Saturday, June 27, 2009

Pittsburgh Reflections

It’s almost 5 PM. I should be flying out of Pittsburgh right now, but - wouldn’t you know it? - my plane is not in the gate.

I cut out of my Bipolar Conference early for this?

A few observations on the International Conference on Bipolar Disorder:

I attended my first conference in 2001. Then, the brain science was only mentioned peripherally and speculatively, and the brain science posters strictly concerned size and structure rather than function and connectivity. The meds researchers were the stars of the show, and for very good reason - a lot of what we take for granted now in prescribing meds was emerging knowledge back then.

For instance, Gary Sachs of Harvard spoke about the NIMH-underwritten STEP-BD real world clinical trials that would be getting underway. That study, which yielded a lot of valuable information, wrapped up two or three years ago. Clinical trials results tended to dominate the posters sessions.

On the other hand, some things stay the same. There was a lot of talk back then about the safety and efficacy of using antidepressants to treat bipolar. With a lot more knowledge now, opinion now leans on the side of “No,” but the debate is by no means closed.

(Boarding call. ... I’m back, cruising over western PA, en route to the east coast.)

Significantly, Robert Post, then of the NIMH, disclosed new findings from the Stanley Foundation Bipolar Network that revealed that although mania gets most of the attention in bipolar, our population is depressed three times more than it is manic. Knock me over with a feather. Everyone else in the room, too.

A completely new and controversial topic was child bipolar. One of the presenters acknowledged the issue wouldn’t have even come up two years ago. Barbara Geller of Washington University (St Louis) reported on a study she was about to publish showing that bipolar kids are sicker than bipolar adults. Two major differentiating features from ADHD, she reported, were grandiosity and risk-taking.

Fast forward to 2009. The brain scientists are the stars of the show. Thomas Insel, head of the NIMH, tells the conference in so many words that bipolar research is starting to catch up to other fields. Husseini Manji who now works for Johnson and Johnson and had spoken before at the conference, talks about how things work at the cellular level while Mary Phillips (another return speaker) connects the dots at the systems level and Nick Craddock of Cardiff University reports on a gene that affects calcium channel function in a small segment of the bipolar population.

(Bear with me. We’re approaching Baltimore-Washington. Time to stow my laptop. ... I’m eating diner food in the terminal, waiting for my connecting flight to Hartford. To continue ...)

The brain science posters are starting resemble an illustrated owner’s manual to how our mind actually works (or fails to work). Hardly any industry sponsored drug trials. I spend a good 20 minutes talking with a researcher about the significance of one of the lit up areas from the functional images on display. It’s too soon to draw conclusions, but it looks like we can show the circuitry that makes bipolars over-react to both reward and disappointment. In the same area of the brain? I’m asking. Two opposite effects? Holy crap!

Meanwhile, at other posters, the first results of a longitudinal study tracking 400 bipolar kids are starting to roll in. The study is going to tell us a lot about the course of early onset bipolar, and whether it turns into adult bipolar over the years. Unlike eight years ago, virtually no one here is questioning the diagnosis. Instead, the debate is over achieving a consensus on the diagnostic fine points.

Of course, the more we find out the more we realize how ignorant we are. Moreover, in the real world, patients would be hard-put to point out any personal benefits from new scientific discovery. Quite the contrary, services have significantly deteriorated over the years while the new-generation meds have failed to live up to their promise, which has set off a justifiable reaction.

You’ll have to trust me on this: The difference between my first conference and the one I just attended is night and day. Mind-boggling findings are coming in thick and fast. Perhaps our generation will only achieve a marginal benefit, but be assured - future generations will be spared a lot of our suffering. It was my privilege to be talking to the people who have dedicated their lives to making this happen.

Time to board my flight. This is John McManamy. Over and out ...

Friday, June 26, 2009

From Pittsburgh: Awards Night

It’s past 11 PM. I just got back from an awards dinner at the Eighth International Conference on Bipolar Disorder in Pittsburgh. This particular dinner is special to me. Allow me to explain:

The Conference honors the memory of Mogens Schou, the late Danish psychiatrist who pioneered lithium treatment in the 1960s, which revolutionized psychiatry and offered hope to millions. Each meeting, the Conference singles out individuals for outstanding achievement in three categories: Education and Advocacy, Research, and Public Service. The Mogens Schou Award is recognized as the highest honor one can attain in the field of bipolar. Past recipients have included Mogens Schou, Kay Jamison, and such paradigm-shifting researchers as Husseini Manji.

At the previous meeting, two years ago, I received the Mogens Schou Award for Public Service. I could say a number of things, but let’s leave it at the fact that I was flabbergasted, humbled, and honored.

This year’s Mogens Schou Award recipients:

Lakshmi Yatham, for Education and Advocacy: Dr Yatham of the University of British Columbia, through various leadership positions including president of the International Society for Bipolar Disorders has been instrumental in improving treatment and diagnostic standards within the medical profession and amongst the general public.

Guy Goodwin, for research: Dr Goodwin, of Oxford University, has been involved in research into the neurobiology of bipolar and psychopharmacology, including developing the basis for large scale and low budget real world clinical trials, including BALANCE, which you will hear a lot more about fairly soon.

Joyce and Dusty Sang, for public service: In 2004, the Sangs, who have a lifelong commitment to public service, created the Ryan Licht Sang Foundation which has fostered awareness, understanding, and research for child and adolescent bipolar.

At the first available opportunity, I introduced myself to the Sangs and told them how honored I felt that they received the Award. We instantly connected. The Sangs got involved through the suicide of their only child, Ryan, age 24. Joyce pinned a Foundation lapel pin on my jacket, which I will continue to wear in memory of their son and as a tribute to their work.

I found my voice catching several times in the conversation.

As I said, this particular dinner is special to me.

Tooting from Pittsburgh - More Brain Science

Above is an illustration of the brain showing the circuitry that is attracting the attention of researchers across just about all fields of mental illness. This PowerPoint slide comes from a talk given at this morning's session at the Eighth International Bipolar Conference in Pittsburgh by Hilary Blumberg of Yale.

What you are looking at is two-way traffic between the reactive/arousal amygdala and the thinking/modulating cortical areas. Abnormalities in these circuits has been implicated in all manner of mental illnesses. Essentially, when things go wrong, the emotional amygdala is shouting too loud and the rational cortical areas fail to reassert control.

