Friday, February 27, 2009

Trick Question: Vincent Van Gogh


Between Feb 1888 and May 1889, Vincent Van Gogh produced an incredible 187 paintings. How many did he produce from Aug 1890 to Sept 1891?

Answer: Zero. On a brilliant day in July 1890, Van Gogh aimed a pistol at his chest and fired. He died two days later. He was 37. The paintings would stop. There would be no more Van Goghs. No more Sunflowers, Irises, or Starry Nights.

Undoubtedly, Van Gogh's madness stoked his creativity. But it also stopped it dead in its tracks.

His last words were: "The sadness will live forever."

From mcmanweb: Vincent and Me

In May of 1889 he entered the asylum at Saint Remy de Provence. "As for me, my health is good," he wrote his brother Theo, "and as for my brain, that will be, let us hope, a matter of time and patience."

***

What got me started on this quick blog was Therese Borchard's excellent video blog from earlier today:
On Creativity and Mood Disorders

Gorillas!

video

Here is some footage of my favorite animals (don't tell my cats). I shot this last summer at the San Diego Zoo. Enjoy ...

Thursday, February 26, 2009

Antipsychiatry: Dumb and Dumber


A few weeks ago, I came across a comment from an antipsychiatry blog referring to Kay Jamison as "lithium-addled." Yesterday, I stumbled on a blog post from someone named Stan, entitled, Kay Jamison, The Unquiet Fraud.

What gives?

First Stan comments on Vincent Van Gogh:

"If he lived today he would be locked away painting blank canvasses to no one ... blinded by antipsychotics ... "

Actually, Stan, for all we know, he might have picked up an Oscar the other night and thanked Pfizer for making it possible. What we do know is that Van Gogh aimed a pistol at his chest and pulled the trigger. He was 37.

But Stan contends, "it was never a life in vain."

Let's defer to Van Gogh, himself, on this: "What am I in the eyes of most people - a nonentity, an eccentric, or an unpleasant person - somebody who has no position in society and will never have; in short, the lowest of the low."

Who knows what choices Van Gogh would make today? Maybe he would choose not to lead a tortured life. Maybe he would choose to stay on meds. Maybe he would choose not to paint. That's the point, he could choose. He would have choices.

I really don't want to pick on Stan, and I would really rather be writing about other things, but this sort of thing is all too typical of the commentary on the blogosphere. The only reason I found this piece was because it came up near the top under a Google Blog search that day.

This is the new democracy of web 2.0. Anyone who takes five minutes to set up a Blogger account can get the same attention as Kay Jamison.

Speaking of Kay Jamison: In the same blog post, Stan takes Dr Jamison to task for ascribing Van Gogh's "precious madness" to the false label of bipolar. Not only that:

"Kay Jamison has been running around for many years publishing one book after another telling us all how wonderful her drugs are in controlling her 'Bipolar Label.'"

Hmm, excuse me if I'm wrong, but ...

Off her lithium, Dr Jamison attempted suicide. On her lithium, she is a professor at Johns Hopkins, co-author of the definitive text on bipolar, best-selling author, recipient of a McArthur genius grant and numerous other awards, plus was in a successful marriage (cut short by the death of her husband).

In short, Dr Jamison exercised a choice that was, sadly, unavailable to Van Gogh.

***

From mcmanweb:

Vincent and Me

There was that little bit of sky pressing down on the fields, as if of a heavier substance than earth, and there were the fields trying to crowd the sky out of the canvas, as if vaster than the heavens. And there were the crows, hedging their bets, represented by stark black flicks. ...

Madly Creative

Says Dr Jamison, in her introduction:

"The fiery aspects of thought and feeling that initially compel the artistic voyage - fierce energy, high mood, and quick intelligence, a sense of the visionary and the grand, a restless and feverish temperament - commonly carry with them the capacity for vastly darker moods, grimmer energies, and, occasionally, bouts of 'madness.'"

Wednesday, February 25, 2009

FDA Approves Depressant Drug for the Annoyingly Cheerful


FDA Approves Depressant Drug For The Annoyingly Cheerful

This, from The Onion, is too funny for words. According to Onion News Network, the FDA has approved the first "depressant" for the 20 million Americans who are "insufferably cheery."

Funny thing, though, if such a drug existed, I'm convinced psychiatrists would be handing out free samples by the truck load. Actually, in a way, they do. I learned very quickly when showing up for a psychiatric visit, that I needed to mask any appearance of chirpy behavior. So fearful are psychiatrists of mania, I'm convinced, that they tend to err on the side of over-medicating us. I've seen way too many examples in support groups.

In my binary world of "smart" vs "dumb," this is an example of "dumb psychiatry." A smart psychiatrist will work to find the patient's sweet spot. But that's for a future blog.

Enjoy the video ...

Viewing Bipolar


Recently, Michael from Stable Moods asked me and eight other bipolar patient authors, plus an abstract artist, to respond to 16 questions. The first few questions I filled in rather quickly, but being a writer, my answers soon expanded to essay length. I spotted a similar pattern when I read the other interviews on the site.

Then I got thinking. Same set of questions. Obviously different answers. How did we compare? I decided to zero in on three questions:

Do you think mental illness is generally looked upon differently now than it was 10 years ago? Better? Worse?

We were all virtually unanimous on this one. "Madness: A Bipolar Life" author Marya Hornbacher's response is fairly typical:

"Yes, I think there's an enormous change for the better. Ten years ago, when I was diagnosed, no one was talking about bipolar, and there was very little public acceptance of schizophrenia either. People still firmly believed in the 'pull yourself up by your bootstraps' nonsense, and I think now the awareness that that's just not how mental illness works is more widespread. But I think there's a very long way to go. I think it's improved in some circles, but the larger population still knows too little about it, still fears it, still vilifies it, and still needs to know the truth about what it is."

Lana Castle, author of "Bipolar Disorder Demystified," notes that "people are beginning to be more sympathetic."

I observe that stigma still exists (and that patients and clinicians can be as bigoted as the rest of society). Nevertheless, we may soon see "bipolar lite" on people's resumes and Facebook pages:

"In professions that value creativity and drive, mild bipolar is looked upon as an advantage. In many social circles, people value those bright sparks who are 'a little bit crazy.' Some people even think bipolars make the best lovers, and I am going to do nothing to disabuse them of that notion."

Do you consider bipolar disorder part of who you are, part of what makes up your character, personality and experience of self?

Julie Fast, author of "Take Charge of Bipolar Disorder," is emphatically negative:

"I see bipolar disorder as an illness that sits on the real me. When I'm not sick, I am a happy, balanced and focused person. ... The REAL ME has nothing to do with bipolar disorder. That's an illness."

In a related question, Ms Fast observes, "there is nothing positive about bipolar disorder - I would be a lot better off without it."

Terri Cheney, author of "Manic, A Memoir," is in accord with most of the rest of us: "I consider it integral to my personality, and to my experience of the world. I think I see things more intensely, and feel things more deeply, than the average person. This has its pros and cons, of course. As a writer, it's invaluable. As a human being - it can be tough."

In a similar vein, Mark Kirchmeir, author of "The Province of Hope," adds: "I say it to the world. It defines me. While a mixed blessing, I have a high IQ and am very perceptive. ... I believe that my intellect and intuition are intertwined with my condition."

Abstract artist Susan Olmetti goes all the way: "My bipolar is my best friend, we will be together forever. I could not live without it. The way I see it, you either grow to love your other half or grow apart. I could not exist without it, it's who I am and will always be."

If the medical establishment could offer you a pill tomorrow that would cure bipolar disorder and remove all the associated symptoms (positive and negative) would you take it and why?

This is the money question. A sampling ...

Lynne Taetzch, author of "The Bipolar Dementia Art Chronicles," replies: "Never. It's like wanting to give up your life for someone else's. Who among us would really want to do that? If nothing else, being bipolar has made my life interesting. As a writer and artist, it is all good material."

Susan Olmetti concurs: "No, I like who I am because I am bipolar, which makes me more unique. Ten percent insanity and ninety percent sweat makes you a really smart person."

