Thursday, February 25, 2010

DSM V and Mood Disorders, Part II -- How Did We Get Here?

Lost Creek Wilderness

Starting point -- Okay, the only way we get anywhere is if we understand very clearly who owns this map.  The pharmaceutical companies do.  It's their map.  Get over it.  This knowledge will help us steer a course, or maybe give them a nudge, or at least anticipate where they are taking us.

For the longest time, depression got no respect.  When they started using medication for schizophrenia, depression was still lost in the la-la-land of Freud's neurosis.  You could either talk it out over years on the couch, or you could snap out of it.   Medical advances in the treatment of depression came about by accident.

So back in the 1950's, Smith Kline and French (today GlaxoSmithKline) were making a killing on thorazine, the first med to treat schizophrenia.  It worked, but thorazine has so many side effects they list them alphabetically.  Other drug companies wanted a piece of the action.  Seeking to improve the side effect profile, they came up with the first tricyclics.  Tricyclics (Elavil, et al.) were a bust, as far as psychosis goes.  But they had an interesting new side effect -- mania.  Happy psychotics.  

Same time frame, different illness, MAOIs were developed to treat tuberculosis.  Again, not so effective against tuberculosis.  But suddenly sullen patients were skipping down the hallways and creating "discipline problems." Happy coughers.

Mile Marker #1 -- We have a whole new market for psychotropic medications -- depression.

These accidental discoveries drove research into the neurological mechanisms of depression, posing not the question, "What causes depression," but rather, "How come antidepressants work?"  Well, one of the consequences of taking these medications is an increase in the presence of neurotransmitters, serotonin et. al.

Mile marker #2 -- We have a simple, catchy sales pitch.  Depression isn't a rich lady's neurosis, after all.  It's a "chemical imbalance in the brain" -- just as diabetes is an imbalance of insulin.  Well, that's not an issue of character, as depression was thought to be.  (And still is, you will find out if you don't get better.)  It can happen to anybody.  And it can be fixed, too.  Take a pill, just as diabetics take insulin, and you fix the imbalance.

At this point, the neurotransmitter hypothesis takes us deep into our map.  Prozac and other SSRIs (Celexa, Zoloft...) were developed by tinkering with the basic concept behind tricyclics, again as attempts to improve market share by improving the side effect profile.  But SSRIs didn't really work as well as the sales pitch did.  The market share threatened to drop as "treatment refractory" patients ran out of new meds to try.  Meanwhile, pharmaceutical companies were running out of patent protections.  Along came SNRIs (Cymbalta, Effexor...), more tinkering.

By now marketing drove/drives the research.  The pharmaceutical companies were not interested in figuring out what is happening inside the depressed brain -- they thought they already knew.  Instead, they funded research into a jillion examinations of the same "chemical imbalance" and what their own medications do for it.

Mile Marker #3 -- The pharmaceutical companies, with their already developed products to market, take over research departments of universities and medical schools.  Research departments fund their way having their top scientists sign on to reports that they have not written.  A scientist will sign more reports than he or she has time to read, much less write.  The practice is called "guest authorship."  (In other academic departments, this is called "plagarism.")  Often the pharmaceutical companies contract out the writing or do it themselves, called "ghost authorship."  They write slightly altered reports of the same clinical studies, and flood the medical journals, who publish the seemingly different reports, neglecting their own publishing standards that call for disclosure of these practices and conflicts of interest.  

No, really. The ethics of medical journal publishing has become so problematic that the AMA (American Medical Association) convened a special forum five months ago to examine the issue.  The results of study after study on various practices in authorship and publishing demonstrate that this problem has not improved since it was raised in the mid-1990's and standards were developed.

What are the prospects for improvement in publishing?  I find particularly amusing/astounding/discouraging the report on Background, Training, and Familiarity With Ethical Standards of Editors of Major Medical Journals. "Although 86% of respondents were “confident” or “very confident” in their knowledge of scientific publication ethics when they began the survey, this number dropped to 71% by the end."  Indeed.  Because: "Performance on the editorial scenarios was poor; correct answers were given by 18% to the question on plagiarism, 30% to authorship, 15% to conflicts of interest, and 16% to peer review."

These are failing grades received by the editors of medical journals.  These are the people who decide which studies get published, what information is available to my doctor and yours.  Why does this matter?  Because reading journals is how my doctor and yours keep up to date, their continuing education after medical school.

So the science has gotten pretty bad.

And in the field of mental health, the pharmaceutical companies own it.  There is one sales representative for every five doctors.  This is the United States of America.

(You get better science, and different results, if you read the journals from Europe.)

