Monday, January 31, 2011

Psychic Perception

Below is an edited version of  a new article on mcmanweb ....

In a poll I conducted here in Aug 2009, nearly one in four (23%) reported they were "borderline or full-on psychic, or at least it seems that way." In contrast, less than one in ten (8%) responded with, "Sorry, I'm totally rational and logical."

I highly doubt that we would find so many with psychic tendencies in the general population. I also suspect most of us keep pretty quiet about this stuff, especially around our psychiatrists. We are talking about a spectrum where intuition overlaps with the paranormal or psychic, which in turn bleeds over into truly irrational thinking - ranging from grandiose and delusional to magical and psychotic.
There is no separation. A hyper-aware brain easily becomes overloaded, to the point that "seems like crazy," with only a slight nudge becomes "genuinely crazy."

Weird stuff happens. Back in the mid-seventies I had a vivid dream about an earthquake. Twenty-four hours later I woke up to the floor shaking beneath me, my first-ever encounter with Richter phenomena. This had to be random chance, I could only think. Odds are, after all, that things will happen that defy all odds - it's one of those paradoxes to the laws of probability. That's my story, anyway, and I'm sticking to it.

The other way of looking at it is that - in order to preserve my sanity - I learned to tune out this sort of thing. Imagine my brain going off every time the earth twitched. I'd be a nervous wreck, especially now that I live in California. In other words, "reality" was my adaptive response to a "hyper-reality" that was too much for me to handle. (Of all things, this is the mirror reverse of the Freudian explanation for "psychosis," which his followers view as a maladaptive "reaction" to reality that is too much to handle.)

Okay, one more weird thing: Back in the late-80s, I joined a "psychic circle." We were asked to face the person next to us and do a "reading." This is stupid, I thought. But if I persisted in my "this is stupid" line of thinking I was only going to prove myself right. I settled down, blotted out all distractions, including "thinking," and went with flow ...

I see you in front of the fireplace, I said to the woman facing me. So far so good, unless of course her house didn't have a fireplace. She motioned me to continue. With your two kids, I added.
I only have one kid, she cut in.

There! Wrong, already! I knew this stuff was bullshit. "Well, I see two," I said anyway. Look, it's not my fault, I wanted to explain. I'm just doing what the lady told me to do - clear your head, no thinking, first thing to pop into your head ...

That week, she discovered she was pregnant.

"We're called nutjobs for recounting these experiences," Liza over at my blog on BipolarConnect commented, "and don't you dare mention them to your psychiatrist unless you want a stay in a psych ward complete with an ECT session or two."

Nevertheless, Liza felt sufficiently safe on BipolarConnect to reveal this:

I was in a small group in my high school English class. The group was discussing the debate we were preparing, and I said, why are we going over this again? We said all this last small-group meeting. Nope. It was the first time we'd met in group. My classmates already thought I was weird, and I'd just confirmed it.

But of all things, Liza went on to say, two of the giants of psychiatry/psychology, Carl Jung and William James, gave such experiences a lot of credence. Jung felt that the human psyche is "by nature religious." In his memoir, he recounted seeing a luminous head, detached from the body, floating from his mother’s room.

Meanwhile, William James, in his classic "The Varieties of Religious Experience," felt that healthy-mindedness had a lot to do with "union with the divine" whereas depression was the sign of a "divided soul" that could be cured by a mystical experience.

None of this, of course, sat well with Freud, who expressed his fear of psychiatry descending into a "black tide of mud of occultism."

These days, science is starting to fill in a lot of the blanks on our behalf. Few investigators are brave enough to risk their careers looking into the paranormal, but research into intuition and creativity - the "soft side" of psychic - is a hot field.

But creativity and intuition (and needless to say, psychic perceptions) are also linked to crazy. It's no accident that some of the top investigators in the field - people such as Nancy Andreasen of the University of Iowa - made their bones researching mental illness.

A psychic reality undoubtedly exists, and the ones with the best insight into this are the people eating out of dumpsters. Our brains tune this stuff out for a reason. I know mine did.


This article is one in four on mcmanweb investigating the connection between creativity, intuition, psychic perception, nonlinear thinking, and crazy, based on blogs originating here and BipolarConnect:

Creativity, Intuition, Non-linear

Saturday, January 29, 2011

Rerun: I Enter My Elvis Pizza in a Cooking Contest

An oldie from 2009. Enjoy ...

There are things I do at 3,500 feet up in the mountains that would never even enter my mind at sea level. Last Sunday at 5 PM I showed up at our local restaurant - Descanso Junction - ready to kick ass. I had entered myself into my first-ever cooking contest and I was determined to walk away with first prize.

I had my world famous Elvis Pizza ready to go. How could I possibly lose? I walked in the door, laden with my pizza gear. "I'm ready for you," I told the owner Tammy. "Are you ready for me?"

I set up in a spot in the kitchen in back. First order of business - pizza stone in the oven. A pizza stone looks like a manhole cover and weighs about the same. Out of my backpack and into the oven it went. The stone would need at least a half hour to absorb the oven heat. Second order of business - caramelize my onions. I had thin-sliced wedges of onions ready to go. Olive oil into a frying pan, then the onions.

I got them going, then dashed over to my corner of the kitchen to get set up. Onto the counter went my covered pizza dough (which I had made and brought to a rise back home), my pulled pork (from a six pound pork butt I had slow-roasted two days before), my barbecue sauce, Ranch dressing, shredded cabbage, a wooden pizza peel, it goes on and on ...

I flew back to the cooking range just in time to prevent my onions from turning into Cajun ashes. By this time, the other contestants were setting up. They had brought things in pots that only needed warming up. And here I was with my Manhattan Pizza Project that demanded precision timing. Rookie mistake. I should have entered my world famous cassoulet.

But no, think big, think pizza. Things in pots - that's for wimps. This is my Elvis Pizza, after all, inspired by the King of Rock 'n Roll.

"I thought that would have been peanut butter and banana," one of the contestants joked.

"That was my first version," I responded, almost with a straight face. Then I got smart. A barbecue pizza. Stand outdoors at Graceland and inhale and you'll see what I mean. Okay, I've never been near Graceland or Memphis, but I assume I'm striking a chord with every music lover who recalls hearing "Hound Dog" for the first time and comes to the realization that the world will never be the same.

