. These menus are increasingly being employed by government and private insurance to ration services.

For instance, what if third-party payers decided not to approve of the use of an antidepressant added to a mood stabilizer for bipolar patients because a large STEP-BD study did not find them effective across a large population?

Dr Goodwin described his experiences dealing with out-of-touch academic researchers back in the nineties. “I couldn’t imagine them ever managing a patient,” he said. (And they didn’t.)

Evidence-based medicine, Dr Goodwin said, is based on what we already know. Innovation tends to come from clinicians breaking the rules, which is how lithium and antipsychotics found their way into psychiatric practice. It isn’t just about the NIH translating scientific research into treatment.

4:00 PM: Afternoon posters. The first one I bump into is about unidentified “threadlike and/or spherical particles” in the cerebrospinal fluid of bipolar patients.

Dang! This looks interesting. Now I really have to budget my time. A few posters down: “Inhaled Loxapine Rapidly Improves Acute Agitation in Patients with Bipolar Disorder.”

Recall what Dr Carpenter had to say about the need to test for a specific part of the illness (such as avolition), not just the illness. Loxapine is an ancient antipsychotic, so we’re not talking about a new med, but the principle is the same. The treatment, if approved, would be taken on an as-needed basis, say when you felt yourself freaking out over a missed plane at midnight in Las Vegas airport (which happened to me). Unlike “popping a Klonnie,” sucking into the inhaler would work instantly, presumably without sedating effects.

Right now, we’re simply talking promising. Maybe the promise of the med won’t play out, but - dang! This looks interesting. There is only 30 minutes to go to this poster session and I’m still not out of the first aisle ...

This is John McManamy, live from my fleabag hotel room, on my way out to grab a burger.

Tuesday, May 19, 2009

Tooting from San Francisco - III: A Major Sea Change

I’m actually thinking with a clear brain. So THAT’S what it’s like. Trouble is I need to be winding down for sleep. To recap my day:

Tuesday 6:00 AM. I’m up way too early and can’t get back to sleep. I’m headed into my third day of the American Psychiatric Association’s annual meeting in San Francisco with precious little sleep in my bank account.

8:45 AM. I’m seated for my first talk of the day. “Have you heard the news?” I ask the psychiatrist next to me. I hand him a print-out. The heading reads:

“Breaking News: Psychiatry Comes Up with New Diagnosis of Asshole.”

The piece is a hard copy of a blog piece I wrote a couple of weeks back. We’re about to hear a talk by Robert Cloninger on “Developing a Positive Psychiatry of the Person,” and it’s nice to know I’m doing my bit.

“Treating symptoms is not enough,” Dr Cloninger opens. It’s all about well-being. Dr Cloninger has been a major paradigm-shifter in mapping out the fine points of personality and their interacting dynamics. Personality, he explains, is non-linear, involving the way we learn and adapt, plus the internal and external forces that pull on the self.

We are shaped by our genes and environment, but our self-awareness (a uniquely human trait) allows us to modify these influences and move forward with our lives.

Personal change, he said, can happen very rapidly, if you can get the person to recognize their strengths and weaknesses.

11:00 AM: I’m struggling to stay awake. Marc Schuckit of UCSD is about to talk on the fine points of the genetic and environmental influences involving alcoholism, and my cortex is running on empty.

I’m at the talk by virtue of Kenneth Kendler’s presentation the day before. Dr Kendler used alcoholism as an example of gene-environment interaction, and I figure this is a way of getting deeper into the topic.

I’m not disappointed. Dr Shuckit’s research into the area began some 30 years ago when he started asking a few simple questions. There are many causes of alcoholism, involving many genes and environmental influences, but Dr Shuckit noticed that when those with alcoholism described their early drinking experiences, they tended to remark about how they could drink everyone under the table.

The technical term is “level of response” (LR). These individuals need to have a lot more drinks to feel the same effect as their peers, and kids drink for effect. Once you get into the pattern of heavy drinking, Dr Shuckit said, then the environment kicks in: You hang out with heavy drinkers; they expect you to engage in heavy drinking.

Dr Shuckit has tracked more than 400 offspring of alcoholics and control subjects for 25 years, and found that LR is a reliable predictor of alcoholism. He is also getting a reading on the genes involved.

So, say you know that your 12-year-old has a genetic predisposition to LR, is there anything you can do about his environment to protect him? Different peers? Different expectations?

12:30 PM: I meet up with a good online buddy, Gina Pera, who has a great ADHD blog. Nearby, we grab some gyros and take them outside. Gina’s been a great moral and intellectual support to me, and I could literally sit out in the sun all day with her, but an afternoon of dark rooms beckons ...

2:05 PM: I walk in late to a very large packed room where an expert panel is discussing borderline personality disorder. What is wrong with this picture?

A mere three years before, at a featured lecture at the APA in Toronto, one of the pre-eminent leaders in the field, Joel Paris, spoke to mostly empty chairs. Earlier, at a bipolar session, one leading expert had been dissing the borderline diagnosis.

In three years, something has dramatically shifted in psychiatry. Earlier - at a session at the same time as Robert Cloninger’s - leading borderline expert John Gunderson had spoken to a packed house. Add to that the packed house from Dr Cloninger’s presentation.

At a brief pause in the proceedings, I ask the psychiatrist next to me what is going on, and he confirms my impressions. In essence, the bloom has gone off biological psychiatry, which translates into sending patients out the door with just a prescription. We’re seeing the pendulum swing back toward an earlier era when psychiatrists used to spend time working with their patients to find solutions to their personal problems.

It is reasonable to infer from this that the profession is becoming receptive to the goal of recovery.

It’s as if at some point in time in the last three years psychiatrists had suddenly woken up. I have no idea how this will play out in the real world, where psychiatric practice is dictated by the insurance industry and where old habits die hard. But I can assure you, this is a major story, perhaps the biggest event in my 10 years of reporting on mental illness, and one readily quantifiable - just count the people in the room.