Julie Fast sees things completely differently: "Where is the water! Hand me a glass! Are you kidding? I'd take the pill."

Holly Hollan, author of "Soaring and Crashing: My Bipolar Adventures," admits to having changed her view:

"In my book, I say that I would not take such a pill. However, at that time, I was experiencing hypomania (not manic, as I was still greatly in touch with reality). However, since I finished the book, I have been in a three-year depression, and have thought that if there were a pill that would take the depression away and make me hypomanic permanently, I would take that pill!"

Jayson Blair, author of "Burning Down My Master's House," would like a smart pill:

"If that cure could eliminate the negative symptoms and consequences, and could preserve the positive ones, I would happily take it. If that pill eliminated both the negative symptoms and the positive ones, I would take it - it would be worth it - but probably not so happily."

How Would You Respond?

Have things improved, stigma-wise? Is bipolar the real you? Would you take that pill? Please leave a comment ...

Check out the interviews.

Tuesday, February 24, 2009

Guest Blog - Bipolar Kids: Is There a Doctor in the House?


The people I love being around the most are the parents of bipolar kids. The stories they tell would break your heart, but one minute in their presence and I'm experiencing one of those rare states they have no words for. It's my pleasure to introduce my good friend Louise Woo, who is active in the Los Angeles area Child and Adolescent Bipolar Foundation (CABF). Louise, over to you ...

Thank you, John.

For the last nine years, I've run a support group in Los Angeles for parents whose children have bipolar disorder.

It's a nice group of moms - and it is almost always the moms, I'm sorry to say. There are about 50 active families in the group and every month or two, a dozen of us convene for lunch, order salads and a glass of wine. If anyone needs to share a drink with their comrades, it's these soldiers. Each and every one knows how grueling and relentless it is to get good treatment and schooling for our kids.

I'm pleased to report that the quality of care has improved immensely in the past decade. Ten years ago, the most common complaint we heard was "Our doctor doesn't believe children can have bipolar disorder." Thanks to the 2005 treatment guidelines published by the American Academy of Child and Adolescent Psychiatrists, we hardly hear that at all anymore.

But one problem persistently, stubbornly remains: There just aren't enough qualified doctors to go around.

A new mom came to lunch this past Saturday. She has a 14 year-old son and her insurance is Medi-Cal. Because of this, Mom has to take her son to a public health clinic for treatment. The in-house psychiatrist only sees kids there a couple days each month and does not return phone calls from the parents.

Needless to say, you can see where this story is going: The poor boy is not stable and not improving in any significant way.

He's currently on a cocktail of four medications -- two of which caused the other mothers to look at Mom with concern and alarm. When the boy became agitated and violent after a few days on Medication No. 4, Mom called the clinic in a panic.

They relayed a message to the doctor... and the remedy was a new prescription for Medication No. 5!

"Did the doctor even see your son?" I asked, incredulous?

"No," said Mom. "It was all done over the phone."

Unanimously horrified, we urged Mom to find a new doctor as fast as possible.

"Do you know of any other doctors who take Medi-Cal," she asked. "How can I find one?"

We looked at each other, biting our lips. One mother said she had a friend down in San Diego who might know someone here in L.A. that had a list of doctors that accept Medi-Cal. I felt like we were looking to find a doctor to do an illegal abortion in Ireland. How could it be this hard?

But it is. It still is.

The American Academy of Child and Adolescent Psychiatrists has 7,500 members nationwide. That seems like a decent number, but when you figure there are roughly 10 million kids who need treatment in the United States that gives every doctor a caseload of approximately 1,333 kids.

And of course, statistics do not tell you the important part.

If you live in Los Angeles County, you can use the AACAP doctor-finder and start calling one of 140 doctors listed on the website. It won't tell you if the doctor is taking new patients, if the doctor takes your insurance or if the doctor is well-liked and respected by patients. But it is a place to start.

The further you drive from L.A., the shorter your cold call list gets.

In San Bernardino County, the largest in California, you'll only have five names to call.

In Fresno County, you can wrap it up in 15 minutes: Only two doctors.

And sadly, if you live in the beautiful rural towns of Kern County, you can call one doctor. One.

We have a terrific psychiatrist for our family. He is not on our insurance network and we pay out-of-pocket. But I fired three HMO-list psychiatrists for being uncaring, medical bureaucrats before we got to this man. In my mind, his expertise, his caring manner and his rapport with my two teenage sons is worth every penny. Nay, it is probably a bargain!

And yet, when other mothers ask that inevitable question: "Who do you see?" I have to pause.

In the same way that parents jealously guard the name of their best and most reliable babysitter, I am also reluctant to give up the name of our doctor.

Why? I don't know. It's not like he won't cap his patient list when it gets too large. I guess I just hate to flood him with referrals. And in my own selfish interest, I hate to make my own life harder by adding to the competition.

Because my sons are pretty stable and have been for years.

Why are they stable? Beyond good medical care, I think it's also the fact that I will rush them in for an appointment at the slightest hint of trouble. And that I make good use of our appointments by faxing in reports ahead of time.

If our doctor's patient load reaches critical mass, will he have time to read those faxes? Will I be able to get my kid in to see him in less than 4 days? Will he have less time and energy to care about my incredible sons?

That's a rhetorical question. We all know the answer.

But naturally, I give up the name. How could anyone ever deny good care to another child so desperately ill?

Even if we had nationalized health care or affordable health insurance offered by every employer, it would not solve the biggest problem: There aren't enough qualified doctors anyway.

My sons' conditions are serious, possibly even life-threatening. In the same way that I would not want my pediatrician treating my kid if he had cancer, nor do I want him treating my kid's neurological condition!

So what can we do about the shortage of specialists?

I don't have any ideas or answers. I don't know why more medical residents don't go into psychiatry, much less child psychiatry. They would certainly have job security and an abundant client roster. They get paid much better than pediatricians and still there's no shortage of underpaid pediatricians!

Is it just because medical school is expensive and specialists need additional training, which means additional education debt? Do our nation's student loan policies discourage students from getting more training because it just costs too much?

Can we do something -- anything -- to change that?

I hope so, because as parent awareness grows, so does the need for doctors. And if we have a shortage of doctors for cash-paying patients, why would any doctor ever bother to take Medi-Cal for low-income patients?

And if there are no child psychiatrists taking Medi-Cal, what are we Women Who Lunch going to tell that Mom? Pack up and move to Canada?

That's not the answer any of us are looking for.

***

For information and support:

Child and Adolescent Bipolar Foundation

From mcmanweb:

The Bipolar Child - What to Look For
The Bipolar Child - Treatment
The Bipolar Child - An Historic Book

Monday, February 23, 2009

Oscar Night High Wire Act

"Man on Wire," directed by James Marsh, last night received an Oscar for Best Documentary Feature. Below is a "rerun" of a blog post I published Feb 3. Enjoy ...

It was a nice relaxing walk - a quarter mile in the air over New York City.

Last night, I watched "Man on Wire," a 2008 documentary about Philippe Petit's improbable 1974 tightrope walk back and forth between the two World Trade Center towers.

Phillippe Petit had already accomplished similar (and illegal) feats between the towers of Notre Dame Cathedral and the Sydney Harbor Bridge.

As the documentary makes clear, pulling off the World Trade Center caper was equivalent to plotting and executing a bank heist. Months of planning, reconnaissance, and rehearsal went into the operation. On numerous occasions, Petit and his accomplices snuck into the towers as they were under construction. Sometimes in the dead of night. Other times during the day, posing as contractors or journalists.

Then, one muggy August night, two separate teams hauled up their equipment, eluded security guards, and strung their wire and its moorings across the chasm.

The operation was not exactly flawless. Petit and his accomplices were amateurs performing the job of professional criminals, and things went wrong. Several times, the mission came close to being aborted. Then, just about dawn - with barely a second to spare - the team on the other tower radioed that they had secured the wire.

It was now or never. Petit stepped out onto the wire - and suddenly he was in his element.