Back in my corner of the kitchen, I sprinkled flour on the metal counter top and plopped on my pizza dough and rolled it out according to exact NASA specifications. My sauce and toppings and implements were right where I needed them to be. Then back over to the range for my onions. Sweet as candy. Into a dish they went and back over to my corner of the kitchen. Final assembly would come later.

The appetizer portion of the contest got underway. I took a seat with the other contestants out front. I think it was a soup that led off the contest. But not just any soup. This was family soup. Soup that the Crusaders had brought back from the Holy Land, soup that had traveled on the Mayflower, that had tamed the West.

Oh, crap! I thought, as the contestants reeled off their recipe narratives to the five judges at the table. I had come prepared with a crisp two-sentence delivery (or one long sentence with commas and conjunctions) and here they were expecting 500 pages of John Galt from "Atlas Shrugged."

The appetizer portion of the contest wrapped up, and the first contestant from the entree portion showed up with his wimpy pot. Time to go back and get crackin'. I was in the number four spot. Plenty of time, no rush.

Tammy poked her head in the kitchen. One of the contestants was a no-show, she informed me. I would be going on at number three.

Rule number one in any cooking contest: Only show up with things in pots, the wimpier the better.

"No problem," I shot back, lying through my teeth. My dough had been lying on the counter too long and I perceived the ugly possibility of a crust build-up. No time to worry about that, as I grabbed my box of corn meal and dusted my pizza peel. Then I moved the dough to the peel, crimped the edges, and started applying my sauce and my pulled pork and caramelized onions.

Thyme! Where's my fresh thyme? No time! I sprinted to the oven with my creation, opened the oven door, and slid my pizza onto the stone. The pizza took off on the stone like a vehicle on glare ice. A small portion of the pizza was drooping off the stone. I stuck my bare hands into a 500 degree oven and managed to pull the pizza back, but now it was no longer circular in shape.

A rustic pizza, I would call it, if worse came to worst. Here I was dealing with a strange oven, hoping like hell the dough wouldn't come out burnt on the outside and raw on the inside.

"How are things going?" Tammy asked. "Right on schedule," I replied in an unbelievably calm and reassuring voice. A good cook can handle any contingency. More than a year before, I had failed a driver's test when my brain went into panic mode and I nearly failed my second time out for the same reason. Now here I was, cool as a cucumber (and there just happened to be a cucumber in the kitchen for comparison). No matter how this contest turned out, I had already passed with flying colors.

Now I had my plating station set up. Onto five plates went shredded cabbage. I inspected my pizza. It was now or never. I slid in my peel and extracted my creation without incident. Then I set the peel with my pizza on the counter. I had found my thyme and began applying it. JoAnn, who works as a waitress at the place (and who had entered her jalapenos wrapped in bacon in the appetizer portion of the contest) walked through and exclaimed how gorgeous it looked. Another contestant said the same thing, then another.

My confidence was returning. Now the final touch, Ranch dressing. It wasn't coming out of the bottle like it was supposed to. I stuck in two fingers and began applying the goop by flicking it with my fingers, a la Jackson Pollock. That was the intention, for the Ranch dressing to create a Jackson Pollock drip painting effect.

"It looks beautiful," Tammy enthused. She suggested I take it out to the judges unsliced on the peel, then I could take it back to the kitchen for slicing and plating.

"Ready?" I asked.

All set, she replied.

Out I went with my pizza. I angled up the peel, edge down on the counter, for the judges' viewing pleasure.

During the appetizer portion of the contest, I had sort of assembled my Crusaders-Mayflower-John Galt narrative in my head, but I hadn't had any time to practice it.

"So this is what it must be like being on the 'Iron Chef,'" I opened. Pregnant pause. "Hi, I'm Bobby Flay."

Thank heaven everyone was laughing.

"Are any of you judges Yankees fans?" I asked, pointing to the Red Sox cap I was wearing. One of the judges raised his hand. I jokingly flipped my cap around, then flipped it back.

More laughs.

Then I opened with my original crisp two-sentence (or one long sentence) spiel: "This is my Elvis Pizza, inspired by the King of Rock 'n Roll, drawing from two great cooking traditions - Italian for its pizza and southern for its barbecue, re-conceptualized in Southern California, home of reinvention."

Now what?

"Think of pizza as an open-face sandwich," I continued. "Anything goes."

Nodding heads. A good sign.

"I came up with my first version about four years ago in New Jersey," I adlibbed. "We had company coming unexpectedly for dinner and I rounded up whatever was in the fridge." Left-over pizza dough, barbecue sauce, a single pork chop, some onions, Ranch dressing.

"My wife liked it so much," I went on to say, "that she divorced me."

That had them rolling in the aisles. For the record my former wife is a very wonderful person. Anyway, here I was in southern California, where I refined my original inspiration, much to the delight of my new neighbors. I then explained how the meat on this particular pizza came from a slow-roasted pork butt, with enough left-overs for pulled pork sandwiches for the next five months.

"Bon appetite," I concluded. Next thing, I had the slices on plates with my shredded cabbage (which is traditional with pulled pork sandwiches). Plus more morsels for the other contestants in the audience.

"Fantastic presentation," people kept telling me. Elvis would be proud. Of course, I knew before I turned up that the other contestants would be bringing their A-game to the event. Anyone who loves cooking at home has at least one dish that is worthy of a spot on the Food Network. We got the best of the best tonight. It was my time to applaud the winner, not take a bow.

Would I do it again? Yes, definitely. With a pizza? What, are you crazy?

Wait, the winner from the dessert portion of the contest is talking to me. A pizza with Cuban pork, she suggests. Yes! Cuban pork. Maybe we can team up. Maybe we can ...

Wednesday, January 26, 2011

I'm Back!

Yes, I'm still here. Since before Christmas, I have been totally immersed in overhauling my mcmanweb site. New design, fresh content, everything. Way back, I had a vision of a website that would be the leading resource on depression and bipolar and related stuff. My website has undergone numerous changes since it first went public in early Dec, 2000 - and so have I and so have you.