Okay, getting us into this map has made for a long enough blog post.  Next week -- Mile Marker #4, and onward.

map of Lost Creek Wilderness made by David Benbennick
in public domain

Thursday, February 18, 2010

DSM V and Mood Disorders, Part I -- What's at Stake

Earlier this month, the American Psychiatric Association released the long awaited proposed revision of their Diagnostic and Statistical Manual of Mental Disorders (DSM-5).  It is available now for public comment, with an anticipated publication date for the final version in May 2013.  To call this the Bible of Mental Illness is to overestimate the significance of the Bible.

The DSM was first written to give clinicians and researchers a common vocabulary and a common understanding of the various diagnoses of mental illness.  John McManamy has related this history on his blog Knowledge is Necessity.  I refer you to his thorough account, found in the links at the bottom of his post. -- [Hey, John -- I recognized your image for "Few Surprises."  It was one that I considered for this post!]

The way the DSM works always reminds me of a Chinese menu.  For example, if you have one symptom from Column A and at least five from columns A and B, for over two weeks, you have Major Depressive Disorder.  You can upgrade your core diagnosis with specials offered alongside the basic menu.  These lists of symptoms provide a common vocabulary and simplify diagnosis, so that family practitioners commonly diagnose depression and prescribe antidepressants, without referral to psychiatrists.  This practice provides a boon to the pharmaceutical industry, which markets heavily to family practitioners.  If patients had to see a psychiatrist to get a prescription, fewer people would take antidepressants, since there is greater stigma attached to treatment by a psychiatrist, psychiatrists are in short supply in many parts of the country anyway, and health insurance plans provide inadequate coverage for psychiatric care. So family practitioners prescribing for depression sells more antidepressants.  Big Pharma wants to keep the DSM simple.

Over time, even as therapists have become more eclectic in their therapies, the sequence of DSMs has more narrowly defined the illnesses which therapists treat, adding more specificity.  The DSM gives a numerical identifier for each diagnosis, along with decimal points after the numbers to indicate variations and severity.  Health insurance companies rely on the DSM to determine coverage.  If you don't have a number, you don't get reimbursed.  But they have become concerned about the multiplication of diagnoses, raising the number of claims.  Health insurance companies want to limit the number of diagnoses and limit the number of people diagnosed.

Meanwhile, mood disorders (major depression and bipolar) represent 9.5% of the adult population in the United States in any given year.  18.1% of the adult population are diagnosed with anxiety disorders.  There is considerable overlap between these two groups.  This is a pretty big market for Big Phama, and considerable expense for the health insurance industry, notwithstanding the extreme limitations on coverage.  So the drug and health insurance industries are major stake holders in the revision of the DSM.

Given my own diagnosis, my interest and maybe yours falls in the mood disorder area.  The DSM V has the opportunity (and the charge) to incorporate changes in what we have learned about mood disorders over the last sixteen years.  One example would be the gender and cultural differences in how depression presents, which could alter that list of nine options from Columns A and B.  Another example is the results from the ongoing "chemistry experiment."  People, all of whom fit  the category of major depression, respond differently to treatment by antidepressants, depending on a more precise differentiation of their symptom profiles.  In this case, incorporation of new knowledge could improve prescribing practices and save lives.

Add patients to the list of stake holders in the revision of the DSM, along side the pharmaceutical and health insurance industries.  Guess who has a voice in the deliberations?

So what changes in the diagnostic criteria for mood disorders have been made from the DSM IV (publication date 1994) to the proposed DSM V (2010)?  Short answer -- practically none.

Okay, a couple changes.  The criteria acknowledge that children manifest depression differently than adults.  But among adults, white women continue to be the gold standard.

There is also a new diagnosis for "mixed anxiety depression."  This category was proposed for further study in the DSM IV.  It provides that all important number to those who fall just short of a diagnosis of both depression and anxiety, allowing the diagnostician to add the two scores together.

The price that patients will pay for the continued status quo is a continued cursory screening for Bipolar and Bipolar II ("Are you manic?" -- yes, that's what she said), followed by a quick prescription for antidepressants (Prozac by doctors who are paying attention to cost, Zoloft by those who are cozy with the sales rep), followed by dangerous side effects, and the triggering of mania or hypomania, followed by an acceleration of cycling, followed by out of control mental illness and disability.

Particularly disturbing is the failure to include new knowledge about Bipolar II.  The proposed revisions do not even keep pace with practice among psychiatrists who do listen to their patients' experience.  The evidence for a link between antidepressants and suicide is most compelling for those who are diagnosed with Bipolar II or those who could be diagnosed with Bipolar II, if the criteria shifted to include them.  The continued narrow definition leads to inappropriate treatment with antidepressants (translation: more sales of antidepressants), and deterioration, including a tripled risk of suicide.  That's pretty much what I said in my last paragraph.  And what I will say if I ever testify at a class action suit.

