Monday, February 1, 2016

Not Just Up and Down -- A New Map for Bipolar

Last week a friend told me she had just been diagnosed with bipolar.  I remember eight years ago when she told me she was finally getting treatment for depression.  I didn't say it at the time, but for the next several days my brain was screaming it: Really?  In 2016 people are still being misdiagnosed, and mis-treated, mistreated with meds that make them worse.  I mean, 

F*cking Really?!!

Lives are at stake here, people.  Careers, families, credit, and yes, lives. That is what people lose when their doctors get this call wrong.

Nancy Andreasen, world prominent researcher of schizophrenia and former editor of the American Journal of Psychiatry once wrote, Since the publication of DSM-III in 1980, there has been a steady decline in the teaching of careful clinical evaluation that is targeted to the individual's problems and social context and that is enriched by a good general knowledge of psychopathology.

What replaced careful clinical evaluation were the damned symptom lists.  The DSM was supposed to make it easier for researchers to talk with each other and check each other’s work.  But when clinicians, the people who treat patients, got hold of the lists, they stopped listening to patients and started comparing us to what we were supposed to look like.  Count the symptoms; assess severity; assign the diagnostic code.

As a consequence, the lists, which were actually rough drafts until DSM-III carved them in stone, turned into circular arguments.  They could never be significantly improved, because when the researchers wanted to learn more about bipolar, they went out and got a bunch of people who already matched what they thought bipolar was.  Deviations were excluded from studies, and so were not able to provide better data.

Downstream from the lab, patents became chained to lists.  We have to learn the language of the DSM, because that is the only language our doctors speak.  Unless we report what matches the lists, our complaints are not heard and not treated; our suffering is not known, let alone addressed.

How many times have I reported to a doctor that my body doesn’t regulate temperature well?  That might illustrate a pattern of difficulty maintaining homeostatsis, like any number of disregulation issues related to bipolar.  But it’s not on the list, and they really aren’t interested.

Shortly before DSM-5 was published, Thomas Insel, director of NIMH declared that treatments for mental illness were just not good enough.  He announced that NIMH wasn’t going to fund research anymore that depended on the damned lists.  It’s time to stop reading the list of features pasted to the car window and start looking under the hood.

Up steps John McManamy to say:
       Look under my hood!

In Not Just Up andDown, John tells the story of how medicine got to such a distorted view of bipolar – the very name of the disorder confuses doctors, patients, and public alike as to the nature of the beast.  He provides his own careful clinical evaluation.  And he proposes a different map to follow to connect the dots.

He tears up the book, looks at the patient, and finds a new way to explain what is going on, exactly what Insel says we need to do.  Finally!  Here is somebody paying attention.

Actually, John goes back to older books.  For thousands of years before DSM-III, people did pay attention.  Well, if you are not blinkered by your presuppositions, bipolar can be hard to miss!

From Galen and his four humours paradigm, through Jean-Pierre Falret with la folie circulaire (circular insanity) describing the continuous pattern of depression, mania, and 'normal' that he observed in his patients,

to Emil Kraepelin's"manic depression," which included the whole domain of periodic distress (including "recurrent depression"), and on to the whole posse of modern experts,

Frederick Goodwin and Kay Jamison who wrote the book, The Book, Manic Depressive Illness,

and researchers Nassir Ghaemi andHagop Akisnal, along with clinician Jim Phelps who all talk about the bipolar spectrum, these people developed their theories by paying attention to what was sitting in front of them, Nancy Andreasen's careful clinical evaluation.

Not Just Up and Down follows this long historical interpretive thread of a long observed malady, that of cycling. McManamy explains the train wreck of DSM-III, with its separation of unipolar  depression from bipolar.  He fails to explain how this radical departure from the observations of millenia (snuck in through a single university's rough draft of symptom lists) has persisted in opposition to the smartest names in the field, from DSM-III's publication in 1980 to DSM-5, thirty-three years later.  But the writers of DSM really need their own diagnostic code, different from the one on which John is working.  I have an idea what that code would be, and who would get it, but in the absence of a careful clinical evaluation...

The major contribution of Not Just Up and Down is the careful tracing of how all the parts under the hood connect to each other and in the lives of real human beings.  We need to start over, Thomas Insel has announced.  McManamy offers up his own map as a start, connecting trauma/stress, sleep, resilience, mood, thought, personality/temperament, energy, anxiety, seasons...

John is an expert patient. He has read all the journal articles, attended all the conferences, knows his science.  And he also knows himself. 

Know thyself has always been John’s mantra.  For those of us who have to live with this thing mis-named bipolar, it is how we can move from surviving to recovery to reclaiming our own most excellent selves.