The one thing that has remained constant is my three-word mission, "Knowledge is Necessity." My job then - and now - was to present information and viewpoints in a way that helped you - patients and loved ones - make up your own mind. I debuted the site with about 70 articles, divided into various diagnosis, treatment, recovery, and science categories, plus personal stories, mental health issues and famous people. The categories have largely stayed intact, but the only articles that remain from eleven years ago are some of the personal stories and the ones on famous people.

Over the next several years, mcmanweb expanded to some 300 articles, most of them my work but also featuring other contributors. By the end of 2007, the site was showing its age. I ditched my ancient FrontPage program, invested in Dreamweaver, learned how to write CSS code along with the HTML I also knew, and brought mcmanweb into a new era. New design, leaner and meaner - half my articles were pruned, the others updated. The new mcmanweb went public in the spring of 2008.

Soon after, I bought a video cam and next thing I was making my own short YouTube videos, which I embedded in mcmanweb. Then, at the end of 2008, I launched this blog, Knowledge is Necessity, intended as a companion to mcmanweb.

By 2009, it became apparent that my new mcmanweb too much resembled my old mcmanweb in approach and outlook. Plus there were numerous design flaws and technical glitches that made the site look like a train wreck in some browsers. But who has time to fix things?

Then about a month ago, I made an executive decision - tear the whole thing down and start over. I invested in an update to Dreamweaver, brushed up on my code, and got cracking. I organized my schedule so I came on duty at nine in the morning and punched out at around midnight, with plenty of breaks, seven days a week.

The good news is I programmed practicing my didgeridoo as one of my break routines, and improved my level of play exponentially. The bad news is I'm feeling inclined to show off my new didge virtuosity on anyone unfortunate enough to occupy my same time zone.

By early January, I was confident enough in my new design to start uploading articles. Things went fairly smoothly until I came to my Treatment section. I had to put a match to just about everything and start from scratch. My ten new articles on meds treatment add up to about 20,000 words (who's counting?), a third of a book. Plus another 10,000 words of fresh content elsewhere - a half a book. Plus edits and rewrites of other pieces, plus stuff originally published here, reworked into articles.

In all, more than 150 articles with a very different look and feel to my previous 150 or so articles, representing more than three, possibly four, books.

At about midnight Monday, I experienced the pleasure of crossing the finish line. My last upload to my last batch of pages. A visitor could now go to mcmanweb, click on any link, and come up with a fresh page.

I still have more work to do, stuff to rewrite, new articles to work on, technical things to iron out, but I can do all that during normal work hours while I tend to other priorities - like getting a life.

Beware - I'm John McManamy and I'm dying to show off my didgeridoo.

Check out the new mcmanweb ...

Thursday, January 20, 2011

Lamictal: The Strange Tale of the Med with No Clothes

I've published different versions of this story on Knowledge is Necessity and elsewhere. Here's my latest version, part of a the same article I excerpted from yesterday, on mcmanweb ...

In 1999, GSK published a study showing that Lamictal was effective for treating bipolar depression in its acute (initial) phase. The finding was at best ambiguous, as the study failed on its primary endpoint.

GSK spent the next six years working to come up with a study that would impress the FDA. (The FDA looks for at least two successful trials.) In all, GSK sponsored seven more acute phase trials testing Lamictal for unipolar and bipolar depression. In each of these studies, Lamictal failed to beat the placebo. Predictably, none of these studies was published.

But GSK did come up lucky in two long-term studies showing that, compared to lithium, Lamictal worked better at delaying relapses into bipolar depression. These studies had a major flaw in that the long-term phase only included patients who had responded to lithium or Lamictal during the initial phase of the study. In other words, "nonresponders" likely to fail had been weeded out.

Another point: Virtually all the patients in the study relapsed anyway. It just took the Lamictal patients a bit longer, so the two studies basically proved nothing.

Nevertheless, on the strength of these two studies, in 2003 Lamictal received an FDA indication for "bipolar maintenance."

Chances are you have heard your doctor sing praises to Lamictal as the magic bullet for treating bipolar depression, even though there is absolutely no scientific evidence to support this. Predictably, GSK did nothing to disabuse patients and clinicians of the notion. Quite the contrary, GSK launched an aggressive advertising and marketing campaign targeted specifically at bipolar depression.

Four North American treatment guidelines, including one put out by the American Psychiatric Association, bought into the hype and came out recommending Lamictal as a first option for treating acute bipolar depression. Ironically, treatment guidelines are supposed to be "evidence-based." (A more recent guideline put out by the APA finally got honest.)

It doesn't stop there. Enter the competition. In late 2003, Eli Lilly received a true FDA indication for its combo Prozac-Zyprexa pill, Symbyax, to treat bipolar depression. Confident its own med would crush the competition, Eli Lilly sponsored a head-to-head trial (with no placebo group) pitting Symbyax against Lamictal under conditions that gave its own drug considerable home field advantage.

Part of the home field advantage included a short seven-week trial period. This is because Lamictal requires a slow titration, involving gradually raising doses over six weeks. Surely, Symbyax would outperform a drug not yet out of the starting gate. But - surprise - on the important measure for bipolar depression, Lamictal and Symbyax ended up in a virtual dead heat. Not only that, those on Lamictal had way fewer side effects.

Here's how Eli Lilly spun the study (published in 2006):

[Symbyax]-treated patients had significantly greater improvement than [Lamictal]-treated patients in change from baseline across the 7-week treatment period on the Clinical Global Impressions-Severity of Illness scale ...

The best way to explain the spin is this: If Eli Lilly were AIG (which went belly up in 2008 in one of the biggest financial scandals in history), they would be reporting record profits.

Ironically, the one unambiguous finding in favor of GSK's Lamictal came from the competition.

Take home message: Psychiatrists swallow this type of bullshit wholesale everyday, which then gets passed on to you as medical advice. Caveat emptor.

Wednesday, January 19, 2011

Five Things You Need to Know About Your Antidepressant

Following is a chopped-down version of a new article I wrote for my mcmanweb site. Another article delivers strong advisories about taking these meds if you even have the slightest suspicion you may have even "a little" bipolar. So, assuming the bipolar diagnosis has been completely ruled out ...