During the bank heist phase of the film, the main soundtrack theme was Greig's "Hall of the Mountain King." Now, suddenly it was the dreamy piano music of Satie's "Trois Gymnopedies."

Get this - now that Petit was back to doing what he was good at doing, he could RELAX. The hard part was over. Walking - make that dancing - a tightrope 104 stories above Manhattan traffic, piece of cake.

The brain is funny that way.

Saturday, February 21, 2009

A Walk in the Country

video

I seem to be on a nature video kick these days, but a picture is literally worth a thousand words. Getting along in today's world takes its toll. We need breaks. We need time out.

I shot this two days ago. This is a walk I frequently take, on old Route 80 that used to lead into San Diego, 40 miles away. The scene is about three miles from my house. Enjoy ...

Friday, February 20, 2009

Rocks!

video

Consider this the fourth installment in my 1000-videos nature trilogy.

Of all the various treatment and recovery strategies, the "nature cure" is the oldest and perhaps the most reliable. I am extremely fortunate to be living in a rural environment, where I all I have to do is open the door.

I shot this two miles (as the hawk flies) from my home in southern CA, forty miles out of San Diego and about ten miles from the Mexican border. The day before, I came back all excited about the waterfall footage in my camcorder. This time, I decided to make the area's magnificent rocks and boulders the subject of my video.

I can't begin to describe the feeling, 3,500 feet up in the mountains, beneath a brilliant cobalt sky, watching the light bounce off nature's Stonehenge wonders on all sides of me.

Enjoy ...

Lessons From Basketball: Outcome vs Process


Sunday's New York Times Magazine feature, The No-Stats All Star, by Michael Lewis, was nominally a piece about Shane Battier, who plays "small" forward (he's only 6' 8") for the Houston Rockets. On paper, Battier looks like an also-ran, with obvious weaknesses to his game and underwhelming stats.

Funny thing, though, when he is on the floor, his team scores more points than the opposing side. This season, Battier is a plus-10. A good player is a plus-3. Battier has a way of making his other teammates better by creating situations that statistically improve their chances of success. His specialty is creating bad nights for the opposing team, in particular their best shooter.

Sports has been experiencing a revolution in statistics - with the introduction of new measures for a player's performance - which in turn is changing how various front offices seek out talent and configure rosters. For instance, baseball, which started the trend, is now giving much greater weight to a batter's on-base percentage (ie the ability to get to first base, such as by drawing walks as well as getting hits).

Now basketball is beginning to catch on. Battier's forte is to force opponents into taking low-probability shots. For instance, if a shooter likes to turn left, he will force the opponent to turn right. Even if Battier scores zero points, if he can keep the other team's star shooter to say 25 points instead of 35, then Houston is likely to win.

Nevertheless, NBA insiders and players fail to perceive Battier's merits. If a superstar has an off-night against Battier, no one gives him any credit. The superstar simply had a bad day at the office.

The article zeroed in on a recent game against the Lakers. Battier would be guarding Kobe Bryant that night. On the pregame show, the co-hosts scoffed at the notion of Battier shutting Kobe down. Said Chris Webber: “I think Kobe will score 50, and they’ll win by 19 going away.”

Here's where it gets interesting. The article made a distinction between "process" and "outcome." The outcome, basically, is out of your hands, but you can control the process. All night, Battier kept forcing Kobe into low-probability shots. Late in the game, in frustration, Kobe drew a technical foul. That was the process - Battier was in control.

But should a low-probability shot hit its mark anyway - that is the outcome. You can't control that. If you have mastered the process, chances are you will achieve favorable outcomes. But if the outcome doesn't go your way, there is no sense in beating yourself up.

I suppose you can put it like this: Say you want to lose ten pounds. Ten pounds is the intended outcome. The process would be rigorously sticking to a healthy diet, exercise, and other routines. If you do that, losing ten pounds is doable. Most of us, though, fail at the process level.

But a good many dieters do everything right, and still the weight refuses to come off. Very frustrating, but if we had been true to the process, we can hold our heads high.

I've met a lot of patients who do everything right. Still, the depression, the anxiety, the agitation - you name it - persists. Extremely frustrating.

I've also met patients whose lives are in complete violation of the process. Not surprisingly, they are stuck in their recovery. Yes, a favorable outcome may be out of reach, but you will never know that until you have given the process your best shot.

Back in Houston, the game came down to the closing seconds. Kobe had the ball 27.4 feet from the basket. Instantly, Battier was all over him like an extra layer of clothing. As the article explained, Kobe misses 86.3 percent of the time when taking 3-pointers from beyond 26.75 feet at the end of very close games. And tonight, Kobe had to do it blind, with Battier's mitt up against his eyes.

He shoots, he ...

Here is Michael Lewis' closing paragraph:

"It was a shot Battier could live with, even if it turned out to be good. Battier looked back to see the ball drop through the basket and hit the floor. In that brief moment he was the picture of detachment, less a party to a traffic accident than a curious passer-by. And then he laughed. The process had gone just as he hoped. The outcome he never could control."

Thursday, February 19, 2009

Treating Marilyn




The following is based on the first part of a talk I gave to clinicians on meds compliance as part of a grand rounds at a psychiatric facility in Princeton:

'Marilyn walks into your office," I began. "She reveals her moods have been all over the place. Everything points to bipolar. Okay. How do you treat her?"

Believe it or not, no one raised their hands. I was the one who had to suggest that a mood stabilizer might be a good idea, then I had to make sure we had a consensus. Then I went to the catch, namely how does the most important person in the equation - the patient - feel? After all, even the best med in the world is useless if patients won't take it.

Maybe we need to ask Marilyn a few more questions, I suggested. Consider:

Marilyn is literally larger than life. Over the top is her baseline. It's a legitimate part of her personality. How long do you think she is going to stay on her mood stabilizer if she thinks her personality is getting medicated out of her?

Hypomania is the first thing to come to mind when thinking of Marilyn, but the operative word from the DSM regarding this type of behavior is "uncharacteristic."

"For someone else to act like Marilyn," I said, "that may be hypomanic. For Marilyn to act like Marilyn - that's normal."

In support, I cited Ronald Fieve MD of Columbia University, who coined the term, "the hypomanic advantage."

"Keep in mind," I said, "a lot of us view the world through the eyes of artists and poets and visionaries and mystics. Not to mention through the eyes of highly successful professionals and entrepreneurs. We don't want to be like you."

How can I describe the look of surprise from my audience? Like I had let rip a roof-rattler and they were too polite to laugh - I think that best sums it up. I should have thrown away my prepared talk at that stage. Seriously, I should have said. We don't want to be like you. Why should that surprise you?

Instead I plowed ahead:

"We don't want to fly too close to the sun," I continued. "But don't clip our wings. Obviously Marilyn needs to be reeled in a bit. But how do we proceed? What do we have to go on?"

Believe it or not, there are zero published studies for treating hypomania. Zip, zilch, nada. The only solid evidence base involves the acute phase of full-blown mania, when we're bouncing off walls, 911 cases.

"So," I asked, "are you thinking of giving someone with hypomania an industrial strength dose?"

What else is going on with Marilyn? Personality issues? Quirky behavior? Does the bipolar itself affect her capacity to think rationally?

"You're the rational ones," I said. "We know where you are coming from. But do you know where your patients are coming from?"

I clicked to two slides: Fear/feeling threatened, problems accepting authority, cognitive distortions ...

The list went on and on. "Looking like a lot of your patients?" I asked.

"Here's the point I'm making," I continued. "Not only are you treating the illness. You are treating any behaviors and attitudes that come in the way of treatment. And you're not going to find that out unless you talk to the patient - and listen."

I wasn't through: "Just sending a patient out the door with a prescription - in my opinion - is not treatment."

Back to Marilyn. She's Marilyn. She has enormous gifts and doesn't want her wings clipped. She has various personality issues. And her illness is affecting her judgment.

"We have the advantage of knowing the tragic outcome," I concluded. "Knowing what you know, are you happy just writing her a prescription and sending her out the door?"

