Rerun - Where Dumb Psychiatry Meets Dumb Antipsychiatry

Yesterday, in Part V of Spitzer and the DSM, I discussed at length how a major error in the DSM-III of 1980 has gone uncorrected for 29 years. This concerned separating out "recurrent depression" from bipolar, to which it is a close cousin, and lumping it with "chronic depression." As a result, many in the bipolar spectrum are misdiagnosed and spend years leading miserable lives on one failed antidepressant after the other. In light of two reader comments to yesterday's piece and the importance of the issue, I thought it appropriate to republish this from February:

In my last blog, I urged that we consider issues in terms of "smart vs dumb" rather than "pro vs anti." In the final analysis, dumb psychiatry and dumb antipsychiatry serve the same master. Let me give you an example:

For at least three decades, it has been widely accepted that prescribing an antidepressant (with no mood stabilizer) to someone with bipolar runs a strong risk of flipping a patient into mania or speeding up the cycle or both. The American Psychiatric Association in it's 2002 Practice Guideline for treating bipolar issues a blanket warning against this practice.

The catch is that it is often difficult to distinguish unipolar depression from bipolar depression. The result is that too many of us with bipolar are misdiagnosed with unipolar depression and prescribed meds that make us worse.

There is an additional twist to this catch: Many people experience "recurrent" and "highly recurrent" depressions that come and go in a pattern very similar to bipolar cycling. The pioneering diagnostician Emil Kraepelin observed this phenomenon way back in the early twentieth century.

When Kraepelin coined the term, manic-depression, he wasn't merely referring to bipolar. He also included those with recurrent depression. This was the widely accepted view until the DSM-III in 1980 separated out bipolar and lumped recurrent depression with "chronic" depression.

The result is that doctors tend to treat all depressions alike - with predictably disastrous results. This is an example of "dumb" psychiatry, the indiscriminate prescribing of antidepressants to anyone who happens to say they're depressed.

Reformers in the profession, such as former head of the NIMH Frederick Goodwin MD and Nassir Ghaemi MD of Tufts, have long urged that psychiatrists think twice before prescribing antidepressants. The best way to turn certain unipolars into bipolar, they would argue, is to prescribe an antidepressant.

Dr Goodwin and a good many others have campaigned for years to realign the next DSM so that it is more closely in tune with Kraepelin's original conception of manic-depression. This would get doctors to rethink their prescribing practices.

We don't know if change will happen. But no doubt the task force charged with issuing an updated DSM is considering the matter. Indeed, the possibility of a new "bipolar III" diagnosis was the basis of a blog post last week from Furious Seasons, fairly typical of antipsychiatry sentiment:

I think it's been a boon to doctors - who get a patient for life - and Big Pharma - which gets a long-term customer - but I have my doubts about how useful the depression-is-bipolar thing is for patients who wind up on an atypical and an anti-seizure drug when they are dealing with something that's not even in the ballpark of mania.

To respond in brief:

Yes, big pharma would love a customer for life, but to make a case for a drug industry conspiracy one would have to bend time a hundred years. Kraepelin wrote his classic text, "Manic-Depressive Insanity and Paranoia," decades before drug manufactures came up with the first psychiatric meds, and psychiatrists have been arguing ever since where best to carve nature at its joints.

Moving on, bipolar is more accurately a cycling illness, not a polar illness. So is recurrent depression. Thus "something that's not even in the ballpark of mania" is irrelevant. The purpose of treatment is to manage the cycle, bring it under control, not necessarily treat symptoms at one pole or the other.

An antidepressant may work in some patients with recurrent depression. But a logical first option is to consider using a mood stabilizer such as lithium or Depakote or Lamictal.

Once the cycle is under control, it may be possible to consider low-meds or no-meds options in conjunction with cultivating cognitive skills such as mindfulness.

Admittedly, Lamictal had a lot to do with drawing attention to "soft bipolar" several years back, and GSK profited handsomely. But these days the drug has gone generic, along with lithium and Depakote. Thus GSK and others have no financial stake in pushing for an expanded bipolar diagnosis.

If anything, an expanded diagnosis would significantly reduce antidepressant sales. This is why you don't see drug companies sponsoring clinical trials to prove Drs Goodwin and Ghaemi right.

No doubt, some manufacturer will try to jump on the bandwagon with some implausible claim trumpeting the virtues of their house antipsychotic, only to be laughed out of town. But this would be an example of opportunism, not hatching a conspiracy.

As for psychiatrists wanting a patient for life: The best indication is that psychiatrists are driving away their patients. Only a small minority of patients adhere to their meds over the long term. Matching the right meds to the right diagnosis might change this.

So now we return to the issue of smart vs dumb. Dumb psychiatry treats all depressions as the same. So does dumb antipsychiatry. Dumb psychiatry favors preserving psychiatry's status quo. So does dumb antipsychiatry. Ironic, isn't it?

Postscript

For how I abandoned my ex-wife that I mooched off of for years and other high-crimes and misdemeanors while the crusading Philip Dawdy was busy saving the world, check out this entertaining piece of fiction from Furious Seasons.

