What Is It With Those Finns?

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

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

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

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

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

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

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

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

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

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

Indeed, this is beyond the realm of human understanding.

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

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

Life will never be the same again.

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

Wait! If You Read That Newsweek Article About How Antidepressants Don't Work and Are About to Flush Your Meds Down the Toilet, First Read This ...

I should have commented on this much earlier. Better late than never ...

A Jan 29 Newsweek cover story trumpeted, Why Antidepressants Don’t Work. There are many things not to like about antidepressants, including the fact that they are not magic bullets and often may make us worse rather than better. Indeed, if antidepressants were as effective as Pharma and psychiatry claim, depression would have gone the way of polio and small pox. Instead, it remains the leading cause of disability in the western world.

Nevertheless, a willing patient working with a smart clinician stands a fairly decent chance of getting somewhat or even a lot better on an antidepressant. And there is convincing data that a patient who stays on an antidepressant has a much better chance of avoiding relapse than one who doesn’t.

The best evidence we have points to the fact that antidepressants do work - only not for all of us and not as well as we wish they would. But, in their limited capacity, they do - actually - work.

So how can Newsweek be so irresponsible? The story begins with an equally irresponsible review article that appeared in the Jan 6 JAMA. Medical journals are notorious for publishing industry propaganda disguised as research. This one went the other way.

The JAMA article reports on a University of Pennsylvania meta-analysis that found that antidepressants were effective on patients with severe depression, but had little or no effect on those with mild or moderate depression. A meta-analysis pools previous studies and crunches the composite numbers. The catch is those putting together meta-analyses can be highly selective in which studies they decide to pool.

An article by Amy Tuteur MD in the Feb 8 Salon, How Did Journalists Get the Antidepressant Study So Wrong?, notes that of 141 random-controlled antidepressant trials the authors included only three involving a single SSRI medication, Paxil. (Three other trials included in the meta-analysis involved the rarely-used old-generation antidepressant imipramine.)

The selective weeding-out process seriously undermined the credibility of the meta-analysis, a fatal flaw the JAMA editors should have picked up. As Dr Tuteur points out, there were 23 trials that did not make the final cut. Of these, 15 of 17 showed antidepressants to be effective for mild to moderate depression.

In other words: “ALL the studies that demonstrated the effectiveness of antidepressants in mild to moderate depression were deliberately left out.”

More convincing evidence against antidepressants are two other meta-analyses cited in the Newsweek piece. These were conducted by Irving Kirsch PhD of the University of Connecticut. His second one, using all the antidepressant clinical trials the drug companies submitted to the FDA, found that those on the antidepressants fared only minimally better than those taking a placebo.

I recall emailing Dr Kirsch about this back in 2002. In other words, I suggested, antidepressants are nothing more than placebos with side effects. Dr Kirsch agreed with this.

Academic researchers managed to look silly attempting to rebut Dr Kirsch. Their main defense was that the stratospherically high placebo response rates (way higher than for say cancer drug trials) are the bane of psychiatric meds trials. They also pointed out that researchers, desperate to recruit patients into studies, may have allowed some in who didn’t meet their criteria for severe depression (a fantastic admission when you come to think of it, namely - we got bad results because in fact we cheated).

More credible was their argument that broad conclusions mask specific results - namely that for certain subpopulations these meds probably work like gangbusters. The problem is no one has identified this subpopulation. More on this in a minute.

Surprisingly, no one mentioned the obvious: A drug trial tests results on ONE drug only. In the real world, patients try a second drug if the first one doesn’t work. Various small studies showed that indeed it is worth not giving up after an initial failure.

The NIMH tested that proposition in a series of real-world trials called STAR*D, published in 2006. In the first round, about 50 percent of patients got better on Celexa. Of those who failed on Celexa, about a quarter to a third got better on another med or meds combination.

Thus, a 50-50 crapshoot turns into odds very much in your favor if you’re willing to play two rounds of pill roulette.