Postscript: This first part of my talk - "The Problem Patient" - went fairly well, perhaps because the audience could spin my message in a way that assigned all blame to the patient. There was no way they could do that with the next two sections, "Problem Meds" and "The Problem Clinician," and I got a very different reaction.

More later ...

Wednesday, February 18, 2009

Waterfall!

video

I could write a thousand words on how moving to southern California from New Jersey two and a bit years ago dramatically improved my mental health, but this short video will actually show you.

Today, I drove two miles to the entrance of a state park and trekked a short distance in. It had been a rainy week, which meant a special treat - waterfall!

In the summer it will be gone, but then I will have different sites and sights to savor. Enjoy ...

Guest Blog - Where Did All the Bipolar Stigma Go?


No one better describes the follicle-tingling fear of a mood about to run away than Terri Cheney. Her book, Manic: A Memoir, published early last year, instantly hit the New York Times best-seller list and soon after was optioned as an HBO drama. Two weeks ago, Manic came out in paperback. Warm congratulations on the success of your great book, Terri. Take it away ...

Thank you, John.

I have had bipolar disorder my whole life, I think. And I have hidden my bipolar disorder practically that whole time. I wasn’t properly diagnosed until I was thirty-four years old (I’m forty-nine now). Although I finally had a name for what was wrong with me, it was a name I dared not speak.

For most of my adult life, I was a very successful entertainment lawyer, representing the likes of Michael Jackson, Quincy Jones, major motion picture studios, etc. In the small and insular world that is entertainment litigation, reputation is key. Upheavals are common, and clients want to know, will you be around tomorrow? Can I trust you with my life? I knew a lawyer who was shunned because she had breast cancer, for example, even though it was eminently treatable. Another man I know lost all his big ticket clients because a rumor went around that he had AIDS. As a young associate, I watched these events with wide eyes and an impressionable mind.

I was very sick while I was practicing law. Stress inevitably exacerbates my mood swings, and the constant deadlines, office politics, and multi-million dollar stakes of a high-profile practice were like venom to my system. When I was manic, of course, I functioned like a dynamo. My pressured speech, exuberant schemes, and frenetic activity went unnoticed in the madness that is Hollywood. But always, inevitably, my mood would switch and I’d collapse into paralysis. Papers piled up on my desk, phone calls went unanswered, and it was not uncommon for me to simply lock my office door and crawl under my desk to cry. When the depression got really severe, I had to stay home, under the covers, immobilized.

Which meant I had to call in sick – but sick with what? It never once occurred to me to tell the truth. No one could possibly want a mentally ill lawyer as their fiduciary, I thought. So I made up dozens of excuses, each one more carefully crafted than the last but none so dire as to raise any real alarms. I had the flu an awful lot, and massive dental problems, and more bouts of food poisoning than the average person could experience in a lifetime. But these were innocuous illnesses, nothing like the horrid truth.

Because I could turn to no one else, I finally turned to the page. In 1999, during a secret hospitalization for suicidal depression, I began writing about my bipolar disorder. And writing. And writing. Seven years later, I found myself with a book, which to my everlasting surprise, HarperCollins wanted to publish.

The night before Manic: A Memoir was to be released, I nearly called my editor at midnight to tell her I’d changed my mind. I wasn’t practicing law anymore, but I was sure I would be ostracized by the entire world once it found out the truth. All these years, I’d been so careful. I’d erected an impeccable fa├žade: you never saw me with a hair out of place. I hid my demons out of sight, behind a career, a lifestyle, a precise and cautious lie of a life.

Manic changed all that. It hit the New York Times bestseller list a month after its release, and now everyone knew my story: the suicide attempts, the nights in jail, the manic infidelities. I was terrified at my first reading, which all my friends attended. What would they think? How would they treat me now? But the response was astonishing, and it remains astonishing. Almost without exception, I’ve been showered with acceptance. Strangers write me daily, from all corners of the world, thanking me for my honesty. People I used to work with email me, telling me how brave I am. My friendships are deeper now, richer because they are real. What’s even more surprising to me is how many “normal” people have openly identified with my story. They may not have faced the extremes I wrote about, but everyone knows the edge.

All of which makes me wonder: where did the bipolar stigma go? Is it possible that it was always mostly in my head? I doubt that, but still . . . If I had told the truth all those years ago, what kind of life could I have lived? If I had trusted people with my despair, would I have had to attempt suicide so many times? Maybe acceptance was always out there, just waiting for me to allow it to emerge. If I have learned anything from the experience of publishing Manic, it’s that so many of the shadows I fear the most exist because I am blocking the light.

Purchase Manic: A Memoir on Amazon.

Tuesday, February 17, 2009

Where Dumb Psychiatry Meets Dumb Antipsychiatry


In my last blog, I urged that we consider issues in terms of "smart vs dumb" rather than "pro vs anti." In the final analysis, dumb psychiatry and dumb antipsychiatry serve the same master. Let me give you an example:

For at least three decades, it has been widely accepted that prescribing an antidepressant (with no mood stabilizer) to someone with bipolar runs a strong risk of flipping a patient into mania or speeding up the cycle or both. The American Psychiatric Association in it's 2002 Practice Guideline for treating bipolar issues a blanket warning against this practice.

The catch is that it is often difficult to distinguish unipolar depression from bipolar depression. The result is that too many of us with bipolar are misdiagnosed with unipolar depression and prescribed meds that make us worse.

There is an additional twist to this catch: Many people experience "recurrent" and "highly recurrent" depressions that come and go in a pattern very similar to bipolar cycling. The pioneering diagnostician Emil Kraepelin observed this phenomenon way back in the early twentieth century.

When Kraepelin coined the term, manic-depression, he wasn't merely referring to bipolar. He also included those with recurrent depression. This was the widely accepted view until the DSM-III in 1980 separated out bipolar and lumped recurrent depression with "chronic" depression.

The result is that doctors tend to treat all depressions alike - with predictably disastrous results. This is an example of "dumb" psychiatry, the indiscriminate prescribing of antidepressants to anyone who happens to say they're depressed.

Reformers in the profession, such as former head of the NIMH Frederick Goodwin MD and Nassir Ghaemi MD of Tufts, have long urged that psychiatrists think twice before prescribing antidepressants. The best way to turn certain unipolars into bipolar, they would argue, is to prescribe an antidepressant.

Dr Goodwin and a good many others have campaigned for years to realign the next DSM so that it is more closely in tune with Kraepelin's original conception of manic-depression. This would get doctors to rethink their prescribing practices.

We don't know if change will happen. But no doubt the task force charged with issuing an updated DSM is considering the matter. Indeed, the possibility of a new "bipolar III" diagnosis was the basis of a blog post last week from Furious Seasons, fairly typical of antipsychiatry sentiment:

"I think it's been a boon to doctors - who get a patient for life - and Big Pharma - which gets a long-term customer - but I have my doubts about how useful the depression-is-bipolar thing is for patients who wind up on an atypical and an anti-seizure drug when they are dealing with something that's not even in the ballpark of mania."

To respond in brief:

Yes, big pharma would love a customer for life, but to make a case for a drug industry conspiracy one would have to bend time a hundred years. Kraepelin wrote his classic text, "Manic-Depressive Insanity and Paranoia," decades before drug manufactures came up with the first psychiatric meds, and psychiatrists have been arguing ever since where best to carve nature at its joints.

Moving on, bipolar is more accurately a cycling illness, not a polar illness. So is recurrent depression. Thus "something that's not even in the ballpark of mania" is irrelevant. The purpose of treatment is to manage the cycle, bring it under control, not necessarily treat symptoms at one pole or the other.

An antidepressant may work in some patients with recurrent depression. But a logical first option is to consider using a mood stabilizer such as lithium or Depakote or Lamictal.

Once the cycle is under control, it may be possible to consider low-meds or no-meds options in conjunction with cultivating cognitive skills such as mindfulness.