Get it?  People's lives are at stake.  That is "What's at Stake."

Okay, there is one significant change.  Bipolar II is diagnosed when Major Depression is accompanied by one hypomanic episode.  [Think "baby mania."]  The proposed DSM V does expand the criteria for hypomania.

Here is the text from the DSM IV: 

Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder.

And the proposed revision: 

Note: A full manic or hypomanic episode emerging during antidepressant treatment (medication, ECT etc) and persisting beyond the physiological effect of that treatment is sufficient evidence for a manic or a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess or agitation following antidepressant use) are not taken as sufficient for diagnosis of a manic/hypomanic episode.

This is a significant revision and supported by clinical experience.  Indeed, the most frequent path to diagnosis of Bipolar II goes through the path of misdiagnosis.  They figure out you have Bipolar II after you take antidepressants and all hell breaks loose.

What is wrong with this picture?

And why does the DSM V preserve this devastation of misdiagnosis?

See above, the identified stake holders.  "Guess who has a voice in the deliberations?"

And if you want a more thorough analysis of why I am so outraged, or if you are curious about other sections of the book as well, do check out John McManamy's work.

Next week:  Where I think we are going and how I think we will get there.

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Sunday, February 14, 2010


Thom is a long-time fellow traveler and now both a Facebook friend and Prozac Monologues reader.  He regularly posts on Facebook the latest segment of the ABCs of Spiritual Literacy.  Last week's entry was on Shadow.  Well, that hits me where I live.  My thanks to Thom for leading me to this post. 

This website presents one spiritual practice at a time, each in a similar format.  First it names what the practice enhances (in this case, wholeness) and what it balances (Pollyannaism/projections).  Then it moves to the Basic Practice and Why This Practice May Be for You, with links to books, films, art, prayer, imagery, discussion questions...

So here is the story on Shadow:

The Basic Practice:
The spiritual practice of shadow encourages us to make peace with those parts of ourselves that we find to be despicable, unworthy, and embarrassing — our anger, jealousy, pride, selfishness, violence, and other "evil deeds."

Kinda reminds ya of a therapy session, doesn't it?

University professor, author and fellow depressive, Parker Palmer is my favorite resource on shadow.  His book Let Your Life Speak has vocation as its central focus.  By "vocation" he means the call to be one's true self, not the self that one finds virtuous.  Ah, but the journey to the true self is treacherous.  He got there himself by traveling the road of depression.  He quotes Annie Dillard:

In the deeps are the violence and terror of which psychology has warned us. But if you ride these monsters down, if you drop with them farther over the world’s rim, you find what our sciences can not locate or name, the substrate, the ocean or matrix or ether which buoys the rest, which gives goodness its power for good, and evil its power for evil, the unified field: our complex and inexplicable caring for each other, and for our life together here. This is given. It is not learned.
(from Teaching a Stone to Talk)

Palmer continues: Why must we go in and down? Because as we do so, we will meet the darkness that we carry within ourselves—the ultimate source of the shadows that we project onto other people. If we do not understand that the enemy is within, we will find a thousand ways of making someone “out there” into the enemy, becoming leaders who oppress rather than liberate others. 

In his chapter on Leading From Within, Palmer writes of what makes people leaders, five virtues or strengths of leaders, and the shadows associated with each of these forms of light.  This is how I encountered Palmer, when I was creating a formation process for spiritual leaders in congregations.  We examined five virtues, things we all wished/hoped we brought to our leadership, their shadows and what we might find if we ride the monster down. 

The first shadow-casting monster is insecurity about identity and worth.  This monster is hidden by an extroverted or outgoing personality that hides its insecurity by creating settings where others are in the disadvantaged or less powerful position.  If we ride the monster down, we find that we are loved and valued simply because we are children of God.  We do not need to make others feel less so that we can feel worthy.

Well, let me pause right here and notice my own projection.  I can name half a dozen people to whom this applies, without pausing for breath.  It is harder to stay with it long enough to find this shadow in me.  I invite you, as I name the other shadows, to take the step deeper, to look within rather than without. 

A second shadow inside many of us is the belief that the universe is a battleground, hostile to human interests.  The strong competitor turns others into enemies that weren't there before the competitor's fear of losing created them.  Palmer asserts that death and loss are part of a circle of life, that harmony is the deeper reality, and that this spiritual truth could transform our lives and our institutions.

