Wednesday, March 31, 2010

Busy Day for Batty

Lily Pads!



Yesterday, Balboa Park.

The People’s DSM: My Alternative Bipolar (Cycling) Diagnosis - Part III

Thus far (in Part I and Part II), I have kept what I refer to as “cycling illness” simple. As long as we appreciate that down and up are connected as different phases in the same cycle, there is little room for confusion. But there is a major complication called psychosis. If the psychosis is severe enough and prevalent enough, suddenly clinicians are faced with some very tricky diagnostic calls.

The current DSM recognizes psychosis as an illness in its own right and acknowledges its occurrence in other illnesses, including depression, bipolar, and schizophrenia, not to mention the hybrid diagnosis of schizoaffective. In theory, clinicians have a rough guide to work with. In practice, uncertainty prevails, namely:

How, precisely, does psychosis tie in to mood? And, while we’re at it, is there actually one person in the whole wide world who can explain schizoaffective, much less the reason for its existence?

Brain science and genetics promise to yield far more definitive answers than we presently have, which may explain why the draft DSM-5 changed virtually nothing. My view is we need to do our best based on the knowledge we have now, even if future scientific discovery proves us wrong. Let’s get to work:

The current DSM treats “with psychotic features” as a specifier to bipolar rather than to depression or mania. Let’s keep the specifier approach, but find more precise applications, thus:

Euphoric Mania with Psychosis

Various euphoric mania characteristics (such as enhanced positive abilities) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself or his or her situation in a grossly exaggerated light (such as a superman on a special humanitarian mission).

Dysphoric Mania (Mixed) with Psychosis

Various dysphoric mania characteristics (such as enhanced negative abilities) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself or his or her situation in a grossly exaggerated light (such as the only one in the world aware of a vast conspiracy).

And a copy and paste from the Alternative Depression Diagnosis Part II:

Vegetative (or Mixed) Depression with Psychosis

Various vegetative domain characteristics (such as excessive guilt) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself as deserving of punishment (such as being tracked by agents for an imaginary crime).

Agitated (or Mixed) Depression with Psychosis

Various agitated domain characteristics (such as a sense of exaggerated bad luck) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself as the object of unwarranted harassment (such as being tracked by agents as a result of a frame-up).

***

Thus, in these situations, psychosis is strongly linked to different phases of the cycle in terms of both timing and congruency. When the mania recedes, for instance, so does the psychosis. This suggests mood stabilizers as a first option rather than an antipsychotic.

If, on the other hand, the psychosis appears have a life independent of the cycle, then the clinician needs to spell it out, such as: “Cycling l, with Co-Occurring Psychotic Disorder.” (The current DSM lists “Delusional Disorder” and “Brief Psychotic Disorder”.)

This suggests different treatment options, such as an antipsychotic for the psychosis plus a mood stabilizer for the cycle (with perhaps the antipsychotic serving double duty in lieu of a mood stabilizer).

It is important to emphasize that psychosis with a life of its own is not synonymous with schizophrenia. Generally, more is going on with schizophrenia than just psychosis. Nevertheless, a very compelling case can be made for an overlap between bipolar and schizophrenia. Unfortunately, the DSM’s ‘tweener diagnosis of schizoaffective is more of a problem than a solution. Thus:

Kill the Schizoaffective Diagnosis

The operative phrase to the schizoaffective diagnosis is: “There is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.”

Criterion A lists other symptoms besides psychosis, and calls for a minimum time of one month. (There is a Criterion C for schizophrenia, which mandates a six-month minimum for “continuous signs of the disturbance,” but there is no reference to this in the schizoaffective diagnosis.)

Schizoaffective, then, is basically short-form schizophrenia punctuated by relatively brief overlays of depression or mania (the DSM minimum for mania, for instance, is one week). The assumption is that it is highly likely that there will be long periods when the schizophrenia symptoms manifest with no mood symptoms, and indeed this is a DSM requirement.

Thus, schizophrenia symptoms can appear without mood symptoms, but mood symptoms can’t appear without schizophrenia symptoms.

Does this sound like schizophrenia to you? Short form or not? Say, schizophrenia with mood symptoms? Is schizoaffective, then, a euphemism diagnosis for clinicians too chicken to tell their patients the truth? It appears that way.

Let’s kill the schizoaffective diagnosis, then. And while we’re at it, let’s rethink schizophrenia, complete with a name that accurately describes the illness. But that’s for later, along with a full review of psychosis. In the meantime, to sum up:
  1. When the psychosis can be linked to a phase of the cycle: Specify the phase within the cycling diagnosis.
  2. When the psychosis appears independent of the cycle but does not meet criteria for schizophrenia: Stick to cycling diagnosis, with a co-occurring psychotic disorder.
  3. When the psychosis appears related to schizophrenia: Go with a schizophrenia diagnosis, with a mood symptoms specifier.
Please note that I do not regard this draft as anything approaching the final word. If you have your own approach to breaking down psychosis, or can think of a hybrid bipolar-schizophrenia diagnosis that makes sense - or for that matter can make a good case for not fixing what ain’t broken - then, please, let’s hear from you.

Monday, March 29, 2010

Iris Chang, An Appreciation


A brief note in appreciation of Iris Chang, who was born yesterday in 1968. Ms Chang is the author of The Rape of Nanking (1997), which documented the atrocities visited on the Chinese by the invading and occupying Japanese Imperial Army beginning in 1937.

In a very short space of time, in one locale, hundreds of thousands of civilians were rounded up and killed in indescribably horrific ways, and up to 80,000 women raped.

Ms Chang was motivated to investigate after hearing personal stories from her grandparents and after attending a seminar in 1994. Unbelievably, no one had bothered to write a book in English on what had happened. Two years of total immersion in the project followed. According to Ms Chang, she was ...

... in a panic that this terrifying disrespect for death and dying… would be reduced to a footnote of history, treated like a harmless glitch in a computer program that might or might not again cause a problem, unless someone forced the world to remember it.

The book was hailed as a journalistic and scholarly tour de force, with many honors accruing to its author, including National Woman of the Year from the Organization of Chinese Americans. Predictably, she was bitterly attacked by ultranationalist Japanese groups in denial, and by attention-seeking nitpicking scholars too lazy to research and write their own account.

To date, Japan has refused to apologize for the holocaust.

I confess to never reading the book, nor, with my tendency to spin into runaway depression, am I likely to. Last year, however, I did view a documentary based on her account. It’s a story that needs to be told and retold, that we need to hear and re-hear.

Ms Chang followed up with 2003 book on The Chinese in America. In Aug 2004, while on the road promoting her book and working on her next book about the Bataan Death March, she suffered a nervous breakdown and was hospitalized for three days with “reactive psychosis.” Over the months, she was beset by depression and was taking mood stabilizers.

In November, by the side of a road in rural California, Ms Chang aimed a revolver at her head and pulled the trigger. She left three suicide notes. She was 36.


Thanks to my friend David Kincheloe for the heads-up. You can read the post on his blog here.

Scenes From the Desert Canyon



Anza-Borrego Desert, Friday.









Sunday, March 28, 2010

The People’s DSM: My Alternative Bipolar (Cycling) Diagnosis - Part II

As opposed to depression, a highly-complex illness that clinicians dangerously over-simplify, one can make a strong case that bipolar is far more simple than it looks. Change the name to “cycling illness” characterized by “phases” rather than “episodes” or “states,” borrow what’s relevant from what we already have for depression, fill in the blanks with a little bit about what “up” looks like, and stop right there.