Oh, and it’s a very funny book.

flair from Facebook.coim
photo of bible in public domain
photo of book burning by Patrick Correia, used under Creative Commons license
book cover from
photo of train wreck at Montparnasse, 1895 in public domain
photo of Socrates by John McManamy, used by permission

Monday, March 30, 2015

World Bipolar Day -- Happy Birthday, Vincent

Today is Vincent Van Gogh's birthday.  Some people give him a post-mortem diagnosis of bipolar disorder, and take the occasion to declare World Bipolar Day. contributor John McManamy says for him, every day is bipolar day.

As for the world in World Bipolar Day, precisely which world are people talking about?  In my memoir, I note:

Maybe someday, aliens will kindly abduct me and return me to the planet of my birth.

In the meantime, I'm stuck on this one, not a planet of my own choosing, performing my own stunts, learning as I go along.  As I like to joke: We're peanut butter people stuck in a tofu world governed by Vulcans.

Back to the beginning: Bipolar is not for a day.  Let's instead celebrate our bipolar lives - the ups, the downs, the bad, the good, the ridiculous, the sublime.  Give lip-service to normal, but stay true to bipolar.  After all, it's who we are.

I like John.

Yeah, I haven't been posting much lately.  I have a friend who checks up on me when I stop posting. But in this case, it's because I am doing so much and well enough that something had to give.  I have missed blogging, and am trying to keep my hand in at  So go there, if you want to follow what I am up to.

Back to the present occasion -- I give thanks today for the life of Vincent. And I share the following in honor of my fellow peanut butter peeps.  I rejoice in every day they spend on this planet.

Wednesday, September 10, 2014

World Suicide Prevention Day - Keeping It Simple This Year

Two things I wish everybody knew:

No matter how you package it, shaming suicide does not prevent it, and

Understanding never pushed anybody over the edge.

photo of candles by Nevit Dilmen, used under the GNU license.

Friday, August 15, 2014

On Surviving - I Wish Robin Williams Had

Nearly a week's worth of reporting on Robin Williams' death, some of it heartfelt, some of it educational, some of it ignorant bloviating -- even if you have been living under a rock and not heard any coverage at all, you can name the bloviators, can't you.  By now, my readers surely wonder, What is the Prozac Monologues take on his untimely death?

I have written reams on suicide and suicide prevention.  Click on those two links and take your pick.  But skip the Suicide Monologue, at least for another week.  It is inappropriate for another week.  And if you do go there, then mind the humor alert.  I am serious -- about the humor alert, that is.  Some of you won't find it funny. It wasn't written for you.

But before we abandon the suicide conversation in favor of the next thing, let's expand the frame.  Here's the deal.  Of all the people alive on the planet today, 50,000,000 will, at some point in their lifetimes, struggle with suicide.

I can't say we will think about suicide.  Those of you who think about it in passing seem to think that the seriously suicidal think.  There is lots going on inside our burning brains.  But thinking doesn't really describe it.

Anyway, of those 50,000,000 pitiful souls, 5,000,000 will die at their own hand.  That number could be a lot smaller, if there were sensible and serious suicide prevention available to anybody who needs it.  Suicide happens when pain exceeds resources to deal with pain.  We could use some more resources.

But let me remind you that Robin Williams had loads of resources, loving friends and family, economic security, and excellent health care to boot.  And he used those resources.  For years, decades, he used those resources.  They weren't enough.  Depression killed him anyway.  Like how people with health care can recover from cancer.  But some of them, even those with the best health care in the world, die of cancer. Just like that.

Back to the 50,000,000.  Do the math.  45,000,000 people are alive today who will at some point in our lives struggle with suicide, and will survive.  Note that I am placing myself, God willing, among the 45,000,000.  I have loads of resources, too, among them the good sense not to own a gun, which significantly improves my odds of survival -- a side note there.  But back to my point.  Gosh, I am having trouble sticking to the point.  Psychiatry has a word for that...  But back to my point.

What about the 45,000,000?  We are cautioned this week.  We are reminded that we struggle against a fearsome beast.  We cannot be careless.  We have to get rid of the damn gun, and the leftover meds, too.

We also have to live.  We have to celebrate every day a victory.  Those of you who love us, maybe you could, too.  That would be really nice, to have somebody celebrate that we are surviving depression, like you would celebrate our surviving cancer.  Why not bring us some flowers?  Or bake us a cake?

