Another Adorable Grandson Pic

Little Teddy, 3 weeks.

My Zombie State is Other People's Normal

On Saturday, I received an email from a friend:

"Two people have emailed me to see if you are alright. How would I know? Hypomania is rocket fuel for your work."

My blog was no busier than usual that past week, save for an animated comment thread. Okay, let's make that a really really animated comment thread. My immediate reaction was a defensive one. There they go again, I thought. Pathologize my behavior. Attribute every action of mine to my illness. Most of you have been on the receiving end of this - show the slightest sign of life, dare to crack a joke and actually look happy, and it must be hypomania. Bipolars are as bad as the general population - worse, far worse - in this regard.

I once emailed a friend with news that I had won a major international award, and, without offering her congratulations or even acknowledging my achievement, she replied that it sounded like I was hypomanic and I needed to be careful.

What the ... ?

Then I had to laugh. All the week before, I had been down for the count with flu symptoms. I had been sleeping 16 hours a day. I would emerge from the blankets only to walk about with the feeling of the inside of my head wrapped inside these very same blankets. I had no energy, I felt like someone three times my age, and my mood was in a slow glide south.

Trust me, had they been auditioning for a remake of Night of the Living Dead, I would have received a call-back for the lead zombie role. Yet, somehow, I had managed to crawl to the computer and crank out my standard quota of blog pieces (two involving the intricacies of diagnostic psychiatry), plus fire off a long round of zinger comments.

What gives? Yesterday, while out on a country walk (with a clear head!), I got thinking about my friend's email. It's easy, of course, to get a totally wrong impression when there is no face-to-face contact. But I could recollect no shortage of real life Twilight Zone experiences dating from way back.

For instance, in my college dorm room 40 years ago - again in a flu-induced zombie state - I responded to someone with a lame comment and the whole room cracked up. I got off a repeat rimshot-worthy one-liner, then another one. I was death warmed-over, but to the people in the room I was Don Rickles.

Twelve or thirteen years later - same state of zombie-hood - I was the steady hand who calmed down a room of anxious individuals. I could go on and on. Sometimes it's the flu. Sometimes it's depression. Sometimes, for no apparent reason, my head is not attached to the rest of my body. There are no guarantees. Often, when I feel out of it, I am really truly, totally utterly, out of it.

On the reverse side of the coin, when I am feeling on my game - that is when I need to watch myself. Frequently, I find myself looking at a sea of perplexed faces. And heaven help if I know I'm off my game and my anxiety takes over. You know those Southwest Airline ads: "Need to get away?"

Anyway, here I was, taking my walk, gazing out into the mountains, when it suddenly hit me in a flash:

My zombie state is the equivalent of other people's normal!

If I could only be a zombie, I could lead a normal life. Here's how it works:

Like a lot of you, I experience racing thoughts. Think of my brain as the UN General Assembly with an angry Khrushchev on every seat yelling wildly and banging his shoe on the table. But the flu or a depression or some kind of brain fog shuts down all those Khrushchevs in my head. There are no distractions. I can focus on the task at hand. I appear sharp and to the point. Of all the crazy things, I give the impression that I'm operating on rocket fuel.

All those Khrushchevs are the equivalent of too much stuff coming in - too much thought, too much emotion, too much sensory input. Since I happen to work in a field that places a high premium on creativity and intuition, I tend to regard this as a good thing. I need those Khrushchevs. They work for me, provided I can show them who's boss.

But too much of a good thing for me has a way of manifesting as bipolar or anxiety or panic or just plain weirdness. This is the downside of Khrushchev. Every once in a while, things get out of hand. For others, these Khrushchevs may show up as ADD, schizophrenia, some forms of depression, or just simply strange or inappropriate behavior.

These days, I am fairly confident in matching the right Khrushchev to the right occasion, so that what comes out of my mouth doesn't embarrass me. Far from it. These days, I actually get invited to places. Back in the old days, I could be counted on to pick the wrong Khrushchev, generally a strange weird specimen that had people backing slowly toward the exits.