There are occasions when antidepressants are appropriate, and that occasion is when you're desperate and willing to try anything. Let's get started:

First Thing You Need to Know About Your Antidepressant

You can get more out of your antidepressant if you don't ask too much of it. Antidepressants are not magic bullets. They are certainly not going to get you 100 percent better. They may not get you even 10 percent better. But even a slight improvement is better than no improvement.

A slight improvement may be all that is required in shifting your critical mass to the next phase of recovery: From not being able to get up out of bed to getting up out of bed, from not wanting to get out the door to getting out the door, from not doing things to help yourself to doing things to help yourself.

The Second Thing You Need to Know About Your Antidepressant

Don't expect an antidepressant to make your miserable life bearable. If the underlying cause of your depression is a toxic relationship or abusive working situation or something similar, at best an antidepressant will perk you up enough to help you resolve it. Doing nothing invites depression back in.

No one should have to endure depression one second longer than necessary. But our psychic pain is often part of the healing process - as part of channeling our grief, acknowledging reality, reaching acceptance, and making tough choices.

An antidepressant may prove extremely useful in keeping us from falling apart when we least need it. But it serves no useful purpose in masking the very thoughts and feelings - however unpleasant - that we so desperately need to experience.

The Third Thing You Need to Know About Your Antidepressant

Your antidepressant will work much better if you put in the work. Mental health advocates stress that mental illness, including depression, is biologically based and therefore no-fault. This may be true, but if you interpret this to mean that all you have to do is sit back and wait for your pill to kick in, you will be sorely disappointed.

To use a medical analogy, statins don't work well for people on high-fat diets. Insulin doesn't work well for people on high-sugar diets.

The Fourth Thing You Need to Know About Your Antidepressant

Doctors (including psychiatrists) are not necessarily your best advisers. Far too many have fallen in love with the idea that a pill will solve all of your problems. They often fail to see the whole picture - that you are a person and not just a diagnosis, and that your medication plays but a small role in your recovery. They don't see their job as working with you in devising a strategy to integrate your meds with other important aspects of your recovery.

Virtually all psychiatrists have swallowed Pharma propaganda wholesale. You cannot sit in a waiting room for more than ten minutes without a Pharm rep walking in the door. Pens and coffee mugs and notepads and literature with drug logos are everywhere. The impression is being in the branch office of Eli Lilly or Bristol-Myers Squibb rather than in the clinic of a professional who has taken an oath to do you no harm.

The Fifth Thing You Need to Know About Your Antidepressant

The scientific/medical evidence base for antidepressant treatment is nonexistent, or at best highly suspect. Virtually all treatment studies regard all depressions as the same, with one-size-fits-all remedies, which means there are no studies in support of what works best for you.

Nearly all short term antidepressant trials (about six weeks) are conducted by drug companies to serve their own interests (an FDA indication to market to the widest possible audience) rather than your own interest (namely, what works best to get you well and keep you well).

As for the long-term, it simply doesn't exist. No one does five-year studies. Studies lasting a year or more are extremely rare and are marred by extremely high drop-out rates and methodological glitches too numerous to mention.

Finally, prominent academic researchers have been bought out by Pharma. "Findings" that support drug company marketing objectives rather than dispassionate scientific enquiry are the rule rather than the exception. Clinical trials are replete with various tricks of the trade to improve the performance of the test med, from weeding out beforehand likely nonresponders to cooking data to spinning results.
The one authoritative proposition that comes out of this is the surprising amount of studies that fail, despite every effort made by the drug companies to optimize a good result.

To Wrap It Up

When we use a fork to do a spoon's job, we tend to be unhappy with the results. Just ask anyone who has ever stuck a fork into a bowl of soup.

It is far worse with antidepressants. Not only are we asking a fork to do the job of a spoon, we are asking it to do the job of a knife, a screwdriver, a hammer, a shovel, the tires on your car.
People who use their forks (and antidepressants) wisely, tend to be pleased with the results. Doctors need to exercise far greater selectivity in their prescriptions. Patients need to recognize that antidepressants can only accomplish so much.

Be wise, live well ...

Tuesday, January 18, 2011

Treating Mania - Part II

My previous piece (the first half of my new mcman web article) examined the disconnect between us and our doctors. Following on ...

You are on the 50 yard line, playing offense, trying to gain yardage, aiming for the end zone. Your doctor has you on the same 50 yard line, playing defense, trying to keep you from losing yardage, from winding up back in your own end zone. What your doctor sees as a win is a clear no-win for you.

An aggressive offense is often the best defense, but there are no guarantees, considerable risk is involved, and you need to be willing to put in the work. Let's get personal ...

A Personal Perspective

My interest in the whole matter is more than academic. Although it is clear that my bipolar manifested in college, it wasn't till I was age 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 (initially with an antidepressant). He didn't overmedicate me or turn me into a zombie. Yes, my thinking was slightly slowed down and my emotions were a bit blunted, but my brain had been running too hard and too fast and too unreliably, even in neutral.

Slightly slow and blunted was good. Soon, I was on my way to a new career in mental health journalism.

Years later, purely by accident, I went to a half dose, ironically when the psychiatrist I was seeing at the time wanted to double it. That doctor, with no inquiry into how I was actually managing my life, simply saw that my dose was about one half of what his patients were receiving. With each successive visit (thankfully three months apart), his hints grew stronger and darker. Always, he framed his hints in terms of "him" putting me on a higher dose, as if my actual situation had nothing to do with it.
Depression was far and away my main issue, not mania. But my doctor showed little concern about how I was faring with this side of my illness.

Then, my health coverage ended, and I requested a switch to a cheaper generic version of the same mood stabilizer. This meant keeping track of four pills a day, which proved impossible. It wasn't long before the rest of my thinking came back on line, along with the rest of my emotions. Trust me, it felt wonderful having all my brain back, but could I manage the extra amplitude?

Over the years, I had picked up a broad range of recovery and coping skills, such as maintaining a strict sleep routine. Looking back, I realized I had only experienced two full-blown manic episodes in my life. The first, back in the eighties, came from a crazy work routine involving very little sleep. The second, years later, was triggered by an antidepressant. Obviously, my chances of mania were remote.