Indeed, my first installment did just that. When stripped to essentials, cycling illness is basically a pattern of down and up. And since we tend to be down way more than we are up, it’s fairly accurate to say that cycling illness is depression with speed bumps.

“Up” is anything that contrasts with down. You don’t have to be dancing on tables. “Normal” or “better than normal” will do, so long as it shows you have a depression that is not standing still.

Complex depression, simple illness. Simple, really.

Okay, “up” needs to be explained a lot better than what you find in the current and highly antiquated DSM mania/hypomania symptom list. You can have racing thoughts, grandiosity, pressured speech, and all the rest, but are you feeling great or feeling lousy?

The DSM doesn’t tell you. Can you believe it? Myth has it that we’re supposed to be feeling like Leonardo DiCaprio with Kate Winslet on the bow of the Titanic (or vice-versa), but too often we’re more like Kim Jong il on a bad hair day.

Depression with a power surge, in other words. “Dysphoric” mania/hypomania, as opposed to “euphoric,” which I laid out in full in Part I.

Another way of looking at it is our depressions and manias are mixed. Hence the need for this Part II exercise. Think of dysphoric mania/hypomania as the cycle gone crazy - out of phase, so to speak - with both up and down screaming for attention at once. One is crashing down the door while the other hasn’t yet left the building.

How much depression inside mania/hypomania do you need? Only enough to turn euphoric mania/hypomania dysphoric. No need to count symptoms. Simple. Do we even have to add the specifier, “mixed,” to dysphoric? No. It’s totally redundant. Then again, maybe we better, thus:
  1. MANIC PHASE, DYSPHORIC (MIXED)
  2. HYPOMANIC PHASE, DYSPHORIC (MIXED)
Meanwhile, over on the other side of the diagnostic divide, we already have “agitated (or mixed) depression with mania” (which we would include on this side of the divide, as well, without specifically having to spell it out). In some cases agitated depression may appear difficult to distinguish from dysphoric mania/hypomania, but, hey, this is life in the real world. Depression and mania co-exist on the same spectrum, and, contrary to what the current and future DSM would have you believe, the two overlap. One bleeds over into the other. They don’t separate for the convenience of clinicians in a hurry.

Finally, what about situations involving say just two symptoms of mania combined with just three symptoms of depression? Going by official DSM criteria, you are healthy. Except for the fact that you are feeling rotten. Fortunately, The People’s DSM is not anal about symptom counts. Problem solved.

Dare we get more complicated?

Coming soon: We get more complicated. In the meantime, your feedback is strongly encouraged. Comments below ...

Saturday, March 27, 2010

Scenes From the Desert Valley

Anza-Borrego Desert, yesterday.





Desert Lilies!


A friend and I trekked two or so miles down a trail in the Badlands region of the Anza-Borrego Desert. There they were ...




Thursday, March 25, 2010

The People’s DSM: My Alternative Bipolar (Cycling) Diagnosis - Part I

In the “rip it up and start over” spirit of this series, let’s replace the term “bipolar” with “cycling illness” to reflect the true nature of what we are dealing with. I know the name won’t fly - that we’re stuck with bipolar - but, hey, this is a rough draft where I get to say what I really think.

The term, “bipolar,” implies a static and symmetrical illness where the subject flips back and forth between two sharply contrasting (and “polar” opposite) mood “episodes” or “states” that bear no seeming relation.

“Cycling” acknowledges the reality of a dynamic and not necessarily symmetrical condition where one mood “phase” gives rise to another and perhaps yet another.

In addition, cycling acknowledges the likelihood of other cycle disturbances, such as sleep.

On with the show ...

Mood Disorders
Cycling Illness (all of the below must be met):
  1. Evidence of a mood cycling pattern (through clinical observation, case history, or patient or witness reports), with discernible contrasting phases.
  2. At least one phase (or the combined effect of more than one phase) must be a significant departure from baseline condition
  3. At least one phase (or the the combined effect of more than one phase) must significantly impair ability to work, relate to others, and enjoy life.
A. Types: 

Cycling I: Subject experiences one or more mood cycles from depressive low or a non-manic low to manic high.

Cycling II: Subject experiences one or more mood cycles from depressive low to hypomanic high.

Cycling III: Subject experiences one or more mood cycles from depressive low to non-depressive high. 

Cyclothymia: Subject experiences one or more cycles from elements of depression to elements of hypomania.

B. Phases:

DEPRESSIVE PHASE

Subject may experience recurrent or highly recurrent or cycling depression (see My Alternative Depression Diagnosis - Part II).

MANIC PHASE (check one):

Euphoric

Subject may experience uncharacteristic feelings of extreme joy, superhuman positive abilities, and a sense of connectedness with the world, him or herself, and those around him or her. Subject may project a magnanimous “larger than life” presence.

Dysphoric

Subject may experience uncharacteristic feelings of extreme irritability, superhuman positive and negative abilities, and a sense of disconnectedness with the world, him or herself, and those around him or her. Subject may project a hostile menacing presence.

Domains (both must be checked):

Behavior:

Subject may display high energy, little need for sleep, pressured speech, a sense of impatience, an inability to control impulses, lack of judgment, and a need to satisfy cravings and indulge in projects or engage in risky behavior.

Behavior must be out of control to the point that subject can no longer responsibly manage his or her affairs or reasonably interact with others. 

Thinking:

Subject may experience racing thoughts, expansive thoughts, or disturbed thoughts. On one hand, subject may become easily distracted, on the other may be focused to the point of tuning out one’s surroundings or neglecting one’s responsibilities. On one hand, subject may experience a state of hyper-awareness; on the other may experience difficulties in basic cognitive tasks.

Thinking must be out of control to the point where subject has a grossly distorted perception of him or herself and his or her surroundings, and is no longer capable of making realistic or responsible decisions. 

Qualifying Criteria:

Mania lasts most of the day for at least two days and is not attributable to alcohol or drug use or a medications side effect (other than antidepressant medications).

HYPOMANIC PHASE (check one):

Euphoric

Subject may experience uncharacteristic feelings of joy, enhanced positive abilities, and a sense of ease with the world and those around him or her. Subject may project a sociable charismatic presence.

Dysphoric

Subject may experience uncharacteristic feelings of irritability, enhanced positive and negative abilities, and a sense of unease with the world, him or herself, and those around him or her. Subject may project an unpleasant mildly threatening presence. 

Domains (both must be checked):

Behavior:

Subject may display high energy, little need for sleep, pressured speech, feel a need to get things done or experience pleasurable activities, and not think through the consequence of his or her actions.

Subject may exhibit unusual or unexpected behavior, but is still capable of responsibly managing his or her affairs and interacting with others.

Thinking:

Subject may experience racing thoughts, expansive thoughts, or disturbed thoughts. On one hand, subject may become easily distracted, on the other may be focused to the point of tuning out one’s surroundings or neglecting one’s responsibilities. On one hand, subject may experience a state of hyper-awareness; on the other may experience difficulties in basic cognitive tasks.

Subject may have a mildly distorted perception of him or herself and his or her surroundings, but is still capable of making realistic and responsible decisions.

Qualifying Criteria

Hypomania lasts most of the day for at least one day and is not attributable to alcohol or drug use or a medications side effect (other than antidepressant medications).

NON-DEPRESSIVE HIGH PHASE

Subject may simply feel “normal” or “better than normal” and not feeling depressed, but does not cycle higher into hypomania or mania. Nevertheless, “normal” or “better than normal” stands in sharp contrast to depression and points to evidence of a cycling phenomenon.