What has changed over the years is that I have slowly learned to read subtle social cues and modify my behavior accordingly. I suspect this is true for most of you. These days, I feel fairly confident walking out the door. Back in the old days, I didn't risk it. I stayed indoors and isolated, which, of course, made me fair game for crushing depressions.

It's a strange world when showing up as a zombie shrouded in a protective depression is the state most likely to create the best impression for me. But when I'm feeling good, I often lack insight to know that I'm feeling too good for my own good. That's why I need to watch myself, and - more important - watch others.

"Knowing thyself" is central to "Knowledge is Necessity." Only through long introspection do we find answers and learn to ask the right questions. Consider this blog piece a long and involved question to all of you. I'm very interested in your answers. Please fire away by going to the comments below ...

Grandson Update

Little Teddy, three weeks old.

Thinking of Going Off Your Meds? - You Need to Read This First

Going off meds may be a sensible and responsible personal decision for you - with the emphasis on sensible and responsible. Tragically, too many of us opt for crazy and irresponsible. Whatever choice you make, first you need to be reading my friend Judy's book, which I very strongly recommend for anyone living with a mood disorder, including loved ones. This review first appeared on my website in 2005:

A sobering reminder of the heartbreak and hurt we can inflict on our partners comes through loud and clear in the poignant memoir by Judy Eron, "What Goes Up: Surviving the Manic Episode of a Loved One." Judy and her husband Jim, whom she had known for nine-and-a half years, were well on their way to realizing their dreams. They had uprooted from Tennessee to build their little hideaway in the desolately beautiful Big Bend region of Texas. There they planned to spend most of their time together in splendid isolation, but no sooner was their homestead ready for occupancy when Jim went off his lithium.

"It is a strange set of circumstances," Judy begins, "when a wife wakes up every morning wishing her husband would get severely depressed or arrested." Or has an automobile accident that sends him to the hospital or is caught running naked in the streets.

Anything that might take him out of his destructive mania.

By the time they reached Washington, their summer retreat from the Texas heat, Jim was already behaving strangely – first the pressured talking, then rudeness and impatience soon escalating into grandiosity, infidelity, dangerous behavior, and abuse. No one was going to tell Jim anything was wrong, least of all his wife.

Writes Judy: "If Jim had met another woman and fallen out of love with me, I could have coped somehow." Her life experience had at least prepared her for getting jilted by the proverbial blonde, but despite being a psychotherapist this was totally new. It was as if the mother ship had switched her loving and caring soul mate for an alien impostor somewhere out over the Texas desert. The eggshells she found herself walking on started to crack and she had no choice but to seek refuge in her friends and family.

Through an agonizing year she waited in vain for the crash that everyone said would happen or the 911 situation that would put him in the hospital. Or for Jim to come to his senses on his own. But the man she loved was far too in thrall to his "natural" self, even if that meant, ironically, trading his prescription drugs for recreational ones. Many a time Judy allowed herself to get her hopes up as the situation appeared it might resolve, only to end up bitterly disappointed. There was nothing she could do except take care of herself. Kay Jamison, herself, had told her exactly that. People in a state of mania, by definition, are out of control.

The book’s title implies that Jim must have come down. But we’ll never know that. He could have remained up. No one was around to see him crash. Judy assumes he must have, but mania has a way of turning on its victim, of creating an energized hell that leaves only one way out. One clear October day in the Texas desert – perhaps depressed, perhaps manic, most likely a combination of both - Jim took that only way out. It was an inevitability rather than a choice.

It was the Jewish Day of Atonement. At-one-ment. Jim had completed his tortured path to spiritual wholeness. For the woman he left behind, putting back the shattered pieces of her life was only just beginning.

Dealing With a Loved One’s Mania

Judy’s penultimate chapter is entitled "Woulda, Coulda, Shoulda." In a cruel twist of the knife, survivors inevitably end up blaming themselves for failing to respond with the impossibly precise measure of support, patience, compassion, confrontation, and tough love. As if they somehow foolishly left the eggs out of a recipe for baking a cake. In truth, Judy did everything she could have done, just like all survivors. There are no manuals, no guarantees.

