Rethinking Psychiatry - Another Look at Paradigms

Yesterday, I re-ran an earlier blog post that talked about paradigms and how psychiatry is ripe for a new one. Thomas Kuhn (pictured here) literally owns the word paradigm. In his seminal 1962 book, The Structure of Scientific Revolutions, Kuhn points out that far from being an objective and dispassionate exercise, scientific research operates from existing conceptual frameworks until they are no longer sustainable.

Thus Ptolemy to Copernicus, Newton to Einstein, and so on. Almost inevitably, the old order is toppled by those outside the field or those just entering the field, who have little or no stake in the status quo.

In psychiatry, we have seen a similar transition from Freud to biological psychiatry. But that paradigm is being challenged by breakthrough discoveries in brain science and what could become "the new science of the mind," as put forward by 2000 Nobel Laureate Eric Kandel, who stated at a conference I attended:

A major need of psychiatry in the future is to put the psychotherapeutic arm of psychiatry on the same solid biological footing as the pharmacological aspect of psychiatry.

In January, after I posted my piece for the first time, Willa challenged the notion of psychopharmacology on a solid biological footing, noting that in medicine "the paradigms dictate the treatments." Unsuccessful treatments, she said, do not challenge the paradigm. "They simply are problems to be solved within the existing paradigm." Thus unacceptable side effects induce researchers to find new meds rather than lessening the reliance on meds.

Yesterday, in response to my second posting, Tony added that every FDA medication in essence carries the warning that says: "We have no idea how this stuff works, but it does... kinda, sorta a little better than a placebo..."

Obviously, we have a lot of frustrated and very well-informed patients challenging the biological psychiatry mindset in the form of the recovery movement. Had psychiatry come up with new meds that worked a lot better than the old ones, with practitioners smart enough to work with us, the current paradigm might be more secure right now.

Mark added another twist to this, of transpersonal psychiatry (that expands on Freud and Grof and others) vying for attention with the new brain science. In Mark's words:

My personal view is that the biological researchers are trapped by their paradigm to look only at the brain. They cannot conceive the possibility of mental disease having any other source than the physical matter of the brain itself. By their paradigm, they not only believe that but refuse to look at any other evidence which would point to the contrary.

He concludes: "The race is on. Let the best emerging paradigm win."

Mark's post really got me thinking. Are the various paradigms-in-waiting mutually exclusive? Or do we see a grand unified theory on the horizon? My bets are on the latter. Here's how I see it:

To my knowledge, every brain scientist is operating off a genes-environment paradigm, which takes into account both biology and how we respond to the world around us. In the old days, psychiatry distinguished between biological causes to mental illness (such as neurosyphilis) and what they saw maladaptive reactions to stress and interpersonal relations.

This harkens back to the old mind-brain distinction. Since we lacked the tools to see into the brain, the first DSM of 1952 classified depression and schizophrenia and bipolar and the like as "reactions" rooted in neurosis or psychosis or personality rather than biology.

Biological psychiatry tipped over that Freudian paradigm, but in the process lost track of the fact that there was a lot of validity to Freud and his followers. Our behaviors are indeed shaped by our environment and buried traumas. The catch was that the only known therapy of the day - psychoanalysis - did not work for serious mental illness. Thus a paradigm ripe for tipping.

The biological psychiatry paradigm naively assumed we could simply find something wrong in the brain and fix it, with no regard to environment, without being able to pinpoint cause and effect. Thus an antidepressant for depression, a mood stabilizer for bipolar, and so on. The catch was that even magic bullets are problematic if someone has to contend with an abusive relationship or a toxic work situation.

The new brain science has broken down the mind-brain distinction. We now know that some of us inherit vulnerable brains that are prone to breaking down under stress, which in turn manifests as various forms of illness episodes and maladaptive behaviors. Those with more resilient genes are far more likely to take stress in stride. This new brain science validates the "diathesis-stress" hypothesis advanced during the seventies.

These discoveries cut across all psychiatric diagnoses and blur the categorical distinctions, spurring researchers to dig deeper into underlying causes (endophenotype) rather than the outer symptoms of phenotype. This demands a new approach to diagnostic psychiatry, which is more likely to come from outside the field rather than from within.