4:00 PM: I am literally sleep-walking through the afternoon poster session. This is usually a great learning opportunity for me, my chance for one-on-one face time with the experts. But my brain isn’t tracking. I’m not engaged. No sense hanging around ...

5:00 PM: I’m back in my room at my fleabag hotel. Sleep, glorious sleep. One minute later it’s 8:00 PM. I get up and splash water on my face, taking an inventory of my brain.

My sleep is not messed up, I decide. I’ll be out like a light before midnight. Moreover, I’m taking tomorrow morning off. Late sleep. A little sight-seeing. Time to wind down ...

Monday, May 18, 2009

Tooting from San Francisco - II: I Love Smart People

Monday, 9 PM: I’m in my hotel room, chilling out after a very stimulating day. To recap:

Morning, 9 AM. I have a front row seat for a lecture by the legendary psychiatric geneticist Kenneth Kendler, who executes a stunning fly-over. Brief sample:

The environment may neutralize genes. Say, for instance, it is difficult for a kid to obtain alcohol. Then certain alcoholism vulnerability genes have less chance to kick in. Conversely, “our brains have feet.” We’re not just passive recipients of our environment. Rather, our genes cause us to create the environment around us.

Genes and environment, in other words, dance a very intricate two-step.

10:15 AM: I step out into the sunlight. I’m headed from Muscone North to Muscone South. As I negotiate my way past the median strip separating two traffic lanes, someone with a bullhorn and a clown nose hands me an antipsychiatry flier.

I hurl it back at him. “F___ing idiot,” I inform him, as I keep walking. I’m across to the other side when I hear the idiot through the bullhorn: "Ooh, f___ing idiots, the best kind.”

No more Mr Nice Guy. “F___ you,” I shout in a voice that carries much louder than his puny bullhorn. “I’m a patient, and I’m going inside where the SMART people are.”

Damn! That felt good.

11:00 AM: I’m listening to an extremely smart individual, Elyn Saks, author of the highly-acclaimed “The Center Cannot Hold: My Journey Through Madness.” Despite psychotic episodes, Elyn graduated valedictorian from Vanderbilt with a major in philosophy (she learned ancient Greek so she could read Aristotle), then went to Oxford where her deteriorating condition resulted in a lengthy hospitalization. An enlightened psychiatrist urged her to go back to doing what she loved and got her hooked up with an equally-enlightened psychoanalyst.

After graduating Oxford, she earned a law degree from Yale, but not before another hospitalization that involved her being placed in restraints 20 hours a day. The “benign neglect” of English care, she said, is “much preferable to the over-intervention in US hospitals.”

Elyn graduated from Yale and procured a teaching position at USC (where she is now a professor specializing in legal-psychiatric issues). Her attempts there to get off her meds simply resulted in the return of florid psychosis. After 20 years she finally got smart and accepted the fact she was mentally ill, which meant her illness had less power over her.

She eventually got married in her 40s and joked with her husband that they’d both skipped their first marriage.

12:30 PM: My first poster session of the day. “Cingulate gyrus” I read on the heading of one poster I walk past. I freeze in my tracks, and address the researcher standing in front. “I’m going to ask a stupid question,” I warn holding up my name badge which shows I’m a journalist. “Can you explain to me the difference between the cingulate gyrus and the anterior cingulate?”

Next thing, I’m being treated to an individualized masters class in brain science. I love listening to smart people.

2:05 PM: I arrive a few minutes late for a session on the DSM-V (due out in 2012). Darryl Regier, vice-chair of the DSM-V task force is raising the topic of “categorical” vs “dimensional.”

This really gets my attention. As opposed to our current categorical system of assigning illnesses to separate pigeon holes, a dimensional approach would recognize the overlap.

The second speaker is Ellen Frank of the University of Pittsburgh, who five years ago opened my eyes to the “spectrum” way of looking at mental illness. Thus symptoms that do not necessarily cluster together over a specific period of time are regarded as clinically significant.

Think of bipolar, for instance, plus a little bit of anxiety. That small dose of anxiety, Dr Frank said, is likely to result in greater illness severity and make treatment more difficult, and she has the studies to prove it.

Dr Frank is pushing for a “simultaneous approach” to the next DSM.

3:15 PM: In the hallway, I say a warm hello to Eduard Vieta from the University of Barcelona. Two years ago, Dr Vieta and I shared the same stage at the Seventh International Conference on Bipolar Disorders, as recipients of the Mogens Schou Award (in recognition of his research and my public service, respectively).

Then it’s over to my second poster session of the day to ask my dumb questions (which is how you get smart answers). Two separate posters concern themselves with the topic of the relationship between impulsivity and suicide. Immediately, I think of my good friend Kevin, who last September threw himself in front of a train. My voice catches. I need to pause.

Kevin is my reminder why I’m here. I may be enjoying myself, but this is no game. We’re playing against our will with a rigged deck, our lives on the line. I’m here to gather in all the information I can, try to make sense out of it, connect the dots, and put it out there in a way that somehow allows us a slightly better advantage.

5:30 PM: Dinner on Fisherman’s Wharf with a “neuro-immunologist.” This is a new field that you will be hearing a lot more from, along with other fields of enquiry that are bound to lead to improvements in our lives - assuming funding is available.

8:00 PM: Chilling in my room. Another long day tomorrow ...

Tooting from San Francisco - I

Today, Monday, 4 AM: What the hell am I doing wide awake this time in the morning? Let’s pick up from where I left off yesterday.

Yesterday, Sunday, 1 PM: I touch down at San Francisco Airport, collect my bag, and take the BART into town. My hotel is a fleabag in a colorful part of town within walking distance of the Muscone Center where the American Psychiatric Association annual meeting is taking place.

Sunday, 3 PM: I pick up my media credentials at the conference, shake the sleep out of my system, and plot my next course of action. Nothing much going on, so I head out to the exhibit hall. Pharma’s out in force, but it is looking like their last hurrah. Conspicuously absent is GSK (Lamictal, Wellbutrin, Paxil), which pulled out a year or two ago, along with Abbott (Depakote) and Novartis (Tegretol). All their drugs, of course, are off-patent.

