Happy Birthday, Abe Lincoln

I know tomorrow is Lincoln's birthday, but I have Feb 12 booked for Charles Darwin. So happy 200th, Abe, one day early.

As most of you know, our greatest President dealt with constant debilitating depression throughout his entire adult life. In the end, what didn't kill him ennobled him and steeled him for the grim task ahead.

This is one of the first videos I ever did. It is my tribute to a hero and saint, a man who has inspired me since I was old enough to talk. Enjoy ...

Is It Bipolar?

"Jane" writes: "My husband thinks he is bipolar. ... We can be fine for days at a time but then he gets upset over the smallest things. He always accuses me of flirting with other people that I'm friends with. ..."

Says "Jill": "My husband was diagnosed (kinda) with bipolar about two months ago. ... I'm not sure if he is just a control freak or if he truly has bipolar. Most of the time when he has an episode it is over something stupid. For example, one time I stayed at Walgreens too long. He put all my things in the yard, kicked me and his three children out of our home. ... Right now, he will not let me sleep in the bed (says it is his cuz he bought it before we got married) or use the computer ... "

"Sally" asks: "Do all bipolar people lie or is it just my husband? He will lie about anything, even trivial stuff. He told his work mates his father had died, not for sympathy. He didn't know why he had said it."

"Sue" wonders: "I have been dating my boyfriend for well over a year now and he has been struggling with bipolar and a heroin addiction. ... He is in denial and thinks that everyone is is crazy and he is the only sane one."

I come across many questions like this as an "expert patient" on HealthCentral's BipolarConnect. I'm not God. I'm not all-knowing. I cannot make problems go away. But I can address in a general way the numerous issues these questions raise:

First, abuse is abuse, whether bipolar-related or not. Bottom line: Whether a person chooses to break off the relationship or try to save it, no one should have to put up with abuse.

But is it bipolar? That seems to be the real question. It's as if these women are wanting me to reply in the affirmative. Please, I'm hearing, let it be bipolar. Let that be the cause. Finding a cause, of course, implies a solution.

If only life were so simple. Needless to say, the behaviors these women describe are not exclusive to people with bipolar. True, bipolar may be a contributing factor, but the real culprit may lie deeply embedded in the individual's personality.

It seems as more and more people are being educated about bipolar, the more willing they are to finger bipolar as the primary suspect for all manner of human failings. Cheating, stalking, anger, violence, verbal abuse, drinking, gambling, sexual promiscuity, fraud, unwillingness to communicate. Again, yes, bipolar may be a contributing factor, but these behaviors and others are endemic in society, independent of bipolar.

Loved ones, of course, need to ask these questions. So do those with a diagnosis, as well as those wondering if they are candidates for a diagnosis. Human behavior is very confusing. We want to know why things are happening, why our lives are going so badly. Then maybe we can change our behavior, or help change the behavior of those we love. Then maybe we can get our lives back in order.

Is it bipolar? Keep asking. But also keep asking: Is it something else? Believe me, even if bipolar is an answer, there is always going to be something else.

Snow!

I returned home late tonight from a meeting to find about a quarter inch of snow had infested our yard. What is wrong with this picture? I'm living in southern California about ten miles from the Mexican border, that's what.

But I'm 3,500 feet up in the mountains and once a year or so Ol' Man Winter really lets loose. The snow will be gone ten minutes after the sun hits it tomorrow.

Meanwhile, here's 24 seconds of video I shot six days before Christmas, a bit deeper into the mountains, about seven or eight miles from where I live. I like to refer to it as "optional snow." The type you can drive out to at your discretion.

Enjoy ...

Zen addendum, next morning: If the snow has melted when you wake up, has it really snowed?

The Bipolar Relationship Riddle

Later this afternoon, I will be making a 50-mile drive in the pouring rain to La Jolla in San Diego to attend a DBSA friends and family support group. It concerns a very bad communication I had last week with a former girlfriend. I really need to talk to some people who understand.

