Showing posts with label bipolar depression. Show all posts
Showing posts with label bipolar depression. Show all posts

Monday, May 30, 2011

Rerun: This Memorial Day


This Memorial Day:

Our men and women are returning from two wars. They have witnessed things and felt things that those of us who stayed home have no clue. Their brains have been overwhelmed, their psychic beings shaken to the core.

This Memorial Day:

Our soldiers may leave the battlefield, but they cannot leave their memories there. Very high percentages are returning home with PTSD, depression, and other mental illnesses. Even those without full-blown symptoms have issues to deal with. Others are ticking time bombs. Suicide will claim more of them than enemy gunfire. Many will attempt to cope by turning to alcohol and drugs.

This Memorial Day:

Many brave men and women have no clue what is about to happen to them. They served as heroes, but, like many who served in Vietnam, may wind up homeless. They may be remembered for their bravery, but we will cross the street to avoid them.

This Memorial Day:

It's not just about flags on graves. It's about serving the people who served our country.

This Memorial Day:

Resolve to do something tangible. Advocate. Donate. Get involved with one of the veteran's organizations. Get involved with a mental health group making an outreach to veterans. Do something. Then keep doing it.

This Memorial Day:

It's our turn now.

Tuesday, November 23, 2010

Rerun: Misdiagnosis - Patients Tell Their Stories


My recent five-part (and counting) series, Are Antidepressants Bad For You?, noted that a large part of the problem has to do with physicians blindly treating anything that resembles a depression with these meds, often with disastrous results. This piece from a year ago elaborates ...

I write a very different blog on HealthCentral's BipolarConnect. There, I take a backseat to my readers, bipolar patients and loved ones. Nearly a month ago, I asked them:

Were you misdiagnosed with depression or something else? How long did it take before you finally received the correct diagnosis?

Readers began telling their stories over the next days and weeks, which I assembled into three blog pieces. The narrative is sobering and instructional:

"Jane's" response is fairly typical. She was diagnosed with depression at age 16 and prescribed Zoloft, “which was making me like a bunny on mass caffeine consumption.” She was put on Paxil, but her depression worsened and she gained 40 pounds. Unable to hold onto her job, she found a new doc, who “cocked his head, asked about my family’s mental health history ... and asked me ‘Did anyone ever ask you if you thought you might be bipolar?’"

Finally, on Lamictal, she has her life back, but "I spent 11 years on the wrong meds and destroying my life because I was misdiagnosed.”

What is coming in loud and clear is that a misdiagnosis of depression is all too common, with years on antidepressants that only worsen one's unrecognized bipolar. Since we tend to seek help when we are depressed rather than manic, it is not surprising that we receive the wrong diagnosis at first instance. But then the problem is compounded by psychiatrists who refuse to listen. As "Rachel," who waited 14 years for the correct diagnosis, describes it:

My major complaint with this whole debacle is not that I was incorrectly medicated, it is that I was incorrectly medicated because an entire comprehensive mental and physical inventory was never taken. AKA no one ever TALKED to me about what I was feeling and why I was feeling it. No one had mined my data for facts and established a clear pattern of my behavior. The first person who did that was me. ... They didn't do their job. Much like getting a bad mechanic job, my tranny dropped out on the freeway and my vehicle hit the wall going 75 - a complete loss.

Doctors who don't listen - that has been by far the number one complaint I have received from readers ever since I began writing about bipolar more than 10 years ago. As "Lorraine," who suffered with antidepressants for three years, writes:

The doctor (as many are) was a know-it-all and rarely listened to me. The doctor rarely considered how I felt. The doctor thought no one could ever know more than this one. The doctor rarely even considered the possibility of what I was feeling.

Why does it take so long for doctors to get smart? "Georgine" responds: "I believe it was because I was diagnosed with [depression] before so instead of trying to find out what I needed, the docs took the previous diagnosis and just agreed with it."

It took 25 years before a doctor finally corrected the original error.

