In the Bleak Midwinter

For Prozac Monologues readers whatever your state this holiday.

In the bleak mid-winter frosty wind made moan,
Earth stood hard as iron, water like a stone;
Snow had fallen, snow on snow, snow on snow,
In the bleak mid-winter long ago.

Bohemian Chanukah

A great miracle happened there.


Happy Hanukkah to all Prozac Monologues readers.
Let the light shine!

Holiday Shopping for True Happiness

Last minute holiday shopping -- I shop later and later every year. I even blog about it later each year. This year I have to do three  blogs in the week to get my shopping guides for the perfect Chanukah/Kwanzaa/Christmas present done. Here is the link for if you are mentally interesting and shopping for the normal in your life, here is if you are shopping for your diagnosed friend.  The second is even diagnosis specific. The most popular pick turns out to be a bluetooth phone for the one who talks back to his/her voices, but is trying to pass. Who knew.

But less than a week, people. Internet.  God bless the internet.

Another year I wrote a post on happiness. This post's holiday shopping picks (a updated rerun from 2011) gets to the heart of it -- where to get what makes for true happiness on the internet.  No, really!

Holiday Shopping - The Mentally Interesting Version

From December, 2009:

A friend once described what it was like to have cancer. Like having a paper bag over your head, you can't see anything outside the bag. It's all about you and your cancer.

Mental illness can be like that. Try it yourself. Put a bag over your head. Make sure it's not plastic! Do you even notice a difference? Our issues can be all consuming, our fears, doubts, grief, hysteria, voices... We lose track of the world outside our paper bag.

But outside that bag are friends, family, allies. There are more of them, and they are truer to us than we can imagine when we are inside that paper bag. The bag, our absorption in our own concerns, makes certain life skills difficult.

Like holiday shopping.

Holiday Shopping for Your Diagnosed Someone

Black Friday, the traditional start of the Christmas, Hanukkah and Kwanzaa shopping season has left us in the dust. Are you still wondering what to get for your neuro-diverse friend or relation? Here is Prozac Monologues' attempt ever to be helpful to my dear readers.  As my therapist said, Virgo -- your destiny is service.  Get used to it.  (I once had a therapist who said stuff like that.) The following is a holiday shopping list to guide neuro-typicals who want to please their loved ones.

This is a repost from ten years ago. So the pricetags have probably changed. But the links have been checked.

Crazy Meds can be your one stop shopping for Straight Jacket T-shirts, when you're crazy enough to let your medication do the talking, with a range of messages for any diagnosis, medication or level of in your face. The lettering is made by arranging real medication capsules for that homemade, from the heart touch. If you are shopping for me, medium size, long-sleeved, and black, of course.  My favorite message: Bat Shit Crazy.  In three years nobody ever took the hint, so I finally bought it myself.  If you are shopping for me, today I'll go with Mentally Interesting.  I'm still into black, and still refusing antipsychotics, so still a medium.

The following gift suggestions are targeted to differential diagnoses.

People With Schizophrenia Who Recover

Among the top five factors that limit recovery for people with mental illness:

The false belief that it's all about the medication.

Medication indeed is part of mental illness recovery. It's a bigger part for some mental health issues (like schizophrenia) than others. And its effectiveness varies from drug class to drug class.

I created a bit of a twitter storm when somebody tweeted: Please quote this tweet with a thing that everyone in your field knows and nobody in your industry talks about because it would lead to general chaos.

To which I responded: Antipsychotics cause loss of brain matter.

 Last week's post described the research study that demonstrated that claim. The study was led by Nancy C. Andreasen, MD of the University of Iowa Carver College of Medicine. One should not reject antipsychotics on the basis of the study. They do what they are supposed to do. They reduce the positive symptoms (like, psychosis) that cause so much suffering. Payoffs and price tags. But they don't do the whole healing.

I continue this week with a broader picture, the what else of recovery in schizophrenia. This post was first published in 2013 with the title:

Fabulous People with Schizophrenia

Antipsychotics and Loss of Brain Matter

What are antipsychotics doing in your brain besides preventing psychosis? This is a report on a study conducted from 1991 to 2009 that looked at that question.

Here is the context:

Progressive brain volume changes in schizophrenia are thought to be due principally to the disease. However, recent animal studies indicate that antipsychotics... may also contribute to brain tissue volume decrement. Because antipsychotics are prescribed for long periods for schizophrenia patients and have increasingly widespread use in other psychiatric disorders, it is imperative to determine their long-term effects on the human brain.

Before I get to what the study revealed, here is the investigator, National Medalist of Science winner, Nancy Andreasen.

Giving thanks for Jerod Poore

Jerod Poore is the walking, talking, tweeting, posting wikipedia of all meds psychiatric and neurological. His manifesto: At Crazymeds [his original website] we make psychiatric and neurological conditions (AKA brain cooties) our bitches with evidence-based medicine and a healthy dose of gallows humor.