Having said that, Judy does proffer some useful advice, based on her experience and research, principally:

• You should not try to deal with mania by yourself. Forge a strong alliance with a psychiatrist and build a support network.
• Know that you are dealing with someone out of control, who can no longer be trusted.
• Be ready to take responsibility for being the decision-maker.
• Look after yourself. Keep your life going.
• Read as much as you can about the illness.
• A manic person "will hammer on your weakest spots to bend you to his way of thinking, namely that he’s not sick."
• "Without a doubt, you will be abused emotionally. You may decide to bail out … You are only human. Love is powerful, but in the face of mania, it is not all-powerful."

You can purchase What Goes Up at Amazon or go to her website.

Airshow

Last weekend, a group of us rented a van and headed out to Edwards Air Force Base, scene of Chuck Yeager breaking the sound-barrier in the Bell X-1 in 1947. He did it again on Saturday, with an authoritative sonic boom, this time as a co-pilot in an F-16. He is 86.

Here are my home movies of the day. Enjoy ....

David Healy: But Is It Depression?

In a recent (and still ongoing) series on Robert Spitzer and the DSM, I touched on some of the history of the difficulties in separating out the diagnosis of depression from both bipolar and anxiety (part of what Freudians used to call neurosis). A different historical perspective is offered by David Healy MD (pictured here) of the University of Wales. I originally published this in an email newsletter back in Nov, 2003, and it has been featured on my website since Dec, 2003:

Consider these scenarios: A patient back in the seventies complains of "nerves" or anxiety and is sent out the door with a tranquilizer (benzodiazepine) such as Librium or Valium. A few years later, that same patient might be asking for Xanax for her panic attack. In the mid-nineties, we have the same patient with the same symptoms telling her doctor she has depression. Today, the same patient is likely once again to complain about anxiety.

Much of the credit for how we understand ourselves goes to the pharmaceutical companies, even if we don’t take meds, David Healy MD of the University of Wales said in a grand rounds lecture at UCLA on Oct 28, 2003 and webcast the same day. Upjohn (since taken over by Pfizer) pioneered the concept of marketing the illness rather than the drug, capitalizing on the DSM-III’s reclassification of anxiety into several disorders to push Xanax for panic disorder. In the mid-eighties, as the benzodiazepines became a focus of concern, the SSRIs in development were first seen as non-habit-forming alternatives to tranquilizers before they were targeted to treat depression. More recently, the SSRIs are returning to their original purpose, with the drug companies spending up to $100 million a year to promote these meds as "anxiolytics" (thereby distinguishing them from the bad associations of tranquilizers).

A thorn in the side of the psychiatric establishment, Dr Healy is the author of "Let Them Eat Prozac" and a dozen other books, has published articles on the suicidal side effects that some patients can experience on antidepressants, has appeared as an expert witness in legal actions against Prozac and Paxil, and recently sued the University of Toronto for rescinding an employment offer. According to Dr Healy, in order to create new markets for its products, the pharmaceutical industry ghost-writes much of the literature that appears in mainstream psychiatric journals, mobilizes expert opinion, designs its own drug trials, engages in extensive media campaigns, and underwrites (and even establishes) patients’ groups.

Dr Healy stressed to this writer that he is not hostile to the industry, simply stating that its influence needs to be recognized.

During the 1990s, Dr Healy went on to say, we converted cases that would have been treated by Valium and Librium into cases treated by Prozac, Paxil, and Zoloft. Back in the 1960s, an Eli Lilly print ad for a tranquilizer showed a young mom playing with her daughter. Another Lilly ad from the same period, by contrast, displayed the face of depression as an elderly woman. Back then, he reminded his audience, depression was regarded as a rare illness affecting mainly older people. In 1996, when the World Health Organization reported that depression was the second greatest source of disability on the planet, the reaction from psychiatry was not how did society become depressed so fast, but rather "we’re the second most important people in medicine after the cardiologists."

But this trend was far from universal, Dr Healy pointed out. During the nineties, the Japanese did not become depressed the way we did. Prozac is not on the market there [Note: this has since changed], and tranquilizer use remains vastly greater than antidepressant use. Most of the rest of the world, Dr Healy reminded his audience, follows the Japanese model.