And this from "Eva":

It was only when I got old and ugly that a doctor finally said, ya man, she's depressed, and she's bipolar. ... When I was young, beautiful and well-groomed, I looked like a female high-powered executive. On top of the world to the doctors who saw me. They dismissed my claims of depression, as ridiculousness. What does she have to be depressed about? Now that I'm old, ugly, unfashionable, I'm believable.

Our own ignorance and denial is another factor. As "Lilly" reports: “I stayed in denial successfully with alcohol and pills.” At last, during her third hospitalization, “I finally opened up a pamphlet on bipolar.” She took her meds as directed, and “was able to see reason. ... I’ve been struggling with this disease for over 25 years since I had turned 16 years old and I was 40 when I excepted it as something I would have to live with and take care of for the remainder of my life. Life is good now.”

***

There is no substitute for listening to real accounts from patients and loved ones. You can check out the full conversation at Bipolar Connect in the comments to my original question and a follow-up question, as well as my three pieces and the comments to these pieces:

Misdiagnosis - Eight Readers Tell Their Stories

Misdiagnosis - The Dialogue Continues

Misdiagnosis - Readers Tell Their Stories

Sunday, February 21, 2010

The Draft DSM-5 - Another Blogger Speaks Out

I'll be quick: Blogger comrade-in-arms Willa Goodfellow (pictured here) of Prozac Monologues has written a terrific critique of the Draft DSM-5. Sample:

Particularly disturbing is the failure to include new knowledge about Bipolar II.  The proposed revisions do not even keep pace with practice among psychiatrists who do listen to their patients' experience.  The evidence for a link between antidepressants and suicide is most compelling for those who are diagnosed with Bipolar II or those who could be diagnosed with Bipolar II, if the criteria shifted to include them.  The continued narrow definition leads to inappropriate treatment with antidepressants (translation: more sales of antidepressants), and deterioration, including a tripled risk of suicide

Say no more. Check it out ...

Monday, January 25, 2010

Introversion and Isolation


The following is a chopped-down version of an article I published on mcmanweb in 2003, plus some additional observations to reflect my current thinking on the topic ...

In May 2003, I asked my Newsletter readers to take an online Myers-Briggs personality test and email the results, along with their diagnosis.

The Myers-Briggs type indicator (MBTI) begins with eight personality functions in contrasting pairs - Introvert (I) or Extrovert (E), Intuitive (N) or Sensing (S), Thinking (T) or Feeling (F), and Judging (J) or Perceiving (P).

The Introvert/Extrovert dichotomy relates to people drawing their energy from being alone or with people rather than simply being either shy or outgoing. Thinking and Feeling are self-explanatory. Sensors tend to focus on the here and now while Intuitives look for meaning and possibilities. Judgers prefer structure in their lives over the messy flexibility of Perceivers.

Falling within these four temperaments are 16 distinct personality types, defined according to the eight paired personality functions, thus INFP, ESTJ, etc.

I analyzed the first 100 responses. Most readers also sent in their diagnosis, nearly all with depression or bipolar disorder. Since most people with bipolar disorder are depressed more than manic, it is safe to conclude that this poll was dealing with a mostly-depressed population. Approximately three-quarters of the respondents were women.

The first eye-popping result was 83 percent of those who replied were introverts, which sharply contrasts with the 25 percent to be found in the general population. According to one reader, who had a strong extrovert score four years ago and a much weaker one when responding to this poll: "Over the last four years I've sunk into a very isolated existence. The mania has worsened despite changes in medication/dosages and I spend most of my time sleeping and avoiding large social functions. I do slightly better in small social gatherings, but up until just a couple of months ago I didn't go anywhere or see anyone other than my immediate family within our house."

The best is yet to come: There were 17 INFJs and 14 INFPs, the largest populations in this study, the "mystics" and "dreamers," respectively, who only account for one percent each of the general population. These groups turned up in higher than expected numbers in at least two online MBTI tests, which may explain the large turnout here.