I have bipolar. Or more accurately, bipolar plus other stuff. I have yet to meet someone who just has bipolar.

My second marriage - to a very lovely women with bipolar plus her own collection of add-ons - ended just prior to Thanksgiving two years back. Then I had a short relationship with delightful cowgirl with bipolar (more pluses) that ended just prior to Thanksgiving a year back. Then a slightly longer relationship with personally stunning ball of fire (bipolar fully loaded) that ended - drumroll please - just prior to last Thanksgiving.

What is it about three Thanksgivings in a row?

I'm obviously no expert on relationships - in fact, call me a jerk - but my experience from both sides of the bipolar fence as a patient and loved one has conferred me with certain insights. In the six weeks this blog has been going, I have already posted two blogs on relationships, and intend to post many more.

The experts talk about "functionality," which is arguably a more reliable indicator of the severity of our illness than ticking off a symptom checklist. The two key indicators of functionality are work and relationships (keeping in mind we may choose healthy alternatives to both). Predictably, our population performs poorly in both categories.

Obviously, figuring out how to get it right is a fairly reliable predictor of recovery.

Think of the above as a preamble to this announcement: My favorite bipolar blogger, Therese Borchard of Beyond Blue is devoting an entire week to relationships. Here, she gives a rundown on what we can look forward to in future posts. Check out her first installment, You Deplete Me: 10 Steps To End a Toxic Relationship. Brief excerpt:

"Be prepared to dry off as you step out of the river of Denial. A few questions will get you there. Ask yourself these, for starters: Do I feel energized or drained after I spent an hour with X? Do I WANT to spend time with X or do I feel like I have to? Do I feel sorry for X? Do I go to X looking for a response that I never get? Do I come away consistently disappointed by X's comments and behavior? Am I giving way more to the relationship than X? Do I even like X? I mean, if X were on a cruise and I didn't know her, would I walk up to her and want to be her friend/boyfriend based on her actions and interactions with others?"

More later ...

From mcmanweb: Family Fallout

"The authors devote a whole chapter to mood triggers, and place strong emphasis on partners working together to reduce the stress in the living environment, from keeping work and social obligations under control to more discriminate TV viewing to proper diet, sleep, and exercise. ..."

Gray Whales!

Each year, some 26,000 gray whales migrate in small groups from the Arctic to Baha, Mexico to mate. The technical marine biologist term is spring break. From December to March, these magnificent mammals can be spotted in the waters off San Diego.

Yesterday, I hopped aboard a cruise boat with my movie camera and played nature photographer.

I'll let the video do the talking. Suffice to say, the sight of one of these leviathans breaching the surface transcended all my expectations. Enjoy ...

Do Antidepressants Work?

In 2002, the July 2002 Prevention and Treatment published a study by Irving Kirsch PhD of the University of Connecticut. The study analyzed the FDA database of 47 placebo-controlled short-term clinical trials involving six antidepressants. These included "file drawer" studies, ie trials that failed but were usually never published.

The study found that the mean difference between the drug and placebo was a "clinically insignificant" two points on the HAM-D depression scale.

In other words, going solely on these data, there is no rational basis for choosing to take an antidepressant, much less for doctors to be prescribing them.

There are two main arguments to rebut this conclusion, both raised in an editorial in this month's American Journal of Psychiatry. In the editorial, Sanjay Matthew MD and Dennis Charney MD (both of the Mount Sinai School of Medicine) use findings from the NIMH-underwritten STAR*D real world clinical trials in support, namely:

"Mean" data is misleading in that it fails to parse out those populations who truly benefit from an antidepressant as opposed to those who don't. Clinical observation reveals that for certain patients an antidepressant is a Godsend. The catch is we don't know in advance which patients are more likely to respond.