When I caught brain cooties fourteen years ago, Jerod was the first person I found who gave me genuine information. When the docs turned my brain into a chemistry experiment, Jerod told me what was happening to it.

That's the sketch I drew of my brain on drugs. Not the drugs they warn you about, but the drugs they scold you for refusing to take. Prozac, Celexa, Remeron, Cymbalta, Effexor.

Giving Thanks for Ellen Frank

If you can manage one, just one self-care exercise for bipolar, make it a regular sleep schedule. This week I am thankful I found Ellen Frank and IPSRT, Interpersonal Social Rhythms Therapy.

IPSRT in a nutshell: people with bipolar have a wonky internal clock. The hormones that regulate everything from when we are alert to when we are hungry to when we are cold are governed by an internal clock. When that clock sproings a spring, so do we. Bipolar is like jet lag on a daily basis.

There are a number of events that set and reset the clock throughout the day. If you have a wonky clock, you can reduce the damage it does by making sure these events happen the same time every day. That is the Social Rhythms part. The Interpersonal part is plain old therapy, focussing on whatever issues prevent you from protecting your clock.

Keeping this clock set correctly is the single most effective strategy for maintaining good sleep patterns. And sleep patterns are almost the whole show. Disruptions cause cascading effects: increased inflammation, cognitive difficulties, irritability, emotional lability, depression, hypomania, mania, all three, weight gain... Somebody has probably written the book. I will write the testimonial, that when my sleep is in order, so am I. Ellen Frank focussed my attention on that #1 strategy. When the meds didn't work, she saved my butt.

Several years ago, I wrote the more detailed version of IPSRT in a review of Frank's Treating Bipolar Disorder, three posts to explain the theory and one summary review. So here it is reposted, with links to the earlier posts within it. 

Treating Bipolar Disorder Part IV -- Summing Up
May 4, 2011

Intending to review Ellen Frank's Treating Bipolar Disorder,  I spent most of April describing the treatment itself, Interpersonal Social Rhythms Therapy, IPSRT.

Part I laid the foundation in work done on the relationship between circadian rhythms (our interior physiological clocks) and mood disorders.

Part II outlined Frank's Social Zeitgeber Theory and the treatment that proceeds logically from it, a process of establishing regular daily rhythms that set our interior clocks and keep them running on time.  (Zeitgeber means timekeeper.)

Part III explained how work on interpersonal issues helps people reduce stressors and prevent disruptions to their social rhythms.

This last post will pull together my appreciation, my reservations and my hopes for future directions.

Social Zeitgeber Theory

Frank builds IPSRT on the theory that people with bipolar are more vulnerable than others to disruptions in our circadian rhythms.  When our interior clocks get screwed up, we do, too.  Daily events, like getting up at a certain time, seeing people, going to work, set our circadian rhythms.  The core of the therapy is to help keep our rhythms regular.

The best brilliant part of Treating Bipolar Disorder is this theory.

A good theory accounts for as much of the data as possible, and then provides a way to solve problems.

The old theory is bipolar is a chemical imbalance in the brain.  The advantages of the old theory is that it is simple, it suggests a way to solve the problem, and it is earning the pharmaceutical companies billions and billions of dollars.  The disadvantages are that decades after it was first offered, it has offered false hope and subsequent despair to millions of sufferers, focused blame on those who won't take the drugs that make them sick and/or don't work, and for a majority of people who receive the best pharmacotherapy possible, simply failed to fix the problem.  It also neglects a lot of data.

The chemical imbalance theory comes from the data of clinical experiments -- that symptoms go away when you change the chemical stew.  Or at least, they go away enough to get FDA approval for marketing claims.  It does explain a piece of the puzzle.

But another set of data has to do with what was going on before the symptoms developed.  Frank and company turn to circadian rhythms to account for how the chemical imbalance developed.  And here there is a wealth of data.  For example, study of circadian rhythms reveals that lack of sleep causes depression as often as it is caused by depression.  This suggests a whole other way to solve problems.

Treating Bipolar Disorder documents this evidence in support of the theory.  Most of the book then describes the therapy that derives from the theory.

People With Bipolar Who Are Doing Well

The Social Zeitgeber Theory accounts for the data of those with bipolar disorder who are managing their symptoms, working, thriving over the long haul.  There are almost no studies done from this angle -- what people are doing to stay well.  John McManamy reports on two of these studies at  Healthy lifestyle is the top strategy for these people, particularly maintaining good sleep.  Most, 85% take medication, but do not make medication the center of their self-care.  None rely entirely on medication to stay healthy.

Medication, Medication, Medication

My chief reservation about the book has to do with its assumptions about medication.

Let me put it this way.  It is a bold move to list the uses of specific medications in a hard copy printed published book.  Chances are that such a book will report positively on a medication for which the manufacturer then settles a class action suit in the same year as publication.  Zyprexa/olazapine is just one example of how quickly the chapter's information became debatable and/or dated.