As for the extroverts: Possibly because it was just one letter off INFP, there were seven ENFPs, “visionaries” who would fit right in with the mystics and dreamers, the only category of extrovert over-represented in this poll. Since other versions of extroverts have descriptions such as “enforcers,” “adventurers,” “helpers,” and “jokers,” you can see what we are missing.

One of the few psychiatric studies using the MBTI, by David Janowsky MD of the University of North Carolina, also found a preponderance of introverts (as well as feelers) among a depressed population.

Several readers commented that their results varied on circumstances and phase of illness. Stephanie wrote that "when manic I'm as sociable as Bette Midler on cocaine and when I'm depressed, seriously come not near me."

Carol, who came up ENTJ back in college and again a couple of years ago when working for a mutual fund company, observed that "if I may draw a conclusion, those of us who can break through isolation and make contact with others, could be better able to keep the depression at bay."

In the meantime, we are left with the disquieting knowledge that our illness can isolate ourselves to the point of virtual no-return. Another study by Dr Janowsky found that 84 percent of 64 suicidal patients he examined were introverts, leading the him to observe:

"The issue of social isolation has been mentioned as a potential risk factor for suicidality. The introverted individual almost certainly has trouble reaching out to others, especially in times of stress and need. Thus the social isolation of introversion may set the scene for suicidality."

In a 2001 article appearing in Current Psychiatry Reports, Dr Janowsky cites various studies to support the proposition that "increased introversion predicts the persistence of depressive symptoms and a lack of remission" (and conversely that extroversion can improve outcomes).

The obvious antidote is to do whatever it takes to get out of the house and into the company of others. This is generally easier said than done, given the nature of our illness, but the stakes are enormous in what could very well be the most important aspect of our treatment.

***
Based on what I have learned and experienced since writing this article nearly seven years ago, I would make some major changes to include the positive features of introversion. On a personal note, I am an INFP and a hermit by nature. What makes my day is connecting two seemingly unrelated thoughts alone in my room or while out on a walk in the middle of nowhere. I do perk up around people, and in these situations I get mistaken for an extravert, but the effort drains me and I find myself relieved to be back in my comforting isolation.

I pity those who have no comprehension of my rich inner world, but when I originally wrote this piece I realized my isolation was killing me, as it had nearly killed me at other times in my life. Accordingly, I made deliberate efforts to get out amongst people, which no doubt reduced my risk of depression, and had the unexpected result of helping me find the kind of ease within myself that had eluded me my whole life.

Getting out amongst people back then was like plunging into ice water. It’s much easier now, but the water is still cold. Your views, please ...

Thursday, November 26, 2009

A Thanksgiving Tribute



This piece, which I wrote nine years ago, is one of the original articles on my website, mcmanweb, which I established in late 2000. The site and its contents have undergone many changes over the years. Today, McManweb contains around 200 articles devoted to all aspects of depression and bipolar, plus videos, and is recognized as one of the most comprehensive resources for learning about either illness. Something to be thankful for ...

It's like a cardiac arrest, only it happens in the brain - something responsible for holding the gray mass together abruptly shifts, there is a sickening feeling of something terrible about to happen, and next thing your head is experiencing the awful sensation of being emptied out. From somewhere inside the power goes down and the body seems to collapse into itself like a marionette being folded into a box. You look for a way out, and what's left of your broken brain does its best to oblige with images of high bridges and frozen ponds and nooses dangling from balconies.

In January 1999 when my family brought me to the emergency room at our local hospital I could never imagine eleven months later that I'd be writing about anything I had to be thankful for, much less paying tribute to this beast inside that sent me there in the first place, the one that goes by two names, both of them woefully inadequate: manic depression and bipolar.

May as well call the thing Fred, as far as I'm concerned.

For most of my life, Fred has been my constant traveling companion, even as I denied his existence and tried so hard to pretend I was a master of my own fate. I'm normal! I kept insisting over and over, much to Fred's quiet amusement.