Qualifying Criteria

Non-depressive high phase lasts most of the day for at least one day and is not attributable to alcohol or drug use or a medications side effect (other than  antidepressant medications).

NON-MANIC LOW PHASE

Subject may feel “normal” or “worse than normal” and not feeling manic, but does not cycle lower into depression. Nevertheless, “normal” or “worse than normal” stands in sharp contrast to mania and points to evidence of a cycling phenomenon.

Qualifying Criteria

Non-mania low phase lasts most of the day for at least one day and is not attributable to alcohol or drug use or a medications side effect.

***

Discussion Points

There is considerable overlap between “Cycling Depression” as part of my Alternative Depression Diagnosis and “Cycling III” as part of my Alternative Bipolar (Cycling) Diagnosis. I would submit the overlap far closer resembles reality than the artificial (and out of position) categorical gap imposed by the current (and future) DSM. Nevertheless, a differentiator or two would be helpful. Perhaps evidence of bipolar in a family member for a Cycling III diagnosis?

Your views?

Also, I can use some help on hypomania. Just because it is a deviation from a subject’s baseline condition doesn’t mean it has to be regarded as a pathology. Like any phase of a cycling illness, hypomania has to be looked at in terms of what is likely to come next in the cycle. A shift from euphoric to dysphoric hypomania? A swing up to mania? A steady slide down into something approaching normal? Or a precipitous crash into depression?

My view is that clinicians tend to treat hypomania as if it were mania and thus they err on the side of over-medicating us. Your views?

***

This is a lot more to come to my alternative bipolar (cycling) diagnosis, including mixed phases, rapid cycling, and dimensional and spectrum considerations. Stay tuned. In the meantime, your feedback is strongly encouraged. Fire away ...

Further Reading from Knowledge is Necessity 

Grading Bipolar - Stating What's Obvious


From BipolarConnect 

The Depression-Mania Two-Step
The Depression-Mania Two-Step - Part II
What It's Really All About is Cycling

Wednesday, March 24, 2010

iPhone Photo of the Day - Lizard!

I looked down. There he was.

Monday, March 22, 2010

Coming Home

Recovery is a journey. Healing is coming home. A lot of what I write here has been about my sense of coming home after leaving New Jersey more than three years ago and settling here in rural southern CA. Today, my good friend George from New Jersey called and offered me a different perspective.

You know, he said, this is the best you’ve sounded since you first moved - to New Jersey.

I thought I had heard wrong. He caught the silence from my end and clued me in.

You and “Sophy” had just got married, he reminded me. The two of you were optimistic, were looking ahead. Our DBSA support group that would meet in Princeton Hospital every Tuesday night had just started up ...

Yes, I remembered. In the weeks and months ahead, a very unusual collection of people walked through the door, sniffed out the vibes, and settled in. There was John “One”, a New York City wiseguy type, dealing with some business setbacks, with a thing for setting land speed records in his silver Porsche on the Jersey Turnpike, particularly in winter with the top down.

There was his polar opposite, John “Two,” a quiet guy with a Princeton doctorate in something that had to do with the science of water, out of work, trying to hold his family together.

There was “Flora,” a lawyer with an Ivy League pedigree and competitive marathoner (and nicotine addict, of all things), suspended from seminary, unemployed and eating through her savings with the clock slowly winding down.

There was Kevin, an earnest and very personable young Jehovah’s Witness with the wisdom of one many years older, picking up the pieces from a disastrous manic episode.

There was Chris, another polar opposite, a young and socially clueless math and computer geek, living with his mom, a prime candidate for being the first voted off the island, who nonetheless grew on you.

There was Christine, with a science degree, jumping from temp gig to temp gig, many times a bridesmaid, never a bride.

Plus a whole supporting cast of characters. Plus me and Sophy. Plus George.

We all had our issues to deal with, demons to wrestle, beasts to confront. All our lives were either on hold or at best in a tentative state of forward movement. The past was something we’d just escaped from, the present probationary, the future uncertain. Somehow, we found each other. Out from the cold of winter New Jersey evenings into the warmth of each other’s company.

We shared our stories. We laughed. We cried. We left feeling way better than when we arrived. Then we’d reconvene ten minutes later at one of the local coffee shops or diners. We’d keep in contact through the week. Fast friendships developed. A romance.

It was a special group of people, George reminded me.

Yes, it was. Yes, it was. I recalled that line from the musical, Camelot. “One brief shining moment,” I related to George, impossible to replicate. In some crazy unpredictable way, we gelled and we pulled in others.  

But things never stay the same. John One and Christine got married and moved to the Washington DC area to pursue a new business opportunity. John Two had a third child and found employment commensurate with his education and experience. Flora went back to seminary, got her degree, found a husband on eHarmony, moved to the Virginia countryside, and is working as a government lawyer. Chris moved out from his mom’s, and found his own place down the road.

As for me, in the space of six weeks, I had a book published followed by a precipitous marriage break-up. Ten days later, I boarded a train out of Princeton Junction. The next day, I strapped myself into the seat of a Southwest flight headed one way to San Diego.

George is still wrestling with his demons, but his struggle has resulted in a series of profound healings. George recently reached out to me, and we’ve reestablished our friendship, with regular phone conversations.

Sophy has started up her own successful blog.

Kevin - alas, Kevin. On a miserable muggy September morning in 2008, just outside Princeton Junction Station, he threw himself in front of a train. George and I, of course, can’t have a conversation without bringing up Kevin. Our breathing falters. Our voices shake. We feel his presence, as if he is part of the conversation.

As for the Princeton group, it’s still there. New people are running it. It is thriving, a source of comfort to many. Sophy is still involved, the one link to what seems a distant past, that brief shining moment.

I thought I had come home by moving out of New Jersey. But my conversation with George served to remind me that coming home is also about reaching a state of acceptance with my past. I lived in New Jersey for just three years, and perhaps I felt like your average traveler who just drives through it.

But I did reach a very significant destination there. A brief shining moment that will stay with me forever. Today, I experienced a new sense of coming home.

Sunday, March 21, 2010

The People’s DSM: My Alternative Depression Diagnosis - Part III


As you know from reading this blog, the people charged with coming up with the DSM-5 failed to turn in their homework. After handing out nine report cards with an average grade of F (I was way too generous), I decided to get crackin' on my own DSM, starting with depression.

My first installment recognizes the true complexity of depression by breaking the illness into six domains (such as “thinking” and “behavior”) which resolve into two types of depression: “Vegetative” and “Agitated,” plus an intermediate “Mixed” state.

My second installment adds a set of specifiers that would further break down depression according to variability, chronicity, dimensional, spectrum, severity, and suicidality considerations. Thus, “Agitated Depression, Highly Recurrent or Cycling,” “Mixed Depression with Anxiety,” and so on, plus a separate diagnosis of “Bipolar Spectrum Depression.”

Today, I drill deeper down to the “modifiers.” These involve environmental, lifetime, cultural, and gender issues that may either trigger or compound the course of an episode. Typically, we cannot prove cause and effect. Coincidence is our only clue.

On one hand, this kind of speculation may be a pointless exercise. On the other, careful attention to the modifying red flags may make all the difference in the world. To pick up where we left off ...

MODIFIERS:

A. Depression Coincident with Stress and Trauma:

Reactive


Depression that anticipates, coincides with, or follows soon after a major personal loss (such as of a loved one, a loving relationship, or employment), hardship (such as financial), interpersonal difficulties (such as a toxic family situation), or traumatic event (such as a danger to one’s physical safety or an extreme change in personal circumstances).

Reactive depression may also result from the culmination of negative personal events and circumstances over time.