Below are two fMRI images of a bipolar brain in action, from a study currently in press. These slides were presented at the same session by Mary Phillips of the University of Pittsburgh. What we are observing are top down images of the two-way traffic between the amygdala and the orbitomedial prefrontal cortex. On the left side, in a normal reaction, you see evidence of heavy and direct traffic while the smaller arrows to the right indicate lighter traffic.

In the bottom image, the denser arrow to the right notes an over-reaction, which shows up in bipolar subjects, but is not in evidence in healthy control subjects or in unipolar depressed individuals.

In yesterday's blog, we were looking at brain dysfunction on the "cellular level". Here, we are viewing the things that can go wrong on the "systems level". Using brain imaging, Dr Phillips has been able to distinguish between unipolar and bipolar. Dialing in the research further promises to further sharpen our diagnostic capabilities.

I asked Dr Phillips about this. On previous blogs, I showed brain scans of similar breakdowns in the circuitry between the back and front areas of the brain in patients with borderline personality disorder, a very similar picture to what you are looking at now. It's only a matter of time before we can use brain scans to separate out borderline from bipolar.

These are exciting times. John McManamy, live from Pittsburgh ...

Thursday, June 25, 2009

Tooting from Pittsburgh II

It's going on 10 PM. I'm just about to get some serious sleep after a full day at the Eighth International Conference on Bipolar Disorder taking place in Pittsburgh. The image comes from a PowerPoint presentation in a morning talk by Husseini Manji on the fine points of BAG-1, a protein which seems to prevent glucocorticoid receptors from migrating to the nucleus of the neuron, if you know what I mean.

Let's put it this way, when glucocorticoid succeeds in its migration bad things happen.

It was heavy duty on the brain science this morning. We're not talking "imbalance of chemicals of the brain," Dr Manji reminded his audience. Instead, think of mood disorders as "impairments of synaptic and neural plasticity."

Don't worry if you don't understand any of this. I'm just giving you a feel for how my day went. Take my word for it, this is brain science 6.0. I'll be better able to break it down for you when I have a clear brain. To bed ...

This is John McManamy, live - well, actually brain dead - from Pittsburgh.

Wednesday, June 24, 2009

Tooting from Pittsburgh

Got into Pittsburgh late last night. Slept like a log at a hotel near the airport. Miraculously, next morning, at a shop adjoining a gas station, I was able to order a fresh fruit smoothie. My first non-junk food in 24 hours. Maybe it was the placebo effect, but suddenly I'm not feeling like someone who has been subjected to hours of torture by the airlines.

Today I'm in a hotel adjoining the convention center where tomorrow the Eighth International Conference on Bipolar Disorder, hosted by the University of Pittsburgh and the Western Psychiatric Institute, takes place. The room is a far cry from my Priceline specials (you know the type - where the air conditioning and plumbing are loud but unoperational, the guests in the next room and foot traffic outside are even louder, the view is into a parking lot or brick wall, towels the size of face cloths, and the wireless plays dead). I received an award at the previous conference two years ago and the organizers still remember - hence the luxurious (by my standards) hotel room.

(Towels! Big fluffy towels!)

Familiar names at the conference include Kay Jamison (part of a panel on suicide and note she just another expert here rather than a celebrity keynoter), Thomas Insel, head of the NIMH, and David Miklowitz, author of "The Bipolar Disorder Survival Guide." Plus a whole bunch of people who have contributed to my understanding of bipolar over the years, including Nassir Ghaemi, Husseini Manji, Ellen Frank, Michael Thase, and many many more.

Plus I look forward to catching up with numerous people I've met at past conferences.

Today I'm chilling. Had a long nap, got my didgeridoo with me (my lightweight "travel didge," not my new one I've been blogging about), and am about to take a walk. Dinner tonight with a friend of a friend. Tomorrow up early for a 7:45 AM start.

This is John McManamy, tooting from Pittsburgh. More in future blog posts ...

Tuesday, June 23, 2009

Tooting off to Pittsburgh

Never fly in the summer. Zoo is the wrong term to describe San Diego Airport. Animals are treated far more humanely. They get knocked out at home and wake up at their destination. I demand to be treated like an animal.

It took me 90 minutes to clear check-in, security, and the news shop. I spot one of those horse collar travel pillows. I have a whole closet full of them. Unfortunately, I didn’t bring my closet with me. Another one to my collection.

I was up at five this morning. Not by choice - my brain won’t let me sleep on travel days. Then they route me to Chicago because they can before dumping me off in Pittsburgh late at night and three hours out of my circadian rhythms.

Fortunately, I was wise enough to schedule a rebound day for tomorrow.

I’m plopped into a seat at my boarding gate. Someone with a high-decibel baby plops into the seat right behind me. I am very tolerant - compared to a lot of adults I know, the baby is a model of exemplary behavior.

I whip out my emergency iPod and jam in the earphones. Kiri Te Kanawa is singing Richard Strauss. Sanctuary, asylum. Ahhh!

I will be attending the Eighth International Conference on Bipolar Disorder, hosted by the University of Pittsburgh and Western Psychiatric Institute. Three days of the world’s top bipolar experts, along with leading brain scientists and geneticists. But right now I’m looking across the aisle, where a lady has open Food Network Magazine.

“Best Burgers,” reads the cover. The shot of the cover burger poses more of a temptation than the Victoria’s Secret Catalogue.

It’s always good to be passionate about something in life.

From Pittsburgh, it’s a family visit to CT. I did have a trip scheduled to visit a rehabilitation farm in the Berkshires, but that fell through. So straight home from there. Correction: The airlines are not familiar with the concept of straight.

This is John McManamy, on the road, tooting to Pittsburgh. Stay tuned for more road blogs ...

Monday, June 22, 2009

Rare Footage: John McManamy and Louis Armstrong

Following is rare archival footage of me on my didgeridoo, accompanied by Louis Armstrong. Louis, of course, is the most exciting musician to ever pick up an instrument - or sing. But here I give him a run for his money. Enjoy ...

Friday, June 19, 2009

Beyond Blue: John McManamy (That's Me) Talks About Play

My favorite blogger, Therese Borchard of Beyond Blue, recently interviewed me on the topic of play, which she broke down into three pieces, published today:

Five Steps to Having More Fun

Play is Crucial to Good Mental Health

Operating Instructions: This is How You Play

Following is a brief excerpt from that interview:

Question: John, could you outline maybe five steps to help the readers have more fun in their lives?

John: Now there you go, Therese, asking tough questions. Look, I already told you I'm an expert in feeling miserable. Why don't you ask me to share my secrets on getting high scores on your math SATs while you're at it? Geesh - okay-okay-okay. I'm thinking ..

