Thursday, October 21, 2010
It turns out Robert Whitaker and I were sitting in the same room, at the same symposium, at the same conference. The venue was the 2008 American Psychiatric Association annual meeting in Washington DC. The session was on "Antidepressants in Bipolar Disorder." Despite the fact that at the time I was writing mainly on my illness, this was only one of two bipolar sessions I recall attending in the five days I was at the conference.
Over the years, I had been expanding the range of my enquiry, which included a lot of research into brain science, as well as illnesses that backed onto and overlapped with bipolar, such as borderline personality disorder, schizophrenia, PTSD, and ADHD. Having experienced a demonstrable improvement in my mental health following a move to rural southern California about 18 months prior, I had also grown interested in the old fashioned "rest cure." So it was that on the first day of the conference, I found myself panning my video camera over a display of postcards of old asylums and spas.
The old institutions had been founded on enlightened principles. They didn't become chambers of horrors till some time later. Whitaker had written quite a bit about this in his 2002 book, "Mad in America." I was moving into Whitaker's world. He was moving into mine.
By two in the afternoon, I was ready to call it a day. My sleep was badly messed up, and this was no time to be a hero. Moreover, I was hardly about to be startled awake by anything new concerning an issue I had been reporting on for years. But the top bipolar experts in the field would be on the panel - two who had written glowing testimonials for my book - and I was not about to miss an opportunity to reconnect, brain dead or not.
Like me, Whitaker was at the conference for other reasons than to listen to bipolar experts. In particular, he was looking forward to a session in which Martin Harrow would talk about long term schizophrenia outcomes. In the meantime, there were two or three hours to kill. As he reports in Anatomy of an Epidemic: "I figured the speakers would simply present trial results that justified, in one way or another, the use of these drugs ..."
Instead, Whitaker found himself furiously scribbling away. I'm glad one of us had the presence of mind to take notes.
First speaker up was Frederick Goodwin, co-author of the definitive "Manic-Depressive Illness," which had come out as a second edition the year before. As Whitaker reports:
"The illness has been altered ... Today we have a lot more rapid cycling than we described in the first edition (which came out in 1990), a lot more mixed states than we described in the first edition, a lot more lithium resistance, and a lot more lithium treatment failure than there was in the first edition. The illness is not what Kraepelin described anymore, and the biggest factor, I think, is that most patients who have the illness get an antidepressant before they ever get exposed to a mood stabilizer."
As I recall, it was not simply a matter of antidepressants making bipolar worse. Dr Goodwin also made a strong case that for many people, clinical depression is bipolar waiting to happen. The rise in the incidence of bipolar, Goodwin noted, coincided with the introduction of SSRI antidepressants. It's not just the bipolar population that is at risk. A lot of those with so-called unipolar depression cycle in and out of depression without ever becoming manic or hypomanic - until you give them an antidepressant. Then they become bipolar.
Other speakers, including Nassir Ghaemi of Tufts and Robert Post, who spent most of his years at the NIMH, backed up Goodwin. Back to Whitaker's account:
Psychiatry, of course, had no "evidence base" for using antidepressants in bipolar disorder, but, Post said, the clinical trials conducted by pharmaceutical companies "are virtually useless for us as clinicians" ... Only a small amount of people, he added, actually "respond to these crummy treatments."
Goodwin further challenged recent pharma studies showing the high rate of relapse once bipolar patients were withdrawn from antipsychotics, noting that the findings were only evidence that "if you suddenly change a brain that has adapted to the drug, you are going to get relapse."
My interest in the whole matter was more than academic. Although it is clear that my bipolar manifested in college, it wasn't till I was 49 that I sought help. I was misdiagnosed with unipolar depression and prescribed an antidepressant which had me bouncing off the walls. Of all things, florid mania proved to be much safer than the suicidal depression I had been in. Ironically, bad psychiatry may have saved my life.
But that same psychiatrist also did something right, for which I am eternally grateful. The second time out, he put me on a low dose mood stabilizer. He didn't overmedicate me or turn me into a zombie. Soon, I was on my way to a new career in mental health journalism. I haven't looked back.
Most patients I have witnessed in more than six years of attending support groups haven't been so lucky. Their mood stabilizer doses were way higher than mine. Plus they were on other high dose meds. These were people in stable condition, but they never got better. Way too often, they got worse.
Whitaker noticed the same thing in the patients he interviewed for his book, but he came to a conclusion I would have never considered: It was the meds that were turning these people into the permanently disabled, he claimed, not the natural course of their illness. There was nothing natural to the course of their illness once the meds structurally altered their brains.
According to Whitaker, back in the old days researchers and clinicians noted that illnesses such as bipolar naturally remitted over a relatively short time. Now something different was going on, and we're not just talking about the side effects most of us know all too well.
As a group, we were more depressed, more manic, more psychotic, more anxious, more stupid, and less able to function than we were before. The medications have changed our brains. And the only answer clinicians have to our meds-induced worsening of symptoms is to respond with - drumroll - yet more meds, in yet higher doses.
How else do you respond to a person in distress? Take him off his meds? Alas, there is no easy answer.
This is a very bleak picture Whitaker paints, but one he is fully justified in painting. I was in the same room as Whitaker more than two years ago. He wasn't making things up. He wasn't taking the speakers out of context. If only we could write him off so easily. But the facts cannot be so easily ignored.
The facts - alas! - the facts.
Much more to come ...
Previous blog pieces:
The Whitaker Controversy: An Irony in Search of Nuance
If Meds Work as Well as Our Psychiatrists Tell Us, Why Do We Have MORE Mental Illness Today Rather Than Less?
RIP: Chemical Imbalance in the Brain