The depression appears to bear a relationship to the coinciding event (such as evidence of a long period of high functionality followed by low functionality in the wake of a messy divorce).

The subject appears to display an inherent lack of resiliency, or of finding an adaptive response, to negative or stressful events in general, or a particular negative or stressful event.

The depression shows no sign of abating after four weeks or after the resolution of the coinciding event (such as finding new employment after being downsized).

Traumatic

Subject may appear overwhelmed or functionally impaired by unresolved trauma issues, such as early abuse or neglect.

The depression appears to bear a relationship to recollections of the traumatic event or events (such as evidence of flashbacks, nightmares, emotional triggers, or obsessive ruminations). 

Subject appears to display an inherent lack of resiliency, or of finding an adaptive response, to his or her traumatic recollections.

B. Depression Coinciding With Age (Check One):


Note: Age ranges are approximate and may overlap.

Child and Adolescent Onset


From early childhood to early teenhood (ages 5 to 15). Symptoms may be masked or exacerbated by developmental issues or hormonal changes, or life transitions particular to children and adolescents.

Youth Onset


From late teenhood to early adulthood (ages 15 to 25). Symptoms may be masked or exacerbated by developmental issues, hormonal changes, or life transitions particular to those entering adulthood.

Adult Onset


From young adulthood to middle age (ages 21 to 45). Symptoms may be masked or exacerbated by life transitions particular to those settling in to adulthood.

Mature Onset


From midlife to retirement age (ages 40 to 65). Symptoms may be masked or exacerbated by hormonal changes or life transitions particular to those in their middle years.

Late Onset

From retirement age upward (ages 60 and above). Symptoms may be masked or exacerbated by hormonal changes, life transitions, or medical and neurological conditions particular those in late life.

C. Depression Coincident with Female Hormonal Fluctuations

Postpartum Onset

The depression occurs within one year of childbirth.

The depression appears to bear some relationship to the childbirth (such as evidence of other emotional difficulties surrounding the birth).

The subject displays unexpected difficulty in adapting to the demands of the new child.

Premenstrual Onset


Depression coincides with the second half of a woman’s menstrual cycle, and ends when menstruation begins or soon after. Subject may also manifest difficulties in managing emotions, and may feel intense mental anguish and physical discomfort. The condition is far more severe than PMS.

D. Gender (Check one):

“Female” Features, Gender Congruent

Depression manifests in a way consistent with “western” social expectations or baseline behavior.

Female subject (or male who identifies as a female) may over-ruminate, may express emotional pain by appearing sad (such as breaking into tears), may seek out others, may see her condition as a situation of her own making and blame herself, may seek comfort in indulgences (such as satisfying a sweet tooth or impulse buying), may reach out for help in indirect ways (such as expressing a wish to die), or may engage in suicidal gestures (such as taking a non-fatal dose of pain-killers).


“Female” Features, Gender Incongruent

Depression manifests with a significant number of features that may run counter to “western” social expectations of female (or male identifying as female) behavior or out-of-character with baseline behavior (such as a male who cries).

“Male” Features, Gender Congruent

Depression manifests in a way consistent with “western” social expectations or baseline behavior.

Male subject (or female who identifies as a male) may lack the capacity for ruminative introspection, may express emotional pain by appearing angry and aggressive or sullen, may not seek out others, may deny anything is wrong and blame others, may seek comfort in alcohol or drugs or risk-taking activities (such as venturing into dangerous neighborhoods), may alienate those in a position to help, and may be planning a suicide attempt.

“Male” Features, Gender Incongruent

Depression manifests with a significant number of features that may run counter to “western” social expectations of male (or female acting as male) behavior or out-of-character with baseline behavior (such as a female who acts aggressively).

E. Cultural Identity

Within any given social or ethnic group regarded as a “minority,” depression features may be masked or exacerbated by cultural norms particular to that group (such as distrust in confiding to outsiders or an emphasis on keeping emotions in check), by language barriers, or by different ways of interpreting similar phenomena (such as seeing depression as a disease of the soul).

On the other side of the coin, behavior that perfectly accords with the cultural norms of a  particular social or ethnic “minority” group (such as demonstrable displays of grief or apparently submissive gestures) may be mistaken by western observers as signs of depression.

Saturday, March 20, 2010

Rerun: Meds in Our Treatment - How Does Smart Factor In?


I've been running a long series of posts on diagnosis and misdiagnosis. The following, on treatment, is from June of last year. You make the connection ....

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

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

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

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

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

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

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

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

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

How is that possible?

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

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

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

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

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

What a difference "smart" makes in the equation.

Wednesday, March 17, 2010

The People’s DSM: My Alternative Depression Diagnosis - Part II


As you may be aware, I’m in the process of writing my own DSM. In Part I of my Alternative Diagnosis to Depression, I scrapped the antiquated and arbitrary depression symptom checklist and replaced it with something I haven’t given it a name for yet, that nevertheless actually offers clues to our real mental state.

Clinicians or patients would tick off contrasting items on a six-part survey organized according to domains. Thus: Emotion (too much feeling or too little); Perception or Sense of Self (wholly negative or some positives); Thinking (overthinking or underthinking); Behavior (wholly passive or some active); Mental (speeded up or slowed down); Physical (high or low).

Symptom (characteristic) patterns or anomalies would resolve into three types of depressive states:
  1. Vegetative depression (Too little emotion, Negative perception, Tendency to underthink, Passive behavior, Slowed down mental state, and is Physically low). 
  2. Agitated depression (Too much emotion, Some positives in perception, Tends to overthink, Some active behavior, Some speeded up mental states, Some physical heightening).
  3. Mixed depression (subject displays roughly equal vegetative and agitated qualities).
But that is merely the beginning. The DSM serves up various “specifiers” (such as “recurrent”) to add variety to its single plain vanilla depression flavor, and it’s useful to borrow the technique.

A heads up or two:

The Atypical Depression/Melancholic Depression dichotomy as specifiers to DSM depression has been scrapped. Those specifiers were based on the antiquated DSM depression symptom list, resulting in considerable confusion and suspect validity. It is submitted that the Vegetative/Agitated distinction as separate diagnoses is more closely aligned to reality.

Considerable emphasis here is placed on dimensional/spectrum considerations to depression. The current DSM acknowledges psychosis in depression and the DSM-5 would acknowledge “mixed anxiety depression,” but with little attempt to explain their dynamics or their interaction. In this presentation, elements of anxiety, psychosis, mania, and personality are presented as bearing a relationship to various depression characteristics.

In particular, close regard is paid to depressions that behave as bipolar depressions, including “Agitated (or Mixed) Depression with Mania” and “Agitated (or Mixed) Depression, Highly Recurrent or Cycling.” The combination of these two forms the basis of a separate diagnosis of “Bipolar Spectrum Depression.”

The diagnosis of "Dysthymia" (low grade chronic depression) has been eliminated. Instead, severity criteria are used to distinguish "moderate" from "severe" from "very severe" depression. Moderate depression may have similarities to dysthymia, but the threshold is higher, removing any ambiguity.

Let’s got on with it:

SPECIFIERS:

A. Variable Characteristics (at least one item must be checked)

Vegetative, Agitated, or Mixed Depression, Pleomorphic

There has been an observable change over time in domain characteristics (such as from agitated to mixed or mixed to vegetative) between episodes or during an episode.

Vegetative, Agitated, or Mixed Depression, Constant

There has been no observable change over time in domain characteristics between episodes or during an episode.