1. - Enjoy the peanut butter. As you can see in the picture, here I am trying to explain to Spock the concept of peanut butter. Spock is telling me that peanut butter is not logical (Cardassian tofu apparently is) which is exactly my point. Forget about the bread. Stick a fork in the jar and go for it.

"Enjoy the peanut butter" is my metaphor for living in the present. It comes from an old Zen parable about savoring strawberries as tigers are about to rip you apart. The present is where life is happening, here, right now.

For lots more, please click the links above or visit Beyond Blue's home page. Therese is a brilliant writer, with great insights and a keen sense of humor. At the same time, she never forgets who she is and the challenges she faces in getting through each day. I can't recommend her blog enough.

Thursday, June 18, 2009

Didge 101

An email from YouTube Services arrived in my email box one hour ago. "ididjaustralia has invited you to become friends!" read the heading.

According to i DIDJ Australia website: "iDIDJ Australia is guided by the traditional Aboriginal owners and custodians of the didgeridoo in raising public awareness of the rich cultural traditions and significant heritage values of the didgeridoo."

Since acquiring my first didgeridoo (made from California yucca) more than two years ago, I have used this great website as a resource to learn more about the instrument and the Aboriginal culture that produced it. Its YouTube channel features nearly 400 videos showcasing great Aboriginal musicians and instrument-makers.

Last week, I acquired my first Aboriginal didgeridoo, and two days later uploaded a YouTube video, My Didgeridoo Experience, which I also embedded into a very recent blog post.

My musicianship leaves a lot to be desired, but I hoped to convey the benefits that even novices can derive from the instrument, as well as showing my appreciation for the oldest continuous culture on earth.

Accordingly, I was flattered to find the friend request in my email box.

Above are three videos from the i DIDJ Australia's YouTube channel. The first displays the virtuosity of Quincey Matjaki, a master of the "hard-tonguing" style that is a feature of the Yolngu people of Northeast Arnhem Land in Australia's Northern Territory. "Yirdaki" or "yidaki" is the Yolngu word for didgeridoo.

The second shows the life cycle of the yirdaki, from tree to ceremonial use, and the third is a scene-stealer of two adorable kids - ages 3 and 5 - already playing the yirdaki far better than I will ever play it in my lifetime.

Enjoy ...

Wednesday, June 17, 2009

A Smart Drug Company? Holy Crap!

This week's Business Week cover story features Novartis, apparently the one drug company not as dumb as Detroit. The good news is that smart management there may provide a new model for badly needed new drug development. The bad news is that none of these drugs are likely to be psychiatric meds.

Novartis is the one drug company headed by a medical doctor, Don Vasella (pictured here). The others are dominated by lawyers and accountants and marketers who fail to appreciate science and who have forgotten who their true customers are. According to Business Week:

"Most big drugmakers shower their research and development funds on diseases such as cancer or depression, where huge potential markets beckon despite a deficit of scientific understanding. In recent years this approach has led to high rates of failure when drugs are tested in clinical trials."

In contrast, seven years ago, Novartis embarked on a policy of pushing drugs through testing and development only if they were backed by proven science. It didn't matter that the particular diseases the drugs treated were rare. In the words of Dr Vasella: "If you are guided purely by financial estimates and not the science, you end up wasting time and money."

Novartis' Gleevec was initially approved for a rare blood cancer that strikes just a few thousand people a year, but has since proved effective against six other diseases. Last year, the drug pulled in $3.7 billion in sales.

The idea is that although there are 24,000 genes in the human genome, there are only a few dozen pathways that are shared by virtually all diseases. The trick is to track down all the links in a pathway, then locate the key signals that switch genes on and off.

In the development phase at Novartis is a drug to treat a rare inflammatory disorder called Muckle-Wells syndrome, involving a single gene variation that may be implicated in other illnesses. Thus, the rare diseases may shed light on a host of other illnesses and hold the key to future drug discovery.

Here's where the drug industry's blockbuster/me-too mentality has left us, according to Business Week:

Experts say drug companies have exhausted the easy targets. With patents on many older blockbusters starting to expire, the industry is poised to lose an estimated $140 billion in sales to generic competition over the next five years. Those revenue sources must be replaced.

Despite multibillion-dollar research budgets, none of the top companies has a wealth of promising compounds in its development pipeline. The industry also faces regulators more vigilant than ever about safety, and health insurers starting to balk at covering costly drugs that bring only modest benefits.

Dr Vasella shook things up when he moved Novartis' main global research operation from Basel, Switzerland to Cambridge, MA, and got a Harvard cardiologist to run it, with a brief to turn things upside down. Under the new order, scientists stared calling the shots rather than executives in sales and marketing.

The men and women in suits fought back hard, but ultimately more than a thousand sales and marketing execs were purged and medically trained scientists brought on board.

Here's the catch: Our current scientific understanding of mental illness would not meet Novartis' rigorous standards for green-lighting new drug development. According to its 2008 Annual Report: "Diseases affecting the brain and central nervous system pose exceptional hurdles in drug discovery."

All our current psychiatric meds are the result of serendipitous discovery, based on old technologies. They get some of the people somewhat better some of the time, and we have no idea why. The drug industry made vast sums of money essentially putting old pills in new bottles. That era is just about over.

The new era would involve finding the precise illness pathways that cause specific mental illness symptoms and figuring out which gene variations are involved. Forget about a treatment for all of depression. Rather, it might be more productive to uncover the underlying mechanisms to, say, lack of motivation. Maybe only a small percentage of depressions involve lack of motivation. But maybe such a drug would get a lot of these people a lot better a lot of the time.

Maybe, also, this motivation drug would help with other diseases and conditions that involve lack of motivation, such as various neurological ills. Maybe also various fatigue ills, and maybe even the flat affect symptoms of schizophrenia.

And maybe the best way of testing the drug would be to first try it on some really rare disease that only two people in the world know anything about, and then branch out.

Would your typical drug company be interested? No way.

Might Novartis be interested? You bet, assuming the science is sound. A ray of hope ...

Related Blog Pieces

It's Official: Pharma is Dead to Us

Pharma and Biotech: No Practical Solution Yet

Tuesday, June 16, 2009

Jumping Right In

I recently joined the board of NAMI San Diego. Last week, this involved going into town three times for various meetings. Today, I'm off for another one, with some homework I need to prepare. Just what I need in my life right now, more work. Why bother?