Comments You Don't Get to See

In my last blog piece, I recollected an unscheduled visit I had made to Walter Reed Army Hospital two years before. These are the type of spur-of-the-moment decisions journalists make all the time when they are on the road.

The purpose of my visit had been to see if I could get into the hospital’s psych unit to learn what was being done for returning soldiers with PTSD. Naturally - and appropriately - they did not let me in, Nevertheless, I made use of the visit in a blog I did for HealthCentral to draw awareness to PTSD.

“Time for quiet reflection on our heroes," I concluded in my piece. “Are they aware of what lies ahead for many of them? About the odium and contempt society will hold them in when it happens? These poor souls don’t have a clue.”

While there, I also encountered young men with missing limbs, which I also reported in my original piece.

At the moment, I am recovering from sciatica, which literally had me flat on my back for more than a week, I ventured out to the local diner last week, only to run into a telling reminder how fortunate I am: A woman at an adjacent table was relating to a neighbor about her husband, who had just had half his foot amputated.

That conversation prompted me to recall some of the suffering in my own family. Then those unforgettable images of those young men at Walter Reed seared through my conscious, with a pain far more intense than anything I had felt in my leg. Suddenly, my sciata didn't seem so bad.

Time to count my blessings. Time to come to terms with the natural process of aging. That was the theme of my most recent blog post here.

It seems “Anonymous” entirely missed the point:

“Let me get this straight,” he wrote. “You made an impulsive, spur-of-the-moment visit to Walter Reed Hospital, where you used the suffering of strangers to make yourself feel better?”

Even though I did not explain the purpose of my visit to Walter Reed in my last piece, it’s pretty obvious the reason wasn’t to make me feel better. But having already made up his mind, Anonymous wasn’t going to let a good tirade go to waste: “I bet they loved being an inspiration to you,” he concluded. “Some compassion, and admiration, for your aunt and cousin might have been warranted, rather than your self-serving, sanctimonious blather.”

Irrational attackers like Anonymous are an occupational hazard for all bloggers. They just happen, and when they try to post a comment, I simply hit the “Reject” button. There is no sense reasoning with them, as they are beyond reason. Typically, they have an antipsychiatry agenda, but a good many are just plain freelancers with anger issues. Here’s a doozy from a few months ago:

Keep popping those wonder drugs SAL aka McPimp {Oh, that's right, you don't do meds Mr. McPimp}. Maybe McPimp can get himself into see his other heros as in Biederman, Goodwin, Jamison, Nemeroff and all the other greed mongering bipolar child Pharma huggers!

Though McPimp is a pretty lame con-man; did you write that post yourself Johnny Boy aka Sal? Did you steal this Page from Herb of many faces and IDs play book? {making up people to talk at is an old trick for sociopaths like yourself}. I guess being a fraud isn't enough; now you make people up to have comments on your "LOST" adventure. You do know that plastic blow up dolls are next in your precarious relationship pattern. {laughing}

Let’s see: This version of Anonymous is confusing me with someone named Sal, is nursing a resentment with someone else named Herb and yet another individual who goes by the screen name ID, is entertaining a delusion that I’m not on meds (I’m on a very light dose mood stabilizer and have emergency meds on standby), that I fabricate imaginary characters, and that I’m part of the Pharma conspiracy.

I’m grateful to Phillip Dawdy of Furious Seasons, who acts as Jupiter to my planet earth. Namely, his gravitational field seems to attract all manner of space debris nursing cosmic resentments, some of whom have ideated physical violence against me. It helps when he makes up things about my personal life such as:

“Maybe that's why a little over two years ago, when I was making the Zyprexa documents available to the public and going up against Eli Lilly, McManamy was going on book tours, divorcing his wife who'd supported him while he wrote said book and moving off to the desert of San Diego County to find himself.”

That little piece of fiction drew a whole meteor shower of nutjob comments. Better they scar his planet rather than mine. But, occasionally one or two migrate into my orbit.

That’s what the “Reject” button is for.

I'm a Tool of Scientology!

This is too funny for words.

Above is a screenshot from the Recovery page on my website McMan's Depression and Bipolar Web taken just a few minutes ago.

No, you are not seeing things. In the lower right hand corner, you are viewing an advertisement for the Church of Scientology. Like nearly everyone who operates a website or a blog these days, I employ Google Ads to help pay the rent. I do not - nor have I ever - solicited advertising. Rather, Google automatically loads advertisements that its various algorithms decide is a good fit for the page.

Apparently, the Google algorithm determined that I am a friend of Scientology.

In a similar fashion, HealthCentral loads ads into the top banner portion of my mcmanweb pages. At the time of this writing, for this particular page, an ad for Ensure is on display. Across another page right now is an ad for Prisiq, which looks like this:







Various antipsychiatry bloggers such as Philip Dawdy of Furious Seasons periodically (and tediously) attempt to discredit my writing based on the fact that I happen to carry these ads on my site.

Apparently I am a tool of Big Pharma.

But no, the conspiracy is even more evil and far-reaching. I'm also a tool of Scientology!

Okay, okay. I confess. It was me you saw on the Grassy Knoll one day in late November. Whew! It's a relief to get that out of my system. In the meantime, don't forget to support my sponsors ...