Frank assumes that IPSRT is an add-on to pharmacotherapy.  She notes that lithium, the miracle drug that was supposed to have solved the problem of bipolar has turned out not to have done so in near as many cases as people think.  She acknowledges that there are problems with side effects and efficacy for anything that is currently in use.  But just barely.

Unfortunately, it is only a minority of patients with bipolar disorder who can comfortably take the medications that seem to control the symptoms of the illness and who are willing to submit to this control.  Especially early in the course of the illness, before it has wrought complete havoc in the patient's life, there is denial that there is anything permanently wrong and a longing for the highs that the medications take away.

Yup.  There it is.  Ellen Frank, too.  They miss their highs.  I won't go there right now.  It's just too tiresome.  But stay tuned...

Frank continues the clinicians' tradition of oversell.  She considers whether a clinician should refuse to work with a person who has bipolar I and does not take medication.  Her recommendation is that the work might proceed anyway, with the goal of revisiting the issue at every opportunity until the patient finally does take meds,and holding open the possibility that treatment may be terminated if the clinician concludes that he/she cannot accept responsibility for somebody who is not on meds.

Okay, on a positive note, Frank pays more attention to side effects than other clinicians, repeatedly urging that the therapist and prescribing clinician work in partnership, and that medication problems be addressed.

On a very positive note, Frank spends a lot of ink on the issue that people with bipolar I or II spend way more time depressed than manic and hypomanic.  And our depressions are far and away the part of the illness that disables us.

Can We Ever Crack This Medication Nut?

This medication debate never seems to get anywhere.  Like abortion or the Palestinian issue in US politics, nuance is not allowed.  You're either pro-med or anti-psychiatry.  And I can feel myself drawn into the blogosphere's quicksand.  So let me do the down and dirty on Frank's position and get out of here.

Frank's assumption that everybody who has bipolar I and not on meds is a trainwreck waiting to happen -- maybe that is a necessary evil to maintain her professional credibility; maybe more of the usual professional wishful thinking: I call it disappointing.

Frank's repetition of the old they miss their highs thing: I call it tiresome.

Frank's concern to take side effects seriously and her criticism of the standard practice of medicating people with bipolar into a permanent state of mild depression, treating anything approaching a normal feel-good state as a danger sign of impending mania: I call that refreshing. 

Clinical Language Alert

I have spent the last several years reading books and articles written not for me, but about me.  It is a perilous business.  Prozac Monologue readers occasionally are on the receiving end of my efforts to manage the consequences of this endeavor.  It is getting less perilous, as I learn some skills, the first of which is simply to acknowledge the intended audience.  So...

Treating Bipolar Disorder is written for clinicians and about people with bipolar.  I am not a clinician; I am a person with bipolar.  Therefore, Treating Bipolar Disorder is not for me; it is about me.

If you are like me, you need to take this into account when reading this book.

Having said that, this book is less perilous than others.

Yes, there are a couple bumps in the road: the bipolar temperament, the attitude of entitlement and they miss their highs.  For the record, Frank never uses those exact words.  Her exact words are above.

On the other hand, this book is exceptional in its tone of respect and genuine partnership between clinician and patient.  Absolutely exceptional.  Props to Ellen Frank.

The Future Of IPSRT

Like I said, this book was written for clinicians, who are addressed directly.  It was not written for people who have bipolar disorder, nor for a general audience.  There is no book, no pamphlet, no article, no website, no youtube that describes IPSRT for a general audience.  Prozac Monologues is as close as you get.  Not enough for a do-it-yourself-er.  But a start.

At this point, getting access to this therapy would be a trick.  If you use one of those Find a Therapist websites and actually do find one in your area whose interests include bipolar, you are still likely to get the response I got, The way to treat bipolar is with medication.

Frank and company keep track of those they have trained.  She says maybe she should develop a website.  A lot of people think maybe they should develop a website.  Most of them have many other things to do.  I wouldn't hold my breath.  I would write her directly and ask.  And then come up with a do-it-yourself strategy.  I have one outlined below.

Frank has the support of NIMH's STEP-BD study giving IPSRT the magic label of evidence-based.  So she has a therapy, a book, a training.  And 5,700,000 people who could benefit from this treatment.  She needs to develop the market for her training the same way pharmaceutical companies develop their markets -- go directly to us 5,700,000 people with bipolar.

There's a whole world of people out here who get our mental health care from Facebook friends and [Name Your Diagnosis and/or Treatment] for Dummies.  We need an IPSRT for Dummies.  We need a workbook.  Once we get started, we'll ask for help, and our care providers might get interested.

Here is my story: The meds don't work.  I have been stalled in Cognitive Therapy for some co-morbid trauma issues.  I don't have the capacity to interview a bunch of therapists who might deal with my bipolar, even if I could find them.  I lose my voice when I talk with therapists -- back to those trauma issues.  So I went back to my CBT therapist.  We are renegotiating to do more interpersonal work and I am experimenting on my own SRT/Mood Chart.  I will do the SRT part on my own.  My therapist and I can talk about my grief for the formerly healthy self.