A bunch of reasons. First of all, I come from a family that believes in giving back to the community. My mother and late father both served on various community boards and were always there to lend a helping hand and so did our neighbors. I'm not sure if any of them could have articulated a reason for their service. Back in those days, it was something you just did. Period.

Another big part has to do with my work as a mental health journalist. Oddly enough, the conventions of my profession dictate against getting involved. Heaven help if I started getting close to patients and loved ones, not to mention those who have dedicated their lives to improving ours. There goes my objectivity.

For three years, I ran a DBSA support group in Princeton, NJ. I was the poor shmuck who showed up a half-hour early every Tuesday evening to turn on the lights, arrange the tables and chairs, display the literature, and welcome arrivals. Then I'd facilitate the meeting or help break in a new facilitator. During the week, I might be fielding phone calls or getting photocopies run off, or doing the zillion-and-one things that no one ever finds out about.

Why bother? Couldn't my time have been better spent doing what I do best - namely writing about my illness? No. Absolutely not. I needed to jump in and get my hands dirty. I needed face-to-face contact with people who lived with my illness, including loved ones, on their terms rather than mine.

Shake me up, surprise me, show me what an idiot I am. Close up and involved was the only way to go. Living in my own bubble just didn't cut it.

Now NAMI beckons. Different type of involvement. New challenges. New things to learn. Besides, it's something you just do. Period.

Saturday, June 13, 2009

My Didgeridoo Experience

I lived in Australia for five years back in the 80s and early 90s, but didgeridoos didn't interest me. Then, two and a half years ago I moved to rural southern CA and suddenly didgeridoos made a lot of sense.

A didgeridoo is a wind instrument made from a hollowed out log. The Australian Aboriginals use eucalyptus trees. The didge - or yidaki or yirdaki - is a mainstay of Aboriginal culture, an integral part of their spiritual and ceremonial and story-telling traditions.

The instrument produces a low pedal note drone, which can be varied by a range of vocalizing and tonguing and breathing techniques. Skillful players can maintain complex rhythms that equate to vocal percussion. Though the instrument itself is simple, its masters are highly-accomplished and equally highly-regarded virtuoso musicians.

The instrument also offers a gateway into Aboriginal culture, which is the oldest continuous culture on earth.

I bought my first didge about two years ago. It is locally made, from a hollowed out yucca plant. My second one is Indonesian teak, from the same local craftsman.

Last week, I acquired my very first Aboriginal-made didge, and I'm very excited. The week before, I happened to run into someone from San Diego, who had a didge he wanted to sell. It was crafted by the great master, Djalu Gurruwiwi, from Northeast Arnhem Land in Australia's Northern Territory. It was literally love at first sight.

I have a long way to go before I acquire even a basic level of proficiency, but right from the beginning I found myself both having fun and tapping into something greater than myself. This video reflects both the playful and spiritual side the instrument brings out in me, as well as paying tribute to the culture that produced it.

Enjoy ...

Thursday, June 11, 2009

Rerun: Gray Whales!

I shot this in late Feb, from a cruise boat a few miles out in the ocean off San Diego, during the gray whale migration season. Enjoy ...

Wednesday, June 10, 2009

Trick Question: Bipolar vs Cycling

The term, bipolar disorder, is used to indicate the duality of the illness: depression at one end and mania at the other. True or false?

True - uh false. No true. Maybe. Never mind. No, wait ...

In the second edition to "Manic-Depressive Illness," Goodwin and Jamison point out that while bipolar is useful to help explain "the coexistence of opposites," just as important (perhaps even more so) is "cyclicity."

A major drawback to the "bipolar" way of looking at things, the authors point out, is that we tend to separate out the dimensions of the illness with no attempt investigate how they tie in together.

Cyclicity is all about the dynamics of the illness, how two apparently unrelated features - depression and mania - relate. In 1854, the French physician Jean Pierre Falret coined the term, "la folie circulaire," in recognition that depression and mania were not separate illnesses, but different manifestations of the same underlying circular phenomenon.

One state, in effect, predicted the other, and back again.

A cyclic view encourages clinicians to investigate their patients over long periods of time and thereby help predict the future course of their respective illnesses, with a view to improving the outcome. For instance, a clinician treating depression needs to anticipate the likelihood of mania, and vice-versa.

In short, it is probably more useful to treat the cycle rather than the symptom of the day.

A few weeks ago, I had a conversation with a brain scientist at the American Psychiatric Association annual meeting in San Francisco. She told me that they do not have an animal model of bipolar. In other words, they have yet to figure out a way to get a lab rat to behave like a bipolar patient.

Wait a second, I interrupted. We can give rats methamphetamines to make them manic and psychotic. We can give them forced swim tests and foot shocks to induce them into learned helplessness (roughly equivalent to depression).

Yes, she said. But we can't do it in the same rat.

Oh, I said.

Technically, we can induce learned helplessness in the little guy before we feed it meth, but that's not going to teach us how we (humans, that is) cycle from one extreme to the other. We have yet to come up with a way of making the rat cycle. And cycling is the key to understanding bipolar, she informed me.

You know, I knew this all along, but suddenly the light bulb went off.

Oh, I said again, or something equally intelligent.

Tuesday, June 9, 2009

Rerun: Illness or Personality?

First Oprah, then Andy Behrman. Time for a mental health break from this blog. Following is a rerun from January. These are the type of pieces I prefer to do (and ones I'm sure you would rather read), ones that shed insight into what makes us tick:

I answer questions as an "Expert Patient" at BipolarConnect. Two days ago, Dark Angel asked, "Why does bipolar seem like your personality?"

The question goes right to the heart of how we see ourselves, and is central to every issue we discuss here at "Knowledge is Necessity."

"Welcome to a lifelong quest for self-knowledge," I began. Okay, let's see if we can figure this out:

The experts distinguish between "state" and "trait." A state equates to an illness episode whereas a trait is part of your personality. Let's use hypomania as an example:

People tend to pair "exuberant" with "personality." Exuberant is seen as beneficial, and, most important, people see YOU as in control.

In hypomania, for the purposes of this conversation, we are talking about over-exuberance. Not only that, hypomania is often a sign that we are really about to lose control of our brain, or that we have already lost it.

I would contend that for many of us hypomania is a normal part of our personality, only in this case we're mixing bad with good. For some, it may be a rational choice to accept the bad with the good. Others understandably want no part of hypomania.

The DSM sheds some interesting light on the topic. According to the DSM, we are in hypomania when we experience "unequivocal change in functioning that is uncharacteristic ... "

In other words, we are talking about a "state" that is not a true part of our personality.