Vegetative, Agitated, or Mixed Depression, Pleomorphic/Constant Undetermined

The clinician has had no opportunity to observe change or lack of change over time, or cannot make a determination based on history or patient reports.

B. Dimensional Characteristics (at least one item must be checked):

Vegetative Depression With Anxiety

Various vegetative domain characteristics (such as exaggerated worthlessness) may manifest as fearful anxiety, an immobilizing state characterized by an irrational unwillingness to engage with others or in tasks (such as leaving the house or completing an important project).

Agitated (or Mixed) Depression with Anxiety

Various agitated domain characteristics (such as irrational worry) may manifest as anxious distress, a state of nervous tension characterized by over-reacting to events (such as obsessing over a perceived insult).

Vegetative (or Mixed) Depression with Psychosis

Various vegetative domain characteristics (such as excessive guilt) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself as deserving of punishment (such as being tracked by agents for an imaginary crime).

Agitated (or Mixed) Depression with Psychosis

Various agitated domain characteristics (such as a sense of exaggerated bad luck) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself as the object of unwarranted harassment (such as being tracked by agents as a result of a frame-up).

Agitated (or Mixed) Depression with Mania

Various agitated domain characteristics (such as racing thoughts) may manifest as highly energized distress that may include an irrational (but nonpsychotic) sense of persecution, extreme impatience with one’s own situation or in dealing with others, irritability, and explosive outbursts.

Vegetative (or Mixed) Depression with Catatonia

Various vegetative domain characteristics (such as psychomotor slowing) may manifest as physical and mental stupor.

Vegetative (or Mixed) Depression with Personality Complications

Various baseline personality traits (such as introversion) may amplify certain vegetative depression characteristics (such as isolating) and impede recovery. Opposite personality traits (such as extraversion) may interact with vegetative depression characteristics in unexpected ways. 

Agitated (or Mixed) Depression with Personality Complications

Various baseline personality traits (such as novelty seeking) may amplify certain agitative depression characteristics (such as reckless behavior) and impede recovery. Opposite personality traits (such as harm avoidance) may interact with agitated depression characteristics in unexpected ways.

Vegetative, Agitated, or Mixed Depression, No Dimensional Characteristics

Are you sure? 

C. Chronicity (Check one):

Vegetative, Agitated, or Mixed Depression, Chronic

Lasting most of the day, most days, for at least two years.
 
Vegetative, Agitated, or Mixed Depression, Recurrent

History of at least one prior depression.

Vegetative, Agitated, or Mixed Depression, Highly Recurrent or Cycling

Depressions come and go, generally of short duration at short intervals, as if part of the same depression cycling up and down. “Up” merely needs to be higher than “down.” Subject in “up” may feel less depressed than usual, perhaps “normal” or “better than normal” for two days or more before cycling down into deep depression.

“Up” in the context of a depression diagnosis is not elevated enough to be mistaken for bipolar hypomania.

Vegetative, Agitated, or Mixed Depression, Chronicity Undetermined

The clinician has had no opportunity to observe a pattern over time, or cannot make a determination based on history or patient reports.

D. Suicidality (Check one):

Vegetative, Agitated, or Mixed Depression with Suicidal Ideation:

Subject obsesses on thoughts of dying or taking his or her own life, may feel an intense need to escape intense psychic pain or stop becoming a burden to others, or may see death as a release from life.

Subject has either formed a clear plan or is strongly considering his or her options, and appears prone to carry out his or her stated intentions.

Subject is not merely thinking randomly of suicidal thoughts, nor seeking attention nor engaging in self-harm such as cutting.

Vegetative, Agitated, or Mixed Depression, No Suicidal Ideation:

Suicidal thoughts and self-harm behavior may be present, but there is a clear lack of intention to act on these thoughts or escalate self-harm.

BIPOLAR SPECTRUM DEPRESSION:

Various types of Agitated or Mixed Depression may present as the above diagnosis.

Existence of both of the following:
  1. Agitated (or Mixed) Depression with Mania Features
  2. Agitated (or Mixed) Depression, Highly Recurrent or Cycling
May also include:
  1. Agitated (or Mixed) Depression, Pleomorphic
SEVERITY (Check one):

Severity is about functionality, not counting symptoms. Thus, for a depression diagnosis, the episode must significantly impair the subject’s ability to work, relate to others, and enjoy life.

Moderate:

Subject is able to function at work and in relationships, and in general is able to meet obligations, but is in a state of constant struggle, finds little joy in life, and may be fearful of the future.

Severe:

Subject is unable to function effectively at work and in relationships, is unable to meet many obligations, may have reached the conclusion that struggle is not worth the effort, finds no joy in life, and may lack the capacity to have regard for the future.

Very Severe:

Subject is unable to function at all at work and in relationships, is unable to meet any obligations or look after him or herself, may have reached the conclusion that life is not worth the effort, and may have lost all hope in the future.

***

Next - situational vs clinical depression, depression and stress/trauma, late onset, early onset, postpartum, PMDD, and more ...


***

Notice to readers - April 13:


I now have good evidence that "Dr Drake" is the result of a hoaxer. Unfortunately, I cannot do a mass erase of the comments. Erasing them one by one will take forever, and I much have better things to do - such as have a life. So, please disregard the comments below.

Tuesday, March 16, 2010

Rethinking Depression

Yesterday I came across a piece in the New Yorker by author Louis Menand, entitled Head Case: Can Psychiatry be a Science? The article offers an excellent review of the key debating points concerning the psychiatry’s reaction to the metaphysics of depression, namely:

Is depression really an illness? Or is it a normal reaction to a crazy world? If antidepressants can fix the problem in six weeks, then why spend six years on the couch soliloquizing about your bad potty training? Or, if they can’t, then what the hell is wrong with psychiatry?

On and on it goes. If you want to get up to speed fast on a subject vital to your life, then I highly recommend the article.

The piece zoomed in on the same set of studies that Newsweek made the basis for its outrageous cover story, Why Antidepressants Don’t Work (see my highly-critical post). Consider the New Yorker piece chess to the Newsweek’s checkers, with a much more nuanced look at the issue.

As you will recall, Newsweek cited two extremely convincing meta-analyses by Irving Kirsch in support of the proposition that antidepressants are basically placebos with side effects. Over eight or so years, no one has been able to shoot holes in these studies. Trust me, the second Kirsch meta-analysis is bullet-proof, but the results are open to interpretation.

Namely: In the real world, patients are likely to try a second antidepressant if the first one fails. Various small studies at the time indicated that the odds of success go way up when patients adopt this approach. A later large-scale series of trials underwritten by the NIMH, STAR*D, confirmed this.

That was how I reported the issue eight years ago and in various follow-ups and this was the approach taken by the New Yorker. (Both the New Yorker and I also shot to pieces a bogus meta-analysis recently published in JAMA that Newsweek took at face value).

Not so fast, says Robert Whitaker, author of "Mad in America." In his blog on Psychology Today, Whitaker accurately points out that STAR*D used statistical hocus-pocus to come up with an otherwise unsupportable claim that two-thirds of the patients in the study recovered on antidepressants.

I too, found this conclusion difficult to believe, and didn’t feature it in my STAR*D reporting. What I did feature were two key results: 1) It is worth trying a second antidepressant after the first one fails. 2) Trying a third after the second one fails is problematic.

The second result is the real STAR*D story, one that features in many of the pieces I write here (and one the New Yorker hinted at) but that Newsweek and Whitaker and just about everyone else missed. Here’s the deal:

The DSM depression diagnosis is an emperor with no clothes. It doesn’t tell us anything we don’t already know. One of it’s nine symptoms is “depressed mood.” Huh? So, if you have “depressed mood” and aren’t sleeping right or eating right and have low energy and seem to be moving in slow motion, what state of mind are you in?

