Tuesday, August 31, 2010

Living Well ...

This is a clip from my appearance on "San Diego Living," XETV, Channel 6, shot live this morning.

Doesn't This Always Happen?

God and irony are one and the same. Really.

Two years ago, I bought some camping gear just in time to break up with my girlfriend. The two of us, of course, had anticipated many overnights together under the stars. 

For two years, the gear sat unopened in the basement. Obviously, camping wasn't in my future. In June, I donated the gear to our local NAMI, which was staging a yard sale. Doesn't this always happen? I joked to the NAMI people. I serve on our NAMI board, and we all had a good laugh.

A few weeks ago, I met a very wonderful woman. She is into the outdoors. This weekend, we are going camping.

Gotta love it.

Sunday, August 29, 2010

Biblemania: Madness, Dysfunction, and Reconciliation

Let us start on a low note:

"All things are wearisome," writes the speaker. "What has happened will happen again, and what is done will be done again, and there is nothing new under the sun."

Speaker, of course, is Jewish for Koheleth, which is Greek for Ecclesiastes. I am not sure what the proper Biblical word is for clinically depressed: "To what purpose have I been wise," our serotonin-deprived author laments. "Alas, wise man and fool die the same death."

Ecclesiastes is the nearest thing in the Jewish Bible to Buddhist literature, but without the Eightfold Path to Enlightenment. Readers are simply advised to place a vague sort of trust in God and to enjoy life to the best of their abilities. The Book was written sometime after the sack of Jerusalem by the Babylonians, and there is a lot to be depressed and disillusioned about:

"How solitary lies the city" we hear in another Book of the Bible, "once so full of people!...Bitterly she weeps in the night..." (Lam 1).

Then there is Psalm 22: "My God, my God, why hast thou forsaken me," later echoed by Jesus on Golgotha.

In the meantime, there is the matter of life's cruel injustices: "Perish the day I was born and the night which said, 'A man is conceived.'" (Job 3.3).

Indeed, looking upon slab after textual slab of unremitting despair and depression, one wonders how any sane person can regard the Bible as inspirational reading. Yet we have all come across soaring lifting quotes (the 800 "glad" passages, according to Pollyanna), plucked out of context, and served up for our easy enjoyment. To me, all this "lift up our voices" talk has all the resonance of the top string of a chord. The challenge as I see it is to reconcile the seemingly irreconcilable, and to come out a better person in the process.

Which leads me to my next topic:


Try this on for size:

King Nebuchadnezzar of Babylon eating grass among the oxen (Dan 4.33), a frazzled King Saul needing to be soothed by a youthful David's lyre, hurling his spear at David, presumably right in the middle of a psalm (Sam 1.11). And of course Jesus driving the evil spirits out of the two madmen of the Gadarenes (Mat 8.28), as well as from Mary Magdalene (Lk 8.2).

But the Bible adds an extra dimension to the meaning of mad. If anything, mad is a positive character attribute. The great prophets transposed to our era would be prime candidates for five-point restraints, electro-convulsive therapy, and industrial strength Thorazine. But in ancient Israel, someone actually wrote down what they said and preserved it for the next generation to read.

Consider: A hypermanic Elijah outrunning King Ahab's chariot (1 Kings 18.45-46), Isaiah and Jeremiah railing against the corrupt authority of the day, Isaiah naked and barefoot, Jeremiah with a yoke around his neck, a starry-eyed Ezekiel and his wild visions, and Daniel, the inventor of apocalypse fever.

All but Elijah have Books of the Bible named after them.

Then there is John the Baptist virtually guaranteeing his head would be served up on a platter.

We can almost coin the term, "holy madness", and Christ was a proud descendant of this tradition, or, if you like, we can say he brought it to its completion. Contemplate this bizarre incident:

"Next morning on his way to the city he felt hungry; and seeing a fig tree at the road he went up to it, and but found nothing on it but leaves. He said to the tree, 'You shall never bear fruit any more!'; and the tree withered away at once." (Mat 21.18)

Hey, whatever happened to turn the other cheek?

Make no mistake about it, an enraged Christ bullying a defenseless fig tree represents the most perplexing passage in all the Gospels, but it's probably the sort of thing we are not meant to understand. Jesus is about to drive the money changers from the Temple. He will condemn the corrupt practices of the religious establishment with allusions to Isaiah and Jeremiah. He is predicting the fall of Jerusalem with references to Daniel. He knows human nature all too well. He sees the future with a clarity of one with the courage to look. He knows what is coming, including his own execution, and he is distressed and disillusioned.

He is a prophet, on one hand the sanest man in the world. On the other, he is far too sane for his own good, sane to the point of mad. Even his own family fails to understand him. Mad, here, is not a clinical condition. It is society's obdurate refusal to recognize a special son in their midst.


We can start right from the very beginning, at the very first sibling rivalry in history, between Cain and Abel. Soon after, we have Noah waking from a drunken stupor and cursing the descendants of his son Ham. Then we have Abraham, the father of his people. Yes, we all know about the would-be sacrifice of his son, Isaac, but ponder this disturbing passage in relation to his other son Ishmael, whose mother was Hagar the slave girl:

"Abraham rose early in the morning, took some food and a waterskin full of water and gave it to Hagar; he set the child on her shoulder and sent her away, and she went and wandered in the wilderness of Beersheba." (Gen 21.14)

Just to set the record straight, we're taking 110 in the shade here in a part of the world where they kill for water. We do not hear Ishmael's or Hagar's side of the story - or Isaac's for that matter - but I'm sure, had they been given a chance, they would have leaped at the opportunity to air a few "issues."

Abraham's nephew, Lot, apparently was a good fit for this family. When the evil rabble of Sodom banged on his door, demanding their civic right to bugger his guests, Lot cried out: "No my friends, do not be so wicked. Look, I have two daughters, both virgins; let me bring them out to you, and you can do what you like with them ..." (Gen 19.6).

Later, Lot entered a cave with his virgin daughters and emerged with his, um, daughters.

Then we have the matter of Jephthah and his only child, a virgin daughter who doesn't even rate a name. On his way to face the Ammonites in battle, Jephthah promised that, if victorious, he would make God a sacrifice of the first creature he met coming out of his house. Well, you guessed it, it wasn't the mother-in-law. And unlike Abraham and Isaac, there was no angel to put a stay to the proceedings. As the Bible records it, "she died a virgin." (Judges 11.39).

Of course, the ultimate dysfunctional family has to be King David's: "I will bring trouble upon you from within your own family," said the Lord through the prophet Nathan (2 Sam 12.13). Considering the source, you just know that David's domestic relations are going to take a severe turn for the worse.

To bring the reader up to date, there's all his wives and concubines, and not content to leave well enough alone he gets someone else's wife pregnant, Bathsheba, and sends the husband off on a suicide mission. A Babylonian or Egyptian king might have got away with something like that, but the God of Abraham and Isaac and Moses was more of a hands-on kind of God.

So it happened that one of David's sons, Amnon, forced himself on his half-sister Tamar. When David would not discipline the son, another son, Absalom, took matters into his own hands, lured Amnon into a trap, and killed him. This episode set the stage for a direct challenge to David's throne, with the unfortunate result of his father's retainers having to kill Absalom.

"O my son!" David wept. "Absalom my son, my son Absalom!" (2 Sam 18.33)

The saga finally concludes with David's son by Bathsheba, Solomon, killing his half-brother Adonijah in order to secure his claim to the throne.