Bristol-Myers Squibb is there by virtue of Abilify, which is still on-patent, along with Astra-Zeneca, with its blockbuster Seroquel. Eli Lilly is no longer flying their Zyprexa and Prozac flags - they have set up their tent by virtue of Cymbalta. Other companies are looking tired trying to generate excitement over new versions of old products.

There is very little taste of the future in the exhibit hall. The biotech companies, with nothing to market, are nowhere in sight. Neuronetics, which recently obtained FDA approval to treat depression with an rTMS device, is basically showing off a new application of an old technology.

In short, for now, the party is over.

6:30 PM: I feel a desperate urge break Rip Van Winkle’s record. Nevertheless, I grab a seat at the grand ballroom of the Hilton Hotel, where Shire is sponsoring a dinner symposium on the pathophysiology of ADHD. This is the last year of industry-sponsored symposia at the APA. Reform is in the air, but the truth is Pharma has lost interest in staging these events. Over the years, as meds have gone off-patent, fewer and fewer of these events have been staged.

Industry-sponsored symposia are a mixed bag. Some of them come across as infomercials, but tonight’s presentation is outstanding. A panel of experts - mainly from Harvard - articulate the underlying biology to ADHD, both on the cellular level (namely what happens when a neuron fails to correctly process information that dopamine is supposed to be delivering) and on a systems level (such as when certain parts of the brain aren’t talking to each other).

Brain scan technology has revolutionized mental illness research. I’m seeing it in all fields - depression, stress, schizophrenia, bipolar, personality disorders, you name it, most of it having taken place in the last three or four years. Thanks to MRI technology, we can now see structural abnormalities in the brain compared to healthy subjects, as well as functional deficits. Example:

A slide of the anterior cingulate cortex goes up. The ACC plays a major role in modulating thoughts - in selecting relevant ones and filtering out irrelevant ones - and is wired into both the thinking cortical areas and primitive reacting limbic system. A series of superimposed markers represents the ADHD brain scan studies performed on this area of the brain. Significantly, the study results testing for an emotional response show activity in the bottom half of the ACC while the study results testing for cognitive response show activity at the top.

Many individuals with bipolar also display cognitive deficits, so what I am learning tonight is shedding light on my own illness.

This is why I am here, to listen to smart people who have dedicated their lives to improving mine. Five minutes into the first presentation and I am wide awake. Last week I got tied down in doing stories about idiots - people like Andy Behrman who have walked away with $400,000 by lying to us, people like Pat Risser who pushes an antipsychiatry agenda predicated on the belief that there is no science to support the concept of mental illness.

Those idiots are irrelevant, as are those who try to legitimize them. Before our very eyes, a picture of the brain at work is emerging, one that is displaying a dramatic interplay between genes, biology, environment, and symptoms/behaviors. This is the real story, the one we need to be paying attention to.

This is the story of the future, as in terms of new drug development. But it’s also the story of the here and now, as in putting recovery principles into practice.

9:15 PM: I’m back in my fleabag hotel, just one block from the Hilton. I flop onto the mattress and am asleep before my head hits the pillow.

Today, 4 AM: The reason I’m awake right now is obvious. I crashed three hours earlier than usual, and had a much sounder sleep. But later today my brain will demand a settling of accounts.

This morning I head out to hear the legendary Kenneth Kendler expound on psychiatric genetics, then the highly-acclaimed author Elyn Saks discuss her journey through madness. Later on, the DSM, new research, and other cool stuff. No way I can sleep through this ...

Sunday, May 17, 2009

Tooting to San Francisco

Sunday, 10 AM: I’m at San Diego Airport waiting for my flight to San Francisco. I’ll be attending the American Psychiatric Association’s annual meeting as a journalist. I’ve been attending each year since 2002.

Consider this “Tooter” and these are my “toots.”

Yesterday, Saturday afternoon: I should have had everything organized for my trip by now, but I’m still tied down with my work. Pre-travel days are always a bummer, It’s as if my system shuts down in anticipation of the energy I need to conserve for the road.

Saturday evening, just before midnight: I’m finally organized. But I know at least one thing had to have gone wrong. What will it be this time? No underwear? I get to San Fran only to find the conference is in Philly?

A few minutes later: I plop onto the mattress, bone tired, but my mind is racing. Oh, crap. This always happens.

Sunday, 7 AM: I’m ready to head out the door. I grab my cell phone, which has been charging all night. I turn it on. It won’t come on. I’m holding a paperweight with buttons. I’m about to hit the road with no phone. No time to worry about that. Gotta plane to catch ...

Saturday, May 16, 2009

No More Mr Nice Guy: Andy Behrman is a Con Artist and We Are His Marks

Tomorrow, I head off to San Francisco to the American Psychiatric Association's annual meeting, which I attend every year as a journalist. There, I have listened to talks given by three Nobel Laureates, plus many many more by Nobel-quality scientists.

These are smart people who have dedicated their lives to improving ours. Believe me, after the week I have had here, I can't wait to get to San Francisco.

It started on Tuesday when antipsychiatry advocate Pat Risser posted this as part of a longer comment to a blog piece of mine:

"Despite all the time, money and effort spent, there is no actual proof of mental illness. There are no biochemical markers, no biological tests, no hard evidence at all, to 'prove' the existence of 'mental illness.'"

Pat Risser is a veteran of the psychiatric survivor movement from the seventies, and we owe his generation an enormous debt of gratitude for their service to our community. But, in my opinion, they are standing in the way.

Let's put it this way: If the gay community had not shaken itself out of its denial back in the eighties and kept insisting that AIDS didn't exist, how much money do you think would have gone into AIDS research and treatment?

Anyway, I started researching the issue for this blog when on Thursday the Wall Street Journal ran a front page story about a sweetheart deal gone sour between "Electroboy" Andy Behrman and Bristol-Myers Squibb.