DSM depression is a plain vanilla diagnosis that disguises the fact that depression comes in many flavors with many different ingredients. The plain vanilla approach encourages clinicians and researchers to treat all depressions as if they were the same.

This is the major reason clinical drug trials - and for that matter talking therapy trials -  tell us so little. In any given trial, we can predict in advance that 50 percent of patients are going to get 50 percent better. The catch is which 50 percent? No wonder the results for the treatment group and the placebo group are about the same.

This is plain vanilla diagnostics at work. In all likelihood, there is a subgroup that is getting 80 percent better 80 percent of the time, as well as a large group of those who should never be taking antidepressants. But who are these people?

Of all things, STAR*D serves up a hint. As Frederick Goodwin, former head of the NIMH, pointed out to me, about two-thirds of the STAR*D study subjects had recurrent depression.

It seems likely that those in the STAR*D study with recurrent depression would not have fared so well on antidepressants, as recurrent depression is a close cousin of bipolar, but we’ll never know. STAR*D made no attempt to separate out this population. To the investigators, depression was depression.

The other lesson to be gleaned from STAR*D is this: After your second antidepressant fails, you need revisit your diagnosis. Maybe you don’t have depression. Maybe you have bipolar or a depression that behaves like bipolar. Maybe you have borderline personality disorder. Maybe depression is part of your baseline temperament.

But plain vanilla DSM depression offers no guidance. Chances are a large population of individuals in the STAR*D study did not even have depression. Same with clinical drug trials. Treatment works only if the diagnosis is correct.

Now we’re getting to the moral of this story:

Yesterday, I premiered “The People’s DSM.” My first installment featured Part I to My Alternative Depression Diagnosis. In the intro to the piece, I joked that, “if you want anything done right, you have to do it yourself.” But I’m not fooling around.

The DSM-IV depression diagnosis is based on an antiquated and totally arbitrary symptom list from 1980. The people working on the DSM-5, if they are serious, need to rip up that list and start over. Maybe then, psychiatry will get serious about what is really going on in our brains and come up with answers. Instead, they plan to leave the list intact.

As I said, sometimes you have to do it yourself. I’m not joking.

Monday, March 15, 2010

Desert Wildflowers! - More Pics



Some more beauties from my Saturday photo safari to the Anza Borrego Desert. Enjoy ...




The People’s DSM: My Alternative Depression Diagnosis - Part I


If you want anything done right, you have to do it yourself. With the DSM-5 task force and its various work groups and study groups a virtual walking and talking “How many psychiatrists does it take to change a light bulb?” joke, it is time for me to take matters into my own hands.

Following is a very rough draft to the first installment of “The People’s DSM,” which I am dedicating to the pioneering spirit of Robert Spitzer and those who worked with him on the ground-breaking DSM-III of 1980. Spitzer and company essentially ripped up the DSM-II and started over. Something the DSM-5 people should have done to the DSM-IV.

Something I’m doing right now. But I need your help. Please give me your feedback and suggestions and we’ll keep reworking it together till we get it right. On with the show ...

Mood Disorders
Depression


Introduction

The current depression diagnosis, with its antiquated symptom checklist, does not adequately account for extreme variations in emotions, thoughts, and behavior. Below are six domains to depression (such as emotion and thinking), each domain arranged in two complementary pairs, each pair with contrasting characteristics (symptoms or sets of symptoms).

These six domains would replace the symptom checklist.

For the Alternative Depression Diagnosis, clinicians need to check at least one characteristic from each domain. All four characteristics from a particular domain may be checked, even if they are opposite. As opposed to the previous DSM, this is not an exercise in symptom counting. More symptoms do not equate to a more severe depression.

Rather, this is an exercise in spotting symptom (characteristic) patterns and anomalies. Clustering of certain characteristics tends to resolve into one of two types of contrasting depressions: “Vegetative” and “Agitated”. There is also an intermediate “Mixed” depression.

All three may be called depression, but they are likely to demand entirely different and extremely subtle treatment and therapeutic approaches, as if they were different diseases. Current diagnostic practice does not encourage this.

A final note: Suicidal ideation is not included as a characteristic (symptom) here. This will be dealt with in a future installment.

Depressive states (all of the below must be met):

  1. Must last most of the day for two weeks or more, with no apparent sign of improvement.
  2. Must be a significant departure from baseline condition.
  3. Must significantly impair ability to work, relate to others, and enjoy life.
Domains (at least one from each of six):

A. Emotion (Too Much Feeling or Too Little):
  1. Subject may feel overwhelmed, and express intense sadness or anger.
  2. Subject may experience emotional numbness, such as loss of pleasure, inability to grieve, or feel motivated.
  3. Subject may experience excessive guilt or irrationally worry about one’s self or others.
  4. Subject may lack the capacity to feel guilt or display concern for one’s self or others.
B. Perception and Sense of Self (Wholly Negative or Some Positives):
  1. Subject may experience exaggerated worthlessness, feel deserving of his or her fate, and undeserving of a better personal situation.
  2. Subject may experience a sense of exaggerated bad luck, feel undeserving of his or her fate, and deserving of a better personal situation.
  3. Subject may view events in a negative light, discount good news, and see one’s personal situation as hopeless.
  4. Subject may view events in a temporarily positive light, react to good news, and may see ahead to the possibility of one’s personal situation improving.
C. Thinking (Overthinking or Underthinking):
  1. Subject may obsessively ruminate on destructive or self-defeating thoughts.
  2. Subject may report difficulty concentrating or trying to plan ahead.
  3. Subject may exhibit difficultly in processing routine mental tasks, such as remembering a phone number.
  4. Subject may experience anxious or racing thoughts.
D. Behavior (Wholly Passive or Some Active):
  1. Subject may experience difficulty engaging in routine tasks (such as keeping appointments or personal hygiene), pleasurable activities (such as hobbies), and relating to others (as if a fish out of water).
  2. Subject may engage inappropriately in routine tasks (such as messing up an easy  assignment), pleasurable activities (such as drug or alcohol use or reckless behavior), and relating to others (such as being argumentative and confrontational). 
  3. Subject may passively withdraw from social contact and isolate.
  4. Subject may aggressively withdraw from social contact and withhold his or her companionship.
E. Mental (Speeded Up or Slowed Down):
  1. Subject may experience a deadening of the senses (such as loss of sex drive or inability to taste food).
  2. Subject may experience a heightened sensitivity to unpleasant sensations (such as the sound of a person’s voice).
  3. Subject may experience a subjective slowing of the brain (such as a feeling of being dead).
  4. Subject may experience persistent psychic pain (such as a feeling of wanting to crawl out of one’s skin). 
F. Physical (High or Low):
  1. Subject may display nervous energy (such as pacing and inability to sleep or not eating).
  2. Subject may display loss of energy (such as psychomotor slowing, fatigue, need to sleep, or overeating).
  3. Subject may experience unexplained pain.
  4. Subject may feel beyond the ability to feel physical pain.

***

Depressive types

Vegetative depression (subject leans toward most of the following):

Too little emotion, Negative Perception, Tendency to underthink, Passive behavior, Slowed down mental state, and is Physically low. 

Agitated depression (subject leans toward most of the following):


Too much emotion, Some positives in perception, Tends to overthink, Some active behavior, Some speeded up mental states, Some physical heightening.