To bring all this to a close, perhaps all Bibles should come with this warning: "Keep out of reach of children." Maybe in those motels where kids stay free, you should slip the Gideon Bible up above the ceiling tiles.

Then again, perhaps the Bible is like a puzzle or a Rubik's cube. We have to make all the pieces fit, not just the ones we want. Human nature is simply too complicated and God more complicated still to expect easy answers. Often it is only the seventh or eighth time after we have read a particular passage that a light goes off in our heads.

It's as if the authors of the Bible deliberately set out to confound and confuse our overworked minds into enlightenment. In trying to reconcile the depressed, the mad, and the dysfunctional, we perhaps become a little more understanding of our own shortcomings, not to mention our possibilities, and in the process come just that much closer to God.

This piece was written about 10 years ago, from mcmanweb.

Friday, August 27, 2010

Wednesday, August 25, 2010

Thinking With Our Emotions - It's Vital

We use our reason to keep our emotions in check. That way we don't do stupid things. We become masters of our domain. Plato believed that. So did the Enlightenment philosophers. So did our Founding Fathers, as did Freud. It stands to reason, right?

Not so fast, says science writer Jonah Lehrer. In his eye-opening (and highly recommended) book, "How We Decide" (published last year), Lehrer cites no end of brain science studies that show that emotion is very much involved in not only making decisions, but in making the right decisions. Not only that, the pre-frontal cortices - those parts of the brain associated with higher reasoning - are very easily tricked into making bad choices.

Lehrer begins his book with the closing seconds of the 2002 Super Bowl (click on YouTube video above). The New England Patriots have the ball on their own 17 yard line, and the Rams defense is expecting quarterback Tom Brady to pass. As Lehrer tells us, "each pass is really a guess, a hypothesis launched into the air." The best quarterbacks make the best guesses.

In the split-seconds he has at his disposal, there is no time for Brady to make a considered decision. Instead, it is his feelings that guide him. Brady starts moving the ball downfield. Then it's now-or-never time. Lehrer picks up on the action:

The primary target, a tight end running a short crossing pattern, is tightly covered. As a result, when Brady glances at the tight end, he automatically feels a slight twinge of fear, the sure sign of a risky pass.

His secondary target is also covered. Again, a negative feeling. Brady needs to get rid of the ball in a hurry. Otherwise, bad things will happen. He proceeds to his third target ...

Troy Brown is sneaking across the center of the field, threading the seam between the linebackers and the cornerbacks. When Brady looks at the target, his usual fear is replaced by a subtle burst of positive emotion, the allure of a receiver without a nearby defender. He has found an open man. He lets the ball fly. ...

As Lehrer explains later in the book, a lot of our decision-making has to do with the dopamine system, most commonly associated with the emotions of pleasure and fear. But dopamine is also involved in the process of anticipation - a lot of it driven by past experience. Thus in a gambling game, if a player drew from a bad deck, the dopamine neurons immediately stopped firing. "The player experienced a negative emotion and learned not to draw from that deck again."

This is a crucial cognitive talent, Lehrer tells us. "Dopamine neurons automatically detect the subtle patterns that we would otherwise fail to notice; they assimilate all the data that we can't consciously comprehend. And then, once they come up with a set of refined predictions about how the world works, they translate these predictions into emotions."

Oddly enough, Lehrer says later on, psychopathic behavior appears to result from lack of emotion rather than a breakdown in reason. Psychopaths tend to have above average intelligence. The problem is they are not guided by their emotions. They never feel bad when others feel bad. As a result, they show no remorse. "This emotional void means psychopaths never learn from their adverse experiences. ... The absence of emotion makes the most basic moral concepts incomprehensible."

Yes, our emotions can lead us astray, but the skilled decision-maker knows when to pay attention:

Brady yells out a snap count, sends a man in motion, then the ball is in his hands. He drops back and notices three defensive linemen are rushing him. The fourth is trying to cut off the short pass. Brady looks to his right. The receiver is covered. He looks to his left. Nobody's open. He looks to the center of the field. Troy Brown, a Patriots wide receiver, is trying to find a plane of unoccupied space ...

Something feels right to Brady. He fires a bullet 14 yards downfield. Brown runs with the ball another nine yards, then steps out of bounds. One more quick pass, then the kicking unit comes onto the field. Adam Vinatieri sends the ball 48 yards through the uprights. Zero seconds on the clock. Game over.

Much more to come ...

Jonah Lehrer authors the outstanding brain science blog, The Frontal Cortex.

Aloysius and Me

Following is an edited version from an article on mcmanweb ...

I transferred to an all-boys Catholic school, and there, on the bus that also dropped the girls at their school, I met the girl who should have been my wife. I'd shot up some ten inches in one summer, so I was almost able to blend in. But my quality of being different sent out some invisible signal, and perhaps this is what she was responding to.

She was a cancer survivor and had the kinds of insights fifteen year olds shouldn't have, together with a beauty that ran far deeper than her amazing good looks. I would come home from dates feeling I'd been dropped onto a balance beam with my legs spread apart. I was innocent. I didn't realize she might have helped me out had I asked.

She was from a professional Catholic family - one that took their religious obligations seriously - but that wouldn't have stopped her, I am sure. Sure, there would have been a few religious technicalities to overcome, such as burning in Hell forever, but these could easily be resolved by other religious technicalities, such as getting to Confession before a truck ran either of us over while in a state of mortal sin.

Perhaps this is a good time to talk about being Catholic.

My grandfather on my father's side came from a large Irish family in Quebec. Like most families of this type back then, there was a designated priest-to-be while all the other kids labored to put food on the table and maybe subsidize a lucky brother or sister's upward mobility. My Grandpa Joe was not one of the lucky ones. Out into the workforce he went, a kid who loved Shakespeare chopping wood in the cold at age fourteen.

Nevertheless, it seems you couldn't keep a good Shakespearean down, for my grandfather eventually brought his charm and eloquence to bear on my Grandma Alice - thirty years old at the time - and together they found their way to Springfield Massachusetts.

Now we jump ahead to when my father was a boy and his parents sent him by train to spend the summer with a rich uncle in Quebec. How this rich uncle fits into the picture and where his wealth came from I will never know, particularly when I could never get a word out of my father. In fact it is only through an aunt I found out in the first place.

It seems this uncle wanted to adopt my father. He had no son. Anyway, he put the question to my grandfather, who said yes. Just like that. Who knows what was going through my grandfather's mind? This was the depression, after all. They were poor. This was a good deal for his son, a dream come true, in fact. What struggling father wouldn't want the best for his boy?

That is, until my Grandma Alice found out what was going on. She was on that train to Quebec in a flash, and when she returned it was with her son.

But now the mystery deepens. Let's backtrack ten or fifteen years and consider: Out of the woods of Canada comes a Shakespearean woodcutter who by now is in uniform and sweeps a gardener's daughter off her feet, a daughter, I am told, who passed a piano exam by nailing a Mozart sonata.

But now it is years later and Shakespeare and Mozart are trapped in what I am told was a loveless marriage, poor with four kids, my father the oldest. My Grandpa Joe is now some kind of religious fanatic, always going to church and praying and making a great show of his faith. Who knows? Maybe his religious excesses did bring him closer to God. 