The new brain science has also revealed that the brain is plastic, capable of reshaping itself. In essence, the brain is software rather than hardware, and we can change the software to make us more resilient and better able to adapt to whatever life may throw our way. It also works the other way - that sustained stress and trauma can change our software for the worse.

Likewise, we can change our environment. If we know, for instance, that we have a genetic predisposition to alcoholism, we learn to avoid situations that put us at risk.

We now have a new model of the brain interacting with the environment and vice-versa, each capable of change, each capable of changing the other. Thus we see the beginnings of a grand unified theory waiting for the next Einstein, where Freud and biological psychiatry are reconciled, along with ancient precepts. Mind and brain are one, leading to new insights into behavioral causes and effects and possible treatments and therapies and self-help tools. This is already well underway.

Those operating within the current paradigm, who simply expect brain science to validate biological psychiatry can be regarded as intellectual dinosaurs. Their days are numbered, but they won't go down without a fight. Some form of Kandel's new science of the mind will emerge and maybe it will no longer be called psychiatry.

But this new paradigm, like all paradigms, will only be a temporary placeholder, awaiting a newer paradigm to unseat it, such is the nature of scientific discovery. Absolute truth will always elude us. The best we can do is proceed on the facts as we know them, with an assist from inspired speculation. This will yield us the best approximation of reality. That is, until a better one comes along.

Rerun - Clinicians: The Worst Purveyors of Stigma

Yesterday, in a blog piece on paradigms and psychiatry, I commented that the profession's major assumptions were under serious attack. In response, one of my favorite bloggers Willa Goodfellow posted two perceptive comments which led me to respond that psychiatry is operating under the fatally-flawed paradigm that they have to be the big know-it-alls. Smart patients with proven success are treated as anomalies to be ignored.

I could have written a lot more. Then it occurred to me - I already have. Following is a piece I published 12 months ago. Please read it in the context of yesterday's piece ...

In a previous blog, I mentioned an email interview I recently completed with I Am Bipolar.

"Have you ever experienced negativity or stigma from people who have become aware of your condition?" Michael, who runs the site, asked.

Hmm. Interesting question.

"Ironically," I replied, the worst stigma came "from clinicians and fellow patients, the very people who are also my best supporters."

Clinicians have long accepted me as a journalist. In 2007, in fact, they even honored me with a major international award. But I am not one of them and never will be. Last year, I was invited to give a grand rounds lecture at a psychiatric facility in Princeton. I accepted with some trepidation. It is not my place as a journalist to tell others how to do their jobs.

I showed up with a talk on medications compliance. I'm sure the 50 or 60 clinicians in the audience expected me to blame patients for being too stupid to work the child-proof cap to their meds bottles and such, and indeed I did touch on that. But I also blasted the pharmaceutical industry for aggressively marketing meds that often made us worse rather than better, as well as clinicians who should know better, at the expense of the individuals they are supposed to be serving.

I wasn't just some antipsychiatrist spouting off. My PowerPoint contained reams of citations from the leading psychiatric authorities, including conferences I had attended and first-rank journal articles and editorials. But it was also my duty to wrap it all up and tie it in a bow. With reference to the fact that over the long-term some 70 to 80 percent of patients either drop out of clinical trials or are in some degree noncompliant on antidepressants, mood stabilizers, and antipsychotics, I pointed out the obvious:

"Just sending a patient out the door with a prescription is not treatment."

I wasn't all negative. I mentioned how compliance rates could be improved upon by employing psychoeducation, support groups, various talking therapies, books, websites, and so on. But this did involve the need to build trust with patients and spending time with them, plus being proactive in referring them to other services and sources of information. Again, just sending a patient out the door ...

As soon as my lips stopped moving, the room emptied faster than a high school Latin class at the three o'clock bell. No one approached me for a polite handshake or to follow up on any points I made, or to request more information. Only one person bought my book.

As I said, it is not my place to tell others how to do their job, particularly when nothing I said could be interpreted as a pat on the back, and my discomfort clearly showed in my talk. But even taking all of that into account, I was truly amazed by the magnitude of this group snub. Had I a PhD or an MD or an MSW to my name, I would have been treated with far more civility. But I happened to be a journalist who was also speaking as a patient.