You have to really have it together to do therapy this way.  I am not starting from a position of crisis.  I have good insurance and a lot of resources.  My wife tells me, if I have lost half of my cognitive functioning, that still makes me smarter than 80% of the people in the room.

So this might work for me and maybe another 100,000 high functioners out there.  5,600,000 more to go.

On July 14, 1990 Ellen Frank knew with absolute certainty that [she] needed to dedicate the next decade of [her] life to doing better by these patients and family members.  It was a decade well spent.  And then another.  I hope she keeps going into the third.

Last Words

If you are a person living with bipolar disorder, cut the author a break for the inevitable mental health provider mentality.  The medication issue is a minor, minor piece of an otherwise helpful, hopeful book.

Treating Bipolar Disorder offers hope.  Read it.  Talk to your therapist about it.  Get yourself a schedule that includes enough sleep at a regular time each day.  Talk with your therapist about whatever keeps you from doing that.

If you are a therapist, read this book.  Give its techniques a try.  If they help somebody, don't you need some CEU's?

If you are a doctor, read this book.  Stop promising more from meds than meds can deliver.  There is more help out there for your patients.  Help us find it.

If you are Ellen Frank, get this stuff out to those of us who can't find or afford a therapist whom you have trained.  And God bless you.

photo of clockworks by HNH and used under the Creative CommonsAttribution-Share Alike 3.0 Unported license
flair from facebook
caution sign by RTCNCA and used under the GNU Free Documentation License,

Giving Thanks for John Moe

Is depression funny?

John Moe begins every broadcast of The Hilarious World of Depression with that question. Then he and the comedian/musician/celebrity of the week talk.

My therapist told me about Hilarious World. I was preparing to do a seminar, OK2Talk about Mental Illness, eight hours total, five segments.  The third would be on humor. It is, after all, part of the Prozac Monologues brand.

Giving Thanks for John McManamy

John McManamy was my introduction to the concept of expert patient, a mental illness educator with lived experience and serious chops, research-wise.

Our relationship began not long after Prozac Monologues, the blog began in 2009, with a skunk. How on earth did I find his tale of too-close-but-thankfully-not-the-worst-sort-of-too-close encounter with a skunk? Probably I googled amygdala. That tells who John is right there. You want to know about amygdala? John will tell you a story about a skunk.

Spiritual Practices for the Dark Night - Giving Thanks. Again.

This post transitions from a month dedicated to  to a month dedicated to gratitude. In short, I am grateful for Psychiatric Times. When I needed to figure out what the hell happened to my brain and how do I fix it, this online magazine for psychiatrists and other mental health professionals began my slow, steady self-education with its research reports, book reviews, philosophical discussions and occasional rants.

Mmm, sort of like Prozac Monologues: information, provocation, entertainment, and an occasional rant. That's how Google describes this blog. What do you think?

In the month of November, I will write posts about other resources and people for whom I am grateful. Today I repeat a post from ten years ago, part of a series on Spiritual Practices for the Dark Night. Those were dark nights, indeed, for me. These days, I think they are dark nights for everybody. But I digress...

From December 30, 2009, Spiritual Practices for the Dark Night -- Giving Thanks:

I don't believe in New Year's resolutions.  They tend to be such cliches.  Quit smoking.  Exercise.  Lose weight.  Well, if you are serious about losing weight, you gather information, you set goals, you plot a course, you prepare your house, you find a buddy (just like in AA), you plan each day, you think a lot and you practice.  It's worth doing, and I did.  The point of all of the above is to change the way you eat.  Permanently.  So I did all of the above and I feel great (at least about the way I eat).  I wish you all the success in the world.

Christians get a second shot at the diet thing in Lent, which begins sometime in the middle of February. It doesn't fare any better than New Year's diets, because so few people want to change their life. They want a quick fix for that swimming suit or class reunion. That's why Lent. It's time limited, forty days, with Sundays not counting. Sundays are free days, for all the bad habits you resume once Lent is over.

Me, I am interested in changing my life. You may be, too, if you, too, have peered into the dark abyss, hoping for something to hold you back from the edge. We are tired of living on that edge. It's just too scary. It wears us out.

So I take advantage of whatever reflecting you might be doing about your life this time of year to introduce some spiritual practices that could change it.

Now don't get twitchy because I use the word "spiritual." Yes, I am a priest; and yes, I have a charge on my life; and yes, I do my best to follow Jesus. It causes me pain that many of you do not have access to that most powerful juju, because of how badly Jesus is represented by some people who have such strange ideas about how to follow him. And I ask him and you also to forgive me for how little I ever do about that.

But give me a hearing. I changed the title for you. I could have called it "spiritual disciplines," which is how I think of them, and which connects these practices to their deep roots in my own and other religious traditions that have been around a lot longer than you or I, so that you might give them a chance to find out why they have stuck around so long.