Admittedly, Lamictal had a lot to do with drawing attention to "soft bipolar" several years back, and GSK profited handsomely. But these days the drug has gone generic, along with lithium and Depakote. Thus GSK and others have no financial stake in pushing for an expanded bipolar diagnosis.

If anything, an expanded diagnosis would significantly reduce antidepressant sales. This is why you don't see drug companies sponsoring clinical trials to prove Drs Goodwin and Ghaemi right.

No doubt, some manufacturer will try to jump on the bandwagon with some implausible claim trumpeting the virtues of their house antipsychotic, only to be laughed out of town. But this would be an example of opportunism, not hatching a conspiracy.

As for psychiatrists wanting a patient for life: The best indication is that psychiatrists are driving away their patients. Only a small minority of patients adhere to their meds over the long term. Matching the right meds to the right diagnosis might change this.

So now we return to the issue of smart vs dumb. Dumb psychiatry treats all depressions as the same. So does dumb antipsychiatry. Dumb psychiatry favors preserving psychiatry's status quo. So does dumb antipsychiatry. Ironic, isn't it?

Monday, February 16, 2009

Of Psychiatry and Antipsychiatry


In January, I asked readers this question: "What best describes your condition over the past 30 days?" Only 14 percent replied they were "back to where they want to be" or "better than they ever could have imagined."

This month, I'm asking: "How do you rate your meds in managing your illness?" So far, 82 percent rate their meds as either "most important," or as important as other tools. Only 12 percent ascribe little or no importance to their meds.

Do you perceive a discordance between the two poll results here? Granted, this is not a scientific survey. Nevertheless, the results beg the following question: Why do we place such great emphasis on meds, when obviously they are not living up to our expectations?

Or: Are our expectations so low to begin with that we have given up on ourselves?

Hold those thoughts for a second, then surf around to various patient/consumer/survivor/whatever blogs. You will note the vast majority have a decided antipsychiatry slant to them. Many of these blogs set out to expose the lies of the drug industry, which - believe me - are in abundant supply. Others have a much greater emphasis on helping their readers achieve recovery through non-pharma interventions.

Even blogs that find value in meds and psychiatry (such as this one) do so in the context of sharply critical enquiry.

It's as if we're all saying in unison to psychiatrists: We trusted you. We placed our faith in you (and apparently still do). But we're the ones who have to live with the results, and - let's put it this way - we're not exactly happy.

Simply put: If meds worked the way the drug industry and psychiatrists would have us believe, compliance rates would be nearer to 100 percent (instead of more like 30 or 40 percent over the long term), we would enjoy similar employment rates and stable relationships as the rest of the population, and mental illness would be in sharp decline rather than (apparently) on the rise.

Thus, there is a rational basis to antipsychiatry.

But life is never that simple. If we have to be binary in our beliefs, it's much more useful to think in terms of "smart vs dumb" than "pro vs anti." Far too many of us have been victims of dumb psychiatry. Similarly, dumb antipsychiatry (and there is an awful lot of it going around) can lead to disastrous personal decisions.

The antidote to both is "smart."

More on this in future blogs ...

Saturday, February 14, 2009

Guest Blog: Valentine's Day Reflections on Love and Friendship

Friends and relationships are crucial in our recovery. I have been extremely fortunate to encounter Cristina Romero, who offers uncommon wisdom in how to pick wisely. Cristina, who lives in Ontario, is passionate about writing about her experiences with mental illness. Cristina, I turn my blog over to you:

Thank you, John.

We've been told to choose our friends carefully. After all: “You are the company you keep.”

But we've also heard: “Birds of a feather flock together.”


So which one is it? Or is it some kind of Catch-22? So who we are to start with determines our choice in the company we keep. But the company we keep determines our growth as individuals.


I have bipolar I. Ironically, this is my blessing, something that practically absolves me of this Catch-22 phenomenon that most people find themselves in. Let me explain.

I have an incredibly vast array of emotions, thoughts and behaviors. There are always people I can resonate with, a flock I can find to fly with. I consider myself fortunate to be able to connect with so many different types of people, but I also realize just how vulnerable I am. I can sync with just about anyone, and this is not always good.

Think of mental illness as a type of unwellness. Financial stressors, physical illness and career problems are some of the other types of unwellness that people deal with. It is not so much the type of unwellness itself that determines our wellness, but how we approach that unwellness. There are similarities in approaches to deal with unwellness, regardless of what it is. We can learn from others in altering perspectives, developing healthy attitudes, and cultivating coping skills.

In other words, a friend doesn’t have to have mental illness in order to teach me about living with mental illness, and I don’t have to have the physical illness that my friend has for me to help my friend live with her physical illness.

Here are some of the questions I ask myself of people to see if they have a healthy influence on me: 


Are they resourceful in finding people to find help? Are they consumed only with their own problems, or do they lend a helping hand to others? Do they want to get better? Are they willing to think outside the box in finding solutions? Have they been stuck on the exact same problem forever, or have they made progress?

As a person with bipolar disorder, my capacity to resonate with people across the entire emotional spectrum can be both destructive and beneficial. Around people who do not approach unwellness in a healthy way, I am at risk of resonance and deterioration, like a superstructure collapsing.


With people who approach wellness in a healthy way, I can resonate and flourish, like those triumphant chords that conclude symphonic masterworks. The choice is mine. I feel fortunate to have that choice.

My friends, family, and husband are carefully selected people. We all work and play together for mutual growth and enjoyment. These people are at the core of any health and happiness I experience.

This Valentine’s Day, as I reflect on the nature of love and friendship, I am grateful for the lessons I’ve learned through my illness. It's all about who I choose to nurture and who I choose to nurture me.

Live well, choose wisely ...

Friday, February 13, 2009

Romantic Love: Valentine's Eve


Happy Valentine's Eve. Some excerpts (with some slight edits) from this article from mcmanweb, The Brain in Love and Lust:

In a study published in 2002, anthropologist Helen Fisher PhD of Rutgers University and a multi-disciplinary team of experts recruited 40 young people madly in love - half with love returned, the other half with love rejected - and put them into an MRI with a photo of their sweetheart and one of an acquaintance. Each subject looked at the sweetheart photo for 30 seconds, then - after a diversion task - at the acquaintance photo for another 30 seconds.. They switched back and forth for 12 minutes.

The sweetheart photos, but not the acquaintance photos, revealed activity in a part of the brain that projects into dopamine pathways, central to reward and motivation. In addition, several parts of the prefrontal cortex that are highly wired in the dopamine pathways were mobilized, while the amygdala, associated with fear, was temporarily mothballed.

Dr Fisher divides love into three categories involving different brain systems: 1) Lust (the craving for sexual gratification), driven by androgens and estrogens; 2) Attraction (or romantic or passionate love, characterized by euphoria when things are going well, terrible mood swings when they’re not, focused attention, obsessive thinking, and intense craving for the individual), driven by high dopamine and norepinephrine levels and low serotonin; and 3) Attachment (the sense of calm, peace, and stability one feels with a long-term partner) driven by the hormones oxytocin and vasopressin.

Romantic love, Dr Fisher explained in a lecture at the 2004 American Psychiatric Association’s annual meeting, is not an emotion. Rather, it’s "a motivation system, it’s a drive, it’s part of the reward system of the brain." It’s a need that compels the lover to seek a specific mating partner.

Love also hurts. Dr Fisher cited one recent study where 40 percent of people who had been dumped by their partner in the previous eight weeks experienced clinical depression and 12 percent severe depression.

Romantic love, Dr Fisher believes, is a stronger craving than sex. People who don’t get sex don’t kill themselves, she said. On the other hand, it is not adaptive to be romantically in love for 20 years. "First of all," she confided, "we would all die of sexual exhaustion."

In a related undertaking, Dr Fisher found evidence that romantic love exists in 150 societies, even though it is discouraged in many of them. But with many women from these countries now entering the workforce and acquiring a sense of independence - together with medical science keeping us relatively younger longer - we can expect to see romantic love on the rise worldwide, she predicted..

Bring it on.

Check out the complete article.