My mother has this little story to tell:

When my older sister was born, in which my mother nearly died from an infection, my Grandpa Joe paid a visit, and the first thing he said to my mother was too bad it wasn't a boy to carry on the family name. My mother was too shaken to reply.

Wait, there's more. When I was born, my Grandpa Joe said John, that's not a family name. This time my mother was ready. He is named after his OTHER grandfather, she let him know.

Ah, my other grandparents. No Shakespeare or Mozart here, but there was a piano in the house. That's the one thing, apparently, both sets of grandparents had in common, the piano in the house. My Grandpa John had a secure job driving a truck for Railroad Express, which made my mother's family well-off by depression standards.

I have fond memories of both these grandparents. But anytime we went for a visit my younger brother and I couldn't help but notice that neither he nor my Nana Tess ever attended mass, which, of course, was a mortal sin. Then my grandfather explained: He took church pills. Not just him. Nana Tess, too. The two of them, church pills.

I gathered this worked something like holy water or a communion wafer, but to a slightly different end. The net result of taking one was you didn't have to go to church. Now I was old enough and smart enough to figure out that church pills weren't available to kids, and that in all probability they were very difficult for even adults to obtain. Otherwise, no one would be going to church, now would they?

Except for my Grandpa Joe, of course.

All which goes to explain the rather lax attitude we had to Catholicism in our own house. Between my mother's parents and my father's reaction to his own father's displays of religion - especially a father who was all too willing to give him away - church and religious instruction were regarded as a sort of family obligation, like getting your kids vaccinated.

But back to the mystery of my grandfather the religious fanatic. The other day, I suddenly recalled this vital piece of the puzzle: You see, when my father was born he wasn't supposed to live more than a few hours. A nun in the hospital suggested that since the day on which he happened to be born was the feast day of Saint Aloysius, he may as well be given that name. My Grandma Alice, hedging her bets, decided that Aloysius would be his middle, rather than first, name.

Now whether it was because of a medical miracle or because Aloysius up there was so grateful to have someone named after him, even though it was only a middle name, my father pulled through. Luckily it was my younger brother - to my infinite relief - who wound up the dubious recipient of the family middle name.

But lately I can't help but wonder: Suppose Aloysius did pull off the miracle. If so, wouldn't this be the logical person to pray to in times of need? In fact, owing to his relative anonymity, it would be like having one's own personal family saint. No waiting, no queues.

Maybe that's what happened to my Grandpa Joe. Maybe, when faced with the prospect of losing his son - the son he would later almost give away - he found God. Maybe he recognized a true miracle for what it was. Maybe when he returned home with a healthy boy in his arms he knew he would never be the same.

Funny thing, I got along really well with Grandpa Joe. Perhaps because he was different, different like me. That's all that counted. There was something in both of us that belonged in another world. I know that because of my father, of all people. He wouldn't say it, but I could see it in his eyes.

When I stopped going to church as a teenager my father immediately followed suit, relieved of his obligation to set an example. Perhaps he thought when you died the lights simply went out. At any rate, I never heard him reflect on it. His Christianity was more of this earth - Chairman of the local Human Rights Commission, director of the local United Fund, involved in more charities than you can name.

On a cold evening in 1994, he fell asleep in the hospital, and never came out of it. We called in a priest for last rites, then they unplugged the life support. His kidneys went. Then his other organs. I stood there with a Bible reading Ecclesiates.

A time to ...

Perhaps there was a part of him that heard it, that managed to reconcile the many complicated parts of his own self before moving on to the next phase of his life. Or perhaps the lights really did just go out. Perhaps he really was ready to accept that possibility. Perhaps he knew a lot more than I ever will.

Oddly enough, my Grandpa Joe, for all his dedication to his faith, died in pretty much the same circumstances as my father. As fate would have it, he spent his last hours in a Protestant hospital. My Nana Tess, by contrast - the one who took church pills - happened to face her maker in a Catholic hospital attended to by no end of nuns and priests.

So anyway, getting back to the present, here I was, a boy of sixteen, with the girl who should have been my wife, the one I was willing to risk eternal damnation for, and had we stayed together any longer it might have come to that, but it never did.

No, we shared a different kind of intimacy. I look back on those moments with both fondness and amazement, the two of us in perfect comfort in the dark on the closed in front porch of her family's double-decker in the ethnic neighborhood where her quality of being different seemed to cancel out mine, without destroying that precious gift in each of us of being unique. Somehow we were able to share it without necessarily making out or talking.

Had I known how precious this was, I would have held onto her for dear life. With her, I could open up the inner spaces of myself and have her walk in and and warm me with her glow. Other women, I would discover, only sought to arrange the furniture or shattered the objects inside, leaving me with a feeling of broken trust and violation.

But I was young and stupid. I let her slip away, and we never kept in touch. Granted, there were probably a million reasons it wouldn't have worked, and I accept that. Still, I can't help but wonder: Where would I be now if I had held on to her? What would I be like?

Would she have brought out something in me that would have made me feel accepted? Would I have eventually found a way to fit in? Or would my quality of being different have proved too much, even for her?

God, of course, won't tell me, so maybe I'll ask Saint Aloysius.

Tuesday, August 24, 2010

Rerun: My Zombie State is Other People's Normal

From Last October ...

On Saturday, I received an email from a friend:

"Two people have emailed me to see if you are alright. How would I know? Hypomania is rocket fuel for your work."

My blog was no busier than usual that past week, save for an animated comment thread. Okay, let's make that a really really animated comment thread. My immediate reaction was a defensive one. There they go again, I thought. Pathologize my behavior. Attribute every action of mine to my illness. Most of you have been on the receiving end of this - show the slightest sign of life, dare to crack a joke and actually look happy, and it must be hypomania. Bipolars are as bad as the general population - worse, far worse - in this regard.

I once emailed a friend with news that I had won a major international award, and, without offering her congratulations or even acknowledging my achievement, she replied that it sounded like I was hypomanic and I needed to be careful.

What the ... ?

Then I had to laugh. All the week before, I had been down for the count with flu symptoms. I had been sleeping 16 hours a day. I would emerge from the blankets only to walk about with the feeling of the inside of my head wrapped inside these very same blankets. I had no energy, I felt like someone three times my age, and my mood was in a slow glide south.

Trust me, had they been auditioning for a remake of Night of the Living Dead, I would have received a call-back for the lead zombie role. Yet, somehow, I had managed to crawl to the computer and crank out my standard quota of blog pieces (two involving the intricacies of diagnostic psychiatry), plus fire off a long round of zinger comments.

What gives? Yesterday, while out on a country walk (with a clear head!), I got thinking about my friend's email. It's easy, of course, to get a totally wrong impression when there is no face-to-face contact. But I could recollect no shortage of real life Twilight Zone experiences dating from way back.

For instance, in my college dorm room 40 years ago - again in a flu-induced zombie state - I responded to someone with a lame comment and the whole room cracked up. I got off a repeat rimshot-worthy one-liner, then another one. I was death warmed-over, but to the people in the room I was Don Rickles.

Twelve or thirteen years later - same state of zombie-hood - I was the steady hand who calmed down a room of anxious individuals. I could go on and on. Sometimes it's the flu. Sometimes it's depression. Sometimes, for no apparent reason, my head is not attached to the rest of my body. There are no guarantees. Often, when I feel out of it, I am really truly, totally utterly, out of it.