Twenty-one years ago I was well on the way to proving it. After all those wasted years at the mercy of the very condition I denied having, I landed on my feet in New Zealand. I had successfully completed my second year of law school there, and I was married with a beautiful three-month-old daughter. There had been some other Americans in our birthing classes and we invited them over, together with another Kiwi-Yank couple we knew, to celebrate Thanksgiving. I recall lifting my glass to make a toast, but then words failed me.

We were seated on cushions on the floor with the turkey and all the fixings on a low table. But the stars of the show were the new citizens of planet earth. I looked at the proud parents and their newborns and all the baby paraphernalia they had brought, and simply choked out, "thanks".

Life was beautiful.

Little did I realize in ten years I would find myself in another country, broke and alone and unemployable and in search of a convenient bridge to jump off. I couldn't blame it all on Fred. Besides, Fred has a way of convincing you he doesn't exist.

Boy, you showed them, Fred let me know less a year after that. You're back on your feet again and working on your own terms, not theirs. I had one book out and another on the way. And there was my daughter, now ten, together with my parents, in my apartment to celebrate Christmas. Like a considerate roommate, Fred made himself scarce.

When he showed up again I was back in the States. Think of someone on a high hill lobbing boulders at you, that was Fred. One large stone would hit me on the chest and send me into a crushing depression. Then the next one would come thudding down on me as I lay sprawled on the ground, compounding my despair with a depression on top of a depression.

But I made Fred work hard, damn hard. Several years and an untold number of boulders it took, but finally I went down and didn't get up. After all these years, I finally acknowledged Fred's dominion, not to mention his existence.

So now, at long last, I'm going to give Fred his due. After all, he made me what I am. Whatever our differences, he is responsible for me being me, so to hate Fred would be to hate me. Besides, having Fred around does have its advantages.

It is Fred who painted my brain with amazing visions and insights, and filled my senses with the type of sensations few mortals experience. It is Fred who made it possible to for me to find the sublime in even the most mundane, and it is Fred who cloaked me in a humanity and godliness that I would not exchange for a winning lottery ticket.

So, yes, Fred, on this Thanksgiving, for the very first time, I will sing your praises and give you thanks. In a few months I will see my grown daughter, here from New Zealand, and I give thanks for that, too. I will give thanks to my family who were there for me, and to a God who somehow has proved to me he does not and does exist.

And yes, Fred, I know one day again, you'll be waiting for me in some dark alley. But for now I invite you to pull up a chair while I lift my glass in a toast.

Wednesday, November 11, 2009

This Veteran's Day


The following is a slight modification of the piece I ran on Memorial Day:

This Veterans Day:

Our men and women are returning from two wars. They have witnessed things and felt things that those of us who stayed home have no clue. Their brains have been overwhelmed, their psychic beings shaken to the core.

This Veterans Day:

Our soldiers may leave the battlefield, but they cannot leave their memories there. Very high percentages are returning home with PTSD, depression, and other mental illnesses. Even those without full-blown symptoms have issues to deal with. Others are ticking time bombs. Suicide will claim more of them than enemy gunfire. Many will attempt to cope by turning to alcohol and drugs.

This Veterans Day:

Many brave men and women have no clue what is about to happen to them. They served as heroes, but, like many who served in Vietnam, may wind up homeless. They may be remembered for their bravery, but we will cross the street to avoid them.

This Veterans Day:

It's not just about flags on graves. It's about serving the people who served our country.

This Veterans Day:

Resolve to do something tangible. Advocate. Donate. Get involved with one of the veteran's organizations. Get involved with a mental health group making an outreach to veterans. Do something. Then keep doing it.

This Veterans Day:

It's our turn now.