Med Schools and Drug Money: Who's Keeping Score?


Yesterday I came across a 2008 Scorecard put out by the American Medical Student Association (AMSA), entitled, "Conflict of Interest Policies at Academic Medical Centers." The Scorecard grades (on a scale from A to F) all 151 medical schools in the US based on their policies regarding interactions between medical campuses and pharmaceutical manufacturers and device makers.

Criteria include: Gifts, consulting, speaking, disclosure, samples, purchasing, access, on campus and off-campus education, industry support, curriculum.

Psychiatric education and practice would fall under each med school's policies.

The University of Pittsburgh (whose affiliated Western Psychiatric Institute is a perennial top ten in US News' top psychiatric facilities) leads the pack with "exemplary" policies. For instance, UPMC "has a model consulting policy" designed to foil attempts at bribery disguised as consulting contracts. Each consulting contract "must provide specific tasks and deliverables, with payment commensurate with the tasks assigned."

Seven other medical schools also received top marks.

Recently, two top psychiatry departments were rocked by scandals involving failures by its academic employees to disclose major payments made to them by pharmaceutical companies - Joseph Biederman of Harvard and Charles Nemeroff of Emory University. These two men are the A-Rods of their fields in terms of accomplishments, and, unfortunately, stand to be branded as A-Rods for all the wrong reasons.

Harvard received an F, along with 51 other schools. In no category did its medical school and affiliated institutions receive a passing grade. According to the AMSA, "the medical school itself reported that it currently has no conflict of interest policies corresponding to the Scorecard domains." Nor do its policies specify an oversight mechanism nor are there specific sanctions for noncompliance.

Emory received an "incomplete," with a provisional grade of C. According to the Scorecard, the school "has indicated that its conflict of interest policies are being reviewed and revised at the present time." Thirty-five other schools with policies under review also received incompletes.

What about those two legendary institutions, the Mayo Medical School and Johns Hopkins? Both Ds.

According to the AMSA:

"The public, policymakers and leaders within the medical profession are becoming increasingly worried about financial conflicts of interest influencing medical care and threatening the doctor-patient relationship. Medical schools and academic medical centers can play a powerful leadership role in setting new standards for the profession.
"

The AMSA through its PharmFree Campaign "continues to advocate for evidence-based rather than marketing-based prescribing practices, global access to essential medicines, and the removal of conflicts of interest."

Thursday, February 12, 2009

Randolph Nesse Interview



In my blog earlier today, I cited evolutionary biologist Randolph Nesse MD of the University of Michigan in support of a more sophisticated view of mental illness - one that acknowledges its selective advantages rather than its mere pathology. Here is a video of Dr Nesse speaking precisely on the topic, interviewed by Richard Dawkins. Also check out the other four videos in the series.

Darwin and the Psychiatric Advantage


Happy birthday, Charles! You're looking great at 200.

Also happy anniversary of "On the Origin of the Species," which was published 150 years ago today.

Here's an interesting fact: Peacock tails drove Darwin crazy. The sight of one "makes me sick," he wrote. These feathered accessories played havoc with his work-in-progress theory of natural selection. Surely, any bird stupid enough to flaunt their colors in the wild wouldn't live long enough to mate.

Darwin's solution seems obvious enough today, but back in the nineteenth century it was a scientific breakthrough, a work of genius. The showy tails, he figured out, were chick magnets. The flashier, the better. The well-endowed cock, so to speak, won the right to make a deposit. The bird's genes would live on, even if its owners' days were numbered.

Evolutionary biologists refer to this as a trade-off. The sickle cell gene, for instance, helps confer immunity against malaria.

Fine. But how does Darwin apply to mental illness? According to evolutionary biologist Randolph Nesse MD of the University of Michigan: "Psychiatrists still act as if all anxiety, sadness, and jealousy is abnormal and they don't yet look for the selective advantages of genes that predispose to schizophrenia and bipolar disorder."

I heard Dr Nesse at the American Psychiatric Association annual meeting a few years back talk about the selective advantage in anxiety. Obviously, sufficiently anxious cave men were able to steer clear of saber toothed tigers long enough to find an opportunity to pass on their genes to the next generation.

Anxiety traits are no mere artifacts of an earlier age. It is crucial to marshaling our wits. We could never survive one day in traffic without it, let alone the full range of personal interactions.

Dr Nesse compared the brain's limbic system to a smoke detector that is programmed to deliver 100 false alarms for every genuine alert. The false alarms are the price of survival. Better to be too anxious. The seriously anxious, it turns out, have hyper-sensitive smoke detectors. The false alarms and the hyper-sensitive in our midst tend to blind us to the fact that a certain degree of anxiety is good, that we would fail to exist as a species without it.

Similarly, you can make a Darwinian case for bipolar. Highly energetic and productive and creative types certainly had a selective advantage over their more mundane kinfolk. Think of mania lite. Passing on the risk of more serious manifestations was an acceptable trade-off.

But what is the advantage to depression? For one, depression is when the rose-colored glasses come off, when reality sets in. If mania is all about daring, depression is about caution. The daring have an advantage in life's ultimate prize, the opportunity to mate. So do the cautious.

Depression also provides an opportunity for regrouping and recouping, not to mention a time of introspection and reflection. Think of depression as an enforced time-out. In its own perverse way, depression may set the stage for needed psychic healing.

As with anxiety and mania, we are talking more benign manifestations. The more virulent versions of depression, it seems, are part of the price we have to pay.

For the longest time, I could see no selective advantage to schizophrenia. There are those who claim that those with schizophrenia would have made perfect shamans and seers back in the old days - a romantic notion of serious mental illness totally without merit, as I see it.

Then I picked up "A Beautiful Mind" by Silvia Nasar. The book chronicles the life of John Nash, the Nobel Laureate who lost some 25 years of his life to schizophrenia. As the book makes clear, John Nash was a social and intellectual oddball well before his schizophrenia erupted. We tend to think of mental illness as a complete break with reality or rationality, but these breaks don't just happen overnight. Subtle symptoms may manifest many years earlier, what the experts describe as "prodromal" states.

And there may be certain advantages. Nancy Andreasen MD, PhD of the University of Iowa mentions that Newton, Einstein, and Watson all had schizotypal tendencies or schizophrenia running in the family. Newton, in fact, had a full-blown psychotic episode later in life.

John Nash confided to a friend that he took his psychotic delusions seriously because they came to him the same way his mathematical ideas did. As the title says, "A Beautiful Mind."

Darwin made no attempt to reconcile his discoveries with religion, but that doesn't mean the two are mutually exclusive. Nevertheless, because one cannot witness evolution in action the way one can observe gravity or thermodynamics in action, Darwin is still a hard sell for most of the population. For many of us, evolution is an act of faith, even though science is virtually unanimous on its general points.

Evolutionary psychiatry, though, is still a speculative endeavor. A legitimate argument can be made that we are retrofitting psychiatry to conform to evolutionary precepts. Then again, a very strong case can be made that our behavior makes no sense without taking evolution into account. Instead of viewing all mental illness as solely destructive, we are forced to consider its advantages. And in looking at the advantages, we find potential in our own worth.

Happy birthday, Darwin, from a big fan of yours.

Wednesday, February 11, 2009

Happy Birthday, Abe Lincoln



I know tomorrow is Lincoln's birthday, but I have Feb 12 booked for Charles Darwin. So happy 200th, Abe, one day early.

As most of you know, our greatest President dealt with constant debilitating depression throughout his entire adult life. In the end, what didn't kill him ennobled him and steeled him for the grim task ahead.

This is one of the first videos I ever did. It is my tribute to a hero and saint, a man who has inspired me since I was old enough to talk. Enjoy ...

Tuesday, February 10, 2009

Is It Bipolar?


"Jane" writes: "My husband thinks he is bipolar. ... We can be fine for days at a time but then he gets upset over the smallest things. He always accuses me of flirting with other people that I'm friends with. ..."