STAR*D made an attempt at this, finding, amongst other things, that depressed people with anxiety or substance use, those with melancholic features, and those with a certain gene variation fare less well on antidepressants.

STAR*D also demonstrated the value of switching to a second antidepressant if the first one fails. The study showed that while at least half those in the study did not achieve a good result on their first try, according to the AJP editorial: "Patients who completed all phases of the study had an overall cumulative remission rate of 67%."

The editorial, however, failed to point out a major catch, namely that the 67 percent remission rate is theoretical, fully acknowledged by STAR*D. In the words of STAR*D's authors:

"The theoretical cumulative remission rate is 67% ... Note that this estimate assumes no dropouts, and it assumes that those who exited the study would have had the same remission rates as those who stayed in the protocol."

Ah, drop-outs. In the words of Holly Swartz MD of the University of Pittsburgh addressing a symposium at the 2006 American Psychiatric Association annual meeting: "If a patient doesn't stay on it, it doesn't do any good, even if it works."

The Kirsh study found a mean drop-out rate of 63 percent in it's review or clinical trials. This finding corresponds to other studies. In STAR*D, of 3,671 who entered the study only 123 made it to Round Four (keeping in mind that those who did well exited at earlier rounds).

Commenting on STAR*D, in a recent blog, Nassir Ghaemi MD of Tufts University noted that:

"Even if antidepressants worked in the short term (2 months, which is also what the meta-analysis assessed), one-half of patients who stayed on them relapsed into depression within one year. At the one year outcome, only about 25% of patients actually had remained well on and tolerated an antidepressant, much below the levels most clinicians seem to feel occurs in their clinical experience."

So what can we learn from all this?

First, beware of the exaggerated claims of the pharmaceutical industry and psychiatry. Also, beware of those making negative claims. All sides in this debate excel at spinning data.

Second - assuming you are not suffering from bipolar or a depression that behaves like bipolar - it is rational to choose to go on an antidepressant. Antidepressants may not work for everyone, but you may be one of the lucky ones.

Further, if your first antidepressant fails, it is worth persevering with a second or even a third antidepressant. Assuming you do not give up, your theoretical chance of success is two in three.

But also keep in mind you may find these meds intolerable and that relapse rates are high. They work in some cases, but they also disappoint. To conclude with Dr Ghaemi:

"We could all wish that clinicians' beliefs about antidepressants were true, or even half true. And perhaps they are the latter, for these agents surely have some uses in some settings; they are just not the dream drugs they seemed to be. ..."

From mcmanweb:

When Your Second Antidepressant Fails

The paradox: Perhaps if we don’t expect much of our antidepressant, we can get much better results.

Clinical Trials - What the Drug Companies Don't Report

So what is the most meaningful figure in an antidepressant trial? Apparently not the response rate, not the remission rate, not the Hamilton Depression scores. It's the drop-out rate, way too high whether going by industry figures or the FDA database. Clearly we are sending an unequivocally strong message that our medications leave much to be desired. Are any drug companies listening?

Does Bipolar Kill?

I recall attending my first-ever bipolar conference in Pittsburgh in June 2001. Robert Post MD of the NIMH informed us that those of us with bipolar can expect to die seven years earlier than the general population, independent of suicide.

A year or two later, I heard Ken Duckworth MD, then in the employ of the state of Massachusetts, relate an anecdote to a NAMI convention that ended in a colleague telling him, "You guys really know how to put on great memorial services."

This month's Psychiatric Services features a review of 17 studies involving 331,000 bipolar patients. The study found mortality from natural causes ranged from 35 percent to 200 percent higher than comparison groups. The rate is similar to that of smokers.

The study yielded no smoking gun, but its authors single out the usual suspects, including:

Stress - Stress is complicit in just about every mental and physical catastrophe, from flipping us out to stopping our hearts. Researchers have connected a range of dots - from genes that predispose our limbic systems to over-reacting to whatever life throws our way to cortisol released into our blood streams to over-excited neurons resulting in cellular breakdown. A very strong case can be made that all mental illness results from stress, as well as its corollary - the best way to manage mental illness is to manage our stress.