***

From Therese Borchard's Beyond Blue:
  • Almost one in three veterans returning from Afghanistan and Iraq confront mental health problems.
  • On an average day in this country, suicide claims another 18 veterans.
  • Approximately 30 percent of veterans treated in the veterans health system suffer from depressive symptoms, two to three times the rate of the general population.
  • More Vietnam veterans have now died from suicide than were killed directly during the war.
  • Approximately 40 percent of homeless veterans have mental illnesses.

Monday, November 2, 2009

Misdiagnosis - Patients Tell Their Stories


I write a very different blog on HealthCentral's BipolarConnect. There, I take a backseat to my readers, bipolar patients and loved ones. Nearly a month ago, I asked them:

Were you misdiagnosed with depression or something else? How long did it take before you finally received the correct diagnosis?

Readers began telling their stories over the next days and weeks, which I assembled into three blog pieces. The narrative is sobering and instructional:

"Jane's" response is fairly typical. She was diagnosed with depression at age 16 and prescribed Zoloft, “which was making me like a bunny on mass caffeine consumption.” She was put on Paxil, but her depression worsened and she gained 40 pounds. Unable to hold onto her job, she found a new doc, who “cocked his head, asked about my family’s mental health history ... and asked me ‘Did anyone ever ask you if you thought you might be bipolar?’"

Finally, on Lamictal, she has her life back, but "I spent 11 years on the wrong meds and destroying my life because I was misdiagnosed.”

What is coming in loud and clear is that a misdiagnosis of depression is all too common, with years on antidepressants that only worsen one's unrecognized bipolar. Since we tend to seek help when we are depressed rather than manic, it is not surprising that we receive the wrong diagnosis at first instance. But then the problem is compounded by psychiatrists who refuse to listen. As "Rachel," who waited 14 years for the correct diagnosis, describes it:

My major complaint with this whole debacle is not that I was incorrectly medicated, it is that I was incorrectly medicated because an entire comprehensive mental and physical inventory was never taken. AKA no one ever TALKED to me about what I was feeling and why I was feeling it. No one had mined my data for facts and established a clear pattern of my behavior. The first person who did that was me. ... They didn't do their job. Much like getting a bad mechanic job, my tranny dropped out on the freeway and my vehicle hit the wall going 75 - a complete loss.

Doctors who don't listen - that has been by far the number one complaint I have received from readers ever since I began writing about bipolar more than 10 years ago. As "Lorraine," who suffered with antidepressants for three years, writes:

The doctor (as many are) was a know-it-all and rarely listened to me. The doctor rarely considered how I felt. The doctor thought no one could ever know more than this one. The doctor rarely even considered the possibility of what I was feeling.

Why does it take so long for doctors to get smart? "Georgine" responds: "I believe it was because I was diagnosed with [depression] before so instead of trying to find out what I needed, the docs took the previous diagnosis and just agreed with it."

It took 25 years before a doctor finally corrected the original error.

And this from "Eva":

It was only when I got old and ugly that a doctor finally said, ya man, she's depressed, and she's bipolar. ... When I was young, beautiful and well-groomed, I looked like a female high-powered executive. On top of the world to the doctors who saw me. They dismissed my claims of depression, as ridiculousness. What does she have to be depressed about? Now that I'm old, ugly, unfashionable, I'm believable.

Our own ignorance and denial is another factor. As "Lilly" reports: “I stayed in denial successfully with alcohol and pills.” At last, during her third hospitalization, “I finally opened up a pamphlet on bipolar.” She took her meds as directed, and “was able to see reason. ... I’ve been struggling with this disease for over 25 years since I had turned 16 years old and I was 40 when I excepted it as something I would have to live with and take care of for the remainder of my life. Life is good now.”

***

There is no substitute for listening to real accounts from patients and loved ones. You can check out the full conversation at Bipolar Connect in the comments to my original question and a follow-up question, as well as my three pieces and the comments to these pieces:

Misdiagnosis - Eight Readers Tell Their Stories

Misdiagnosis - The Dialogue Continues

Misdiagnosis - Readers Tell Their Stories

Monday, May 25, 2009

This Memorial Day ...