Which raises the $64,000 question: Are we better off with antidepressants? The answer may elude us, if we follow Dr Healy’s reasoning. Randomized clinical trials, he says, were never meant to prove a treatment works. Rather, they are designed to show something doesn’t work, as in the case of a charlatan promoting snake oil. It is industry’s "greatest achievement," claims Dr Healy, to turn this around. Although he does prescribe antidepressants in his clinical practice, one senses it is with the confidence of one recommending a Tylenol for unexplained pain than an antibiotic to knock out a particular infection. Indeed, he concluded, if SSRIs worked for depression or anxiety the way antibiotics do for GPI (syphilis), we wouldn’t have the illness around anymore.

Don’t expect this guy to be the guest of honor at any industry-sponsored symposia.

More

In his UCLA grand rounds lecture, and in an internet article, Dr Healy gave several examples of how pharmaceutical companies influence medical and public opinion. One of these involved the company, Current Medical Directives (CMD), which ghost-writes and coordinates medical articles for its clients. As part of a legal action against Pfizer, Dr Healy obtained access to a document that listed the progress of 85 articles on Zoloft. Two articles in preparation related to Zoloft and PTSD, for which Pfizer was seeking a license. The authors were listed as "TBD," for "to be determined." The articles eventually appeared in JAMA and the Archives of General Psychiatry, with several academic psychiatrists credited as the authors. In a study published in the British Journal of Psychiatry, Dr Healy found that the 85 CMD articles were cited three times more often than non-CMD Zoloft articles. One hundred percent of the CMD articles reported favorable results for Zoloft vs 44 percent of the non-CMD articles.

Another example involved six academic articles on pediatric depression, with the authors hailing Paxil as "effective, safe, and well tolerated," despite clear evidence of suicidal thinking and behavior in some patients, greater than those on the placebo and comparison drugs. Since then, citing the same data the academic authors had access to, authorities in the UK have advised against prescribing Paxil to patients under age 18 while the FDA in the US has announced strengthened warnings on product labeling.

Postscript: In 2004, following two highly-publicized public hearings, the FDA announced that black box warnings advising of increased suicidal risk for non-adults would appear on antidepressant product labeling.

This Just In: We Are Sheep

The events leading to this blog piece started out as a joke. A good friend of mine dropped “dihydrogen oxide” into a conversation. Call me the sharpest knife in the drawer, because after ten minutes and 800,000 laps around the frontal lobes, I instantly got it. Dihydrogen oxide - two atoms of hydrogen, one of oxygen - is “water.”

A quick Google search turned up its more sinister cousin, “dihydrogen monoxide” (DHMO), also known as “water.” The Dihydrogen Monoxide Research Division has discovered that DHMO, among other things, is the enabling component of acid rain, the causative agent in most instances of soil erosion, is present in high levels in nearly every creek, stream, pond, river, lake and reservoir in the US and around the world, has been verified in measurable levels in ice samples taken from both the Arctic and Antarctic ice caps, and been found in the devastating Indian Ocean tsunami in 2004 which killed 230,000 in Indonesia, Thailand, Malaysia. and elsewhere.

According to Snopes.com, back in 1997, Nathan Zohner, a 14-year-old student at Eagle Rock Junior High School in Idaho Falls, based his science fair project on "the dangers of dihydrogen monoxide." Forty-three of 50 ninth-grade students favored banning it. The prank was based on previous circulated hoax petitions.

In an earlier blog piece, I had fun with DHMO’s more benign cousin, dihydrogen oxide, also known as “water.” Spoofing Oprah’s predilection for featuring wacko fad cures on her show, I introduced "The Dihydrogen Oxide Cure: Nature's Boner-Popping Miracle Answer to Depression, Aging, Heart Disease, Obesity, Wrinkles, Memory Loss, Impotence, and Just About Everything, Totally."

Among other things, I noted that dihydrogen oxide is natural and is found in all of nature, accounts for 60 percent of our body weight, and that without it we would die and all life on this planet would cease. I noted that people were achieving miracle results drinking it and even bathing in it, and that you could buy this miracle nature cure from me for just four dollars a bottle.

Oprah, of course, loved it and invited me back on her show. (Not really, that was a joke.)