Mixed depression (subject displays roughly equal vegetative and agitated qualities)


***

Vegetative, agitated, and mixed depressions may bear a relationship. A subject may present first with agitation, as if struggling against his condition, then give in to a vegetative depression. Conversely, an agitated depression may signal progress from a vegetative state toward remission or a worsening of one’s condition.

Final Word (for now)


Replacing the classic symptom checklist helps address some major concerns, namely:
  • “Male” traits are mentioned for the first time, such as anger, drug use, confrontation, and aggression (along with “female” traits such as rumination), which should help redress the gender imbalance in the depression diagnosis.
  • It helps identify the subject’s predominant state of mind (other than just “depression”), as well as other states, which gives clinicians and patients something to work with.
  • It acknowledges the complexity of depression and its infinite variations.
In addition, the vegetated/agitated distinction eliminates the current and confusing melancholic/atypical depression distinction. It also accounts for the “pleomorphic” nature of depression, where symptoms (characteristics) may present differently from depression to depression or even within the same depression.

Two important first principles: No two depressions are alike. Depressions cannot be treated as if they are all the same. The current DSM discourages both clinicians and patients from thinking this way. The People’s DSM is offered as an antidote to this practice.

***

This is a lot more to come to my alternative depression diagnosis, including chronicity, cycling, severity, dimensional concerns (such as anxiety, mania and temperament), suicidality, and relationship to stress. Stay tuned. In the meantime, your feedback is strongly encouraged. Fire away ...

Sunday, March 14, 2010

Cognitive Dissonance - When Your Brain Won't Let You See the Facts

Just a quick follow-up to a blog piece I published last week. The piece was a response to a totally irresponsible Newsweek cover story, entitled, Why Antidepressants Don’t Work.

The headline may as well have said, “Flush All Your Meds Down the Toilet Right Now.” No doubt, a lot of people did, and no doubt some of them are paying in full measure.

The hook for the Newsweek piece was a meta-analysis published earlier this year in JAMA. According to Newsweek:

In an analysis of six large experiments in which, as usual, depressed patients received either a placebo or an active drug, the true drug effect—that is, in addition to the placebo effect—was "nonexistent to negligible" in patients with mild, moderate, and even severe depression.

Earlier, Benedict Carey in the NY Times reported:

Some widely prescribed drugs for depression provide relief in extreme cases but are no more effective than placebo pills for most patients, according to a new analysis released Tuesday.

Clearly, Newsweek was riffing off the NY Times. Based on these accounts, I naturally assumed that JAMA had published a study highly critical of antidepressants. But, then again, why would JAMA publish this kind of article at all? This is hardly the MO of medical journals, which can best be described as friends of Pharma.

So I went to the JAMA piece and read it. Or, to be more precise, I misread it. Yes, the JAMA study was highly flawed for all the reasons I stated in my blog piece, but this observation I made was completely wrong:

Medical journals are notorious for publishing industry propaganda disguised as research. This one went the other way. 

No, it didn’t. The JAMA piece was actually strongly supportive of antidepressant treatment. It was only days later that a light went off in my head. Here’s my best explanation for what happened:

The NY Times and Newsweek accounts led me to assume that I would be reading a critical study. Although I was highly skeptical of the NY Times and Newsweek accounts (as there were obvious rebuttals they didn’t report), I nevertheless went to the JAMA piece with certain filters already in place in my brain. In other words, my brain was likely to screen out any information that contradicted my operating assumption. The experts refer to this as “cognitive dissonance,” and we see this happening all the time in daily life.

Politics is a prime example. Republican brains filter information in a way that make them think their shit don't stink, even when the facts blatantly contradict their views. The brains of Democrats are wired the same way.

Of all things, Benedict Carey authored a 2005 NY Times piece related to this, based on a study that suggests our genes may influence our gut-level responses to political and social issues. Ironically, his article may explain his own egregious serial misreporting on mental illness (see, for instance, my blog piece on HealthCentral, Antipsychotics - the NY Times Gets it Right - and Wrong).

Newsweek led off with two meta-analyses conducted by Irving Kirsch of the University of Connecticut. Using the FDA database that included unpublished drug trials, Kirsch found that antidepressants performed only minimally better at best against placebos. There are various ways of disputing Kirsch’s conclusions, but no one has done it by coming up with a better meta-analysis.

The JAMA meta-analysis was a direct response to Kirsch (and another supporting study). According to the JAMA piece:

One limitation to these meta-analyses is the restricted range of baseline severity scores included in their constituent studies.

In other words, the authors (Jay Fournier et al from the University of Pennsylvania) thought that the inclusion in these trials of patients with less than severe depression may have polluted the study sample. So, they set out to do a more refined meta-analysis, and judging from the article, seemed very happy with the result:

For patients with very severe depression, the benefit of medications over placebo is substantial.


See? goes the thinking. Antidepressants DO work. The catch is they don’t work for everyone. To tease out the efficacy data the authors needed for severe depression, they were left with no choice but to make this major concession concerning the benefit of antidepressants for depressions less extreme:

True drug effects ... were nonexistent to negligible among depressed patients with mild, moderate, and even severe baseline symptoms ...

The authors thought they had successfully rebutted Kirsch (though conceding various points of agreement), and in the process had defended the efficacy of antidepressants. The NY Times and Newsweek saw it another way.

This, in turn, affected how I would interpret the article. My eyes saw one thing (an article defending antidepressants), but my brain told me I was seeing something else (an article critical of antidepressants). My factual error fortunately did not effect my analysis. But it serves as a sober reminder of how careful we all need to be. The phenomenon of cognitive dissonance, as much as any mental illness, can take over our brains and rob us of our ability to reason.

My E*Trade Grandson























Lindsay? That milkaholic?

Saturday, March 13, 2010

Desert Wildflowers!

Today I drove 90 minutes to the Anza Borrego Desert for a photo safari with a camera I paid way too much money for. But who cares when the flowers are popping like this? Above, a crimson-tipped ocotillo.

I'm always amazed at what winter rains can do to a desert floor.

I must have checked out hundreds of this type of cactus. This was the only one that had a bloom on it.

I was driving up a mountain road on the way home. Suddenly, something yellow caught the corner of my eye. I screeched to a stop and scrambled up the rock face. Literally, this was the only thing in bloom as far as the eye could see on this desolately beautiful moonscape. I think it's an agave plant.

Barrel cactus in bloom.

Technically, there are no flowers on this ocotillo. But who needs flowers with this kind of light?

You want flowers? I'll show you flowers. Check out the bloom on this ocotillo.

A desert bouquet

Thursday, March 11, 2010

Grading Bipolar - Looking Back At My DSM-5 Report Cards

Let’s review the six DSM-5 bipolar report cards I issued:

Episodes

My first report card noted that the current DSM and its would-be replacement look at various mood states (depression, mania, hypomania, mixed) in isolation, as if they bear no relation to each other. I started out by challenging that assumption, a theme I kept returning to in subsequent report cards.

We’re all familiar with the symptom checklists. The draft DSM-5 got off to a bad start by repeating the errors of previous DSMs, namely by copying and pasting the unipolar depression checklist into bipolar as if all depressions are the same. Not only are they different, but anomalies in depression can tip off clinicians to dig deeper for evidence of past mania/hypomania episodes.

One thing that needs to be constantly borne in mind: The DSM is not a science project. It’s not a codeable reimbursement system set up for the convenience of the healthcare industry. The only reason for its existence is to guide clinicians in making an accurate diagnosis, based on the best information we have.

So right off the bat, we have the draft DSM-5 perpetuating old mistakes that are only going to encourage misdiagnosis. As I concluded here: “What were these people thinking? They weren’t. Grade: F-minus.”