According to the WSJ, BMS paid Andy $400,000 over two years as a celebrity patient spokesperson for Abilify. Nothing wrong with that, had the drug actually worked for Andy. But Andy had only been on the med for four days when he said in a promotional video that "since I switched to Abilify, almost all the side effects have gone away ... In fact, all of them have gone away."

Then in a live speech: "If Abilify had been available to me then, I might have avoided electroshock therapy."

Trouble was, soon after taking Abilify Andy developed side effects (akasthesia and mental sluggishness) and had to go off the med. Nevertheless, apparently with the consent of BMS, Andy continued to deliver speeches written by BMS. He was paid $40,000 per reading.

(The image you see is a photoshopped cover of BP magazine, featuring Andy and what used to be a pile of books. The "sold out" slash is from the original cover.)

The same day the WSJ story broke, a mass email from Andy arrived with this heading: "Andy Behrman Tells the Truth," with the message to read all about it in his soon-to-be-released tell-all book.

That did it. Forget about Pat Risser. Time to blog about Andy Behrman, which I posted on Thursday. The piece concluded with:

"Um, Andy. I think I'm detecting an anomaly in the truth-reality continuum here. Here is where I'm confused: If you are telling the truth now, precisely what the hell were you telling four years ago?"

That same day, Andy commented to my blog, but did not answer my question. Rather, he curiously made himself out to be a hero for disclosing that he turned down an additional $50,000 from BMS.

Nevertheless, on Friday I decided to run Andy's comments as a blog post.

This morning, I viewed his short video, entitled: "Abilify Kills." Says Andy in the video: "I stopped taking Abilify because I didn't want to experience the final side effect - death."

Okay, Andy. No more Mr Nice Guy.

According to Andy's own account in "Electroboy," as described by the WSJ: "He spent time as a stripper, swindled friends and family out of thousands of dollars for a film project he never completed, and ran an art forgery scheme that cost him five months in prison."

The subtitle of Andy's book is "A Memoir of Mania," but could well have been "A Memoir of How I Blew Cocaine Up My Nose."

Was it the mania? Was it the cocaine? Who knows? But one thing we know for certain, Andy's word counts for nothing. He's been a con artist all his life, and in true con artist fashion, he has never taken responsibility for his actions. Rather, he is an expert in reframing events to cast himself as the hero: first for disclosing his illness in Electroboy, and now for blowing the whistle on Pharma ...

He also relishes the victim role: first as a puppet at the mercy of his alleged mania, and now as the puppet caught in an evil Pharma conspiracy.

In true con artist fashion, Andy views people as marks, easy targets: First, all those he defrauded in his life as a Manhattanite on the make. Then a patient community looking for a bipolar hero. Then a low IQ drug company with money to burn together with a patient community that trusted Pharma. And, last but not least, a patient community that has turned on Pharma.

Finally, in true con artist fashion, Andy shows no remorse for his true victims, the people who believed him. "No side effects ... Abilify kills." How many patients have been harmed as a result? First those who never should have gone on Abilify. Now those who never should go off.

I wish I could say we have seen the last of Andy, but he happens to be a brilliant self-promoter. I'm sure his book will be a best-seller and that his "Electroboy" movie proposal - the one he's been telling us for the last five years is about to go into production any month now - will finally get green-lighted.

Ironically, we inherited both Andy and Abilify from Pat Risser's generation. Had our community actually been blessed with smart advocates - like those AIDS heroes who demanded and got serious funding - we might actually have much better treatments right now.

Instead ...

Enough. Time to start packing. Tomorrow, I'll be in San Francisco listening to smart people. It can't come soon enough.

Friday, May 15, 2009

Andy Behrman Replies

Yesterday, I posted a piece that was less than complementary concerning Andy Behrman's involvement as a celebrity patient spokesperson for Bristol-Myers Squibb, makers of Abilify. Andy is the author of "Electroboy."

In response, Andy posted a comment stating his position. Without comment, I'm reposting his remarks here:

I'd like to set the record straight. I'd like to explain what was not mentioned in the article in the Wall Street Journal. I'd like to explain that WHILE I was still employed by Bristol-Myers Squibb, I spoke at a DBSA convention in Sacramento and to an audience of hundreds of people and disclosed the fact that I suffered from side effects - akathasia and cognitive impairment - from Abilify (and this was at an event at which BMS was a sponsor).

But until then, even after I complained about my side effects to my doctor, Dr. Mark Frye, a BMS consultant, I was begged not to discuss my side effects and that "we'll prop you up on other meds until things 'even out.'"

They tried. It didn't work. I ultimately told a BMS employee at the time (now at Otsuka) that I suffered from side effects and was no longer taking the drug. I was told that it wasn't "necessary to bring this up." So finally, I spoke up about my situation - in public - and then wrote about it - on - and BMS made sure that those statements were removed.

I was convinced by my own doctor and several BMS employees that it was "normal to have side effects and that there was no reason to go off Abilify." I disagreed. I finally came off Abilify and went public with the story.

I was constantly reminded by more than 15 people managing me, that "it was all fine." I told the truth. I wasn't re-hired. Curiously, even after BMS/Otsuka knew that I had side effects and was NOT on the drug, I was asked to speak - six months later - as a successful patient for a 50th Anniversary Celebration for Otsuka in L.A.

I was offered $50,000. I turned down the invitation. I was also told that it was "okay" to speak for Otsuka, because it was a separate company from BMS. I have always told the truth about my experience with Abilify. But more importantly, BMS made every effort to cover up the truth. And now, because I'm blowing the whistle on them, they don't even have a real comment, except for, "we didn't know."

They knew EVERYTHING. It's curious that my doctor and their medical director, Dr. Mark Frye, is no longer employed by them. I think people will be curious to see his medical records which he kept of my treatment and perhaps to learn more about media training that BMS gave to me. Or to see the speeches that they wrote for me. There's a lot that was not reported in a 3,000 word front page story.

But I think the real story here is that companies like BMS not only hide side effects (like akathasia), but do whatever they can do when they see that their spokesman, the guy who launched their big drug, is failing on it.