Third round success rates, however, were dismal - in single figures to very low double digits. In other words, after two failures, patients and clinicians need to be seriously rethinking their options, including revisiting the diagnosis.

What no one has seriously looked into is the fact that DSM depression may be completely wrong in the first place, that it is in fact a catch-all diagnosis for all manner of things going wrong in the brain.  In a recent blog piece, The Draft DSM-5 - Rip It Up and Start Over, Part II, I mention:


In my book, "Living Well with Depression and Bipolar Disorder," I cite a 2004 article by Gordon Parker MD, PhD of the University of New South Wales in support of the proposition that this one-size-fits-all view of depression results in clinical trials that indiscriminately lump all patients together, with no regard to critical distinctions that may spell the difference between success and failure.

Would, say, an SSRI such as Paxil work better for a melancholic depression and a dopamine-enhancer such as Wellbutrin work better for a low-energy depression? We’ll never know. The drug industry has no incentive to test for this sort of thing.

In an article on my mcmanweb site, I cite Frederick Goodwin MD, co-author of Manic-Depressive Illness, who informed me that most of the patients in STAR*D had recurrent depression, ie depressions that come and go. These depressions may have a lot more in common with bipolar than with unipolar chronic depression. One study found that nearly 40 percent of those diagnosed with unipolar depression in fact fall into that diagnostic Terra Incognita known as the bipolar spectrum.

These are patients who could conceivably respond better to mood stabilizers than antidepressants. The catch is the current DSM doesn’t recognize the bipolar spectrum and neither will the next one.


To conclude ...

Antidepressants DO work, but you will probably be a lot more satisfied with the results if you don’t expect too much of them. A lot of failures are the result of patients quitting too soon. The same can be said of clinicians who don’t know what they are doing.

If your first antidepressant fails, it is wise to try a second one, perhaps even a third.

But after your second one fails, it is wise to revisit your diagnosis. You may in fact have bipolar, or a type of unrecognized depression that has more in common with bipolar than unipolar. Or you may have a depressive temperament - part of your personality - that is better suited to talking therapy. Or you may have some kind of personality disorder (such as borderline) that definitely does require talking therapy.

Antidepressants leave a lot to be desired, but their greatest fault can be attributed to human error. These meds simply don’t work for certain types of depressions, and definitely not for a range of conditions that only superficially resemble depression. But for the right kind of depression, they probably work a lot better than we give them credit for. If we could only get researchers interested in looking into this.

Maybe then, Newsweek would have something to report.

Further reading from McManweb


When Your First Antidepressant Fails
When Your Second Antidepressant Fails
Clinical Trials - What the Drug Companies Don't Report

***

Coming soon - back to my DSM-5 report cards ...

Oprah is an Unmitigated Idiot and a Menace to Society

"Crazy Talk," reads the cover of this week's Newsweek. "Oprah, Wacky Cures, and You."

Finally, someone willing to take on the cult of Oprah. The article, by Weston Kosova and Pat Wingert, opens:

"In January, Oprah Winfrey invited Suzanne Somers on her show to share her unusual secrets to staying young. Each morning, the 62-year-old actress and self-help author rubs a potent estrogen cream into the skin on her arm. ..."

Then progesterone on her other arm (two weeks a month) and a daily syringe estrogen injection into her vagina, plus 60 daily vitamins and other preparations. According to Newsweek:

"The idea is to use these unregulated 'bio-identical' hormones to restore her levels back to what they were when she was in her 30s, thus fooling her body into thinking she's a younger woman."

In case you're looking for a medical opinion:

"Several times during the show [Oprah] gave physicians an opportunity to dispute what Somers was saying. But it wasn't quite a fair fight. The doctors who raised these concerns were seated down in the audience and had to wait to be called on. Somers sat onstage next to Oprah, who defended her from attack."