Risky lifestyles - Including smoking, drug and alcohol use, poor diet, and lack of exercise, not to mention lonely lives in toxic living conditions.

Our meds - Patients have been telling their psychiatrists since Day One that they don't enjoy being fat stupid zombie eunuchs. But only recently, on the heels of the NIMH-underwritten CATIE studies from a few years back, is psychiatry waking up to the fact that our meds may in fact kill us, particularly in regard to the metabolic effects of certain second-generation antipsychotics. Smart meds strategies may work wonders. Too many of us are exposed to dumb ones.

Bad health care - GPs and others tend not to take seriously patients they view as crazy, combined with the inability in some patients to effectively communicate with their doctors.

Bipolar kills. So do depression, anxiety, schizophrenia - you name it. Actually, death wins regardless of whether or not we have a diagnosis. No exceptions. But we don't have to sit around waiting for the inevitable. We can still make choices. Live long and prosper ...

We Have Competition!

It seems there are THREE singing bipolar bloggers!

Followers of "Knowledge is Necessity" and Beyond Blue are well aware of the Bipolar Singing Blogger Smackdown between yours truly and Therese Borchard.

Therese got off to a flying start with her "12 Bipolar Days of Christmas" video, but I came right back rappin' to "Gonna Build Me a Tree." (See "The Bipolar Singing Blogger Smackdown" here at "Knowledge is Necessity" and on Beyond Blue.)

In the next round, Therese and her smiley faces thought they had me smoked with "A Few of My Favorite Things," but me and my gorilla homey, we were ready with my bluegrass "Recovery Anthem."

In the process, I invented a new hybrid music form that combines the worst of bluegrass and rap - "bluecrap."

Now Therese informs me we have competition - serious competition - Giannakali of Beyond Meds. One quick listen and you will realize that Giannakali and her canine homey have put my sistah Therese and me on serious notice that we need to lift our games.

Otherwise it's Metamucil and retirement for us.

Okay, Giannakali and homey: You may have wiped the floor with my face this round, but next time I'll be ready. Therese, too. You may think you have your howls and yowls down pat, well I got news for you - I have a didgeridoo that I can't play. You just wait.

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?

High Wire Act

It was a nice relaxing walk - a quarter mile in the air over New York City.

Last night, I watched "Man on Wire," a 2008 documentary about Philippe Petit's improbable 1974 tightrope walk back and forth between the two World Trade Center towers.

Phillippe Petit had already accomplished similar (and illegal) feats between the towers of Notre Dame Cathedral and the Sydney Harbor Bridge.

As the documentary makes clear, pulling off the World Trade Center caper was equivalent to plotting and executing a bank heist. Months of planning, reconnaissance, and rehearsal went into the operation. On numerous occasions, Petit and his accomplices snuck into the towers as they were under construction. Sometimes in the dead of night. Other times during the day, posing as contractors or journalists.

Then, one muggy August night, two separate teams hauled up their equipment, eluded security guards, and strung their wire and its moorings across the chasm.

The operation was not exactly flawless. Petit and his accomplices were amateurs performing the job of professional criminals, and things went wrong. Several times, the mission came close to being aborted. Then, just about dawn - with barely a second to spare - the team on the other tower radioed that they had secured the wire.

It was now or never. Petit stepped out onto the wire - and suddenly he was in his element.

During the bank heist phase of the film, the main soundtrack theme was Greig's "Hall of the Mountain King." Now, suddenly it was the dreamy piano music of Satie's "Trois Gymnopedies."

Get this - now that Petit was back to doing what he was good at doing, he could RELAX. The hard part was over. Walking - make that dancing - a tightrope 104 stories above Manhattan traffic, piece of cake.

The brain is funny that way.