A third shadow common among leaders is “functional atheism,” the belief that ultimate responsibility for everything rests with us.   Those who take on the responsibility for making every good thing happen ourselves often end up with burnout, depression, and despair, when we learn that the world will not bend to our will and we become embittered about that fact.  When the load becomes so heavy that we have to drop it, then we can receive the gift of community, in which we trust that each will give and each receive. 

Palmer's fourth shadow within and among us is fear of the natural chaos of life.  Those who are organized can become rigid, imprisoning the organizations we lead, rather than liberating them.  Following the monster down, we learn that chaos is the precondition to creativity: as every creation myth has it, life itself emerged from the void. Even that which has been created needs to be returned to chaos from time to time so it can be regenerated in more vital form. 

The last shadow is the fear of failure or death itself that keeps the successful leader from letting go.  The best leaders in every setting reward people for taking worthwhile risks even if they are likely to fail. These leaders know that the death of an initiative—if it was tested for good reasons—is always a source of new learning.  The monster takes us down to the place where we can learn that death does not have the final word.  It is the source from which new life can spring.

So many of these shadows participate in depression.  Before we get to Annie Dillard's matrix... which buoys the rest, the monster takes us through the darkness that depressives know too well.  Here we touch a question both quietly pondered and hotly debatedIs there anything good about depression?

Palmer's point seems to be that going through the darkness is how we get to the light.  His personal story is one of finding his true vocation after depression deprived him of what he thought he should be doing.

Depression, like pain, can be good, if it is used for what it is good for -- telling us that something is wrong -- that we are hiding our insecurities at the expense of others, that our combative attitudes deprive us of peace, that we have false expectations of ourselves and others, that excessive control has stifled our creativity, that our fear of death is preventing us from being born again.

Those who ride the monster down have stories to tell to the rest.  We believe there is a link between our depressive personalities and our depth of thought, understanding and feeling.  We can rattle off the names of authors, poets, musicians and artists who have struggled with mental illness and sometimes lost, Hemingway, Scott Fitzgerald, Woolf, Mary Shelley, Plath, Whitman, Handel, Cobain, van Gogh, Ansel Adams, O'Keefe...

I have a friend who responds to this question with anger -- there is nothing romantic about this terrible disease that destroys minds and sometimes those who suffer from it.

It is time to distinguish between depression and Depression, one the feeling common to all thinking and feeling people, the other an out of control extreme that is caused by and causes further brain damage.  The Shadow is not the latter.  It is part of the human experience.  Everybody benefits by becoming mindful of its place in their lives.  While the disease is overrepresented among artists, perhaps every true artist rides the same monster down to find the truth expressed in his/her art.

I wonder, how often does the disease interfere with artists' creativity?  According to Ernest Hemingway who was there, when T.S. Eliot and F. Scott Fitzgerald were being wrestled to the ground by their personal demons, they were not writing.

I was going to say, "putting to one side the works that were not created because their creators were dead..."  But I can't say that.  We can't put suicide to one side.  That is the romantic garbage of which my friend speaks.  It calculates the value of artists for what they give us, their utilitarian purpose, not for their own sacred selves.

In my own experience -- my books lie unfinished, out of reach of this brain that the Grim has gone through with a paper punch for the last five years.  It takes me a week's effort to write a blog post, two sentences at a time.  The Shadow is something else.  It calls me to my self.  It shows me that I am of value, even with a brain that has holes in it, even if I have to lay down my work in formation of spiritual leaders, even if my books remain unpublished.  It brings me to the place where I am held in the hands of a tender God.

Even if I am still fighting it all the way down.
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Sunday, February 7, 2010

Release the Kraken!!

Well, it's one of those weeks in a remitting/recurring disease. "Release the Kraken!" -- my favorite line from Clash of the Titans, a 1981 movie to be remade and released this summer.  Oh, you gotta check out that link to the trailer!

My apologies to regular readers who are looking for a new post.  It's an interesting one, Shadows.  Maybe I will be able to write it next week.  Come to think of it, the image on the right would fit that post, too. (Anonymous, in the public domain for copywrite expiration). For now, here is a reprint from last July:

What is Depression, Anyway?

When I thought the meds would work, I didn't ask this question (referring to the title, not the caption!) Depression is a disease of the brain and also of the mind. The best results are obtained by working on both fronts. Take your meds. Talk to your therapist. Simple.

Then I discovered that the meds made me worse. Whenever I say that, I rush to say that, my experience notwithstanding, for most people they work. They can save your life. And then I rush to say, but not for everybody. If you think they make you worse, you might be right.