On the reverse side of the coin, when I am feeling on my game - that is when I need to watch myself. Frequently, I find myself looking at a sea of perplexed faces. And heaven help if I know I'm off my game and my anxiety takes over. You know those Southwest Airline ads: "Need to get away?"

Anyway, here I was, taking my walk, gazing out into the mountains, when it suddenly hit me in a flash:

My zombie state is the equivalent of other people's normal!

If I could only be a zombie, I could lead a normal life. Here's how it works:

Like a lot of you, I experience racing thoughts. Think of my brain as the UN General Assembly with an angry Khrushchev on every seat yelling wildly and banging his shoe on the table. But the flu or a depression or some kind of brain fog shuts down all those Khrushchevs in my head. There are no distractions. I can focus on the task at hand. I appear sharp and to the point. Of all the crazy things, I give the impression that I'm operating on rocket fuel.

All those Khrushchevs are the equivalent of too much stuff coming in - too much thought, too much emotion, too much sensory input. Since I happen to work in a field that places a high premium on creativity and intuition, I tend to regard this as a good thing. I need those Khrushchevs. They work for me, provided I can show them who's boss.

But too much of a good thing for me has a way of manifesting as bipolar or anxiety or panic or just plain weirdness. This is the downside of Khrushchev. Every once in a while, things get out of hand. For others, these Khrushchevs may show up as ADD, schizophrenia, some forms of depression, or just simply strange or inappropriate behavior.

These days, I am fairly confident in matching the right Khrushchev to the right occasion, so that what comes out of my mouth doesn't embarrass me. Far from it. These days, I actually get invited to places. Back in the old days, I could be counted on to pick the wrong Khrushchev, generally a strange weird specimen that had people backing slowly toward the exits.

What has changed over the years is that I have slowly learned to read subtle social cues and modify my behavior accordingly. I suspect this is true for most of you. These days, I feel fairly confident walking out the door. Back in the old days, I didn't risk it. I stayed indoors and isolated, which, of course, made me fair game for crushing depressions.

It's a strange world when showing up as a zombie shrouded in a protective depression is the state most likely to create the best impression for me. But when I'm feeling good, I often lack insight to know that I'm feeling too good for my own good. That's why I need to watch myself, and - more important - watch others.

"Knowing thyself" is central to "Knowledge is Necessity." Only through long introspection do we find answers and learn to ask the right questions. Consider this blog piece a long and involved question to all of you. I'm very interested in your answers. Please fire away by going to the comments below ...

Friday, August 20, 2010

Rerun: Oprah Totally Endorses Me - Well, Sort Of

Yesterday, I ran a piece highly critical of Oprah. But there was a time when we were good buddies, as this oldie from June, 2009 illustrates ...

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 mcmanweb.com."

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.

Thursday, August 19, 2010

Oprah Is At It - Again

Katherine Stone authors an outstanding blog on postpartum disorders, Postpartum Progress. In a December blog piece on my mental health heroes, I cited her as my "Internet Hero" of the year.

Today, Katherine features a contribution from Alexis Lesa. In response to an open request from the Oprah show, Alexis went to the site and entered in a brief account of her experience with postpartum depression. To the surprise of Alexis, the next day she received a follow-up email requesting more information. One of the follow-up questions included:

After your child's birth...are you feel empty and sad instead of elated and excited?

And another:

Are you scared you were going to hurt your child or yourself?

(The badly mangled grammar is theirs.)

As Alexis writes:

I know that the questions were most likely meant to get a broad sense of what PPD is like and I should probably just let it go, but I can’t help myself. ... It seems that people are intent on pigeonholing PPD as a crazy-making disease, one that turns women into baby haters, baby killers.

She adds:

Why is it that the first thing that comes to people’s minds when they hear PPD is “This woman probably doesn’t love her child,” or “This woman is probably going to hurt her child.”? It’s as though all the literature about the range of PPD symptoms simply doesn’t exist--in the eyes of the world, all PPD moms are a danger to themselves or their children. It’s no wonder many women fear speaking out.

Ah, deja vu all over again.

Three years ago, Julie, a producer from Oprah, contacted me. They were interested in doing a show on bipolar. Julie saw my website and wanted to talk. Who doesn't have time to talk to someone from Oprah?

Soon into our phone conversation a day or two later, it became obvious why Julie was calling. She wanted to know about my mad scene. My mad scene of 20 years ago is fairly boring as far as mad scenes go. (I had merely quit my job in a huff.) A total disaster from my point of view, but hardly a newsworthy one. Depression is the real bane of my life, and Julie didn't want to hear about that.

"Did Bipolar Drive a Mother to Kill Her Child?" read the home page of Oprah's website, about a month later. "Tune in Monday."

The show started out with a 911 call: The mother, Andrea, had just confessed to choking her six year-old son. It turned out her idiot family doctor had been giving her antidepressants. In prison (she is serving a 42-year term), a doctor made the right diagnosis, put her on a mood stabilizer, and now she is doing fine, all things considered.

The entire first segment of the show was devoted to Andrea, while nearly all the second featured Andrea's friends. Then Kay Jamison came on. Two minutes. Kay Jamison, two minutes.

Then came "General Hospital" star Maurice Bernard, talking for 10 minutes about his "blow-out" that turned out to be an anxiety attack. The last segment featured actress Jennifer Lewis who turned out to be smart and personable. Then a hurried one-minute wrap-up with Kay Jamison. End of show.

Three years later: Postpartum depression is about to get the Oprah treatment. Many thanks, Katherine, for tipping me off. My suggestion, Katherine: Time to suit up as an internet hero. Maybe Oprah is way too powerful for the likes of us, but we don't have to take this lying down, either.

Time to make some noise ...

Tuesday, August 17, 2010

What Is It With Those Finns?

This is too weird not to let go unnoticed. Newsweek just came out with its first-ever World's Best Countries. Finland topped the list of 100 countries surveyed. Finland? Fortuitously, I had prepared myself for this eventuality. Three weeks ago, I was in New Zealand - by rights a country that should rank number 1 on the list - having a beer with my old friend Chris.

"What is it about the Finns?" he happened to ask, seemingly out of the blue. But nothing in our conversations is ever out of the blue. We're both in search of a grand unified theory of everything. Every topic, however arcane, is on the table, and - who knows? - this could very well be the one that would yield the ultimate universal truth - 42 explained - the answer to life, the universe - everything.

Think about, he said. The Finnish language is only one in four in the world not connected to any major language group. (Okay, technically, Finnish belongs to the Finno-Ugric language family that also includes Estonian, but you get the point.)

Hmm, I thought. A language - and by extension, a people - from nowhere. Interesting. For extra credit: The word "sauna" is Finnish in origin. So is a type of granite known as "Rapakivi."

Next, Chris said, the Finns beat the Soviet Union during World War II.

I nodded my head appreciatively. During the Second World War and its aftermath, the Soviets overran Latvia, Estonia, Lithuania, Nazi Germany, Poland, Hungary, Czechoslovakia, Romania, Bulgaria, and Japanese-occupied Manchuria. Yet they had no luck trying to subdue a nation of a mere five million people right on its border.

What is it about these mysterious Finns? I could only wonder.

Last but not least, Chris added. They make Nokia phones.

Holy crap! I could only think. They make Nokia phones. If this were in any way connected to the Swedish making IKEA furniture then this was very significant indeed.