But what about managing the extra amplitude? Would my brain cooperate with me when I needed to focus on my work? Would I have dominion over my emotions when I found myself in a challenging social situation? Would I continue to enjoy my present peace of mind, or would I be spending most of my waking hours in a state of agitation?

I Make My Own Decision

It wasn't an all-or-nothing decision. I could always bump my dose back up, I realized. I could always go back to the more expensive one-a-day pill. So, I made my choice: High dose recovery, low dose med.

I didn't consult my doctor. Or, rather, my doctor never would have consulted me. Here I was, a mental health writer advising fellow patients to forge trusting relationships with their clinicians, going behind my doctor's back. It was clear I would have to fire my current doctor and find a new one. A year later, I booked an appointment with a new doctor. But then my life intervened. Next thing, I was on my way to California, where - eventually - I did find a doctor who actually listened to me.

I will be the first to acknowledge that managing the extra amplitude can be a challenge. Often I have to deal with emotions I don't want to deal with, but that is the point. Back when I was on a higher dose, I did not experience the same range of emotions the rest of the world did over the tragedy of 9/11. I needed to cry, if not real tears, then full-strength cathartic psychic ones. Yes, on a higher dose I was comforted by the thought that I could venture out in public without Crazy John showing up. But my daughter quickly picked up on the fact that the delightfully wacky side of my personality - one that played such a central role in the unique bond we had forged over the course her life - was missing.

My wacky side is back, much to the simultaneous delight and consternation of people I deal with. It is a legitimate part of who I am. Meds are not meant to medicate personality out of people, and heaven help if they ever came up with one that did. But earlier in my recovery, my leave of absence from this side of my identity was a very small price to pay to manage an illness I could not have otherwise managed. I consider myself very lucky.

Real World Observations

Most patients I have witnessed in my years of attending support groups have not been nearly been so lucky. Their mood stabilizer doses are way higher than mine. Plus they are on other high dose meds. These are people in stable condition, but they never got better. Way too often, they got worse.

In his 2010 book, "Anatomy of an Epidemic," Robert Whitaker noticed a similar phenomenon, but he came to a conclusion I never would have 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 are 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.

This is a very bleak picture Whitaker paints. Like all the rest of us, he is speculating, but his speculations are grounded in the same phenomena I have been witnessing at eye level, and which statistics bear out in the most distressing way:

According a 2001 finding from the Stanley Bipolar Network of the outpatients in its participating clinics: More than eight in ten had been hospitalized in the past, on average three times. Half had attempted suicide. A third were currently married, another third single, and the rest were separated, divorced, or widowed. Despite the fact that approximately 90 percent had high school diplomas and a third had completed college, almost 65 percent were unemployed and 40 percent were on welfare or disability.

Data from STEP-BD validates these findings, as does a European survey from the advocacy group GAMIAN.

Wrapping It Up

I could have been one of those statistics. I just happened to have stumbled into a meds strategy that worked. But we should not have to stumble. We need smart meds strategies, capable of being tailored to our individual situations, that look to the future, aimed at leading fulfilling lives, that complement our recovery strategies.

Note, I did not say recovery strategies that complement our meds. Unless you are one of the fortunate exceptions, meds will merely get you out of crisis and into stability. Then the heavy lifting shifts to you. As the articles in the Recovery section to mcmanweb make abundantly clear, you reorient every minute of your life to gaining the upper hand over your illness. Your meds, at this stage, need to be regarded as an adjunct rather than the cornerstone to your recovery.

Our meds are dumb, but in the hands of a smart clinician they may be recruited in the service of smart. But, in an era of too many dumb clinicians and even dumber health care, we need to be the smart ones.
Be smart. Live well.

Friday, January 14, 2011

Treating Mania

Following is the first portion of a new article (slightly edited) I just wrote for the new Treatment section of mcmanweb ...

Treating mania in its initial phase is like striking out the pitcher in baseball. Anyone can do it. All you have to do, if you are a doctor, is administer way too much of any knock-out pill intended for an elephant or other large mammal and congratulate yourself for living up to the potential your mother saw in you.

But then what?

Psychiatrists do their residencies in psychiatric units where patients are brought in (often by the police) in a state of crisis. If it's mania, we are bouncing off of walls and ceilings, a danger to ourselves and others. It is a frightening state - of us at our worst - and it is generally a budding psychiatrist's first (and most lasting) impression of an individual who lives with bipolar. A compassionate and caring physician, quite naturally, never wants to see us in this wretched condition again. That's where the trouble begins.

A Time and a Place

Meds overkill is the logical - and indeed compassionate - response to a manic individual in a state of crisis. In this state, a clinician hardly has to worry about whether the med will interfere with the patient's ability to drive or have sex or stay thin. The only object of treatment at this stage is to safely bring the patient back to earth. Once back to earth, the doctor will ease up on the doses, but in this era of mangled care, the patient tends to be prematurely sent out the door, over-medicated and disoriented, unlikely to find a doctor brave enough to lower his or her doses.

Here's the rub: The recommended dosing you find on the labels of drugs used to treat mania - the ones that doctors follow to the letter - are based on clinical trials of patients in mania - that is patients in a state of crisis. These trials typically last four weeks.

Out of Time, Out of Place

But your situation has changed. You are stable, no longer in a state of crisis. You are looking ahead - to the whole rest of your life - to returning to your normal life. Your doctor, on the other hand, is looking back - from the days or weeks that you emerged from crisis - at preventing another hospitalization. Already, there is a major disconnect between you and your doctor. In every field of endeavor, including this one, this portends disaster.

Clinical trials convincingly demonstrate that anti-manic agents are good at bringing patients out of mania. Where the evidence is far more tentative is in showing whether they are good at keeping patients out of mania or whether the side effects justify the result.

Long-term studies for name-brand drugs typically last 12 to 18 months and are aimed at merely showing delays to relapse (which may be sufficient to warrant an FDA maintenance indication) rather than actually preventing relapse. The major conclusion to draw from these studies is the high drop-out rates (eight in ten patients from one long-term Zyprexa study), indicating that even the best med in the world is useless if patients can't put up with the side effects.