Anyway, "practices" gives the sense that if you mess up one day, well, that's what people who are practicing do. Then they practice some more.

Having spent so much space on the title, I can't get to all three practices today. For which I am glad, because I do better when I don't have to figure out what I will write about, and now I know for three weeks, because I have just created another series. I hope I will remember the second practice next week, which I don't right this minute.

I try, I don't always succeed, but I try to start each day with three things for which I am thankful. I am not particularly profound, and don't ask myself to be moved. I just notice three things. Today I am thankful that the sun came up. It didn't come out, but I can cut it slack some mornings. I haven't been out yet either. But it came up. That's a start, for which I am thankful.

I am thankful that I have a psychiatrist who listens to me. Let's not spend any time on the one who didn't. Let's focus on the present, for which I am thankful, because she listens to me.

I am thankful my sweet Mazie is still alive. She has renal failure, and every day we notice more signs. It began with weight loss, then bad breath. Now she needs to go out several times a day, instead of three. I am the one who takes her for two long walks, and that gets me out, as well as up, whether the sun is joining us or not. Which is good for my mental health and for my heart, and so I am thankful.

Three things for which to give thanks makes me mindful, makes me pay attention the the present, which is a gift, which is why it is called the "present." For those of us who have peered into the dark abyss, the present is indeed a gift. Because we can imagine not receiving it.

Sometimes I forget to practice this practice. But I almost always give thanks at mealtime. That covers me three times a day. I give thanks for the food, for the hands that prepared it, and sometimes for those who grew it and picked it, and those who packed and delivered it, depending on how mindful I am at the time. When appropriate to the menu, I might thank the chicken or the pig, especially if there's bacon! And while I am at it, I apologize to them that I am not yet a vegetarian.

When I am in Central America, I hear my friends giving their thanks in quiet and rapid Spanish, so rapid I can barely pick out a few words. But I hear them pray for those who do not have food, and for a world in which everybody will have food every day, like how we pray in the Lord's Prayer: Thy will be done. This also is mindfulness.

I was at a restaurant once on A Day Without Mexicans, when lots of people from Central American stayed home from work to demonstrate how much the rest of us depend on them. I overheard a woman ranting at this demonstration, and how they should go back to where they came from. All the while, she was eating a big beautiful salad. This is not mindfulness.

Since that day, sometimes I pray, Bless this food and the hands that prepared it. May it bless us or curse us, according to how we treat those who brought it to us. This encourages me to keep practicing mindfulness.

I treat this practice gently. Once in a while I wonder who I am thanking, and that reminds me how mad I still am at God about this disease that blew up my brain. I don't know how to give thanks for that yet. Part of my dark night is this alienation from God. Even alienation is a relationship. But it's not one I want to press too hard.

Don't press it too hard. Thankfulness will do its work over time. Treat it as an experiment, to find out what it will work in you.

Happy New Year.

Hmm, I feel the melancholy in this post from ten years ago. A lot of recovery has happened since then. Maybe this spiritual practice played a part in that recovery. Blessings to you in yours.

photo of sunset by Stefan Mayrhofer who took placed it in the public domain
photo of Mazie by the author
photo of picking lettuce from the Artus Folklore Center, used under the GNU Free Documentation License,

The Brain Science of Caffeine

It's Pumpkin Spice Latte Season -- what better time to pour a cup of Caffeine: Neurological and Psychiatric Implications? It's the next up in my Appreciation Month.

Sergi Ferré, MD, PhD offers this continuing education course for doctors and other health care providers. The goal of this activity is to provide an understanding of the mechanisms involved in the innervating effects of caffeine and the impact that caffeine may have on psychiatric disorders.

So settle in to learn about your favorite beverage.

Disclaimer: Though I have read the thing many times and looked up many big words, I cannot honestly say that I have satisfied all of the learning goals. Specifically, I cannot:
  • Explain the adenosine-dependent modulation of striatal dopamine and glutamate neurotransmission
  • Describe the adenosine-dependent modulation of glutamate neurotransmission in the amygdala.
Good thing I don't need the grade.

Nevertheless, I gleaned a few fun facts which I will share with you.

Caffeine is the most commonly consumed psychotropic drug in the world, used primarily for its psychostimulant properties on the central nervous system. Yes, I think we already knew that, but it's nice to begin with a softball.

The coffee bean, one source of this blessed drug, along with tea and cocoa, seems to have originated in Yemen, where it was described in 1450 as an aid to Sufi monks who were prone to nod off during meditation. I don't trust anyone who doesn't nod off during meditation.


How does it work, you ask? They have been asking for a long time. The latest thought is that it has something to do with adenosine receptors. Adenosine is a neurotransmitter that wants to put you to sleep. Caffeine keeps adenosine from getting the job done by blocking the receptor point for adenosine. 

Cornerbacks, that's it. For all you football fans, caffeine is like cornerbacks! For insomniacs, falling asleep is the touchdown. Adenosine is the football. Caffeine blocks the receiver, aka, the adenosine receptor, from catching the adenosine football to carry it over the goal line, your downy pillow.