In the Penn and Teller clip above, from an episode from their ShowTime series Bullshit, the two magicians dispatch a woman to an environmental gathering to collect signatures for a petition to ban dihydrogen monoxide. Hundreds of people signed.

It was tempting for me to sneer at these gullible sheep until I realized it could have been me. In an instant, what had been a joke to me turned serious. Okay, let’s analyze the Penn and Teller piece:

The woman fit right in with the crowd and thereby didn’t arouse suspicion. These were people at an environmental event, primed to lend a sympathetic ear to an attractive and earnest woman wanting to save the planet. My guess is that an older man wearing a suit and spouting corporate jargon would have received no signatures.

I’m also guessing that had Penn and Teller dispatched a redneck to a gun show with a petition to ban the author of this highly inflammatory and un-American piece of rhetoric, “that whenever any form of government becomes destructive to these ends, it is the right of the people to alter or to abolish it,” that he would have collected as many signatures.

The author, of course, is Thomas Jefferson, and the quote is from the Declaration of Independence.

About four years ago, I was in the studio audience for a taping of the Food Network’s hit show, Emeril Live. A major part of the production involved priming the audience for Emeril’s grand entrance. Loud music was played, a comedian warmed us up, and a stage manager with paddles in both hands (the kind ground crews use to guide 747s to their berths) played us like a puppet on a string. I swear, by the time Emeril made his appearance, had he or anyone else affiliated with the show instructed us to take off our clothes and swear allegiance to Rush Limbaugh we would have done so in a heartbeat.

Remember those Nuremberg Rallies? Hitler and his henchmen were master psychologists.

I encountered the phenomenon in my previous incarnation as a financial journalist some 20 years back. In contrast to classic economic theory that posits that marketplace behavior is rational and self-regulating, nearly every day I ran into examples of irrational behavior and out-of-control events. The strange thing is that the same person who would spend an hour clipping coupons to save ten dollars on groceries would not hesitate to entrust a stranger with $70,000 of hard-earned savings he or she might never see again.

There are various terms for the phenomenon: mob psychology, group-think, and so on. The only cure is a highly-skeptical mind. The catch is, as the Penn and Teller piece so vividly illustrates, that we all tend to let our guard down in situations where we feel comfortable and with people we think we can trust.

Con men and rabble-rousers thrive in these situations. They see us as sheep. Think it can’t happen to you? That it has never happened to you? Replay the clip. If you believe in environmentalist causes: Would you, in that situation, have signed that petition? Alternatively, if you don't believe in environmentalist causes: Would you, at say a gas and oil industry convention, have signed a petition saying global warming is a myth? Be honest now.

Is The Government Spying on Those with Schizophrenia Enough?

This from the Onion: The government needs to do more to help individuals with paranoid schizophrenia, such as implant devices in their heads so voices can tell them which bus drivers hate them and which manholes are covering up underground government prisons.

On a serious note, too many of us have bitter experiences of well-intentioned people charged with helping us doing the very opposite: Threatening restraints, not listening, telling us we will never work again, making us feel like outsiders ...

Have a good laugh, then when you're through laughing ...

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.

Spitzer and the DSM - Part V

Earlier installments in this series framed the creation of the modern DSM in terms of Kraepelin vs Freud. But is that truly accurate?

Robert Spitzer’s achievement represents a Nobel-worthy leap forward in the history of psychiatry, but his DSM-III was only meant to be a first installment to a work-in-progress, not frozen in time as psychiatry’s diagnostic Bible. Its present incarnation as the DSM-IV-TR of 2000 is essentially the same old 1980 book in a new cover.

There are many dangers to this. One of them is that the universal success of the DSM has entrenched its original errors. What may have started out in 1980 as a descriptive trial balloon by 1984 was unaccountably accepted as scientific fact, which by 1990 was regarded as wisdom of the ages. Now, in 2009, thanks to all the stake-holders invested in the status quo - insurance companies and so on - undoing these mistakes borders on the impossible.

For instance, a pharmaceutical company with billions riding on a new antidepressant does not suddenly want to find out that depression no longer means what it used to mean.