The biggest complaint I get from my readers, I said in my talk, doctors who don't listen. Boy, did they prove me right.

Future blog: Stigma from patients. Stay tuned ...

Me, Apollo 15, and the Future

The following is a continuation of Me, Captain Ahab, and the Anterior Cingulate Cortex:

The year - 1971. Location - the moon. After 23 hours with no sleep, Apollo 15’s two moonwalkers were back in their command module in lunar orbit, preparing for their return home. Back in Houston 240,000 miles away, ground controllers picked up anomalous EKG readings from one of the astronauts. Jim Irwin’s heart was skipping a beat, then beating twice rapidly. After communicating with Irwin, the flight surgeon at Mission Control diagnosed a specific type of heart arrhythmia known as bigeminy.

Had Irwin been on the ground, doctors would have treated him for heart attack. But it turned out that the command module, with a 100 percent oxygen atmosphere and zero gravity, was better than any ICU he would have been placed in on earth. His heart soon settled back to normal, and Apollo 15 later successfully splashed down without incident. A few months later, Irwin had a heart attack. Twenty years later, yet another heart attack killed him.

Fast forward to the present. Location - earth. An individual very close to me was admitted to a psychiatric unit, and, after careful evaluation, was diagnosed with depression and given an antidepressant. Following a second hospitalization, he was put on different meds and released. Soon after, he was back in the hospital.

Basically, this individual has broken brain disease, and if we knew exactly what part of the brain was broken and could link the malfunction to the symptoms he was experiencing, we would have an exact term for it and perhaps have a clue of how to best treat it. But diagnostic psychiatry in 2009 is no match for the diagnostic cardiology of 1971 - at least not right now it isn’t.

Part of what is holding us back is that mental illness is far more complex than cardiac illness. What brain scans are showing is something akin to a total system collapse in the brain, involving many interconnected brain regions, rather than a specific fault. The brain science is beginning to tease out subtle structural and functional distinctions across a range of diagnoses. But this is hardly equivalent to taking an X-ray, finding a bone fracture, and knowing exactly how to set the break.

Nevertheless, brain scans are providing us with a sneak preview of the future. In a famous set of experiments performed two or so decades ago, OCD subjects (ones obsessed with cleanliness) shared a brain scan machine with a "dirty" sweat sock. Their respective brain loops lit up like a Christmas tree. When exposed to a "clean" sock, their brains quieted down.

The anterior cingulate cortex (ACC), part of the mid-brain, contains specialized neurons responsible for “gating.” which allows the brain to focus on certain incoming information (such as a conversation) while tuning out others (such as the background hum of an air conditioner). When things go wrong in the ACC, all manner of bad things can happen, such as OCD or schizophrenia or depression.

Thanks to this knowledge, doctors were able to adapt deep brain stimulation (DBS), used for Parkinsons, to experimental (and still extremely rare) psychiatric surgery. In Feb this year, the FDA approved DBS as a last resort treatment for OCD. The procedure also shows promise for depression. In DBS, a metal lead is inserted through folds in the brain. An electric pulse breaks up neuronal signals (such as those responsible for distracting thoughts and ruminations) in the ACC region. Unlike earlier generations of brain surgery (such as cingulotomies) no surgical lesions are involved. The surgery is reversible, but does involve risk.

Let’s be clear on this: This is not a piece extolling the virtues of psychiatric brain surgery. Indeed, it is difficult to imagine psychiatry headed in this direction. But what we are witnessing nonetheless presents us with a tantalizing peak at what tomorrow may involve, namely:

It is foreseeable that advances in technology will make MRI machines, or some other brain scan technology, convenient and affordable and routine, equating to advances in computer technology.

In the meantime, we already have the means to do gene scans - the chips are getting faster every year. Now imagine the software to interpret data coming from a whole ranges of sources - gene scans, brain scans, psychiatric evaluation, neurological testing, etc - to give the treating psychiatrist a range of options to consider.