I would argue that for many of us this is not necessarily the case. Nevertheless, the DSM is making a valid point. Keep cranking up the volume, and, at a certain point, we are definitely not ourselves. We are not in control of our brains.

Think of two individuals who are "up." They are thinking alike, they are acting alike. But one is behaving rationally and in character while the other is not. Same behavior, yet a profound difference. One may be on his game, the other may need meds. On and on it goes.

Hypomania is just one example. We need to apply this ruthless self-examination to all our behaviors, as well. This includes our depressions and anxieties, as well as a range of personality quirks.

For many people, our illness is fully integrated into our personality. Others rightfully view their illness as an interloper. Well-meaning experts, including friends and family, are not hesitant to proffer advice, but, in the end, you are the only expert in knowing where you stand. But this kind of wisdom only results from responsible self-enquiry. Welcome to "Knowledge is Necessity."

Monday, June 8, 2009

Andy Behrman - Some People Don't Know When to Stop [khoot-spuh] - noun slang 1. Supreme nerve or gall; 2. Andy Behrman.

Today, I received a spam email with this heading: "Abilify Kills: An Update on the Dangers of Abilify."

The sender is the infamous Andy Behrman, author of "Electroboy." The memoir detailed Andy's career as hustler, stripper, art forger, convicted felon, sex addict, recreational drug user, and psychiatric patient. In the book, Andy attributes his strange behavior to bipolar disorder, and back in 2002 when the book came out a sympathetic public (myself included) took him at his word.

In light of events that occurred after publication, and particularly more recently, however, it is clear that bipolar is not Andy's main diagnosis. A revisit of the book indicates there are far more believable ways to explain his deviance: novelty-seeker, drug addict, antisocial, and narcissistic all come to mind.

I do not want to play "pin-the-diagnosis" on Andy. But let's take bipolar out of the equation. Bipolar is an episodic illness: whatever happens in mania stays in mania. Andy is not like that. His behavior plays out a lot differently. To recap:

Beginning in 2004, Bristol-Myers Squibb paid Andy $400,000 over two years as a celebrity patient spokesperson for Abilify. According to a story in the Wall Street Journal, 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."

But soon after taking the drug, 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.

While still a spokesman for the drug, Andy started saying bad things about it. Not surprisingly, BMS did not renew his contract. According to the WSJ, Andy asked for $7.5 million and was seeking hush money to stay quiet. Soon after his confidentiality agreement with the company ended at the end of 2008, Andy started singing a different tune.

In a spam email dated May 14, Andy wrote: "Today I am preparing to sell a new book, Adventures in the Drug Trade, which details my nightmarish experience with Abilify, my treatment by ... a former UCLA psychopharmacologist now at the Mayo Clinic and curiously no longer a medical consultant for BMS, and my experiences as a pusher of their not-so-wondrous wonder drug."

According to Andy: "Today, The Wall Street Journal published a front page story about my experience titled, 'A Celebrity Patient's Backing Turns Sour for Drug Company.'"

Andy did not link to the article, which made him look a lot worse than BMS (which is no mean feat). According to the WSJ: "Mr Behrman adds that he doesn't care what people think about his changing accounts of his experiences with Abilify. 'I think it is normal to have had a lapse in judgment because I was handled and manipulated by so many people,' he says."

In the same spam email, Andy included two links to his short YouTube video, entitled "Abilify Kills."

Today's spam email is basically a repeat of the first. Again, he lauds the WSJ for "exposing" the practices BMS and its partner Otsuka and "bringing the issue ... into public scrutiny." Again, no link to the article. Again, two links to his YouTube video.

Here's where the chutzpah part comes in. Aside from antipsychiatry bloggers, support for Andy has not been forthcoming. In two previous blog posts (here and here) I was highly condemnatory of Andy. Nevertheless, in his latest email, Andy claims: "TENS OF THOUSANDS OF PEOPLE HAVE SEEN THIS VIDEO SINCE IT WAS ORIGINALLY RELEASED AND THE VIDEO HAS ALSO BEEN POSTED AND MENTIONED ON INNUMERABLE MENTAL HEALTH WEBSITES." (Caps are all his.)

Andy-Andy-Andy ...

Sunday, June 7, 2009

Oprah Absolutely Totally Endorses Me - Well, Sort Of

My last blog was entitled, Oprah is an Unmitigated Idiot and a Menace to Society. Perhaps, I was being too harsh. After all, at the time I was as bitter as the Phantom of the Opera. A bit of background:

In Oct 2006, HarperCollins published my book, "Living Well with Depression and Bipolar Disorder: What Your Doctor Doesn't Tell You ... That You Need to Know." The book drew an unprecedented range of endorsements, including psychiatric experts (such as Frederick Goodwin MD, former head of the NIMH), advocates (such as Susan Bergeson, at the time President of DBSA), authors (such as Pete Early, who wrote "Crazy"), and alternative/complementary practitioners (such as Amy Weintraub, author of "Yoga for Depression").

But apparently, my book was not Oprah-worthy, and for more than two years I have been prowling the underground catacombs of Paris fantasizing my revenge. Then, suddenly, the other day, in the middle of a tenor solo, I had an epiphany, a realization, a sudden change of heart. Rather than crash a chandelier (or, alternatively, an overhead studio light) on Oprah's head, instead I would write a book that would do her proud, and today I'm pleased to announce the happy outcome:

"The Dihydrogen Oxide Cure: Nature's Boner-Popping Miracle Answer to Depression, Aging, Heart Disease, Obesity, Wrinkles, Memory Loss, Impotence, and Just About Everything, Totally."

Dihydrogen oxide is one hundred percent natural, and is found in all of nature. Dihydrogen oxide accounts for 70 percent of our body weight at birth, but as we age the percentage drops to around 60 percent. Without dihydrogen oxide, we would all die. Life on the planet would cease.

Yesterday, I finished taping my first Oprah show, and five more are in the works. My people and her people are negotiating a spin-off series. The first show should air any day now. Following is a partial transcript:

Oprah: "Today's show is entirely devoted to John McManamy, author of "The Dihydrogen Oxide Cure" (holding up book). I am absolutely blown away by this guy. Ladies and gentlemen, if women could pop boners I'd be popping one right now."

John McManamy: "Thank you, Oprah. That's a real nice outfit you have on, by the way."