This Memorial Day:

Our men and women are returning from two wars. They have witnessed things and felt things that those of us who stayed home have no clue. Their brains have been overwhelmed, their psychic beings shaken to the core.

This Memorial Day:

Our soldiers may leave the battlefield, but they cannot leave their memories there. Very high percentages are returning home with PTSD, depression, and other mental illnesses. Even those without full-blown symptoms have issues to deal with. Others are ticking time bombs. Suicide will claim more of them than enemy gunfire. Many will attempt to cope by turning to alcohol and drugs.

This Memorial Day:

Many brave men and women have no clue what is about to happen to them. They served as heroes, but, like many who served in Vietnam, may wind up homeless. They may be remembered for their bravery, but we will cross the street to avoid them.

This Memorial Day:

It's not just about flags on graves. It's about serving the people who served our country.

This Memorial Day:

Resolve to do something tangible. Advocate. Donate. Get involved with one of the veteran's organizations. Get involved with a mental health group making an outreach to veterans. Do something. Then keep doing it.

This Memorial Day:

It's our turn now.

Wednesday, March 25, 2009

Trick Question: Lamictal for Bipolar Depression


GSK manufactures Lamictal (lamotrigine), used for treating bipolar depression. Which drug company sponsored the one unambiguous clinical trial showing that Lamictal is effective for this use?

Answer: Eli Lilly. Here's the story, which I reported in full in my Newsletter in early 2007:

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, "non-responders" likely to fail had been weeded out.

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

The news was interpreted as an FDA indication for treating bipolar depression, which was clearly not the case. 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."

One beneficial result of GSK's efforts was that bipolar depression - which is more prevalent and destructive than mania, not to mention much harder to treat - began receiving the attention it deserved. Lamictal's flavor-of-the-month status also drew long-overdue attention to bipolar II and "soft" bipolar.

Here's where Eli Lilly comes in. In late 2003, the company 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.

Get ready for this: 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 lamotrigine-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, they would be reporting record profits.

So, there you have it: The story of how Eli Lilly came to sponsor the one unambiguous trial showing that GSK's Lamictal works against bipolar depression.

A couple of follow-ups:

Following the revelation of the unpublished GSK studies, in its new bipolar treatment guideline due out next month, the American Psychiatric Association will no longer be recommending Lamictal as a first treatment option for acute bipolar depression.

In the wake of Lamictal going generic last year, GSK no longer heavily markets the drug.

Further reading from mcmanweb:

Treating Bipolar Depression

At the 2008 APA symposium, Robert Post MD of Penn State advised: "We have to change the way we practice this illness."

Back in 2001, in a survey by the Stanley Foundation Bipolar Network, Dr Post and his colleagues did some counting of their own. Their tally revealed that, despite the fact that mania gets virtually all the attention, bipolar patients are depressed three times more than they are manic or hypomanic.

Knock me over with a feather. Now if we only knew how to treat bipolar depression. ...

Friday, March 20, 2009

Depression - Are We All Alone?


Trying to tell someone who has never experienced depression what depression is like is like trying to describe a headache to someone who has never had a headache. People just don't get it, and they never will.

No one writes about this better than Therese Borchard of Beyond Blue. Here's the last three paragraphs from a blog post from yesterday:

"The pain of severe depression is quite unimaginable to those who have not suffered it," Styron wrote. "To the tragic legion who are compelled to destroy themselves there should be no more reproof attached than to the victims of terminal cancer."

Like Styron, I was both enraged and saddened that friends and family were shocked to hear that two doctors sliced me open--before full anesthesia kicked in--to save little David's life in an emergency C-section. Yet when I voiced the desperation of depression--which made the knife cut feel like a knee scratch--they often brushed it off, as if I were whining to win some undeserved sympathy votes.

But I should know better. Most people don't get it. And the day I get that through my head I'll be less disappointed.