The following is wild speculation: Keep in mind that the dominant operating paradigm for mental illness is system breakdown, a host of things going wrong seemingly all at once. But suppose we could get a bit closer to the source - say the hippocampus (involved in memory) failing to boot up, say key parts of the frontal lobes going off-line, say certain stress pathways overloading. Say we were able to pinpoint various signaling bottlenecks and hubs.

Thus, depression is no longer just depression. In fact, once we get a true read on what is going on, we may call its manifold variations something entirely different. All this would suggest targeted treatments and therapies, even with today’s highly imperfect remedies. Perhaps a dopamine enhancer to kickstart a certain brain system rather than an SSRI. Perhaps talking therapy focusing on past trauma rather than directed at here and now challenges.

The long-term pay-off would be that this kind of knowledge would spur future drug development (namely smart meds) and further refine talking therapies. It could also open the way for pinpoint electrical therapies and who knows what.

Private investors would need to see the solid science - a clear idea of how to get from A to B to C - before they were willing to put their money on the line. The catch is this type of science is dependent on the public sector. Basic research into mental illness is notoriously underfunded as it is. For lack of will, then, we may be unable to see our way to the future, much less realize it. The Apollo program was supposed to signal the beginning of manned space exploration. We haven’t been back to the moon since 1972, nor do we have the rockets for it.

The future - so near, yet so far ...

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.

Where Dumb Psychiatry Meets Dumb Antipsychiatry

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?

Of Psychiatry and Antipsychiatry

In January, I asked readers this question: "What best describes your condition over the past 30 days?" Only 14 percent replied they were "back to where they want to be" or "better than they ever could have imagined."

This month, I'm asking: "How do you rate your meds in managing your illness?" So far, 82 percent rate their meds as either "most important," or as important as other tools. Only 12 percent ascribe little or no importance to their meds.

Do you perceive a discordance between the two poll results here? Granted, this is not a scientific survey. Nevertheless, the results beg the following question: Why do we place such great emphasis on meds, when obviously they are not living up to our expectations?

Or: Are our expectations so low to begin with that we have given up on ourselves?

Hold those thoughts for a second, then surf around to various patient/consumer/survivor/whatever blogs. You will note the vast majority have a decided antipsychiatry slant to them. Many of these blogs set out to expose the lies of the drug industry, which - believe me - are in abundant supply. Others have a much greater emphasis on helping their readers achieve recovery through non-pharma interventions.

Even blogs that find value in meds and psychiatry (such as this one) do so in the context of sharply critical enquiry.

It's as if we're all saying in unison to psychiatrists: We trusted you. We placed our faith in you (and apparently still do). But we're the ones who have to live with the results, and - let's put it this way - we're not exactly happy.

Simply put: If meds worked the way the drug industry and psychiatrists would have us believe, compliance rates would be nearer to 100 percent (instead of more like 30 or 40 percent over the long term), we would enjoy similar employment rates and stable relationships as the rest of the population, and mental illness would be in sharp decline rather than (apparently) on the rise.

Thus, there is a rational basis to antipsychiatry.

But life is never that simple. If we have to be binary in our beliefs, it's much more useful to think in terms of "smart vs dumb" than "pro vs anti." Far too many of us have been victims of dumb psychiatry. Similarly, dumb antipsychiatry (and there is an awful lot of it going around) can lead to disastrous personal decisions.

The antidote to both is "smart."

More on this in future blogs ...

When Your Meds Fail - Is Heidi Klum Lying?

Your life isn't going right. Your doctor diagnoses you with clinical depression and prescribes an antidepressant. The antidepressant doesn't work or partially works or makes you feel worse. What now?

The American Psychiatric Association in its 2000 Practice Guideline for treating depression suggests going with a different antidepressant. This recommendation is backed up by the NIMH-underwritten STAR*D clinical trial results of 2006.

Fine, but what about if your second antidepressant fails? The APA recommends keep trying, but STAR*D shows the success rates drop off dramatically at this stage. What gives?

For one, it may be time to revisit the diagnosis. Psychiatric treatment guidelines are based on the fallacy that your doctor has nailed your diagnosis on the first try. But, more commonly, those of us with bipolar tend to first get misdiagnosed with depression.