If you are one of the 50,000,000, aspiring to be one of the 45,000,000 -- don't wait for somebody else to bake you that cake.  Bake it yourself.  Even if nobody around you celebrates, there are 50,000,000 people alive today who know something of what you are going through. And we rejoice that you are still here.  We are all in this together, us 50,000,000, even if we do not speak a word when others are bloviating about those of us who stumble on the way

In that spirit, I repeat a post from September, 2009:

Cut the top ten and go straight to the number one reason why Willa Goodfellow should never get herself committed to the psych ward:

I suck at arts and crafts.

I didn't used to.  I used to produce Christmas cookies and gingerbread houses that made adults and children alike respond, "Oh! My! God!" -- though not the way this cake does.  I used to make big gingerbread houses.  No kits. and no showing off with royal icing and special decorating tips (which might have improved this cake, if I had been able to find them).  I used Golden Grahams for shingles, individually placed sprinkles on the door wreaths, graham bears ice skating in the yard, pretzels for fences.  I made Dr. Seuss-like trees out of marshmallows and gummy savers, M&M's for roofing material, or maybe candy-canes for the Swiss chalet touch -- those were a bitch to hold in place until the frosting glue dried.  Once I used peanuts to construct a fire chimney.  All color coordinated.  I must have made thirty of those suckers, and each an original masterpiece.

Then I took Prozac.  And Celexa, and Cymbalta, and Effexor.  And part of my brain has never come back.  I think the part that departed included the "good taste" part.  Also the "give a damn what you think" part.

This cake and the guerilla party I held in the hospital lobby to celebrate the 45,000,000 people at risk for suicide who will survive it, the same hospital whose psych ward I hope never to call home, definitely come out of the Prozac Monologues spirit.  So does the grammar of that last sentence.

This one, I am submitting to  So, Elaine, (a friend who happened by the party and was speechless) you can go ahead and say it.  Yes, I know.

Some people actually do get it.  One of the guests was a psychiatrist who laughed along when I bemoaned having thrown away all the meds I have stopped using over the course of the Chemistry Experiment, so that I was reduced to Smarties and Mike and Ike for decorating material.


"I have a dream. Okay, technically it's a fantasy." [Elmont, Doonesbury]  That when people who survive self-injury are transferred from ICU to the psych ward, they will be greeted with a cake.  That when they get home, there will be a party, just like the party that will greet my friend who just made it through colon surgery.  A quiet party, befitting the energy level of the guest of honor.  But a party with a guest of honor, for having survived this latest round with a disease that has a 15% mortality rate.  I have a fantasy that people who survive self-injury, or manage to avoid it altogether, will be treated like people who survive breast cancer.

I have a fantasy that next year the Psych Department itself will host the party for Suicide Prevention Week, with both Emergency Room workers and the patients, out on a pass, sharing the honor.

For sure, the hospital-catered cake will look better.

photo of Robin Williams by John J. Kruzel/American Forces Press Service, in public domain
flair from
photo of cake by author
photo of Prozac by Tom Varco, used under Creative Commons license
photo of miscellaneous pills used under Creative Commons license

Friday, May 2, 2014

Antidepressants and Suicide: Defending Prozac

It amazes me how many research scientists seem to have flunked statistics.  Or ought to have.  Me, I majored in the liberal arts.  But at Reed, even those who took Science for Poets would be required to rewrite some of the scientific papers I have read on the subject of antidepressants.

So the vocabulary terms for the week are observer bias and confounding variables.  No worries -- lots of pictures.

Clinical Experience in Defense of Prozac

Let's say you are a doctor treating 100 patients with severe depression.  You give them all antidepressants.  It seems irresponsible not to, doesn't it.  Thirty of them get better.  Fifteen do not make a follow-up appointment.  You switch the fifty-five who are still trying to another antidepressant.  Another fifteen get better.  And another fifteen do not make a follow-up appointment.

Over the course of a year, you get up to fifty whose depression is remission and ten who are still struggling.  You don't know what happened with the forty who are no longer seeing you. They couldn't afford treatment; they didn't like your face; they couldn't find parking; they got worse on your medication. You have no idea.  But you have fifty patients who think you saved their lives.  You feel pretty good about yourself, don't you.

Friday, April 18, 2014

Antidepressants and Suicide: A History

Do antidepressants prevent suicide, or do they cause it?


Well, maybe.

It's a no-brainer, right?  People who commit suicide are depressed.  Take away the depression, and how better than with an anti-depressant, and you decrease the risk of suicide.

So what's with the question?  Here is the story:

History of Antidepressants

Thursday, April 3, 2014

How To Tame Your Mind -- Ruby Wax

It's like training a dragon, only harder.

Ruby Wax nails depression: when your personality leaves town, and suddenly you are filled with cement.

She nails the problem: our brains don't have the band width for the 21st century.  Nobody's brain does.  Yours doesn't, either.

And she nails the solution: learning how to apply the brakes.