Here it is more detail and pictures:

There is another step in here that has to do with that dopamine and glutamate. And I do understand it, sort of. But not well enough to explain it -- that's beyond my pay grade.

Moving on -- Caffeine dissolves in both lipids and water and hence spreads rapidly through the whole body, including the brain. Its average half-life is 2-6 hours. That means that at two hours, its effect is cut in half. But if you are on the six hour end of the spectrum, half of that cup after supper is still in your system well past your bedtime. Good time to meditate, I suppose.

Various things interfere with the effectiveness of caffeine. Smoke of any sort increases a liver enzyme that metabolizes caffeine. So firefighters have to keep chugging to get an effect. Pregnancy, on the other hand, a high estrogen state can increase the half-life up to fifteen hours. It's hard enough to sleep with that six pound bundle of joy kicking your kidneys -- skip the caffeine. The SSRI Luvox shoots the half life through the roof. Mmm, could contraband Luvox replace meth?


That bit about adenosine-dependent modulation of striatal dopamine, one of the learning goals of this course, actually, I do kind of understand it. It means roughly that caffeine is its own reward. You drink it, you love it, it revs up the dopamine, the neurotransmitter that both rewards you and leads you to pursue more reward. Here is a link to the post I already wrote about why you sell plasma to support your Starbucks habit.

I happen to be very proud of this graphic I created to illustrate that blogpost. It's how we get those memes that promise to shoot you if you take away my coffee.

Classic psychostimulants work by increasing dopamine. Caffeine works differently, again by its cornerback function. Adenosine is the spoiler, blocking dopamine. Caffeine takes out the adenosine and lets the dopamine run riot, pursuing reward, inhibiting the freeze/withdraw/escape from punishment function of the amygdala. This is when you order the chocolate volcano cake to go with your post-dinner cup of coffee. Gonna meditate the whole night, aren't you.


Let's bring some anxiety into this discussion.

Short version: that first cup hits the fear extinction part of the brain and puts hair on your chest.

The second hits the Are you nuts? Danger, Will Robinson, danger part of the brain and raises anxiety. I think it's a different brain systems, different threshholds of activation thing.

Don't take my word for it on dosage levels, by the way. Individual results may vary.

Ferré's course ends with the researcher's obligatory:

However, much work remains to be done... particularly in relation to the psychiatric implications.

In the Episcopal Church, my other biz, this is the equivalent to Go in peace to love and serve the Lord.

Then it's time for Coffee Hour.

flair from
photo used under Creative Commons license
graphic created by author
Mighty Mouse found at
danger gif from
coffee gif  from

Trading Symptom Relief for Side Effect Relief

Why do people stop taking their psych medication?

Psychiatrists spend a lot of time on this question. They used to call it noncompliance. Then they figured out that the word fed the power struggle between doctor and patient. Now they call it nonadherence. Me, I am not convinced that the word change reflects an attitude shift on doctors' parts, i.e., that they have changed their attitudes toward noncompliant patients, have abandoned the power struggle themselves, and instead want to partner with their patients. I suspect the word change is a cosmetic shift designed to change the patient's attitude.

Psychiatric Times regularly publishes articles on why patients don't take their meds and best practices for improving adherence. Suboptimal adherence is pervasive among individuals with chronic health conditions, including psychiatric disorders... However, many mental health practitioners ascribe nonadherence to the mental illness itself.

Xavier Amador thinks it is because we don't understand that we are sick. His special word for it is anosognosia. It means lack of insight. He has developed a whole franchise around that word. Anosognosia is a real thing. It refers to a particular kind of brain damage. Amador's application of it to mental illness is, well, idiosyncratic. His solution to the nonadherence issue is relational. Patients take the medication not because they acknowledge that they need it, but because somebody they care about wants them to do so. Well, he says it worked with his brother.

A more mainstream approach recommended to doctors is Motivational Interviewing. The doc asks the patient about the patient's goals and builds a partnership to achieve those goals. The case studies presented in the linked article present patients with some [extreme] level of naiveté and ignorance, which does suggest the doc has his/her fingers crossed behind the back about the nature of this relationship. But that's what I get for reading articles written by and for doctors, not for me.

Psychotherapeutic methods assume that taking the medication is the best course, that the person who fails to adhere is making the wrong choice, and the eventual goal is to get the patient back on the bus. They say, Weigh your risks and benefits. But the prescribing sheet from the pharmacy, where the risks are actually listed, says This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. Hmm.

Okay, let me answer an objection here. Yes, psychiatrists have special knowledge in the area of psychiatric illness and psychotropic medication that most patients don't. They do not, however, have knowledge of the patient's life, goals, values, and culture. They do not generally understand what side effects really feel like and how they impact the patient's life, goals, values, and culture. Many are focused on symptom reduction and do not see the big picture. They also make mistakes. There is more to this issue than knowledge and training.