The rhetoric keeps shifting on this point, depending on what the speaker is selling. I
think the current prevailing stats are that the meds help half of us, harm a quarter of us, and for another quarter, they just don't work. And for most of us in any of those groups, the disease does go away on its own anyway, though it leaves its wreckage behind. But that is what I am gleaning from the research. Nobody in the scientific community has summed it up so simply.

Me, I am in the serious harm group, which has turned me into a dog with a bone. The bone is this one question, What the hell happened to me. I can't let it go, because I don't know what will happen next.

The popular understanding is that depression is a "chemical imbalance" in the brain. This simple formulation is the simple sales pitch for the simple solution, Prozac, to be specific, and then other selective serotonin reuptake inhibitors (SSRIs), and later serotonin norepinephron reuptake inhibitors (SNRIs). These meds (siblings and cousins -- they all address the same mechanism in the brain) were thought to be the single bullet solution for the single bullet problem, not enough serotonin.

SSRIs worked wonderfully for a while. They emptied the psych wards. They still work wonderfully for many. But over time the evidence accumulated, and eventually doctors started to believe their patients who claimed that the meds were not working, or had stopped working, or were driving us over the edge.

The people who believe in SSRIs have solved the pesky problem of the quarter of us who are screaming by coming up with a new diagnosis. We don't have regular depression, they tell us, we have Bipolar II. Which is a very effective way to shut us up, because Bipolar is a scary diagnosis that first flattens us and then drives us underground. While depression has less stigma than it used to have, Bipolar is as scary as ever, even if you add that "II." Plus, it opens up a whole other set of medical options, with side effects that are even less appetizing. Other options for the alternate label are anxious depression or depression, mixed state. They all mean the same thing: we fit the diagnostic criteria for major depression, but we go crazy when we take the meds for major depression. So the problem must be us, because it can't be the meds, which reduce suicidality, not cause it, notwithstanding the reports of people who are, after all, mental patients, and at risk of suicide anyway.

Here is the issue. Depression is a physical and objective illness in the brain that is diagnosed on the basis of symptoms that are subjectively experienced in the mind. Remission is defined in the same way, by self-report of subjective experience.

But it turns out, according to fMRI's, the brains of people who have been depressed
but currently have no symptoms work differently than those who have never been depressed at all. The physical manifestations of the illness in the amygdala and the pre-frontal cortex persist, even when the mental aspects have temporarily abated.

Regarding that chemical imbalance, if you artificially reduce the serotonin in a depressed brain that is on meds and in remission, you will cause a return of the symptoms. However, if you artificially reduce the serotonin in a brain that has never been
depressed, there is no depressive effect. So the physical evidence and the mental experience do not always coincide.

So what is depression, anyway? And why does it go away? And why does it come back? I might let go of this bone, if only it didn't keep coming back.

The brain is a complex system with communications channels and feedback loops that maintain homeostasis and interacting mechanisms that make it work well when it works well, and even repair itself when it is injured. The experiences of relapse and of "Prozac poop-out" seem to indicate that these mechanisms also maintain homeostasis when the brain does not work well, when the set points are set in ways that make us sick.

There are set points other than the amount of serotonin in the synapses. The early success of SSRIs led researchers to place all their eggs in the neurotransmitter basket and neglect the development of other approaches. We all loved that "chemical imbalance" idea that gave so many people permission to seek treatment, because it is so objective and suggests that there is physical evidence. The downside of the simple explanation is it has caused a lot of suffering for those who follow instructions and "keep trying" to find the med that works, when the whole idea behind the meds may be off base. And that suffering is compounded by suspicions of malingering from people who believe the sales pitch, that depression has been solved.

And what about therapy? There is evidence that it works, that it prolongs remission. But remember, remission is defined as the current absence of subjectively reported mental symptoms, not what is actually going on inside the skull. So how does therapy work? And then why does it stop working? My therapist thought I was still depressed because I wouldn't stop thinking certain thoughts. I said I couldn't stop thinking certain thoughts because I was depressed. Maybe that is the mental feedback loop. Sometimes my efforts to interrupt it work, sometimes for a long time. And then homeostasis reasserts its grip.

I like to think that each time I go under I learn new tricks for how to come back up. That's the good news. The bad news is that I can keep going down deeper, where the new tricks I learned last time don't work. I need a different relationship with my brain and the places it takes me.

I expect that scientists will spend the rest of my lifetime trying to make brains like mine work like the brains of non-depressed people, that some people will be helped in that ongoing chemistry experiment, and some people will be harmed. But the mystery will not be solved. And in the end, brains like mine will persist in being different.

Depression comes from a brain that works differently than the norm. I have a suspicion that it will be easier for me to find a way to survive being different than to find a way, whether through drugs or therapy or surgery or whatever, to get my brain to conform.