Two years ago, I came to the conclusion that Oprah was an unmitigated idiot and a menace to society. "Did Bipolar Drive a Mother to Kill Her Child?" ran a website promo back in August 2007 for an upcoming show. "Tune in Monday."

The show started out with a 911 call: Mother Andrea had just confessed to killing her child. In an interview from jail, Andrea was treated to a whole segment, then nearly a whole studio segment was devoted to her friends gossiping about Andrea.

Then Oprah went to the audience where Kay Jamison PhD was seated. In case you're wondering how Oprah finessed this unlikely transition, she didn't. She bluntly introduced Dr Jamison as the leading bipolar expert in the world, as if she herself were the expert at deciding who the experts were. Then she asserted in the form of a question that bipolar was the new term for manic-depression.

You could see the slight hesitation in Dr Jamison. The second edition to her definitive "Manic-Depressive Illness" (with Frederick Goodwin MD) had just come out three or four months before. The subtitle reads: "Bipolar Disorders and Recurrent Depression."

The book goes to elaborate lengths to inform physicians that a good deal of so-called unipolar depression is also part of the manic-depressive phenomenon, with enormous treatment implications.

But Dr Jamison was smart enough not to dispute Oprah. She allowed the misconception to stand. By the time Oprah asked her first substantive question, just about all the time had ticked off the clock. Oprah broke into a commercial, and Dr Jamison was forgotten.

Then came two segments devoted to two C list TV celebs, and one final drive-by wrap-up with Dr Jamison from her seat in the audience.

So that was the world of bipolar according to Oprah. As for my part in the production:

Earlier, a producer from the show had called me, and I was very happy to brief her. But soon it became obvious that all she wanted to know from me was my mad scene. Nearly all of us diagnosed with bipolar I can rattle off juicy mad scenes, but I happen to lead a spectacularly boring life and my mad scene was pathetically lame.

Still, there was enough in my life (and the lives of the rest of us with bipolar) to educate and inspire viewers.

How was I to know Oprah was really looking for a baby-killer?

What the show drove home loud and clear was the power of Oprah. Kay Jamison may or may not be the leading authority on bipolar disorder, but she is certainly by far the best known and the most in demand. Yet Oprah could literally summon Dr Jamison from her crowded schedule in Baltimore to play the role of spear carrier in her sham production.

Not only that, Oprah could get away with not according Dr Jamison the time and respect - much less a place on stage - she gave to her non-expert guests.

As to how Oprah can get away with this: My own book had come out some 10 months earlier. Trust me, I'm only slightly exaggerating when I say that I would have skipped my daughter's wedding for 10 seconds on Oprah.

I detailed a lot of this in a blog I did for HealthCentral's BipolarConnect, and looking back I wish I had been far more disapproving. In a later blog that was critical of the way "60 Minutes" covered the tragic death of Rebecca Riley, I did say that Katie Couric was as dumb as Oprah, and I feel good about that.

The Newsweek story devotes six pages to how Oprah gets away with highlighting non-expert guests who promote various quack cures and too-good-to-be-true beauty treatments, not to mention vaccination fear-mongers, while keeping expert dissenters in their place. Unfortunately, the Oprah phenomenon is growing, if such a thing is possible - her own new cable channel is in the offing, which will include Oprah-approved programming on health and living well.

But in the end, the joke may be on Oprah. As the article notes, Oprah became enthralled to some old positive thinking repackaged as "The Secret," to which she devoted three shows. Amongst other things, The Secret advises that "you cannot 'catch' anything unless you think you can." But here she was, reported Newsweek, in the months that followed, "worrying over her thyroid, ingesting bioidentical hormones and putting on pounds."

Concluded Newsweek:

"What if Oprah had managed to solve all of her problems, to end her search for meaning and fulfillment and spiritual calm and a flatter, firmer stomach by summoning the very power of the universe itself? It might have been hard for her to take Suzanne Somers seriously after that."