It just so happened that we had both seen a "60 Minutes" report from the 1990s, "Tango Finlandia," narrated by Morley Safer (the pic above is from the report). The surrealism in the piece would have made Salvador Dali jealous. According to the report, the Finns are a highly depressed and morose race, intensely private and painfully shy, who pay the equivalent of twelve dollars to take part in a national obsession - the tango.

Indeed, this is beyond the realm of human understanding.

And now - number one on Newsweek's Best Countries list. Very - very intensely - significant indeed.

Clearly, without doubt, cracking the Finnish Code will yield the secrets that Einstein spent the last half of his life searching for in vain. And I just know many of you are putting the final pieces in place right now. Those last neurons are connecting, about to reveal the ultimate answer to everything.

Life will never be the same again.

Don't be shy, post your comments now ...

Monday, August 16, 2010

Creativity - We Are Killing It Off; Hopefully There Will Be Enough Creative Thinkers Left To Rescue Us From the Disaster We Are Headed Into

I excelled at every subject just for the purpose of excelling, not learning. And quite frankly, now I'm scared.

High school valedictorian Erica Goldson (pictured here) had the guts to speak out. In an address to her graduating class, she spelled it out in a way that even the stupidest teacher in the audience could comprehend, if not accept:

Between these cinderblock walls, we are all expected to be the same. We are trained to ace every standardized test, and those who deviate and see light through a different lens are worthless to the scheme of public education, and therefore viewed with contempt.

She went on to say:

And now here I am in a world guided by fear, a world suppressing the uniqueness that lies inside each of us, a world where we can either acquiesce to the inhuman nonsense of corporatism and materialism or insist on change. We are not enlivened by an educational system that clandestinely sets us up for jobs that could be automated, for work that need not be done, for enslavement without fervency for meaningful achievement. We have no choices in life when money is our motivational force. Our motivational force ought to be passion, but this is lost from the moment we step into a system that trains us, rather than inspires us.

Coincidentally, last month Newsweek ran a cover feature, The Creativity Crisis, that reported that for the first time, measures of creativity in US school kids are way down. The implications are enormous. As Newsweek points out:

The potential consequences are sweeping. The necessity of human ingenuity is undisputed. A recent IBM poll of 1,500 CEOs identified creativity as the No. 1 “leadership competency” of the future. Yet it’s not just about sustaining our nation’s economic growth. All around us are matters of national and international importance that are crying out for creative solutions, from saving the Gulf of Mexico to bringing peace to Afghanistan to delivering health care. Such solutions emerge from a healthy marketplace of ideas, sustained by a populace constantly contributing original ideas and receptive to the ideas of others.

Ironically, as the rest of the world is moving beyond from the old "drill and kill" method of learning, the US is heading in precisely the opposite direction toward prepping students for acing standardized tests. Meanwhile, arts in the schools have been liquidated.

Creativity is not just about the arts. It's about generating original ideas, across all fields of endeavor. The creative process involves both "divergent" and "convergent" thinking. In the divergent phase, the brain is literally roaming the library stacks, gathering up books by the armload. A strong body of research suggests that creative individuals may have brains that are less than efficient at filtering out incoming information.

But we are easily overwhelmed by too much information, not to mention sensory input and emotion - which may explain much of mental illness. This is where the convergent phase comes in. The brain becomes ruthlessly efficient in weeding out irrelevancies and focusing only on the facts that matter. Finally, the brain needs to find associations between apparently unrelated facts and ideas to come up with an original solution.

In his outstanding 2009 book, "How We Decide," science writer Jonah Lehrer reports on what was going on in the minds of the flight crew of United Airlines Flight 232 from Denver to Chicago when one fine day over Iowa in 1989, the rear engine of their DC-10 exploded and took out all three hydraulic systems.

Without a functioning hydraulic system, Captain Al Haynes had no control of his plane. UA 232 was on the verge of flipping into a death spiral. Emergency procedures never anticipated a total loss of hydraulics. The manual had not provided for this contingency. The experts on the ground had no answers. Haynes and his crew were totally on their own.

As Lehrer reports, the first remarkable thing to happen was that Haynes and his crew fought back their panic. Haynes then did a mental scan of all the cockpit controls he could operate without hydraulic pressure. The list was a short one, and only one was useful - the thrust levers. But you couldn't steer a plane with thrust levers.

Or could you?

Haynes' DC-10 had two working engines. If he idled one while boosting the other - what they call differential thrust - in theory he could steer the plane. It was a crazy idea. No one had ever thought of it before, much less tried it. Lehrer notes that the pilots dealt with potential information overload only by focusing on the most necessary bits of data:

For instance, once Haynes realized that he could control only the throttle levers - everything else in the cockpit was virtually useless - he immediately zeroed in on the possibility of steering with his engines. He stopped worrying about his ailerons, elevators, and wing flaps.

Meanwhile, inside the brain, the prefrontal cortex took an abstract principle - the physics of engine thrust - and applied it "in an unfamiliar context to come up with an entirely original solution."

The brain at this convergent stage of creative thinking was uncompromisingly disciplined and rational. Without a strong "I" in the cockpit, mentally we are nothing more than flakes and fruitcakes. Likewise, without wide horizons in the divergent stage, we are mere industrious drudges unable to think our way outside of a paper bag.

Haynes and his crew managed to get UA 232 to an emergency landing strip. But they couldn't control the speed of the landing. The plane skidded into a cornfield and shattered into several sections, leaving 112 passengers dead but sparing 184 lives.

Meanwhile, in the US, our school system is gearing us to a crash landing. It is conditioning our young to become mere takers of tests and uncritical followers of received wisdom. Bound to the past, our next generation may lack the means to think our nation into the future, much less work its way out of our next round of current social, political, environmental, and economic jams.

Thank heaven, then, for boat-rockers such as Erica Goldson. "We are the new future and we are not going to let tradition stand," she told her graduating class. "Once educated properly, we will have the power to do anything ... We will not accept anything at face value. We will ask questions, and we will demand truth."

Ah, there is hope.

Sunday, August 15, 2010

Visitors From Outer Space

This isn't any old domed ceiling you are looking up at. This was taken from my iPhone Friday night, lying on a quilt on a wooden floor, seemingly looking down. I was near Joshua Tree National Park in the Mojave Desert with two friends to view the Perseids meteor shower. And what more fitting place for a viewing than the site of the "Integratron," inspired by visitors from Venus?

In 1947, in his late thirties, George Van Tassel left his job as an aircraft inspector and headed for the desert to operate his own landing strip, cafe, and dude ranch. In 1951, he was transported astrally to an alien spacecraft, where he met the Council of Seven Lights, and in 1952 visitors from the planet Venus dropped in.

The upshot of this meeting was a new building project that was to occupy Van Tassel the rest of his life. Built upon an energy vortex, the Integratron is an all-wood (no nails) combination rejuvenation chamber and time machine - 38-feet high and 55-feet in diameter - based on the design of Moses’ Tabernacle and the King's Chamber of the Great Pyramid, the writings of Nikola Tesla, and telepathic guidance from the Venusians.

The project was funded by UFO conventions that Van Tassel staged over the years. He completed the structure in 1959, but continued to tinker with it till his death in 1978. Its current owners operate the Integraton as a tourist attraction, and visitors are treated to a 25-minute "sound bath" of recorded quartz crystal vibrations reverberating throughout the dome.