Says "Jill": "My husband was diagnosed (kinda) with bipolar about two months ago. ... I'm not sure if he is just a control freak or if he truly has bipolar. Most of the time when he has an episode it is over something stupid. For example, one time I stayed at Walgreens too long. He put all my things in the yard, kicked me and his three children out of our home. ... Right now, he will not let me sleep in the bed (says it is his cuz he bought it before we got married) or use the computer ... "

"Sally" asks: "Do all bipolar people lie or is it just my husband? He will lie about anything, even trivial stuff. He told his work mates his father had died, not for sympathy. He didn't know why he had said it."

"Sue" wonders: "I have been dating my boyfriend for well over a year now and he has been struggling with bipolar and a heroin addiction. ... He is in denial and thinks that everyone is is crazy and he is the only sane one."

I come across many questions like this as an "expert patient" on HealthCentral's BipolarConnect. I'm not God. I'm not all-knowing. I cannot make problems go away. But I can address in a general way the numerous issues these questions raise:

First, abuse is abuse, whether bipolar-related or not. Bottom line: Whether a person chooses to break off the relationship or try to save it, no one should have to put up with abuse.

But is it bipolar? That seems to be the real question. It's as if these women are wanting me to reply in the affirmative. Please, I'm hearing, let it be bipolar. Let that be the cause. Finding a cause, of course, implies a solution.

If only life were so simple. Needless to say, the behaviors these women describe are not exclusive to people with bipolar. True, bipolar may be a contributing factor, but the real culprit may lie deeply embedded in the individual's personality.

It seems as more and more people are being educated about bipolar, the more willing they are to finger bipolar as the primary suspect for all manner of human failings. Cheating, stalking, anger, violence, verbal abuse, drinking, gambling, sexual promiscuity, fraud, unwillingness to communicate. Again, yes, bipolar may be a contributing factor, but these behaviors and others are endemic in society, independent of bipolar.

Loved ones, of course, need to ask these questions. So do those with a diagnosis, as well as those wondering if they are candidates for a diagnosis. Human behavior is very confusing. We want to know why things are happening, why our lives are going so badly. Then maybe we can change our behavior, or help change the behavior of those we love. Then maybe we can get our lives back in order.

Is it bipolar? Keep asking. But also keep asking: Is it something else? Believe me, even if bipolar is an answer, there is always going to be something else.

Monday, February 9, 2009

Snow!

video

I returned home late tonight from a meeting to find about a quarter inch of snow had infested our yard. What is wrong with this picture? I'm living in southern California about ten miles from the Mexican border, that's what.

But I'm 3,500 feet up in the mountains and once a year or so Ol' Man Winter really lets loose. The snow will be gone ten minutes after the sun hits it tomorrow.

Meanwhile, here's 24 seconds of video I shot six days before Christmas, a bit deeper into the mountains, about seven or eight miles from where I live. I like to refer to it as "optional snow." The type you can drive out to at your discretion.

Enjoy ...

Zen addendum, next morning: If the snow has melted when you wake up, has it really snowed?

The Bipolar Relationship Riddle



Later this afternoon, I will be making a 50-mile drive in the pouring rain to La Jolla in San Diego to attend a DBSA friends and family support group. It concerns a very bad communication I had last week with a former girlfriend. I really need to talk to some people who understand.

I have bipolar. Or more accurately, bipolar plus other stuff. I have yet to meet someone who just has bipolar.

My second marriage - to a very lovely women with bipolar plus her own collection of add-ons - ended just prior to Thanksgiving two years back. Then I had a short relationship with delightful cowgirl with bipolar (more pluses) that ended just prior to Thanksgiving a year back. Then a slightly longer relationship with personally stunning ball of fire (bipolar fully loaded) that ended - drumroll please - just prior to last Thanksgiving.

What is it about three Thanksgivings in a row?

I'm obviously no expert on relationships - in fact, call me a jerk - but my experience from both sides of the bipolar fence as a patient and loved one has conferred me with certain insights. In the six weeks this blog has been going, I have already posted two blogs on relationships, and intend to post many more.

The experts talk about "functionality," which is arguably a more reliable indicator of the severity of our illness than ticking off a symptom checklist. The two key indicators of functionality are work and relationships (keeping in mind we may choose healthy alternatives to both). Predictably, our population performs poorly in both categories.

Obviously, figuring out how to get it right is a fairly reliable predictor of recovery.

Think of the above as a preamble to this announcement: My favorite bipolar blogger, Therese Borchard of Beyond Blue is devoting an entire week to relationships. Here, she gives a rundown on what we can look forward to in future posts. Check out her first installment, You Deplete Me: 10 Steps To End a Toxic Relationship. Brief excerpt:

"Be prepared to dry off as you step out of the river of Denial. A few questions will get you there. Ask yourself these, for starters: Do I feel energized or drained after I spent an hour with X? Do I WANT to spend time with X or do I feel like I have to? Do I feel sorry for X? Do I go to X looking for a response that I never get? Do I come away consistently disappointed by X's comments and behavior? Am I giving way more to the relationship than X? Do I even like X? I mean, if X were on a cruise and I didn't know her, would I walk up to her and want to be her friend/boyfriend based on her actions and interactions with others?"

More later ...

From mcmanweb: Family Fallout

"The authors devote a whole chapter to mood triggers, and place strong emphasis on partners working together to reduce the stress in the living environment, from keeping work and social obligations under control to more discriminate TV viewing to proper diet, sleep, and exercise. ..."

Sunday, February 8, 2009

Gray Whales!

video

Each year, some 26,000 gray whales migrate in small groups from the Arctic to Baha, Mexico to mate. The technical marine biologist term is spring break. From December to March, these magnificent mammals can be spotted in the waters off San Diego.

Yesterday, I hopped aboard a cruise boat with my movie camera and played nature photographer.

I'll let the video do the talking. Suffice to say, the sight of one of these leviathans breaching the surface transcended all my expectations. Enjoy ...

Friday, February 6, 2009

Do Antidepressants Work?


In 2002, the July 2002 Prevention and Treatment published a study by Irving Kirsch PhD of the University of Connecticut. The study analyzed the FDA database of 47 placebo-controlled short-term clinical trials involving six antidepressants. These included "file drawer" studies, ie trials that failed but were usually never published.

The study found that the mean difference between the drug and placebo was a "clinically insignificant" two points on the HAM-D depression scale.

In other words, going solely on these data, there is no rational basis for choosing to take an antidepressant, much less for doctors to be prescribing them.

There are two main arguments to rebut this conclusion, both raised in an editorial in this month's American Journal of Psychiatry. In the editorial, Sanjay Matthew MD and Dennis Charney MD (both of the Mount Sinai School of Medicine) use findings from the NIMH-underwritten STAR*D real world clinical trials in support, namely:

"Mean" data is misleading in that it fails to parse out those populations who truly benefit from an antidepressant as opposed to those who don't. Clinical observation reveals that for certain patients an antidepressant is a Godsend. The catch is we don't know in advance which patients are more likely to respond.

STAR*D made an attempt at this, finding, amongst other things, that depressed people with anxiety or substance use, those with melancholic features, and those with a certain gene variation fare less well on antidepressants.

STAR*D also demonstrated the value of switching to a second antidepressant if the first one fails. The study showed that while at least half those in the study did not achieve a good result on their first try, according to the AJP editorial: "Patients who completed all phases of the study had an overall cumulative remission rate of 67%."

The editorial, however, failed to point out a major catch, namely that the 67 percent remission rate is theoretical, fully acknowledged by STAR*D. In the words of STAR*D's authors:

"The theoretical cumulative remission rate is 67% ... Note that this estimate assumes no dropouts, and it assumes that those who exited the study would have had the same remission rates as those who stayed in the protocol."

Ah, drop-outs. In the words of Holly Swartz MD of the University of Pittsburgh addressing a symposium at the 2006 American Psychiatric Association annual meeting: "If a patient doesn't stay on it, it doesn't do any good, even if it works."