Oprah: "You like it? But you know what? I used to look like a frump in this exact same get-up until I tried your Dihydrogen Oxide Cure. Suddenly, I started drinking about seven or eight glasses a day like you recommended, and, I mean my life has totally - totally - absolutely, totally absolutely, turned around. John, can you explain how dihydrogen oxide works? Oh, and do you have an easier-to-pronounce name for it?"

John McManamy: "Well, Oprah, since I see dihydrogen oxide as nature's miracle answer, I like to call it "Namirans," which by the way is the name of my dihydrogen oxide cure product, available in all health food stores.

Oprah: (Holding up bottle.) "'McMan's Namirans', to be more precise. One hundred percent natural. Just four dollars a bottle. And you can also order it online by going to John's website at"

John McManamy: "Anyway, Oprah, did you know that Namirans forms the basis of just about all of our medicines, both pharmaceutical and alternative?"

Oprah: "You mean even naturopathic?"

John McManamy: "Exactly. It's the major ingredient in everything we take to get us better. Not only that, it's the major ingredient in everything we eat and drink. So I was thinking - if this is the one ingredient common to everything, literally everything, why mess around with all the other stuff, such as additives that can be bad for you. Suppose, just suppose, we could isolate this compound? Then people could enjoy the one hundred percent Namirans experience."

Oprah: "This is amazing. How come we've never heard of it, before?"

John McManamy: "Well, Oprah, as you know doctors would be out of jobs if everyone were healthy. And because the stuff is one hundred percent natural, the drug companies don't have a patent on it."

Oprah: "Okay, John, before you go on, the entire medical profession is calling you a fraud. I have three Nobel Prize winners in the audience ready to totally rebut your claims. What do you have to say to them?"

John McManamy: "Well, Oprah, I know that Namirans sounds too good to be true, but the fact remains that we could not live one minute without it ..."

Oprah: "Say no more, John. And when it comes time to call upon these quacks, namely ten seconds before we're due to break into a commercial, I'll be sure to treat them with a total lack of respect."

John McManamy: "As you so totally should, Oprah. I mean, after all, you're Oprah. By the way, those are totally bomb ass earrings you're wearing."

Oprah: "Why, thank you, John. And you're quite the bomb yourself. Now, John, this is going to sound weird, but the other night I took a bath in your product. It's hard to describe, it was like a ... cleansing ... experience."

John McManamy: "There's no end of uses to Namirans, Oprah. You should see the fan mail I'm getting from people all over the world. A lady in New Zealand is using it to grow her plants - really, I'm not making this up. Someone in Massachusetts is actually cleaning his car with it. And this is just the tip of the iceberg. Speaking of icebergs, did you know that Namirans is the main ingredient in icebergs, both Arctic and Antarctic?

Oprah: "Get ... out ... of ... here! I have to hear more about this! But first commercials. Next up. Elizabeth Taylor and her miracle Namirans story, and how Angelina Jolie is using Namirans to promote world peace. John, we have twenty seconds before we cut into commercials. Tell us real quick about your other product."

John McManamy: "Oh, you must mean my special avocado crotch rub ... "

Oprah: "You mean you rub it into your crotch?"

John McManamy: "No, Oprah, you have someone else rub it into your crotch."

Oprah: (In total admiration.) "John, you are a true boner-popper. Perhaps you can demonstrate it on me after the show. Ladies and gentlemen, the great, totally mind-blowing, John McManamy!"


Hey, if you can't beat 'em, join 'em. And don't forget to order McMan's Water, I mean, uh, McMan's Namirans - nature's miracle dihydrogen oxide cure - today.

Friday, June 5, 2009

Oprah is an Unmitigated Idiot and a Menace to Society

"Crazy Talk," reads the cover of this week's Newsweek. "Oprah, Wacky Cures, and You."

Finally, someone willing to take on the cult of Oprah. The article, by Weston Kosova and Pat Wingert, opens:

"In January, Oprah Winfrey invited Suzanne Somers on her show to share her unusual secrets to staying young. Each morning, the 62-year-old actress and self-help author rubs a potent estrogen cream into the skin on her arm. ..."

Then progesterone on her other arm (two weeks a month) and a daily syringe estrogen injection into her vagina, plus 60 daily vitamins and other preparations. According to Newsweek:

"The idea is to use these unregulated 'bio-identical' hormones to restore her levels back to what they were when she was in her 30s, thus fooling her body into thinking she's a younger woman."

In case you're looking for a medical opinion:

"Several times during the show [Oprah] gave physicians an opportunity to dispute what Somers was saying. But it wasn't quite a fair fight. The doctors who raised these concerns were seated down in the audience and had to wait to be called on. Somers sat onstage next to Oprah, who defended her from attack."

Two years ago, I came to the conclusion that Oprah was an unmitigated idiot and a menace to society. "Did Bipolar Drive a Mother to Kill Her Child?" ran a website promo back in August 2007 for an upcoming show. "Tune in Monday."

The show started out with a 911 call: Mother Andrea had just confessed to killing her child. In an interview from jail, Andrea was treated to a whole segment, then nearly a whole studio segment was devoted to her friends gossiping about Andrea.

Then Oprah went to the audience where Kay Jamison PhD was seated. In case you're wondering how Oprah finessed this unlikely transition, she didn't. She bluntly introduced Dr Jamison as the leading bipolar expert in the world, as if she herself were the expert at deciding who the experts were. Then she asserted in the form of a question that bipolar was the new term for manic-depression.

You could see the slight hesitation in Dr Jamison. The second edition to her definitive "Manic-Depressive Illness" (with Frederick Goodwin MD) had just come out three or four months before. The subtitle reads: "Bipolar Disorders and Recurrent Depression."

The book goes to elaborate lengths to inform physicians that a good deal of so-called unipolar depression is also part of the manic-depressive phenomenon, with enormous treatment implications.

But Dr Jamison was smart enough not to dispute Oprah. She allowed the misconception to stand. By the time Oprah asked her first substantive question, just about all the time had ticked off the clock. Oprah broke into a commercial, and Dr Jamison was forgotten.

Then came two segments devoted to two C list TV celebs, and one final drive-by wrap-up with Dr Jamison from her seat in the audience.

So that was the world of bipolar according to Oprah. As for my part in the production:

Earlier, a producer from the show had called me, and I was very happy to brief her. But soon it became obvious that all she wanted to know from me was my mad scene. Nearly all of us diagnosed with bipolar I can rattle off juicy mad scenes, but I happen to lead a spectacularly boring life and my mad scene was pathetically lame.

Still, there was enough in my life (and the lives of the rest of us with bipolar) to educate and inspire viewers.