Previously, I pointed out that Spitzer was inspired by the pioneering German diagnostician Emil Kraepelin, who was born the same year as Freud. Unfortunately, Kraepelin was undoubtedly rolling over in his grave when the DSM-III was published. This is not an esoteric debate. The health and safety of anyone who has ever been depressed is riding on an accurate diagnosis, and unfortunately the DSM guarantees that won’t happen for a good many people.

It was Kraepelin who coined the term, manic-depression, but what he meant by the term was not a simple synonym for what we later called bipolar disorder. By manic-depression, Kraepelin also meant what we now call unipolar depression. Unipolar and bipolar could not so easily be separated out.

A later generation of researchers (including Jules Angst) did find a sizable exception. These were individuals who suffered from long-term and relentless “chronic” depression. These depressions contrasted with those who cycled in and out of their shorter-term “recurrent” depressions. To Kraepelin, recurrent depression and what we now call bipolar were part of the same manic-depressive phenomenon.

Contrary to conventional wisdom, an astute clinician does not need evidence of a manic episode to suspect bipolar in a patient. A history of recurrent depression is cause to probe for further indicators. Keep in mind, a patient never walks into a psychiatrist’s office complaining that he is feeling better than usual. Also keep in mind that when depressed, our brains trick us into forgetting what is was like to feel good, or, for that matter, too good for our own good.

Thus, unless a family member is present to remind her loved one to tell the doctor about the time he got a speeding ticket driving home from karaoke night with someone who wasn’t his wife, all the clinician has to go on is the patient’s current condition, along with his tale of woe.

During the seventies, expert opinion - led by Frederick Goodwin and David Dunner and others - favored Kraepelin’s approach. No matter how one chose to slice and dice manic-depression, the thinking went, it was crucial to draw a line between chronic and recurrent depression, and to recognize recurrent depression, at the very least, as a close cousin of bipolar.

So what happened? Spitzer and company did the unthinkable. They separated out recurrent depression from bipolar and lumped it with chronic depression. In addition, unless an individual cycled up into an extreme mania, he or she was deemed to have unipolar depression. (It took 14 years to get “bipolar II” with its less stringent hypomania threshold included in the DSM, and a strong body of expert opinion contends this does not go nearly far enough. Today, ironically there is extremely misinformed commentary that bipolar II is some form of new and unauthorized "expanded" version of bipolar. )

The result is that unless a patient is bouncing off the walls and ceilings, he or she is bound to be incorrectly diagnosed with major depression and be prescribed an antidepressant (this happened to me), which tends to worsen the condition. For those with bipolar II, a correct diagnosis is virtually impossible. Their lot is typically the frustration of years of antidepressants that don’t work or make them feel worse.

As for those with recurrent depression, forget about it. So might a mood stabilizer work on this population? Decades ago, lithium pioneer Mogens Schou found promising evidence. But thanks to the DSM, further research in this direction has been strongly discouraged, with pharmaceutical companies typically viewing all depressions as the same. (A notable exception was GSK testing Lamictal on a recurrent population.) Thus, we know that any given antidepressant will have some benefit on 50 percent of those who are depressed. The catch is we have no idea which 50 percent.

We can go on and on about all the DSM screw-ups just within the depression-bipolar sphere - its highly restrictive view of “mixed” states, its failure to account for anxiety symptoms, its bias toward finding depression in women - but let’s stop here. It’s enough to say the DSM, for all its good intentions, fails much of those deemed mentally ill much of the time.

Go to nearly any mental health website (not mine), and you will be treated to descriptions of depression and bipolar based on DSM-IV criteria (as in the screenshot on top). Read a book, glance at a brochure, take an online test, talk to your doctor - all DSM all the time. Spitzer, in the end, proved far too successful for our own good. But the fault lies with his successors, who failed to take corrective action, not necessarily with Spitzer.

Spitzer was a mold-breaker who inadvertently created a dogma as stifling as the Freudian Reign of Error he overthrew. What we now need to break the stranglehold of the Spitzer legacy is another mold-breaker - another Spitzer.

To be continued ...

Previous installments in this series:

Part I
Part II
Part III
Part IV