Thursday, May 14, 2009

Trick Question: Bias in the Media, Andy Behrman, Abilify, And Anomalies in the Truth-Reality Continuum

What is wrong with this sentence?

"In 2004, Bristol-Myers held a retreat for 1,250 sales representatives, to prepare them to market a powerful psychiatric drug for a new use - bipolar disorder."

This sentence appeared in an article on the front page of the Wall Street Journal.

Answer: The adjective "powerful" is highly emotive. When you see the word "powerful" in proximity to mention of a drug, you can expect a negative story against the med or the circumstances surrounding it to follow.

We want our prescription meds to be powerful. We want them to work. If you doubt this, next time you're being prepped for surgery, ask for a "weak" anesthetic.

It turns out that aside from the unfortunate adjective, the WSJ turned in stellar work:

The story is about Andy Behrman, author of "Electroboy." In 2004, Bristol-Myers Squibb paid Andy $400,000 as a celebrity patient spokesperson for Abilify. (Editorial sidebar: Fair enough. No one complained when Terry Bradshaw became a Paxil spokesperson.) But, as the WSJ reports, Andy had only been on the drug for four days before being filmed in a promotional video. According to the WSJ, at a company retreat for sales reps:

"A video of Mr. Behrman, a 42-year-old bipolar patient, filled a gigantic screen. He recounted how a Bristol-Myers drug, called Abilify, had changed his life. Unlike other medicines he had tried, Abilify had no side effects, he said. The testimonial drew a standing ovation."

(The image to this blog piece is from BMS's Abilify website, the image of the happy patient the company wishes to promote.)

You can probably figure out what happened next. Andy developed side effects severe enough to cause him to stop taking the drug within a year. Nevertheless, "he continued to talk glowingly about Abilify throughout 2004 and 2005."

In 2006, Andy wrote a piece for about his bad experiences with Abilify. BMS was predictably unhappy. pulled the piece. BMS was running Abilify ads at the time.

Wait, there's more to this. Andy has written a book on his experience, about to be released. Today, in my email box, came a mass mailing from Andy with this heading:

"Andy Behrman Tells the Truth."

In the email, Andy says: "It's time to hold drug makers like BMS accountable for their corrupt practices and harmful products. Just as culpable, if not more so, are the licensed physicians that aid and abet them. Do no harm? I don't think so."

Um, Andy. I think I'm detecting an anomaly in the truth-reality continuum here. Here is where I'm confused: If you are telling the truth now, precisely what the hell were you telling four years ago?

Star Trek: How I Outwitted Spock and Almost (but not Quite) Saved the World

Here I am in the movie Star Trek trying to explain the concept of peanut butter to an incredulous Spock.

"Peanut butter is not logical," Spock keeps telling me.

"You of all people would know that peanut butter is logical," I retort. "And if your mother truly loved you, you would feel the same way about peanut butter that I do."

Spock is valiantly trying not to give in to his anger. Although he identifies as a Vulcan his deceased mother was human. Earlier in the movie, his Vulcan father informed him he had a choice between two paths in life, his rational Vulcan self or his emotional human self.

Neither is right or wrong, he informs his son. Both have advantages and disadvantages. Head or heart. Informed decision or gut.

So, here we are - Spock and me - on the bridge of the starship Enterprise. The Romulan renegade Nero has just destroyed Spock's planet and Earth is next. But first, time for a sandwich.

Spock keeps trying to explain that Cardassian tofu is logical.

"Yeh," I reply. "But it tastes like shit." I mean, seriously, have you ever seen a happy Cadassian?

"What does happiness have to do with it?" Spock shoots back at me.

Now I know I have him. Spock's finally-honed logarithmic sensibility is blind to our world of emotion. It represents a variable he cannot factor into his equations, which renders him totally vulnerable to my manipulations.

"Maybe you'd be happy and much better adjusted," I fire back at him, "if the milk coming out of your dead mother's breast didn't taste like Cardassian tofu."

As you recall, this was the dramatic high point of the movie.

"You and your peanut butter can go f___ yourself!" Spock rails at me. For a nerdy Vulcan, let me tell you Spock knows how to land a punch.

Of course, having gone postal on me, Spock has no choice but to relinquish his command to me. Here you see me in the captain's chair plotting our next course of action. The bridge, as you will note, is empty. The crew has sided with Spock and abandoned ship en masse. It's just me standing in the way of the evil Romulan Nero.

The entire fate of the world is resting on my ability to anticipate my opponent.

Unfortunately, I got something like a 450 on my math SAT. Instead of intercepting Nero inside the orbit of Mars, I plot a course for the moons of Pluto.

By now, you all know the tragic result. The earth got destroyed, along with Klingon and all the planets in the Federation. So, here we are, all adrift in this strange realm called the Blogosphere. Look, I'm really sorry.

If only I had studied harder in school.

Wednesday, May 13, 2009

Should Parents Who Call God Instead of the Doctor Be Punished?

This is the title of a provocative new article in Mother Jones by journalist Deena Guzder. This week, Leilani Neuman goes on trial for reckless endangerment. Her husband is scheduled to go on trial in June. A year ago, daughter Kara, age 11, died of undiagnosed and untreated juvenile diabetes. According to the article:

"If her parents had called the hospital that day, Kara might have lived."

Instead, as their child lay motionless in bed, the couple knelt in prayer beside her. Dale and Leilani are followers of the Unleavened Bread Ministry, "an online church that shuns medical intervention."

Further down, we get to mental illness, this time in a context that includes adults. According to the article:

Mental illness is an area that remains especially taboo in orthodox religious communities. "A lot of fundamentalist Christians, including pastors, believe that people have mental illness symptoms because they do not pray hard enough or do not believe in God enough," says John McManamy, mental health journalist and author of Living Well With Depression and Bipolar Disorder. McManamy notes that "religion is often a very positive experience for people with mental illness," but extremists cling to a "medieval belief that mental affliction is the result of the work of the devil and lack of sufficient faith in God."