How was I to know Oprah was really looking for a baby-killer?

What the show drove home loud and clear was the power of Oprah. Kay Jamison may or may not be the leading authority on bipolar disorder, but she is certainly by far the best known and the most in demand. Yet Oprah could literally summon Dr Jamison from her crowded schedule in Baltimore to play the role of spear carrier in her sham production.

Not only that, Oprah could get away with not according Dr Jamison the time and respect - much less a place on stage - she gave to her non-expert guests.

As to how Oprah can get away with this: My own book had come out some 10 months earlier. Trust me, I'm only slightly exaggerating when I say that I would have skipped my daughter's wedding for 10 seconds on Oprah.

I detailed a lot of this in a blog I did for HealthCentral's BipolarConnect, and looking back I wish I had been far more disapproving. In a later blog that was critical of the way "60 Minutes" covered the tragic death of Rebecca Riley, I did say that Katie Couric was as dumb as Oprah, and I feel good about that.

The Newsweek story devotes six pages to how Oprah gets away with highlighting non-expert guests who promote various quack cures and too-good-to-be-true beauty treatments, not to mention vaccination fear-mongers, while keeping expert dissenters in their place. Unfortunately, the Oprah phenomenon is growing, if such a thing is possible - her own new cable channel is in the offing, which will include Oprah-approved programming on health and living well.

But in the end, the joke may be on Oprah. As the article notes, Oprah became enthralled to some old positive thinking repackaged as "The Secret," to which she devoted three shows. Amongst other things, The Secret advises that "you cannot 'catch' anything unless you think you can." But here she was, reported Newsweek, in the months that followed, "worrying over her thyroid, ingesting bioidentical hormones and putting on pounds."

Concluded Newsweek:

"What if Oprah had managed to solve all of her problems, to end her search for meaning and fulfillment and spiritual calm and a flatter, firmer stomach by summoning the very power of the universe itself? It might have been hard for her to take Suzanne Somers seriously after that."

Thursday, June 4, 2009

New Zealand and the US: Clearing Up Some Misperceptions

Two people who know me well sent me a story from yesterday's Washington Times, entitled New Zealand Rated Most Peaceful, US 83.

I hold dual citizenship. I lived in New Zealand for 11 years during the 70s and 80s. My daughter calls it her home. Naturally, I was interested in reading further:

"Americans pining for a peaceful existence might consider moving to New Zealand, the most peaceful nation on Earth, according to the 2009 Global Peace Index released Tuesday by an Australian-based research group that counts former President Jimmy Carter, Ted Turner and the Dalai Lama among its endorsers."

The article went on to say that the Sydney-based Institute for Economics and Peace rated the relative tranquility of 144 nations according to 23 indicators, including gun sales, the number of homicides, the size of the military, the potential for terrorism and the number of people in jail.

I don't take much stock in this type of information, and, frankly, New Zealand's number one ranking surprised me. If you want to see a New Zealand the tourists don't see, rent one of my favorite (and most disturbing) movies of all time, "Once Were Warriors." (Check out the YouTube highlight above.)

New Zealand has a reputation as a Pacific Shangra-la existing in splendid isolation. The impression is some sort of National Park Middle Earth (I wonder where that came from?) populated by smiling white people, plus 60 gazillion sheep (is that why they're so f-ing happy?).

Actually, last time I checked, New Zealand had one of the highest rates of depression and teen suicide in the world. But the tourist industry there creates an entirely different impression. Indeed, "Once Were Warriors" played brilliantly on this. In the opening shot we see a pastoral mountain scene. Then the camera pulls back to reveal the image as an illusion: We are really looking at a billboard situated in an ethnic urban slum.

The Washington Times piece raised a very interesting animated discussion on what an ideal country should be. Some of the comments were extremely intelligent and perceptive, but a lot of it was embarrassingly stupid and jingoistic. Some examples of the latter:

"When payment comes due it is Americans who have to shed blood to protect those knuckle headed morons who think everyone in the world wants to sit in a circle with them singing campfire songs. How long would New Zealand last without the nations such as US, Britain, Australia, Japan, Canada, that rally to the 'peaceful' nation's defense?"

"So two of the indicators are gun sales & size of the military? If that's the case, then I'm proud the USA comes in at #83. I don't want to be at the top of a list like that."

"Face it folks....the Reason New Zealand & those other countries are ranked so high is the clear & obvious LACK of mexicans & blacks...sorry but sometimes the truth hurts, but somebody has got to acknowledge it."

Okay, time for the facts:

New Zealanders fought in World War I three years before the US entered that conflict. They and the Australians were used as cannon fodder and suffered more casualties per population than the other allied nations. (Check out my ANZAC Day blog piece.) New Zealanders fought in World War II two years before Pearl Harbor, in all theaters but the Russian front. Again, their sacrifice was way out of proportion to their population. New Zealanders also served with distinction in Korea and Vietnam, and currently the country has elite forces serving in Afghanistan.

Some 15 percent of the New Zealanders are indigenous Maori and 7 percent Pacific Islanders, plus a fair percentage of Asians and recent Europeans. These cultures are responsible for a vibrant and dynamic melting pot society that is the pride of nations like the US. But the downside is the type of social tensions well-known in the US.

One major difference between New Zealand and the US, as I see it, is that in New Zealand religious and "patriot" extremists are confined to the lunatic fringe. Similarly, special interests have a much more difficult time writing social, economic, and health policy. Not surprisingly, the public discourse there is far more to my liking.

The other major difference is that because New Zealand is so small (with a population of 4.3 million) it has no margin of error should things go wrong. Think Iceland. The country cannot afford to ignore obvious signals and it doesn't. The US, until recently, could and did. This creates the irony of isolated New Zealand being outward-looking and highly adaptive. The US is still learning.

Of course, as has always been the case, if the US sneezes, New Zealand (and the rest of the world) catches a cold. These days, we are all holding our breath.

Both the US and New Zealand were founded on and continue to operate on ideals that are the envy of the rest of the world. I am proud to hold citizenship in both. The US is a great country, but not for the reasons the right wing fringe here would have you believe. New Zealand is one of the best spots on earth, but not for the reasons its tourist industry would have you believe.

The bottom line is that any place that calls itself a country has to figure out what kind of society it wants to be and what kind of world it wants to live in. We don't always get the answer right, but the important thing is we are asking the right questions. God bless America, God defend New Zealand.

Wednesday, June 3, 2009

Managing Anger

Here's a video I shot last year. No koalas were harmed making this movie. Enjoy ...