This doesn't mean you should take yourself off of your meds. But it is your right to insist on a dose you can tolerate, even if the levels are significantly lower than what the labeling recommends. "Go lightly on the lithium," I recall Ross Baldessarini of Harvard advising a panel of journalists at the 2005 International Conference on Bipolar Disorder. Lithium (which is not a name-brand drug) is one of the few bipolar meds that has been extensively studied for long-term use and a lot of the credit goes to Dr Baldessarini, who, with colleague Leonardo Tondo, has found that relapse is likely if lithium is abruptly discontinued.

Over the years, recommended lithium dosing has dropped substantially, but psychiarty, Dr Baldessarini contends, is still heavy-handed. Unprompted, he referred to American psychiatrists as "cowboys" and in response to my follow-up question acknowledged that "patients don't want their wings clipped."

This is a point psychiatrists seem to miss entirely. A 2003 study by Pope and Scott pointed to a clear disconnect between psychiatrists and patients. The psychiatrists in the study thought that bipolar patients went off their meds because they "miss their highs." The patients who quit cited other reasons.

In 2006, I heard Dr Scott talk about her study at the International Society of Bipolar Disorder
conference in Edinburgh. When I included it as a PowerPoint slide in a grand rounds I gave two years later to clinicians at a hospital in Princeton, NJ I was greeted with stony cold frozen Kelvin grade silence.

Finding a Middle Way

Keep in mind that full-blown manias tend to be rare events, non-existent in people with bipolar II and nowhere near as prevalent as depression in bipolar I. Manias are often precipitated by outside events, such as lack of sleep and working long hours. In a 2005 interview, John Gartner, author of "The Hypomanic Edge," told me that psychiatrists need to consider how many episodes the person has had, how prone they are to episodes, how long ago the prior episode was, and so on.

Medication decisions based on rational assessments of risk vs reward rather than fear would bring psychiatry into alignment with the rest of medicine. Trust me, the fear factor looms large when psychiatrists reach for their prescription pads. They don't want to see us back in the hospital, remember? The irony is that, in this scenario, rehospitalization is almost inevitable.

Overmedicated patients labor under burdensome side effects, often from one or more meds administered at full strength. The side effects can be horrific in their own right, but what may be worse is these effects militate against the patient gaining the upper hand over his or her illness. Individuals who feel like fat stupid zombie eunuchs are hardly motivated to get into the kinds of healthy routines that encourage recovery.

Both the 2002 and 2009 Bipolar Treatment Guideline put out by the American Psychiatric Association stress the goal of a return to remission, which they define as symptom-free AND a return to functionality. But this message has yet to filter down to the rank and file. They have the symptom-free part down pat. (Technically, an over-sedated patient is symptom-free, and a clinical trial will chalk up this type of result as a success.) The functionality part (which would include making sure no side effects are holding you back) only makes their jobs a lot harder, and they're not getting paid for that.

So, here's the patient, feeling his life slipping away, who, thanks to his doctor, is reduced to making an all-or-nothing decision. The patient goes off his meds, and - of course - lands in the hospital (usually after a brief and shining moment of feeling gloriously normal). See? says the doctor. I told you so.

I see the same individuals our doctors do, only I'm interpreting what I see a lot differently. I see too many patients living miserable half lives - stuck - unable to return to their old lives. I see failure. The doctors see these very same people as out of crisis and stable. They see success.

More to come ...

Wednesday, January 12, 2011

Your Bipolar - Not Your Grandfather's Bipolar

As you know, I'm trashing most of the articles in the Treatment section to mcmanweb and writing entirely new ones. Yesterday, I presented a sneak preview to one, The Problem with Bipolar Meds. Today, I managed to come up with a satisfactory introduction to it. Without further ado ...

When I was first diagnosed with bipolar at age 49 in 1999 (after a lifetime of denial), I was told by numerous clinicians and well-meaning lay people that my illness was highly treatable, a message reinforced by just about everything I read. I'm not saying these individuals lied to me, but the reality is rather different. Two explanations are in play:

First, doctors and researchers have a very different idea of successful treatment than patients. Clinical trials are based on the artificial criteria of symptom-reduction rather than return to function. Meanwhile, doctors are content to leave us in a state of over-medicated limbo - stable but not well, out of crisis but going nowhere.

 The other explanation is that your bipolar is not your father's bipolar or your grandfather's bipolar. "The illness has been altered," Frederick Goodwin MD, former head of the NIMH, informed a session at the American Psychiatric Meeting in 2008, with more rapid-cycling, mixed states, and other complications since the first edition to his classic "Manic-Depressive Illness" came out in 1990. We have no definitive answer, but the best guess by far (which Dr Goodwin advances) has been the indiscriminate use of antidepressants, which he declared a "disaster" for one-third of us.

This may account for the disconnect between the memoirs of Kay Jamison and Patty Duke, writing about their experiences at least two decades before SSRIs came on the scene, and the accounts you hear today walking into support groups. Lithium was the miracle med for both authors. Today, lithium has only half the success rate it had back when Dr Jamison and Ms Duke were put on the med.

The harsh reality is that despite spectacular advances in our understanding of the brain and mental illness, our doctors appear at a loss in how to treat us. Your best chance of success is coming to terms with this grim fact of life so you can make intelligent choices.

Tuesday, January 11, 2011

The Problem With Bipolar Meds

As you are aware, I am in the midst of a massive website overhaul. The last week has involved scrapping most of the articles in the Treatment section of mcmanweb and writing new ones (some of them based on recent blog posts here at Knowledge is Necessity). Thus far, I have 11 new articles, with more to follow, that I look forward to uploading two or three says from now. Following is a sneak peak at one of them, slightly chopped ...

The best data we have is from the NIMH-underwritten STEP-BD trials conducted over the mid-2000s. The study followed "real world" patients over two years, on a variety of meds. Of those who entered the study in a symptomatic state, 58 percent achieved recovery (nearly symptom-free for eight weeks). Of these, nearly half (48 percent) relapsed over two years, mostly into depression.