Following our sound bath, we headed out into the dark, settled back in our folding chairs, and gazed up into the brilliant night desert sky at nature's fireworks. I looked up into the filmy Milky Way and let out an involuntary gasp. A brilliant blue bolt appeared from out of nowhere and streaked across the heavens.

A piece of cosmic dust? I can't get the Venusians out of my mind.

Tuesday, August 10, 2010

Earth to Psychiatry: We Want to be Well, Not Just Stable

My last three blog pieces covered the main points I gave in a grand rounds to clinicians at a psychiatric facility two years ago in Princeton. There, I was accorded the same reception as Bill Gates at an Apple convention. Really, it went almost that well. Anyway, here is a major point I nearly overlooked, well worth underlooking ...

I clicked my PowerPoint. "The concept of maintenance is fundamentally flawed," read the slide.

Frozen Kelvin grade silence. Oh, shit, now what?

I had already told them that simply sending a patient out the door with just a prescription is not treatment, that we don't want to be like them, that from where I stand they all have flat affect, that there is a reason that all the pharm reps who visit them look like Heidi Klum or Russell Crowe, and that when their patients complain to them about feeling like fat stupid zombie eunuchs on the meds they prescribe and overprescribe we are not doing this to ruin their day.

Geesh. It wasn't like I was accusing them of something major, such as dancing like a white man. Okay, maybe they read that into my flat affect observation.

By way of background, treatment roughly divides into two categories: Acute and maintenance. There is a further distinction involving maintenance vs continuation treatment, but we won't go into that.

Acute treatment is short term. Typically, we are in a state of crisis. Psychiatry is very good at getting us out of crisis and into a state of stability. What I would call a state of undepression, unpsychosis, unmania, unanxiety, and so on. But then what?

Maintenance treatment seems based on keeping us in this stable state. But here's the catch, I explained. We're stable, but not well. The confusion seems to stem over the definition of remission. Up went a PowerPoint slide from Dorland's Medical Dictionary with this old world view:

Diminution or abatement of the symptoms of a disease.

But back in 2002, I came across this, from the American Psychiatric Association Bipolar Treatment Guideline issued that year:

Complete return to baseline level of functioning and a virtual lack of symptoms.

Here's how the APA links treatment to remission:

Treatment is aimed at stabilization of the episode with the goal of achieving remission, defined as a complete return to baseline level of functioning and a virtual lack of symptoms.

In other words, it's not good enough for our clinicians to have us feeling merely less miserable than before. You can also read into this that any trade-off between reducing symptoms and major side-effects is totally unacceptable. After all, how can we lead satisfying (ie functioning) lives when the thinking and feeling parts of our brains are off-line, not to mention what's going on elsewhere with us?

Thus, contrary to popular belief, there is no distinction between the medical model and the recovery model. The APA nailed "recovery" in their 2002 Guideline. In theory, we are all on the same page. But this principle has yet to percolate throughout psychiatry.

Up went this PowerPoint:

Instead of "acute" and "maintenance," I choose to distinguish between the crisis, stabilization, and recovery phases of our illness. During the early phases, with our illness at its worst and our knowledge and insight at its least, we are nearly totally dependent on psychiatry and medications, and we would be fools to believe otherwise. Then, in a best case scenario, as our skills and insight improve, we become less reliant on psychiatry and medications and become more active in our own recovery.

The stabilization phase is where the doctor-patient relationship begins to change. The patient is out of crisis, with significantly reduced symptoms, but is merely better and not well. Moreover, he or she is likely contending with serious meds side effects. Nevertheless, the patient is in a position to intelligently discuss his or her illness and treatment options, and wants to move on to being well.

So, here's the deal: Getting patients from crisis (acute phase) to stabilization (maintenance phase) is only half the battle, the easy half at that. The real work lies just ahead. Up went this PowerPoint, from a 2004 international bipolar treatment guideline:

The real key to treatment of bipolar disorder is successful maintenance treatment.

The catch is there is no reliable evidence base for maintenance treatment. Virtually all psychiatric meds studies focus on short-term treatment for patients in the acute (crisis) stage. This from the Depakote product labeling:

The effectiveness of Depakote ER for long-term use in mania, i.e. for more than 3 weeks, has not been systematically evaluated in controlled clinical trials.

Now had I really wanted to insult my audience, I would have asked them why the friggin' hell are you treating us at this stage with industrial-strength doses as if we're 911 cases bouncing off the ceiling when maybe all we need right now is just a teensy bit to take the edge off.

Think about it: If you have a broken leg, you don't wear a cast the rest of your life. But I spared my audience all this. See, I do exercise restraint. Then I had to ruin it all by clicking on my infamous slide:

The concept of maintenance is fundamentally flawed.

All the maintenance studies that I am aware off use as their measure of success relapse prevention, often expressed as time to relapse. So, here we are - stuck - unable to move forward, like a paleolithic hunter entombed in a glacial ice sheet, and psychiatry is celebrating because we're not back where we started. But actually the opposite is true. In virtually all these studies the relapse rates are horrendous.

Here's how Eli Lilly spun a 2006 Zyprexa maintenance study result:

Compared to placebo, olanzapine delays relapse into subsequent mood episodes ...

This appeared as an abstract in the leading psychiatric journal, the American Journal of Psychiatry, which means it turned up as the opening to the article and in all the various medical databases such as PubMed. Who, after all, reads entire journal articles?

What really happened was that eight in ten of the Zyprexa patients dropped out of the study.

"Does everyone agree this is highly deceiving?" I asked my audience. Thankfully, every head in the room bobbed up and down.

"I would go further," I replied. "I would call it immoral."

Kelvin grade frozen silence. Seems I just can't keep my mouth shut.

Monday, August 9, 2010

My Totally Surreal Experience Lecturing on Problem Meds to Psychiatrists and Other Clinicians

In my two previous blog posts, I described my unequivocally frosty reception involving a grand rounds lecture I delivered on meds compliance two years back to a psychiatric facility in Princeton, NJ. My first section involved The Problem Patient, my last The Problem Clinician. Following is my version of the middle part of my talk, Problem Meds ...

Okay, maybe I went out of my way to piss off my audience. "Here's a question for you," I opened. "What is the one drug taken by 85 percent of those with schizophrenia and two in three with bipolar that they are 100 percent compliant with?"

They came up with nicotine right away.

We know that auditory gating is mediated by the alpha-7 nicotinic receptor. Those with schizophrenia have trouble filtering out background noise, thus have trouble concentrating. I recall Robert Freedman of the University of Colorado explaining this to a symposium of the American Psychiatric Association annual meeting a number of years before.

Dr Freedman and his colleagues noticed that those with schizophrenia seemed to experience a desperation that went way beyond normal cigarette cravings and decided to investigate. What they found was that in the brief time a cloud is in the patients' lungs, a cloud clears from the brain.

Mind you, this is hardly a long-term solution. But think about it. Nicotine works. With nicotine, some patients actually get their brains back - even if just for a precious few seconds. I don't know about you, but I don't take my brain for granted. Every precious second the reception comes in loud and clear is a gift to me.

Mind you, I'm not advocating cigarette use. But it appears that nicotine may be an effective drug for schizophrenia. Its major fault is the delivery system, but thanks to the research of Dr Freedman and others alpha-7 nicotinic agonists are in development.

"So, if you prescribe cigarettes," I joked, "you will get much better compliance than if you prescribe an atypical antipsychotic."