Obviously, Therese touched a raw nerve. Her blog post (as of right now) drew an incredible 209 comments, nearly all of it along the lines of "my friends and family don't get it, either."

So, are we on our own? No, not really. Way too many of us, unfortunately, get depressed. Between those with major unipolar depression and those with bipolar depression, not to mention those with depression as a symptom of another illness, we are talking in the neighborhood of one in five Americans who experience major depression over the course of their lifetimes.

So, if your family and friends are deaf to you, all you have to do is reach out a little further. Literally, throw a stone out the window. It is bound to land on someone who has been through depression. You will have someone to talk to. Keep in mind that Bill Styron, cited by Therese, cultivated friendships with fellow depressives Mike Wallace and Art Buchwald.

Also, keep in mind that although most people don't get depression, they are not exactly hostile, either. Chances are, depression has touched their lives in some way. They may not understand what is going on, but a good many are truly moved by the suffering they have witnessed close-up.

Finally, be mindful of the fact that depression affects our capacity to process positive news. Friends and family may be more supportive than you give them credit for.

Tuesday, February 3, 2009

Mixed Bipolar Depression: You Really Need to Be Reading This


Four and a half years ago, I sat down with leading bipolar expert Ellen Frank PhD of the University of Pittsburgh. I asked her to talk about a study she had been involved in concerning mixed depressions, that is, depression with some features of mania.

"What we've been arguing about is that even isolated symptoms that don't cluster together to create episodes may be important," she told me.

Emil Kraepelin, the pioneering diagnostician who coined the term manic-depression, recognized back in the early twentieth century that depression and mania could combine together to produce no fewer than six mixed states. Yet the DSM recognizes only one - full-blown mania with full-blown depression. By this criteria, only those with bipolar I are recognized as having mixed states.

The DSM is due for revision in 2012, and clearly things need to change. This month's American Journal of Psychiatry features the latest findings to emerge from the NIMH-underwritten STEP-BD real world clinical trials on bipolar patients.

In the study, of 1,380 patients diagnosed with bipolar depression, 54 percent had co-occurring subthreshold (one to three) manic symptoms while another 15 percent had a full mixed episode (at least four manic symptoms). Significantly, 71 percent of the mixed population had a bipolar II diagnosis. Only one-third of the patients had "pure" bipolar depression - that is, depression with no mania symptoms.

More than two thirds of the mixed population showed marked or severe irritability (think road rage). The mixed group were also more prone to attempt suicide. Common manic symptoms included distractibility, racing thoughts, and psychomotor agitation. We are talking depression with unwanted add-ons, and, not surprisingly, these depressions are more difficult to treat.

An earlier series of STEP-BD studies found that adding an antidepressant to a mood stabilizer did not, as expected, induce more switches into mania in the "pure" depression group. But this changed for the "mixed" group. As the study authors pointed out, clinicians who fail to pick up mania symptoms in depression may mistakenly "assume a beneficial role for antidepressant psychopharmacology."

Leading researchers such as Hagop Akiskal MD of the University of California, San Diego have advanced strong cases that the "mixed" population is much larger than psychiatry recognizes. STEP-BD now provides overwhelming evidence in support of this proposition.

Mixed states also jump the artificial divide between bipolar and unipolar depression. Perhaps even more important than knowing whether you have unipolar depression or bipolar is knowing precisely how "mixed" your depressions (and manias and hypomanias) are.

Chances are your psychiatrist is operating on the assumption that your depression is just depression. Maybe, maybe not. The onus is on you to get a dialogue going. Now more than ever, "knowledge is necessity."

Further reading from mcmanweb:

Treating Bipolar Depression

When Nassir Ghaemi MD of Tufts University was in residency at McLean Hospital, he assumed there was no harm in using antidepressants to treat bipolar depression. After all, "depression was depression," or so he and just about every clinician thought.

The Mood Spectrum

So what do we do with these irritable and depressed people with or without mixed states that the DSM presently ignores?