The math says it all: 1,469 symptomatic patients at study entry, a mere 422 (one in three) who managed to get well and stay well over two years. In classic understatement, the authors of STEP-BD concluded that:

The finding that nearly half of the study participants nonetheless suffered at least one recurrence during follow-up highlights the need for development of new interventions in bipolar disorder.

Cycling vs Episodic

The term, mood stabilizer, suggests that we are not merely treating episodes of an illness. Rather, we are looking to treat the cycle that drives these episodes. Accordingly, it is more helpful to think of bipolar (and recurrent depression) as a cycling illness rather than an episodic one.

Treating an episode for a patient who cycles is highly problematic - just ask any bipolar patient who has ever been prescribed an antidepressant to treat her depression. Too often, the patient flips into mania. Another result is the cycle may be speeded up, ironically resulting in more depression episodes.

An antimanic agent may not yield such a spectacular mirror effect, but the same principle is in play. As I heard it explained at an International Society of Bipolar Disorder conference I attended in 2006 (sorry, the name of the presenter escapes me), clinicians who treat a manic episode need to be aware of the next phase of the cycle, as well. In other words, being saddled with the sedating effects of an antimanic agent on top of a debilitating depression is the equivalent of pushing two rocks uphill.

So - in a perfect world, we would have a perfect mood stabilizer, one that brought the cycle under control and thus obviated the need for any other agents. Alas, our mood stabilizers (lithium, plus a range of antiepileptic agents pressed into service as bipolar meds) fall well short of even pretty good. This forces clinicians into an episode mindset, of devising pharmaceutical blockades to box in mania on one pole and coming up with entirely different blockades to keep depression at bay on the other.

In effect, our doctors are stepping on the bulges of an air mattress rather than regulating the flow beneath. Meanwhile, side effects pile up on top of side effects.

More to come ...

Thursday, January 6, 2011

Rerun: Figuring Out Schizophrenia - Part III

Still nose down, ass up, remodeling my website. Here's the last part to my rerun series, published in March-April 2009. A few more reruns, then back to live posting ...

Yesterday was the last day of the International Congress on Schizophrenia Research, held in San Diego. A brief recap of my third day there:

Early morning: My brain has clearly not booted up, not even after two coffees. I sleepwalk into the main hall for a lecture on "The Hidden Life of Genes: Endophenotyping Schizophrenia," by David Braff of UCSD, the year's recipient of the Congress' prestigious William Warren Award (that's Dr Braff pictured).

I've already given you a major hint into endophenotype: Me, with bipolar, with major difficulty regulating my sleep, which seriously interferes with my ability to function. The general population also experiences sleep disorders, but clearly sleep is tied into my illness.

Thus, rather than look for illness-specific genetic needles in haystacks, it may be more constructive to seek out more common and obvious bio-markers (such as sleep) and work one's way upstream or downstream from there.

Dr Braff was writing about endophenotypes back in the seventies, but it is only within the last five years or so that the topic has really taken off. For instance, Dr Braff explains, patients with schizophrenia experience major problems in sensory gating, ie screening out irrelevant stimuli (such as a noisy ventilation system) which plays havoc with their ability to focus on relevant stimuli (such as a conversation).

What we are finding, according to Dr Braff, is a clustering of patients around various different endophenotypes (eye movement - saccades - involving reaction time is another). Thus, one drug is not going to fit all. The next generation of meds, he says, need to be far more specific.

Schizophrenia, Dr Braff concluds, is a malignant terrible disease that is not going to give up its secrets readily. Instead, we "have to conquer schizophrenia gene by gene, step by step."

Late morning: "Optimizing Cognitive Training Approaches in Schizphrenia," reads the title to this two-hour symposium. Translation: The brain is plastic. As Michael Merzenich of UCLA describes it, "Basically, we create ourselves."

The brain is born stupid, then evolves and becomes "massively optimized to fit into your world."

In recognition of this, a relatively new field is opening up that involves drilling patients in cognitive tasks we tend to take for granted, such as holding a thought in our working memory long enough to lay down new neural roadwork or responding to stimuli in a timely fashion.

New computer programs are being developed and being tested on patients, Sophia Vinogradov of UCSF explains, and we are seeing enduring changes in the cognitive performance of patients six months later.

Afternoon: Today's poster presentation has a treatment theme, and here there is a clear disconnect from the rest of the conference and earlier poster presentations. Pharma is out in force, with products based on 50s technology. An example:

I stop at a J&J poster testing Invega on a schizo-affective population. No surprise, the antipsychotic knocks out the psychosis. Invega is son of Risperdal, which in turn is a descendant of Haldol.

See what I'm driving at? The emphasis of current schizophrenia research is on cognition and the underlying biology. Psychosis is what gets patients in trouble, but difficulties thinking is what keeps them from winning back their lives. Pharma has nothing in its current inventory for this, but they're still in a state of denial pretending that they are still relevant. (Think Detroit, only not nearly as smart.)

So here is J&J, pitching a med with roots in the 1950s, with a study designed for no other purpose than to milk its current patent. I ask some of the other researchers about this and get a lot of nodding heads and knowing looks.

If only these researchers were running Pharma, I can only think. The good news: Everywhere, Pharma is clearly losing both its influence and credibility. The bad news: In another year or two, we are going to know J&J as makers of baby powder and other fine consumer products. Same with the other drug companies.

Where, then, are the new smart meds going to come from?

Much more in future blog posts ...

Tuesday, January 4, 2011

Rerun: Figuring Out Schizophrenia - Part II

Nothing like a three-part piece from March 2009 to rerun while I perform clean-up on the Augean Stables that is my website. Looking forward to being back live soon ...

Another full day at the International Congress on Schizophrenia Research, here in San Diego. To recap:

Breakfast: Beatriz Luna of the University of Pittsburgh tells me she isn't a schizophrenia researcher. Rather, she's into something called "development." I'm thinking development, as in a child psychologist.