The Kirsh study found a mean drop-out rate of 63 percent in it's review or clinical trials. This finding corresponds to other studies. In STAR*D, of 3,671 who entered the study only 123 made it to Round Four (keeping in mind that those who did well exited at earlier rounds).

Commenting on STAR*D, in a recent blog, Nassir Ghaemi MD of Tufts University noted that:

"Even if antidepressants worked in the short term (2 months, which is also what the meta-analysis assessed), one-half of patients who stayed on them relapsed into depression within one year. At the one year outcome, only about 25% of patients actually had remained well on and tolerated an antidepressant, much below the levels most clinicians seem to feel occurs in their clinical experience."

So what can we learn from all this?

First, beware of the exaggerated claims of the pharmaceutical industry and psychiatry. Also, beware of those making negative claims. All sides in this debate excel at spinning data.

Second - assuming you are not suffering from bipolar or a depression that behaves like bipolar - it is rational to choose to go on an antidepressant. Antidepressants may not work for everyone, but you may be one of the lucky ones.

Further, if your first antidepressant fails, it is worth persevering with a second or even a third antidepressant. Assuming you do not give up, your theoretical chance of success is two in three.

But also keep in mind you may find these meds intolerable and that relapse rates are high. They work in some cases, but they also disappoint. To conclude with Dr Ghaemi:

"We could all wish that clinicians' beliefs about antidepressants were true, or even half true. And perhaps they are the latter, for these agents surely have some uses in some settings; they are just not the dream drugs they seemed to be. ..."

From mcmanweb:

When Your Second Antidepressant Fails

The paradox: Perhaps if we don’t expect much of our antidepressant, we can get much better results.

Clinical Trials - What the Drug Companies Don't Report

So what is the most meaningful figure in an antidepressant trial? Apparently not the response rate, not the remission rate, not the Hamilton Depression scores. It's the drop-out rate, way too high whether going by industry figures or the FDA database. Clearly we are sending an unequivocally strong message that our medications leave much to be desired. Are any drug companies listening?

Wednesday, February 4, 2009

Does Bipolar Kill?


I recall attending my first-ever bipolar conference in Pittsburgh in June 2001. Robert Post MD of the NIMH informed us that those of us with bipolar can expect to die seven years earlier than the general population, independent of suicide.

A year or two later, I heard Ken Duckworth MD, then in the employ of the state of Massachusetts, relate an anecdote to a NAMI convention that ended in a colleague telling him, "You guys really know how to put on great memorial services."

This month's Psychiatric Services features a review of 17 studies involving 331,000 bipolar patients. The study found mortality from natural causes ranged from 35 percent to 200 percent higher than comparison groups. The rate is similar to that of smokers.

The study yielded no smoking gun, but its authors single out the usual suspects, including:

Stress - Stress is complicit in just about every mental and physical catastrophe, from flipping us out to stopping our hearts. Researchers have connected a range of dots - from genes that predispose our limbic systems to over-reacting to whatever life throws our way to cortisol released into our blood streams to over-excited neurons resulting in cellular breakdown. A very strong case can be made that all mental illness results from stress, as well as its corollary - the best way to manage mental illness is to manage our stress.

Risky lifestyles - Including smoking, drug and alcohol use, poor diet, and lack of exercise, not to mention lonely lives in toxic living conditions.

Our meds - Patients have been telling their psychiatrists since Day One that they don't enjoy being fat stupid zombie eunuchs. But only recently, on the heels of the NIMH-underwritten CATIE studies from a few years back, is psychiatry waking up to the fact that our meds may in fact kill us, particularly in regard to the metabolic effects of certain second-generation antipsychotics. Smart meds strategies may work wonders. Too many of us are exposed to dumb ones.

Bad health care - GPs and others tend not to take seriously patients they view as crazy, combined with the inability in some patients to effectively communicate with their doctors.

Bipolar kills. So do depression, anxiety, schizophrenia - you name it. Actually, death wins regardless of whether or not we have a diagnosis. No exceptions. But we don't have to sit around waiting for the inevitable. We can still make choices. Live long and prosper ...

We Have Competition!



It seems there are THREE singing bipolar bloggers!

Followers of "Knowledge is Necessity" and Beyond Blue are well aware of the Bipolar Singing Blogger Smackdown between yours truly and Therese Borchard.

Therese got off to a flying start with her "12 Bipolar Days of Christmas" video, but I came right back rappin' to "Gonna Build Me a Tree." (See "The Bipolar Singing Blogger Smackdown" here at "Knowledge is Necessity" and on Beyond Blue.)

In the next round, Therese and her smiley faces thought they had me smoked with "A Few of My Favorite Things," but me and my gorilla homey, we were ready with my bluegrass "Recovery Anthem."

In the process, I invented a new hybrid music form that combines the worst of bluegrass and rap - "bluecrap."

Now Therese informs me we have competition - serious competition - Giannakali of Beyond Meds. One quick listen and you will realize that Giannakali and her canine homey have put my sistah Therese and me on serious notice that we need to lift our games.

Otherwise it's Metamucil and retirement for us.

Okay, Giannakali and homey: You may have wiped the floor with my face this round, but next time I'll be ready. Therese, too. You may think you have your howls and yowls down pat, well I got news for you - I have a didgeridoo that I can't play. You just wait.

Tuesday, February 3, 2009

Mixed Bipolar Depression: You Really Need to Be Reading This


Four and a half years ago, I sat down with leading bipolar expert Ellen Frank PhD of the University of Pittsburgh. I asked her to talk about a study she had been involved in concerning mixed depressions, that is, depression with some features of mania.

"What we've been arguing about is that even isolated symptoms that don't cluster together to create episodes may be important," she told me.

Emil Kraepelin, the pioneering diagnostician who coined the term manic-depression, recognized back in the early twentieth century that depression and mania could combine together to produce no fewer than six mixed states. Yet the DSM recognizes only one - full-blown mania with full-blown depression. By this criteria, only those with bipolar I are recognized as having mixed states.

The DSM is due for revision in 2012, and clearly things need to change. This month's American Journal of Psychiatry features the latest findings to emerge from the NIMH-underwritten STEP-BD real world clinical trials on bipolar patients.

In the study, of 1,380 patients diagnosed with bipolar depression, 54 percent had co-occurring subthreshold (one to three) manic symptoms while another 15 percent had a full mixed episode (at least four manic symptoms). Significantly, 71 percent of the mixed population had a bipolar II diagnosis. Only one-third of the patients had "pure" bipolar depression - that is, depression with no mania symptoms.

More than two thirds of the mixed population showed marked or severe irritability (think road rage). The mixed group were also more prone to attempt suicide. Common manic symptoms included distractibility, racing thoughts, and psychomotor agitation. We are talking depression with unwanted add-ons, and, not surprisingly, these depressions are more difficult to treat.

An earlier series of STEP-BD studies found that adding an antidepressant to a mood stabilizer did not, as expected, induce more switches into mania in the "pure" depression group. But this changed for the "mixed" group. As the study authors pointed out, clinicians who fail to pick up mania symptoms in depression may mistakenly "assume a beneficial role for antidepressant psychopharmacology."

Leading researchers such as Hagop Akiskal MD of the University of California, San Diego have advanced strong cases that the "mixed" population is much larger than psychiatry recognizes. STEP-BD now provides overwhelming evidence in support of this proposition.

Mixed states also jump the artificial divide between bipolar and unipolar depression. Perhaps even more important than knowing whether you have unipolar depression or bipolar is knowing precisely how "mixed" your depressions (and manias and hypomanias) are.

Chances are your psychiatrist is operating on the assumption that your depression is just depression. Maybe, maybe not. The onus is on you to get a dialogue going. Now more than ever, "knowledge is necessity."

Further reading from mcmanweb:

Treating Bipolar Depression

When Nassir Ghaemi MD of Tufts University was in residency at McLean Hospital, he assumed there was no harm in using antidepressants to treat bipolar depression. After all, "depression was depression," or so he and just about every clinician thought.

The Mood Spectrum

So what do we do with these irritable and depressed people with or without mixed states that the DSM presently ignores?