Zero degrees Kelvin frozen silence. It probably didn't help that earlier I had called out my audience for all the "No Smoking" signs on the grounds of the facility. (Mind you, perhaps thanks to the nicotine patch, patients and those who speak for them are putting up little resistance to hospital smoking bans.)

Now it was time to compare and contrast. Up on my PowerPoint went this slide from a 2007 editorial in the American Journal of Psychiatry:

Without adequate dopamine signaling, our patients do not feel ‘well.’ When dopamine systems are dysfunctional, patients seek a change. This may involve stopping a medication, such as antipsychotic drugs that block dopamine.

Rather than clearing the brain, these meds actually take major parts of the brain off-line. The major problem with schizophrenia is cognitive deficit. Up went a quote from leading schizophrenia researcher, John Krystal MD of Yale:

"Our medications are least effective for the most disabling symptoms of schizophrenia," namely, "the cognitive dysfunctions that seem to prevent people from performing in the workplace."

The pioneering diagnostician Emil Kraepelin, who "discovered" schizophrenia back in the early twentieth century, pointed to cognitive dysfunction as a core symptom, and we are also recognizing it looms large in bipolar.

I was just getting warmed up. "So, what's your answer?" I asked. "You give patients a drug that actually worsens the most pronounced feature of schizophrenia - and a significant feature of bipolar. Not only that, you're telling us we're going to have to take it the rest of our lives. Sure, it knocks out the psychosis, but so what?"

I could have gone on about the metabolic catastrophes from meds such as Zyprexa - surely the long-term risk to health was as bad as cigarettes - but I compassionately spared my audience. Instead, I simply drove home this point: 

"Far from lacking insight into their illness, even patients with schizophrenia have a much better understanding than the people charged with treating them. Far from refusing to put up with side effects, they are willing to put up with a drug with one of the worst side effects profiles in the world. Why? Because it works. It works where they want it to work."

"Let's face it," I concluded. "We've all been badly oversold on the new generation antipsychotics - you, me, family members. When all is said and done, these new generation atypicals are basically Thorazine with the tires rotated."

For some crazy reason, to my total amazement, they cracked up at that line. Then they went back to being bumps on a log.

"My question for you," I concluded in this part of my presentation, "is why did it take you so long to figure this out? The same info was in the journals you subscribe to, on the labeling of the meds you prescribe. More important, your patients have been telling you this for years. Why haven't you been paying attention?"

As I mentioned in previous blog pieces, my audience heard me out, then made for the exits the second my lips stopped moving.

Sunday, August 8, 2010

Message to the "Flat Affect" People - We Don't Want to Be Like You

My last blog piece was a rerun involving a section of a grand rounds lecture I gave at a Princeton psychiatric facility two and bit years earlier. That part was called "The Problem Clinician," which went over like Slobodan Milosevic at a war crimes tribunal. We pick up on the action (drawn from two previous blog pieces and a book I am working on) ...

The first part of my talk - "The Problem Patient" - went somewhat better.

'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."

"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. Honestly, I’ve experienced seaweed with more personality. Then I blurted out: “To me, you all have flat affect.”

Kelvin grade frozen stony cold silence. And this is the part of my talk that went over reasonably well, mind you. At this point I should have tossed away my script and tried to engage them in a dialogue. “Why should this be a surprise to you?” I should have asked. “Let’s talk about this. Tell me where you’re coming from.”

We - those of us living with bipolar - are obviously a lot more animated than the general population, but the way I see it is that not all of this is pathological. Quite the contrary - the rest of the world should be more like us.

A year after my talk, I was in LA touring the brand new Grammy Museum with a good friend of mine. Louis Armstrong happened to come up on the film display. “I love this guy!” I enthused. I practically levitated off the floor.

My friend does not have bipolar, but, for lack of a better term, I would describe her as having a “bipolar personality.” She sparks and sparkles. Not surprisingly, she is drawn to similar people. My over-reaction to Louis Armstrong was music to her ears. She wasn’t dragging a block of wood around the museum with her. 

“Look at that!” she blurted out, several exhibits later. “Three of these people had Martin guitars!”

Yes! I had just noticed the same thing!

From my point of view, I felt emotionally safe. I did not have to worry about a disapproving reaction. I could be myself. I could experience the moment. More important, I had someone I could share the moment with. Neither of us have time for boring. Smart, funny, intellectually curious, creative, and lively are just some of the traits we are drawn to.

But there is the obvious downside, especially when it comes to romantic relationships. But life with the “flat affect” people? I can’t even begin to imagine it.

Two years later, I would be addressing a Depression and Bipolar Support Alliance (DBSA) state convention in Kansas. The audience were mostly individuals living with either illness. "We are peanut butter people trying to fit into a tofu world governed by Vulcans," I related. I had to pause for the laughter to die down. They got it instantly.

Saturday, August 7, 2010

Rerun - Meds Compliance: The Problem Clinician

This from April ...

Yesterday, I raised the topic of physicians turning a deaf ear to our complaints about meds side effects. The obvious conclusion to draw is that patients will simply stop taking their meds. You don’t need a medical degree to understand that. In fact, it helps if you don’t have one.

Two and a half years ago, a psychiatrist who practices in Princeton, NJ (I used to live just outside Princeton) invited me to deliver a grand rounds to a psychiatric facility there. I was very hesitant. I’m a journalist, I explained. It’s not my place to tell others how to do their jobs.

But I had been doing my own research into meds compliance. Perhaps it would be okay, I suggested, if I were to report on my research from the perspective of a patient. The psychiatrist loved the idea, and we booked a date.

How controversial can meds compliance be, right? I mean, no one is against meds compliance. So I went back over my old research, then did some more, and started connecting the dots. Suddenly, I realized I was in big trouble. Psychiatrists came out looking worse than the patients. A lot worse.

There’s no way I can sugar-coat this, I confided to my friends. They’re going to run me out of town on a rail.

The first part of my talk - “The Problem Patient” - went over reasonably well. But I started sinking fast when I got into “Problem Meds.” Then “The Problem Clinician” went up on my PowerPoint.

Frozen silence. We’re not talking ordinary frozen silence, as in “stony cold” frozen silence. We’re talking zero degrees Kelvin silence, as in utter cessation of all molecular motion frozen silence.

What’s totally weird is they should have been rolling in the aisles. My PowerPoint slide featured a photo of Hugh Laurie from the TV series “House” snapping on a latex glove. “House” is set in Princeton. Surely, my audience would at least chuckle in knowing appreciation.

Silence. Zero degrees Kelvin silence. 

Up went a slide of Heidi Klum. “Have you ever noticed how many drug reps look like Heidi Klum?” I asked. Or Russell Crowe?

To paraphrase George Bush, I “misunderestimated” my audience.

Let’s take a look at some of the hard cold facts from my PowerPoint:
  • According to a 2002 study by Scott and Pope, 50% of  bipolar patients on mood stabilizers acknowledged some degree of medication nonadherence in the previous 2 years.
  • According to a 2007 Swedish study, 25 percent stopped taking their lithium in 45 days. The median time to discontinuation of lithium was 181 days.
  • In one of the NIMH-underwritten CATIE schizophrenia trials, no one completed the study.
  • In a 2006 long-term Zyprexa trial, nearly 80 percent of the patients on the drug dropped out.
  • A 2005 Medscape article reported that only 28% complied with their SSRIs at 6 months.
I asked the clinicians in the audience if these non-compliance rates were higher than they thought, and managed to coax out some reluctantly nodding responses.