Recently, I devoted a blog piece to the positive aspects of faith and spirituality in our recovery, noting that:

"There have been a number of studies that convincingly demonstrate that people of faith recover more quickly from a variety of illness than their non-faith counterparts."

And that:

"For most of us, faith and spirituality is a no-brainer. We've grown up with it. We're comfortable with it. So, when we finally start thinking about our own recovery, we are not contending with learning a new skill that may not be a good fit for us. Faith and spirituality is something we can incorporate into our recovery right now, with positive benefits."

The negative side is that much of the stigma we face today stems from medieval Christianity, which saw mental illness as a form of divine retribution. This represented a total reversal of ancient and humane Greek belief. Not surprisingly, Freud described religious beliefs as a mass delusion and the Catholic faith as the enemy. As recently as the 1990s, the DSM-III-R used religious behavior in 23 percent of its examples of psychopathology.

But the future lies in working together. Medical schools now incorporate spirituality and healing into their curricula, and university centers such as Duke's Center for the Study of Spirituality, Theology, and Health are forging new understandings. NAMI, through NAMI FaithNet, is making an outreach to the faith community.

The potential for good things happening is enormous.

Further reading from mcmanweb:

God Power

In 2001, Dr Koenig, along with fellow Duke scientist, David Larson MD, MSPH, and Michael McCullough PhD of Southern Methodist University, published "Handbook for Religion and Health" (Oxford University Press). In preparing the book for publication, the authors reviewed more than 100 studies on the relationship of religion to depression. Two-thirds of those studies found religious persons have less depression than those who are non-religious, and if they become depressed, they recover more quickly.

A review of 12 studies by Dr Larson et al published in the Journal of Psychology and Theology in 1991 found a positive relationship between religious commitment and lower suicide rates. A study by Nisbet et al published in the Journal of Nervous and Mental Disorders in 2000 found that adults 50 years or older who never participated in religious activities were four times more likely than religious people in their age group to commit suicide, replicating the results of a 1972 study.

Skeptics cite the placebo effect as a probable cause of the benefits of spiritual belief, together with the fact that religious communities offer the kind of support networks that reduce stress and ease mental anguish. Additionally, those who attend religious services have better health habits, such as drinking and smoking less. Finally, religions encourage marriage, which is a reliable predictor of longer life.

But the true cause of the healing effect hardly matters. In an interview in the Winter 2002 issue of Health and Spirituality Connection, Dr Koenig explained that religion gives people hope and optimism and helps them better overcome a negative life experience. Some religious people may think God is punishing them or become overburdened with guilt, but religion can also relieve guilt and grant forgiveness.

Brilliant Lives Cut Short

Marilyn, Van Gogh, Meriwether Lewis, Tchaikovsky - no doubt you detect a common theme.

This one comes out of "the vault," back from a year ago when I was still learning. Please overlook all my rookie mistakes - the message speaks for itself.

Monday, May 11, 2009

Pharma and Biotech: No Practical Solution Yet

I concluded my last blog piece on this downbeat note:

So, where are the new meds going to come from? Don't bank on Pharma. They got out of drug development - assuming they were ever in it - at least a decade ago. Hopefully, new players looking to make profits based on innovation will fill the vacuum.

In the meantime, it's as if Pharma doesn't exist. Those meds you are taking right now? Probably generic from generic suppliers. Get used to them - these will be your only choices for quite some time.

An article by NY Times business journalist Lawrence Fisher appearing in the quarterly publication, The Milken Institute Review, provides the lowdown:

In theory, "biotech" is where the innovation is supposed to be coming from. As opposed to Pharma, which is rooted in ancient chemistry, biotech is all about sexy proteins and genes and stuff. These are your go-go companies founded by brainy people using smart-money venture capital. Think Genentech, Amgen, Gilead.

One catch: Take these three companies out of the mix "and the cumulative return on investment over the life of the sector was negative even before the financial markets' collapse."

In hindsight, it's easy to see why. It takes ten years to bring a new drug to market, but the way the game is set up investors need to see returns in five years. We're talking on average a billion-dollar stake in a high-risk crap shoot where nine out of ten compounds in development fail.

Not surprisingly, innovation-rich and cash-strapped biotech turned to innovation-poor and cash-rich Pharma. Unfortunately, the marriage didn't quite work out as planned. As Lawrence Fisher explains:

"Pharma ideally seeks companies with products on the market close to receiving approval. But most biotechs are risk years away from that goal, and those that are closest often come with substantial infrastructure and big employee bases that the majors neither need nor want."

Then, there's the matter of niche vs one-size-fits-all drugs. It's a question I have been asking virtually the entire ten years I have been writing on mental health, and I have yet to receive a satisfactory answer.

We know, for instance, that antidepressants work really well for about one-third of those who take them. But what about the other two-thirds? We need more flavors aimed at different palates. But Pharma is not set up for that. Plain vanilla spells blockbuster, their license to print money.

Biotech is all about the sophisticated niche meds we badly need. But who wants to roll the dice on a high-risk, low return product? Thus, when biotech meets Pharma worlds collide.

The two somehow need to figure out how to work together, most likely with government partnership. Foundation money and NIH grants are keeping the biotechs on a Ramen noodle diet for the time being, but this isn't going to last forever. Meanwhile, Pharma has run out of products, together with its license to print money.

And here we are, stuck with meds based on technologies that were considered new when Eisenhower was President.

It's Official: Pharma is Dead to Us

And on the pedestal these words appear:
`My name is Ozymandias, King of Kings:
Look on my works, ye mighty, and despair!'
Nothing beside remains. Round the decay
Of that colossal wreck, boundless and bare,
The lone and level sands stretch far away.
-Percy Bysshe Shelley

In My Top Ten Mental Health Stories that I posted here last week, I listed "The beginning of the end of drug companies." As I stated in my entry:

Everything seemed to happen at once: Patients and doctors seeing through the Pharma hype, blockbuster meds losing their patent protection, and no new meds coming out of the pipeline. No longer with any financial interest in influencing psychiatry, Pharma virtually backed out of the game. And with mega lost revenues from loss of patent protection, Pharma may lack the resources to ever get back in it.