Even those correctly diagnosed with depression may be out of luck. Psychiatry tends to treat all depressions as alike, with one-size-fits-all antidepressants. There is, for instance, a clear distinction between chronic and recurrent depression, and a body of expert opinion that says antidepressants may be problematic for the latter.

This distinction is way too subtle for your average psychiatrist. But eventually they may wise up and try a bipolar diagnosis and prescribe a mood stabilizer (or antipsychotic). But what if a series of trials on mood stabilizers fail? Or only yields partial results? What now?

Way too many of us are struggling. Check out the poll at the top left corner of this page. At the time of writing this, of 58 people who have responded so far, 25 say they are stable but not well and 12 that they're in crisis or close to crisis. Only eight are where they want to be or feel better than they ever could have imagined.

This is where the frustrated clinician often starts blaming the patient. The meds are supposed to work. That pharm rep who looks like Heidi Klum said these meds work, and she wouldn't be lying, right? It has to be your fault.

Time to revisit the diagnosis? Again?

More in my next blog ...

Further reading from mcmanweb: When Your Second Antidepressant Fails

Noncompliance - Time for Psychiatrists to Practice Real Medicine

In my most recent blog, I mentioned a grand rounds lecture I delivered last year to a psychiatric facility on meds compliance. In the talk, I made two comparisons: 1) A psychiatric drug trial to a cancer drug trial, and 2) A hypothetical oncologist appointment to a psychiatric appointment.

The first clinical trial was an Eli Lilly trial of bipolar patients on the antipsychotic Zyprexa. These were patients who responded well to the med in the initial going. Despite that, 79 percent dropped out of the study after 48 weeks. Believe it or not, Eli Lilly actually found a way to put a positive spin on the findings.

This study is all too typical of long term studies on virtually all classes of psychiatric meds, with drop-out/noncompliance rates averaging about 70-80 percent. In one trial, 100 percent of the patients dropped out. In other words, no one finished the study.

The second trial I referred to was an AstraZeneca study of breast cancer patients on tamoxifen. In that study, 26 percent dropped out after one year, almost the exact inverse of the Zyprexa study. But rather than put a positive spin on the finding, AstraZeneca was so alarmed by the high drop-out rate that they stopped the study.

What is going on? Both drugs have horrible side effects, but one group of patients is obviously buying into long term treatment and the other isn't. Could the difference lie in what doctors are telling their patients?

Consider the gist of the message the oncologist gives to a patient:

"It's going to be hell, but there's an excellent chance your cancer will go away."

I made sure all the heads in the room were nodding on that point before proceeding to my next PowerPoint. Now here's what I know too many psychiatrists are telling their patients, I said:

"What are you complaining about? These meds work. Something must be wrong with you. You're much better off than you were before. You need to stay on these drugs for the rest of your life."

I sensed the hackles in the room rising, but plowed straight into my next PowerPoint:

"What the cancer patient may be thinking: One year of hell - if that's what it takes to get my old life back, I'm willing to put up with that.

"What I know the psychiatric patient is thinking: This is the best you can do? You mean I am going to have to spend the rest of my life - like this?"

By now, my audience of clinicians was turning into a lynch mob. But it was only going to get worse. Up until now, I had only been presenting the facts. Now I was about to tell this group of highly-educated and highly-experienced clinicians how to do their jobs:

There is the crucial "window of opportunity" phase in the doctor-patient relationship, I said. The patient has been brought out of crisis and has been reasonably stabilized, but is clearly not well. For many patients, a long hard road lies ahead. You have one chance to get your patient to buy into long-term treatment, and you need to be brutally frank about presenting the bad news along with the good.

First the bad news: These meds are not magic bullets. You may have to put up with significant side effects in the short term. It may take time to dial in your meds just right. You may not feel like yourself. You may want to quit altogether.

Now the good news: I am going to work with you on your recovery. As your knowledge and skills improve, I will be in a better position to help you. You will also be in a better position to help yourself. Trust me, there is light at the end of this tunnel.

So how did this go over? No sooner did I wrap up my talk than I was looking at empty chairs. Literally, it was as if the fire alarm had gone off.

I rest my case ...