Sending patients out the door with just a prescription is not treatment, I reminded them. (They positively hated hearing that.)

Obviously, I went on to say, a clear psychiatric disconnect exists. According to another study by Scott and Pope, clinicians felt their patients quit lithium owing to "missing highs." Patients who quit, on the other hand, cited other reasons.

At the 2006 national NAMI convention, Stephen Goldfinger MD of SUNY told his audience: “Patients will be adherent if the meds do their real job.”

I did my initial research into meds noncompliance about eight years ago when I came across a Kirsch meta-analysis (summarized in a recent piece) that revealed, amongst other things, that only 63 percent of the patients in antidepressant drug trials completed the four to six weeks these trials ran.

Curious, I began checking if these drop-out rates applied across the rest of medicine, such as cancer. So I picked a cancer med at random, Nolvadex (tamoxifen) and read that AstraZeneca had stopped a 1997 study due to 26 percent of patients quitting after one year.

Hmm, I thought. A 74 percent completion rate over one year, significantly higher than the antidepressant completion rate over a mere six weeks. Yet, this was totally unacceptable in the field of cancer. I remember reporting in a Newsletter at the time that a drug company would be touting the exact same completion rate for an antidepressant as a stunning success. Indeed, two weeks later, Lundbeck proved me right by publishing a one-year Lexapro trial that highlighted a mere 26 percent of patients dropping out of the study.

I didn’t bring this up this in my talk. What I did note was that the 26 percent Nolvadex drop-out rate almost exactly corresponded to the 21 percent Zyprexa completion rate.

Psychiatry and oncology clearly have different standards. So, are oncologists telling their patients something different? My guess is they are. I acknowledged to my audience I was speculating, but I managed to get them to sign off on this PowerPoint:

What oncologists may be telling their patients:

It's going to be hell, but there is an excellent chance your cancer will go away.

Then I showed them this PowerPoint:

What I know too many psychiatrists tell their patients:

What are you complaining about? These meds work. Something must be wrong with you. You're much better off than you were before. You need to stay on these drugs the rest of your life.

What I’m guessing the cancer patient may be thinking is this: One year of hell - if that's what it takes to get my old life back, I'm willing to put up with that.

What I know the psychiatric patient is thinking is this: This is the best you can do? You mean I'm going to have to spend the rest of my life - like this?

As Ross Baldessarini MD of Harvard told a 2006 American Psychiatric Association annual meeting: "We need to be a lot more sensitive to minor complaints."  Otherwise, "we will drive patients out of treatment."

So maybe psychiatrists need to be working off a bad news/good news script. First the bad news:

Your meds are only part of the equation. You are unique. It may take time to find the right meds and doses that work right for you. Until we dial in your meds just right, you may have to put up with significant side effects. You may also not feel like yourself. You may feel you want to quit altogether.

Now the good news:

We are going to work together on your recovery. As your knowledge and skills improve, I will be in a better position to help you. You will also be in a better position to help yourself. Trust me, there is light at the end of this tunnel.

I wrapped up my talk a few minutes later. The audience, composed entirely of clinicians, showed their appreciation by stampeding for the exits the second my lips stopped moving.

Wednesday, August 4, 2010

Looking Back at New Zealand

I arrived back home four days ago after a week in New Zealand. Some random recollections and observations:

Then and Now Ruminations

I was 26 when I first arrived in New Zealand in 1976. I was a freshly-minted husband. My wife was a Kiwi. We had met in California the year before and lived together in Vancouver, BC. Now here I was on a far shore, my whole life ahead of me. I discovered that law was an undergraduate degree in New Zealand and that they paid a modest stipend to students who attended university.

What’s the catch? I wondered. Both my wife and I enrolled at the University of Otago in Dunedin, on the lower part of the South Island. We got our degrees and a baby daughter, but not in that order. Then we headed up to Wellington on the North Island to begin our new careers.

Now, all these years later, my daughter Emily and I were driving on the streets of Wellington. Her son - my 10-month-old grandson - was safely strapped in a child seat in back. She and her husband are doing very well.

“I was just thinking,” I began. Always a dangerous sign. I looked over to the passenger side of the vehicle (which all come equipped with a steering wheel, instrument panel, and pedals) for signs of rolling eyes from my daughter, but they were preoccupied scanning for competing traffic, which I interpreted as a sign to proceed.

If I were age 26 right now, I speculated to her, arriving here in New Zealand for the first time, experiencing a new country as it is now, making a fresh start, what choices would I have made? New Zealand’s film industry got going in earnest in the 1980s. These days, its films and production houses are world-renowned.

Instead of asking in disbelief, “you mean I can go to law school here?” would I have gasped in amazement, “you mean this is where they made Lord of the Rings?” And instead of poking my nose in the nearest available law school, might I have turned up at Peter Jackson’s studio (or, for that matter, Joe Bloggs, the quintessential New Zealand Everyman) and offer to sweep the floors for nothing?

Just wondering ...

Speaking of the Film Industry

When I first arrived in New Zealand back what seems in another lifetime, I had expected to run into a lot of anti-American sentiment. This was immediate post-Vietnam, and resentment ran high in various parts of the world. I had encountered some of this in Canada. But New Zealand was entirely different. “A Yank,” they would exclaim once I’d opened my mouth, as if this were an enviable heritable trait.

Inevitably, it turned out they knew more about my country (and the rest of the world) than most of my countrymen. Nevertheless, some things - our healthcare system, for one - perplexed them. The whole time I lived there, Kiwis were very gracious in opening up their homes - and doors - to me.

But it would be naive to say the American brand has universal appeal. My daughter related how she encounters some people who say they can’t stand anything American, including the movies.

I pondered this for awhile, then replied: “Next time someone says they don’t like American movies, ask them what's wrong with Lord of the Rings?”

How to win arguments and confuse your enemies: Hit ‘em with a non sequitur.

Time to Say Goodbye

It only seemed I had just arrived. It was time to board the plane. Back when I lived in New Zealand, Wellington Airport was a disgrace to aviation. The terminal was basically a drafty over-sized shearing shed - corrugated iron in search of walls and ceiling to hide behind. Electric heaters jerry-rigged to exposed supporting beams burned to a crisp anyone unfortunate enough to be stuck standing in line below. Ten feet on either side, though, and one could easily identify with Scott of the Antarctic penning his final missive to his wife.

We step into a glass-encased building and I feel that I am in a mall in the trendiest part of town. A jazz combo is belting out a tune in the main lobby area. No, I’m not making this up. Outside is a magnificent panorama of planes taking off over the water. There are no boarding calls or other intrusions. We walk past upscale shops and a wine bar and cafe, and next thing I’m enjoying a micro-brew in a snug upstairs pub.

I swear, I could bring a date to Wellington Airport for a romantic evening.

We finish our brews, take some final photos, then head back downstairs. It is time to hand back my grandson. I badly want to pack him in my carry-on and bolt for the boarding gate. My daughter and son-in-law graciously accept the return of their baby. I can’t keep down the lump in my throat as I give them a farewell hug. Time to head back to my world.

I will be back ...

Tuesday, August 3, 2010

The Ultimate Baby Music Video

A souvenir from my recent family visit to New Zealand, starring Little Teddy and his posse.