Bottom line: Due to their arrogance and stupidity, Pharma fully deserves what's coming, but do we?

In short, how the mighty have fallen. Until just a short time ago, it seemed that Pharma would remain forever at the top of the mental health food chain. Technically, they still are, but we are clearly witnessing the beginning of the end.

I started to see the signs two or three years ago at the American Psychiatric Association's annual meetings. Certain manufacturers were not exhibiting, nor were they sponsoring symposia. The reason was clear: Their current stock of meds had gone off-patent, with no new ones on offer.

The handwriting turned up on the wall even earlier at DBSA conferences I attended. Gone were the frills, such as the canvas conference bags with the GSK logo and the ice cream breaks. A quick comparison of DBSA annual reports two years apart reveals an obvious stampede to the exits.

The DBSA 2005 report lists one $500,000-plus donor - Wyeth. The 2007 report lists none. Fortunately, over the same period, DBSA has been weaning itself off Pharma. What I'm seeing is a far more focused organization in a much better position to serve its constituents.

Psychiatry's make-over may prove far more dramatic and beneficial. Not too long ago, you couldn't throw a stone in the direction of a psychiatrist without it bouncing off at least 10 Pharma hacks. Their tentacles were everywhere: In research, in publishing, in professional education and continuing education, in universities, in hospitals, right into the very sanctity of the psychiatrist's office.

Now, on all fronts, they are disengaging. We are already beginning to see signs of reform in the profession. It's going to take time, but one hopes the final outcome translates into patients being able to take the word of their doctors at face value.

I know what you're thinking: With Pharma gone, where are all the new meds going to come from? Let's define "new," namely something that is not an updated version of an old technology. By this criteria, Pharma has not come up with a new psychiatric med in the last 50 years. To give you one example: J&J's Invega is Son of Risperdal which in turn is based on the ancient Haldol.

It's as if the people running Detroit have been moonlighting as Pharma CEOs.

So, where are the new meds going to come from? Don't bank on Pharma. They got out of drug development - assuming they were ever in it - at least a decade ago. Hopefully, new players looking to make profits based on innovation will fill the vacuum.

In the meantime, it's as if Pharma doesn't exist. Those meds you are taking right now? Probably generic from generic suppliers. Get used to them - these will be your only choices for quite some time.

Sunday, May 10, 2009

Obviously, I'm Going to Have to See the Movie

My Mother's Day News

Happy Mother's Day, mothers of the world and mothers-to-be. I have some personal news that I have been waiting for the right time to share. Here it is:

My daughter Emily is going to be a mother!

Which will make me a grandfather. She phoned me about two months ago from New Zealand, where she and her husband live. The baby is due in early October. Of course, this is the best news I've had since a time long ago and far away when I found out I was going to be a father.

Like any grandfather-to-be, I am concerned about the postpartum mental health of my daughter, and you can read my thoughts on this in Katherine Stone's Mother's Day Rally for Mom's Mental Health on her excellent blog, Postpartum Progress. The Rally features 24 "warrior moms" posting their thoughts throughout the day to new moms. (Scroll down the various entries to get to mine, but please read the other contributions.)

My daughter was born in New Zealand (I lived there for 11 years), grew up there, and calls it her home. Last year, in March, I attended her wedding there. She is the best daughter in the world. Out of respect for her privacy (and that of her family), that is all I will disclose about her. From time to time, I will bring you up-to-date on my life as a grandfather-in-progress.

And, of course, I will share the news when the big day arrives.

So to my daughter Emily, as well as my own mom and Emily's mom, plus all moms and moms-to-be - you are the best. You deserve our love and support. There is no such thing as a day off for a mom. So as well as wishing you a happy Mother's Day, my best wishes to you all the other days of the year, as well.

Saturday, May 9, 2009

Mother's Day Rally for Mom's Mental Health

Tomorrow, fellow blogger Katherine Stone will be hosting a special Mother's Day rally at Postpartum Progress. Her blog is undeniably the best source of postpartum information on the web, which every mom-to-be, new mom, and their families need to be reading religiously.

Following her own recovery from postpartum OCD, in 2004 Katherine launched her blog. In 2008, WebMD honored Katherine as a web hero.

Tomorrow's event promises to be especially noteworthy. As Katherine explains in her blog:

The Mother's Day Rally for Moms' Mental Health is an online event featuring 24 open letters to new mothers on the importance of maternal mental health. All of the letters will be written by survivors of and experts on perinatal mood and anxiety disorders, including postpartum depression and postpartum psychosis, as well as by others who care about the emotional well-being of moms and moms-to-be.

Each hour, on the hour, for 24 hours straight, Postpartum Progress will post a different "Letter to New Moms". The letter writers were given a blank canvas to share their humor, experience, tips and ideas, focusing on the mental health of women during pregnancy and postpartum.

I'm proud to be included in Katherine's list of "mommy bloggers." What am I doing there? Stay tuned for my big announcement, tomorrow, Mother's Day.

Again, important reminder: Mother's Day Rally for Moms' Mental Health.

Friday, May 8, 2009

I'm a Tool of Scientology!

This is too funny for words.

Above is a screenshot from the Recovery page on my website McMan's Depression and Bipolar Web taken just a few minutes ago.

No, you are not seeing things. In the lower right hand corner, you are viewing an advertisement for the Church of Scientology. Like nearly everyone who operates a website or a blog these days, I employ Google Ads to help pay the rent. I do not - nor have I ever - solicited advertising. Rather, Google automatically loads advertisements that its various algorithms decide is a good fit for the page.

Apparently, the Google algorithm determined that I am a friend of Scientology.

In a similar fashion, HealthCentral loads ads into the top banner portion of my mcmanweb pages. At the time of this writing, for this particular page, an ad for Ensure is on display. Across another page right now is an ad for Prisiq, which looks like this:

Various antipsychiatry bloggers such as Philip Dawdy of Furious Seasons periodically (and tediously) attempt to discredit my writing based on the fact that I happen to carry these ads on my site.