No, she tells me. This is about brain development, as in the child brain maturing into the adult brain. She will be one of the speakers at a two-hour symposium later in the morning. (That's her in the photo.) Curious, I check it out:

Think of research into normal brain development shedding valuable light on schizophrenia, and, by extension, all of mental illness. The first speaker, Patricio O'Donnell of the University of Maryland, talks about cortical microcircuits and the balance between excitation and inhibition. Dopamine, he says, plays a large role in the modulation of circuits in the prefrontal cortex. During adolescence, he explains, these circuits experience dramatic connecting changes.

For instance, "phasic dopamine" (firing in bursts) gets dialed in, with improved signal to noise ratios.

But suppose the brain doesn't mature? Are we then looking at an approximation of schizophrenia?

David Lewis of the University of Pittsburgh shows slides that highlight the neuron's "dendritic spines." These spines play a major role in brain cells talking to one another. We know that people with schizophrenia are not favorably endowed in this category, but what does it mean?

In normal brain development, he explains, there is an early dramatic increase in spine density followed by a dropping off in adolescence and leveling out in adulthood. But are we talking about a drop-off in "functionally mature" or "functionally immature" connections? In other words, when the brain experiences structural changes, are the right chemical messages crossing the dendritic divide or the wrong ones?

Early intervention, he says, might be directed at enhancing the normal development of these synapses.

Dr Luna informs the audience that adolescence involves major risk of mental illness. As she explained to me over breakfast, this is when the brain changes gears. But what if something goes wrong in the transition? Might this underlie the pathology of mental illness?

During adolescence, the brain undergoes "synaptic pruning," along with axonal "myelination." In essence, brain function becomes more equally distributed, with less reliance on impulses from the basal ganglia and other more primitive regions of the brain.

But what if something goes wrong? Normal child brain function is suddenly not so normal, not in an adult brain anyway. You can kind of see this with the current economic meltdown, Dr Luna explains. It's a new world. AIG and GM and the rest can't behave the way they used to. The failure in executive behavior in this new context, she concludes, now becomes obvious.

Lunch time posters: This is where I get to ask all my stupid questions. For instance, over the past two days, the area of the brain I've been hearing most about is the dorsolateral prefrontal cortex, the brain function I've been hearing the most about is working memory, and the researcher I have been hearing most about is Joseph Callicot of the NIMH.

"Allelic Variation in KCNH2 is Associated with Dorsolateral Prefrontal Cortex Activation During Working Memory," reads the poster.

The name tag on the man standing in front of the poster reads Joseph Callicot.

Knock me over with a feather. Fire away with all your stupid questions, says the look on his face.

I love this job ...

Monday, January 3, 2011

Rerun: Reporting on Schizophrenia

Until I get my website overhauled (a mammoth undertaking), I will be posting reruns. This three-parter (from March, 2009) will get me through most of this week. Looking forward to being back live very soon ...

My annual conference season unexpectedly began three weeks early today, when I attended what I thought would be an afternoon local family forum on schizophrenia. I turned up at the Grand Hyatt on San Diego's waterfront only discover the forum was a satellite to a four-day major world conference: The International Conference on Schizophrenia Research, held every two years.

So that explained the star-studded list of speakers at our local family forum.

(Small sound-bite from that forum: According to John McGrath MD, PhD of the University of Queensland, hallucinations and delusions are "very very common" in the general population. Four percent of the US population hears voices.)

As soon as the forum ended, I headed over to the registration area of the main conference to secure media credentials. Mind you, here I was, a mental health journalist feeling obliged to explain why I knew nothing about a major world schizophrenia conference in my own backyard until today.

"Bipolar," I said to someone behind the desk, pointing to a copy of my book I happened to have in my bag, as if that explained everything. Another person was called over to assist.

"Tamminga," said the name on her tag.

She caught the look on my face. "It looks like you're familiar with the name," she said. "I'm her daughter." As in daughter of Carol Tamminga MD of the University of Texas Southwestern Medical Center, first rank researcher and one of the conference organizers. In addition, Dr Tamminga is very generous in giving her time to NAMI and other causes. (That's Dr Tamminga's photo on this blog post.)

Nearly two years ago I happened to sit next to Dr Tamminga over dinner in Pittsburgh at a closed function at the Seventh International Conference on Bipolar Disorder. (I was a special guest by virtue of a public service award I would receive two nights later.) Just to show you what a thoroughly gracious person Dr Tamminga is, our section of the table also included Thomas Insel MD, head of the NIMH, and Darrel Regier MD, co-chair of the DSM-V task force, but Dr Tamminga talked to me as if the other two weren't there.

"I was about to use your mother as a reference," I joked, then I briefly explained the connection.

Ten minutes later, I was at a patio table, poring over my conference materials. A brain scientist from Australia sat down, and for the next hour we talked about the brain, the metric system, politics, the environment, Einstein, and autism (she has a son with autism). Ninety percent of marriages involving an autistic child end in divorce, she informed me.

Tomorrow, I will be waking up before dawn to catch Dr Insel at a plenary session, then over to a morning symposium on "Dopamine Signaling in the Era of Molecular and Genetic Pathways." I'll hit the research poster sessions over lunch, then take in an afternoon of "Aberrant Functional Connectivity in Schizophrenia: Changes in Frequency, Symptoms, Drugs, and Genes."

Tuesday and Wednesday will be more of the same.

What is a depression and bipolar writer doing at a schizophrenia conference? From a recent blog post:

Back in 2003, I had one of those breakthrough moments, the type you associate with light bulbs switching on. I was at the American Psychiatric Association's annual meeting attending a symposium on genetics. Robert Freedman MD of the University of Colorado started explaining his research into schizophrenia.

"The DSM-IV was not designed with human gene function in mind and genes do not encode for psychopathology," he said. Instead, "genes encode simple molecules in cells that alter cell function and brain information processing."

I had kind of been aware of this, but this time I went, "Aha!" ... The upshot of my Aha! moment was the realization that to better understand my own illness (bipolar) I needed to research other illnesses as well, such as schizophrenia. The brain, after all, doesn't organize itself according to the DSM.

Listening to the schizophrenia people, in effect, gives me insights into my illness that I would never get from limiting my enquiry to the mood disorders experts. Take my word for it, I'm like a kid in a candy store at these events. The only thing about my job that I love more than listening to super-smart people who have dedicated their lives to improving yours and mine is writing about it.

Stay tuned ...