I also turned it the other way around, namely that evidence of “up” points to how one’s depressions cycle. So how high, then, does “up” have to be? Only high enough to separate it from down and thus identify that the depression is not unipolar. Who needs to count symptoms? I wimped out with a grade of “incomplete.” I should have issued an F.

I also noted that the draft DSM-5 did nothing to clear up the myth concerning good time manias and hypomanias. In fact, a lot of us are miserable in these states, what can best be described as energized psychic pain, or, more technically, “dysphoric” mania/hypomania. Why no symptom list to separate this out from “euphoric” mania/hypomania? As I concluded: “Is there a secret DSM with accurate information that only a privileged few are allowed access to? And a fantasy DSM for all the rest of us? Grade F.” (I was way too generous.)

Mixed Episodes and Spectrum Considerations


My second report card focused on where mania and depression meet. The draft DSM-5 got off to a good start by recognizing for the first time the reality of antidepressant-induced mania/hypomania, but turned a potential A into a C-minus by burying this in the boilerplate fine print that no one reads.

The recognition that one doesn’t have to be fully depressed and manic at the same time to experience a mixed episode was also an encouraging development. The next DSM-5 is likely to acknowledge the reality of depression symptoms inside mania/hypomania and mania/hypomania symptoms inside depression, which would embrace the bipolar II population for the first time.

But what does a mixed state look like? Presumably we are talking about symptoms strong enough to turn “euphoric” manias “dysphoric” and mind-numbing depressions “agitated.” The problem is the DSM leaves us presuming. Thus a potential A got knocked down to a C-minus. “Do we have to Google the answers ourselves?” I asked.

Also, the DSM-5 could have gone a lot wider in its recognition of mixed states, thus turning another potential A into a C-plus.

The other dimension to the bipolar spectrum includes “soft bipolar” not recognized by the current DSM (unless you stick NOS to the diagnosis). These are so-called unipolar depressions that behave like bipolar and need to be treated as such. There are three ways the DSM-5 could have approached this: 1) Widening the bipolar II diagnosis, 2) Adding a bipolar III diagnosis, 3) Getting creative with the unipolar recurrent depression diagnosis.

I issued two grades in this category. One was an F-minus. The draft DSM-5 managed to turn my second potential F-minus into a D by indicating that it was willing to tweak hypomania (the threshold for bipolar II) just a tad.

Severity

My third report card looked at severity issues. As I noted in my piece:

The DSM-5 Task Force mandated its various workgroups to come up with sophisticated severity measures analogous to assessing hypertension. This would place far greater emphasis on functional impairment (such as inability to hold down a job) rather than simply ticking off symptoms.

Severity is vital in separating out “normal” from hypomanic and hypomanic from manic. The current DSM already uses this as its main criteria (“not severe enough to cause marked impairment”) to distinguish hypomania from mania, but a lot more deep thinking is required, which I decided wasn’t going to happen when I handed out my standard F-minus.

I had already introduced the theme on my first report card, noting:

How do we delineate “normal” (that include ups that are characteristic of a particular individual) from hypomanic from manic? Get it wrong and we will never find the patient’s treatment sweet spot.

A minor tweak to the symptom list would have done wonders, but this, apparently, was asking too much. My grade of F was far too generous.

Of all things, the draft DSM-5 decided severity didn’t apply to episodes. Huh? F-minus. The same group of people also didn’t think to have regard for the cardinal feature of bipolar, namely cycling. Another F-minus.

There were opportunities for the draft DSM-5 to get creative by coming up with severity measures for stress and context (as in you may feel okay right now, but are you okay to go back to work?). F-minus or incomplete? I was a softee on this one.

Psychosis and Schizoaffective

My previous report cards placed considerable emphasis on bipolar bleeding into unipolar. My fourth installment looked in the other direction toward schizophrenia. The current DSM seemed to have the issue covered with its recognition of “psychotic features” to both depression and mania, plus the diagnostic hybrid of schizoaffective disorder.

But closer examination revealed considerable room for clarification. As I noted in my piece: “Misinterpreting psychosis leaves no room for error, as a diagnosis of schizophrenia sends (very wrongly) a clear message to abandon all hope.”

For one, we had no clear definition of psychosis (F), or an explanation as to the difference between a psychotic symptom and psychotic feature (F) or an adequate guide for when a clinician should stop going with a specifier in favor of a different diagnostic call (such as schizoaffective).

The draft DSM-5 explicitly pointed out a major problem with schizoaffective, namely: “The current DSM-IV-TR diagnosis schizoaffective disorder is unreliable.” Their remedy was no remedy. You gotta be kidding! F-minus.

Somewhere in the middle of all of this, I actually handed out a B, but that’s like praising Charles Manson for being a model prisoner.

Child Bipolar


For my fifth report card, the draft DSM-5 outdid itself, with a string of F-minus’ as my highest grade. For one topic, an F-minus would have been way too generous, so I issued a “no-grade” in protest.

Essentially, the draft DSM-5 refused to acknowledge “pediatric bipolar” as a diagnosis in its own right. Even an “early onset” specifier would have at least acknowledged the reality that one doesn’t have to be of voting age to qualify for a bipolar diagnosis. Technically, the draft DSM does not dismiss the possibility of kids with bipolar, but lumping kids with adults offers no guide to clinicians.

In a nutshell, bipolar kids tend to act out somewhat differently than bipolar adults, with emphasis on extreme rapid cycling and raging mixed states.

The draft DSM-5 thought it solved the problem by introducing the entirely new diagnosis of “temper dysregulation disorder with dysphoria.” These are basically raging kids who don’t cycle, and thus are not be be regarded as having bipolar. There may be some merit in the diagnosis, but the draft DSM-5 failed to cover its tracks. The justifications its working group put out literally scream internal politicking and nasty turf wars.

The result was an ill-considered and hastily-conceived new diagnosis that violated the draft DSM-5’s own standards for scientific validity. Had the new diagnosis been presented in the context of a pediatric bipolar diagnosis, this may have been acceptable, instead, as I noted:

The result is an unmitigated disaster, one that shames psychiatry and performs a considerable disservice to the public, whose interest is supposed to come first.


Cycling

Cycling is bipolar’s cardinal symptom, though you would never know it by going to the current DSM or its would-be successor. By this time, my sixth report card, I had decided no more Mr Nice Guy. No more easy grading. This time, an unbroken string of F-minuses.

As I noted in my piece:  “We cycle up, we cycle down. Strip bipolar to its most essential element and what we’re left with can be best described as ‘cycling illness.’”

This brings me back to the theme I introduced in my first report card: that episodes (such as depression) make no sense in isolation, with no regard to where and when and how severe the cycle may trend next (such as mania).

I also observed that there was more to cycling than simply mood, including sleep/energy and thoughts, and that these didn’t necessarily have to occur in sync with our moods. This is classic Kraepelin, dating from the early twentieth century. In addition, Kraepelin also figured out that mixed states were the result of out-of-alignment cycles (including physical activity).

As I concluded: “Kraepelin got it right the first time. The DSM is about to get it wrong the fifth time.”


My DSM-5 bipolar report cards:

My DSM-5 Report Card: Grading Bipolar - Part VI
My DSM-5 Report Card: Grading Bipolar - Part V
My DSM-5 Report Card: Grading Bipolar - Part IV
My DSM-5 Report Card: Grading Bipolar - Part III
My DSM-5 Report Card: Grading Bipolar - Part II
My DSM-5 Report Card: Grading Bipolar - Part I