Further reading from mcmanweb:

Anger in Depression and Bipolar Disorder

This is pure anger talking, as potentially as deadly as cyanide on a personal level, more powerful than a nuclear weapon on a collective level. Sooner or later everyone must learn to deal with their anger or face the consequences. For people with mood disorders the stakes are even higher, as anger is to an episode what a match is to a keg of gunpowder. The process also works in reverse, as our population, including our loved ones, generally have a lot to be angry about. ...

Tuesday, June 2, 2009

Thinking Our Way to Well

This is my fourth post that reports on a lecture on personality and wellness by Robert Cloninger MD two weeks ago at the American Psychiatric Association's annual meeting in San Francisco.

The first three pieces:

What the Hell is Well-being, Anyway?
Who the Hell Are We?
Breaking Down Personality

We left off with the proposition that although personality is heritable and stable, we can change. To pick up ...

Change is a very nonlinear dynamic process. We tend to maximize our strengths to move in more positive directions. By contrast, if we deteriorate we tend to maximize all our weaknesses.

We are shaped by the interactions between our genes and environment, and our self-awareness (a uniquely human trait) allows us to modify our environment. So what happens when we grow up in a hostile home environment?

Dr Cloninger cited a Finish study that followed 3,600 kids from birth to adulthood. Among other things, the findings showed the effects of growing up with parents who were either overly strict (tending to bring out anger and novelty-seeking) or overly neglectful (tending to bring out anxiety).

An angry or anxious individual is going to be restricted in reacting to his environment. This is because if you get the limbic system, the emotional brain, all charged up and defensive "you shut off reasoning."

(Have you ever tried to reason with someone who is angry or anxious?)

Brain imaging studies amply demonstrate the over-reactive limbic system at work, but the same body of research also shows activity in the prefrontal cortex (PFC). A 2001 study that Dr Cloninger was involved in demonstrated a correlation between heightened left dorsal medial PFC activity and and those with high "self-directedness."

Translation: The thinking parts of the brain can transcend the emotional brain. Instead of blindly reacting or engaging in avoidant behavior, well-adjusted individuals evaluate what is going on inside them.

So - how to engage these recently-evolved rational parts of the brain to mobilize change? Okay, take a guess: How many thoughts do we have per second?

Answer: Ten, as in ten thoughts a second. Try snapping your fingers as fast as you can - your thoughts are going way faster. What's remarkable is that when a person has a new thought or looks at something from a new point of view, "ALL the connections in the brain shift just like that."

So we're not sending messages by neurotransmitters down highways. Rather, we are going from Point A to Point Z in the brain. (Think quantum change.)

Below is a diagram of how the internet was connected in 1999. We are looking at long tracks that connect local networks.

There is another property. Complex adaptive systems operate like nonlinear thermodynamic systems. "Stable State A," for instance, may be okay, as everything nearby is worse. But "Stable State B" (that manifests a gain in potential energy) is where you want to be. But activating the energy to get from A to B tends to involve perturbations that initially makes one feel worse.

"You have to go through this valley of tears to get there, and that's painful."

Psychiatry tends to be focused on "keeping people close to their local optimum," in other words at Stable State A.

Development is a spiral, Dr Cloninger told his audience. You can spiral up or spiral down. You need to seize on your strengths to get through your pain.

Hold that thought. More later ...

Monday, June 1, 2009

New Poll Results: Meds in Our Treatment - How Does "Smart" Factor In?

"How well have your meds worked for you?" I asked you in a poll I ran here through the month of May. Of the 168 who responded, only 14 percent of you answered, "very well." In other words, only a small percentage of you thought your meds worked like gang-busters. The overwhelming rest of you had reservations.

Thirty-six percent of you - about one-third - responded, "conditionally well." In other words, your meds may not be perfect but they were meeting your expectations. When you add in the "very well" group, fully half you reported satisfactory results with your meds.

So, can we put a positive spin on the results? Hold that thought.

One in five of you (19 percent) told me that your meds were "rather problematic." In other words, you're not happy with your meds, but you are experiencing some benefit.

Nearly one in five (17 percent) responded that your meds were "very problematic" and 11 percent told me your meds were "a complete disaster." Added together, nearly one-third of you have given an unambiguous thumbs down to your meds.

So, how do we interpret the results? Keep in mind this is hardly a scientific survey. Let's go negative, first:

The fact that more than eight in ten of you reported that your meds are not working "very well" - for whatever reasons - speaks volumes. Add to that the fact that the "complete disaster" group is running in a virtual dead heat with the "very well" group and we are talking very low levels of customer satisfaction.

In other words, if meds were automobiles, car makers like General Motors would be in bankruptcy. Wait, let me rephrase that. Uh, never mind ...

Now let's go positive. This means first seeing possibilities in the "rather problematic" grouping. Suppose, for instance, half of you in this group were to graduate to "conditionally well." Then 60 percent of you - nearly two thirds - would at least be reasonably satisfied with your meds. Suppose we could get similar conversion rates from the "very problematic" and "complete disaster" groups. Then three-quarters of you would be happy customers.

How is that possible?

The meds are constant in this equation. The two variables are you and your psychiatrist. First imagine a smart patient working with a smart psychiatrist. Now picture a naive patient placing his or her trust in a lazy psychiatrist. Are we likely to see dramatically different outcomes? I rest my case.

Okay, one example: You come to your psychiatrist depressed. He diagnoses you with clinical depression. The antidepressant doesn't work. In fact, it makes you feel worse. The psychiatrist tries you on another antidepressant, then another. You are starting to feel like you are crawling out of your skin.

Then your psychiatrist gets a bright idea - or rather a thought implanted in him by a drug rep the day before. Based on his conversation with someone way too dumb to get into med school in the first place but attractive enough to take up a career in modeling (whether male or female), he now decides that the answer to your problem is an atypical antipsychotic to kickstart the antidepressant.

A smart psychiatrist will know exactly the right situation to make this call, but in your case would probably never have to make it. Instead, after not getting a good result with your second antidepressant, she - the smart psychiatrist, that is - would probably revisit the diagnosis. It could turn out - on further enquiry - that you have bipolar or something in the bipolar spectrum. So she takes you off the antidepressant and puts you on a mood stabilizer.

If the mood stabilizer works, your "complete disaster" scenario has been turned around. Maybe not all the way. In all likelihood, in fact, you still have a long way to go. But now, at least, you are in a position to learn more, to move up to from being a naive patient to a smart one.

What a difference "smart" makes in the equation.