Apparently I am a tool of Big Pharma.

But no, the conspiracy is even more evil and far-reaching. I'm also a tool of Scientology!

Okay, okay. I confess. It was me you saw on the Grassy Knoll one day in late November. Whew! It's a relief to get that out of my system. In the meantime, don't forget to support my sponsors ...

My Top Ten Mental Health Stories

Following is what I view as the ten most significant events or trends affecting all of mental health in my ten years researching and reporting on my illness. Obviously, had I been reporting on say schizophrenia rather than bipolar my list would be different. Then again, only one entry here is bipolar-specific. So, without further ado, in no particular order:

Recognition of child bipolar

Ten years ago, virtually everyone thought you had to be of voting age to qualify for a bipolar diagnosis. A lot of the credit for changing that misconception goes to the parents, who have taken it upon themselves to educate clinicians and educators. There has been a noisy public backlash over labeling and medicating kids, but the alternative of turning your back on them is totally unthinkable.

Key people: Demitri and Janice Papolos, authors of "The Bipolar Child"; Joseph Biederman, Harvard child psychiatrist and paradigm-shifter.

Bottom line: A child who jumps out of a moving vehicle has something very serious going on. Finally, we have woken up and are doing something about it.

Coming of age of borderline personality diagnosis

Surely, the thinking went, there could be no biological basis to this Freudian artifact. Guess what? The brain scans tell a different story. The scientific evidence, coupled with proof that interventions such as DBT work, not to mention the realization that borderline may be one reason why many so-called bipolar patients do not get better, is slowly shaking psychiatry out of its denial and raising public awareness.

Key people: Marsha Linehan, developer of DBT; Paul Mason and Randi Kreger, authors of "Stop Walking on Eggshells."

Bottom line: Countless individuals currently living tortured lives can look forward to a fresh start.

Brain science research

Where to start? The mapping out of stress-vulnerability and thought and modulation pathways, new revelations about plasticity and brain cell growth, new discoveries into how neurons work, new insights into how the brain interacts with the environment, the emergence of brain development as an explanation for mental illness, plus a host of candidate illness genes and the mapping the human genome ...

Key people: Eric Kandel, Arvid Carlsson, Paul Greengard, who shared the 2000 Nobel Prize in Medicine for their work in how neurons communicate.

Bottom line: Very smart people are changing the way we think, and - eventually - how we live.

Validation of talking therapies

CBT, interpersonal therapy, and other short-term therapies focusing on the here and now have been around since at least the seventies. But only in the last decade do we have the studies to prove just how useful these interventions are. Their popularity is growing, along with new applications, including CBT for schizophrenia (once regarded as a waste of time).

Key people: Aaron Beck and David Burns, founder and popularizer of CBT, respectively.

Bottom line: Growing numbers are learning to actively take charge of their own brains.

The spectrum concept

It's not whether you have bipolar - it's how much bipolar you may have. In other words, your depression may be more than just depression. In addition, the spectrum concept is encouraging researchers and clinicians to more closely examine various relationships between supposedly separate illnesses such as schizophrenia and autism - not to mention how such things as temperament and illness interact - and come up with original insights.

Key people: Hagop Akiskal, bipolar spectrum proponent; Robert Cloninger, personality pattern-spotter and paradigm-shifter.

Bottom line: The brain is not organized according to the DSM. Thank heaven for that.

Recovery movement

Earth to psychiatry: We want to get well, not just stable. We want to have lives, not just subsist as over-medicated zombies. In response, patients have taken matters into their own hands, with a growing grass roots recovery movement that trains peer specialists and encourages patients to take positive steps to move their lives forward.

Key people: Mary Ellen Copeland, proponent of WRAP; Daniel Fisher, recovery rabble-rouser; Eugene Johnson, founder of Recovery Innovations.

Bottom line: Psychiatry makes us stable. Only we can make ourselves well.

Patients and loved ones figure out the internet

Suddenly, we weren't alone and isolated. We could talk to each other online, support each other, learn, organize, and advocate. In addition, we could find information on our own from expert sources, then become our own experts. The downside, of course, is what happens with this tool in the hands of the ignorant and unprincipled.

Key people: Martha Hellander, founder of the Child and Adolescent Bipolar Foundation, the first internet-based mental health advocacy organization; Peter Frishauf, founder of Medscape; Deborah Gray, founder of "Wing of Madness," the template for many patient sites to follow.

Bottom line: For better and worse, the internet is where most of us go to for information and support.

Beginning of the end of drug companies

Everything seemed to happen at once: Patients and doctors seeing through the Pharma hype, blockbuster meds losing their patent protection, and no new meds coming out of the pipeline. No longer with any financial interest in influencing psychiatry, Pharma virtually backed out of the game. And with mega lost revenues from loss of patent protection, Pharma may lack the resources to ever get back in it.

Bottom line: Due to their arrogance and stupidity, Pharma fully deserves what's coming, but do we?

Deterioration in services

Not being able to afford meds and the doctors who prescribe them is only a small part of the problem. Lack of access to costly and time-consuming services is major. You name it - long-term therapy, psychiatric rehabilitation, higher education, crisis intervention, social services, vocational training, jail diversion, decent housing - not only is the money not there; the system is seemingly designed to fail us.

Bottom line: In this economy, things are only going to get worse.

Returning vets mental illness time bomb

Vets are returning from Iraq and Afghanistan with high rates of mental illness, or at high risk of mental illness, including PTSD and depression. Add to that the challenges in fitting back into society, then consider what many do to cope, such as drugs and alcohol.

Bottom line: Vietnam vets account for a large percentage of the homeless. Unless we act fast and plan long term, a new generation of vets will join them.

Big story of the next ten years: The current economic crisis

Whichever way events play out, society's most vulnerable will be the hardest hit, and those better off aren't immune either. Nevertheless, before we predict a pandemic of stress-related mental illness, the data shows that people actually experience better health and live longer when times are bad. Something to do with a return to core values?

Bottom line: However we come out of this, nothing is ever going to be the same again.