But there is also a third party not yet heard from in this transaction. Big Pharma. Let's be clear. These people don't care about power struggles. They don't care about autonomy. They don't even care about outcomes. Big Pharma wants to sell drugs. Sometimes it is helpful to consult people whose motives are naked and clear.

So I listened up when the American Journal of Managed Care reported on a survey by Alkermes, an international pharmaceutical company specializing in psych meds:

A recent survey of patients with bipolar I (BP1) disorder showed the extent to which they are so bothered by side effects to antipsychotic (AP) medications that they will stop taking them, or will trade more symptoms for fewer side effects.

The results, which were presented at a recent meeting of mental health professionals, found that dislike of side effects (54%) was the most common reason for nonadherence. Other common reasons for nonadherence included not liking taking medication (37%), thinking that they did not need their medication (31%), and thinking that their medication was ineffective (23%).

54% said the meds made them feel worse. 23% said the meds didn't work. (The total of all responses exceeds 100%, presumably because the responders could choose more than one answer.)

Now really. Would you take a med that made you feel worse and/or didn't work? What would you say to the doc who ascribes your nonadherence to a lack of insight? How about, Who exactly is lacking this insight?

Psychotherapeutic approaches address the concerns of a minority of patients. So why do doctors use them? Their advantage, I suppose, is that they do not challenge the wisdom of the healthcare provider who has the knowledge and training to decide which medicines are right for a specific patient.

I don't think Alkermes will use their continuing education seminars to teach doctors more effective ways to get their patients to take their meds. I think they will focus on reducing side effects. Side effects have always driven innovation in psych drug development. That's where the money is to be made. When they asked patients about their preferences for a new antipsychotic, they found that patients chose improvements in many side effects... over symptom relief. Interestingly, nearly 30% were willing to accept a slight worsening in symptoms in order to see fewer side effects in [weight gain and sexual dysfunction.]

I made that choice myself. In my case it meant not taking an antipsychotic at all and tolerating a moderate depression in favor of publishing a book. Actually, I kept reading Psychiatric Times and found an over the counter solution that resolved the depression.

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Physician-Assisted Suicide for Mental Illness - It's Complicated, or Not

Two years ago, Mark Komrad attended and presented at a symposium in Belgium on physician-assisted suicide for people with mental illness. Komrad is a clinical psychiatrist, ethicist, and faculty member at Johns Hopkins. He just finished a 6-year tenure on the APA Ethics Committee and helped craft the current APA position on Medical Euthanasia for non-terminally ill patients. [That position joins the AMA to say, in a word, Don't.]

Komrad reported back on his experiences to You can read or listen to the his entire report here. This post quotes the parts that particularly struck me from a suicide prevention perspective.

In 2002 Belgium legalized euthanasia by physician (typically by injection) at the request of patients, and removed any distinctions between terminal vs. nonterminal illness, and physical vs. psychological suffering. As long as the condition is deemed "untreatable" and "insufferable," a psychiatric patient can be potentially eligible for euthanasia. There is a consultative process that basically needs a minimum of two doctors to agree about the patient's eligibility. Also, the patient gets to weigh-in on whether their condition is "treatable." Since the patient has the option to refuse treatments, this refusal may create an "untreatable" situation.

The medical associations of the rest of the world oppose this practice. Belgium and now the Netherlands are outliers on this position; they claim the high moral ground for acting with compassion and concern for patients' suffering and autonomy. Komrad provided context which included the recent anti-Catholic attitude of the country and the reluctance of opposition voices to resist, for fear of being dismissed as "Catholic."

But opposition does exist, and discussed the matter with Komrad privately. In Komrad's public comments, he made mention of the ways that the leading and most celebrated psychiatrists in Nazi Germany lost their ethical moorings, swept along by a powerful social movement, and participated with dedication and relish in the "T4" program to exterminate the mentally ill.

Wow. A cautionary note that Komrad believes went unheeded.

I keep writing about my ambivalence on the subject. I want a doc who doesn't give up on me, but I also want a doc who will not inflict more suffering on me in the effort to keep me alive. I want a doc who understands that some of the tools at his/her disposal to keep me alive make my life unlivable, and my refusal of such tools is not a refusal of his/her care. I also know that when I am suicidal, I may not be in "my right mind." On the other hand, I may understand quite well, better than the doc, what I am able to tolerate and for how much longer.

One issue that has us all stuck is the lack of options for care. In the US, there's hospitalization, frequently traumatizing and a bleak experience at best, ECT, stronger drugs. That's about it. Psychiatrist readers might object with a longer list. But fancier treatments are available to the privileged few, and a hypothetical treatment is not a treatment. So I'm sticking with it.

Another cautionary note is how many people commit suicide immediately upon discharge from the hospital.

That cautionary note also seems to go unheeded.

We suffer from a lack of imagination and anyway no way to fund whatever better solutions we might develop. What struck me was that Belgium itself has some imaginative solutions.

