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 ...


Marvin said...

You really nailed the situation.
Very well written !!

Smitty said...

What makes your writing so effective is, besides the air of authority, your unremitting professionalism. Even with the dicey provocative language, which gave me a smile.

You have compassion...for patient and doctor, that ensures a wide readership.

You know that what you say for mania, applies to schizophrenia. That may mean I have a niche, because to all intents and purposes, that is my jack in the box, that the good docs keep trying to fit me in. Bunch of hooey, but so it stands. That doctor complacency you describe can easily make me mad. But you skirted that anger very effectively in your writing.

My role model, indeed!