It turns out that there have been a couple of positive consequences of legalizing psychiatric euthanasia. One speaker, a psychologist, showed how she used the euthanasia law to introduce to Belgium the "Recovery" concept. She was able to build a peer support Recovery-oriented group of patients who have been approved for euthanasia but haven't yet implemented it. The purpose of the group is to use the Recovery model to help build more momentum, meaning, and support to 'live', an alternative to proceeding with the approved euthanasia. One of the most common motivations for psychiatric euthanasia in Belgium, according to data reported to review commissions, is being 'tired of living' or 'loneliness.' So that gives a compelling focus for a Recovery group.

How ironic, that somebody in the land of physician-assisted suicide has discovered there are other ways to prevent suicide than getting the person to a doctor's treatment. David Conroy is channeling here... Suicide is not a choice. It happens when pain exceeds resources for coping with pain. Ergo, suicide prevention is reducing pain, whatever that pain is, or increasing resources, whatever those resources are.

Komrad continues with a second option:

Another interesting development is a new specialty - psychiatric palliative care. The criteria for euthanasia -- a condition that is "insufferable and untreatable" - has called into existence a new category for the mentally ill who have those characteristics. As in the US, the notion of a truly "untreatable" condition in psychiatry really didn't exist in the Benelux countries, until their legislatures conjured that category into legal existence, thinking of the terminal somatic conditions with which physician administered euthanasia originally began. Once this category opened to "psychological suffering" it became a beckoning space which influenced how psychiatrists and their patients began to see some cases.

Oh my gosh, it's only the psychiatrists in the US who don't get an "untreatable condition" in psychiatry. Their patients who have quit them certainly understand the concept.

Suddenly "palliative care" for non-terminal psychiatric patients began to make sense. Without euthanasia, "palliative psychiatry" doesn't seem much different than ordinary psychiatry practiced with excellence (probably much more intensive than average). This new psychiatric specialty provides for the "hopeless and insufferable" cases a level of service intensity that can mitigate the need many patients feel to have euthanasia. Indeed, one of the psychiatric patients who attended this symposium told me that it is said in Belgium, "If you want better and more intensive psychiatric care, just say you want euthanasia."

With all those quotes around "palliative care" and "hopeless and insufferable," I fear Komrad may have missed the point.

Palliative care is not psychiatry practiced with excellence. It is a shift in relationship and in goals. It is the promise that nothing more will be done that will cause more pain. No more chemistry experiments - the patient is no longer a test tube. No threat of coercion - the patient can speak his/her truth. The psychiatrist relinquishes the "power over" relationship and relinquishes the threat of withdrawing from the relationship entirely.

Part of the pain of suicidality is the ongoing chemistry experiment, the "treatment" itself. The implicit threat of coercion removes resources from the patient who has to guard what s/he discloses. If these conditions were changed, this shift to palliative care may indeed relieve enough pain and provide enough resources that the patient can survive.

No, I don't want doctors handing out suicide methods. Komrad is right, the slippery slope is way too well greased in the US today. But I do long for psychiatrists to listen to oncologists about palliative care: What is it like to be a doctor who gives permission to your patients to die?

Talk among yourselves.

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Got Bipolar 2? Chris Aiken Can Help

If you want to know best practices for treating bipolar, "bipolar not so much," recurrent depression, "more than depression," "something-about-this-depression-treatment-just-isn't-working," read  Chris Aiken.

When I needed a subtitle for my book, I tried really hard to sell my publisher on What if it's more than depression? - a subtle reference to Bipolar Not So Much by Aiken and Jim Phelps, who is another of my mental health go-to resources. I flatter myself that Prozac Monologues is the companion piece, written from the other side of the prescription pad. The publisher had something else in mind, but if you find one book useful, you will like the other.

When my new nurse practitioner talked me into a chart review by the cookie cutter psychiatrist employed by the practice, the recommendation came back, Abilify and Zoloft. I said, No thanks, and sent her an article by Aiken. I hope it helps my NP get over her Free-Range Bipolar on Aisle 2 (i.e., non-medicated) panic before my next appointment. Aiken reports that Social Rhythms Therapy (my lifeline for years) can be as effective as medication, without the sedating effects that would have ended my writing career. Not to mention most other reasons to get up in the morning. Or even capacity to get up in the morning.

My third of this Chris Aiken sampling is a podcast, How to talk to patients about Bipolar Disorder. It is addressed to doctors, which makes sense because it is posted on Psychiatric Times, an online journal for mental health professionals. But since it is about "how to talk...," it includes that talk, maybe the one you got when you got your diagnosis, maybe the one you wish you had gotten.

Aiken hangs out at the Mood Treatment Center, his home base in North Carolina, and The Carlat Report, an online psychiatric journal that does not accept revenue from Big Pharma. He also edits the bipolar section of Psychiatric Times. Isn't that a nice fresh young face? He is where bipolar treatment and understanding is going.

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