Friday, May 27, 2011

Summer Reading Picks from Prozac Monologues -- Repeat

The following is a repeat.  I tweaked it a bit and added book jackets.  If you click on a book jacket, you will go to a fuller description of the book at Amazon.com.  Ditto if you click on the title in the text.

Summer Reading Picks from Prozac Monologues -- June 17, 2010

Last winter I did the blog piece on movies for surviving the family holiday scene.  With or without family issues, here come my picks for summer reading.  This is an all purpose list, for normals and the mentally interesting alike, and just for fun.   Books to take to the beach -- or the backyard, should the beach be out of reach.

The following is my opinion.  Strongly-held, but my opinion.  Feel free to have your own.  That's what comments are for.

I asked friends for their input in two categories: lovable loonies and alternate worlds -- fiction, unless they could make a very compelling case otherwise.  Now I have a new reading list, too.

Lovable Loonies

We begin with lovable loonies.  My all-time number one favorite book, perfect for beach, book club, hospital bed, you name it, is Lamb: The Gospel According to Biff, Christ's Childhood Pal by Christopher MooreYou know, there were other gospels that didn't make the original cut.  I don't think this one would have, either.  Nevertheless, it had me at this sentence: The first time I saw the man who would save the world, he was sitting near the central well in Nazareth with a lizard hanging out of his mouth.  It seems Joshua (Jesus) was entertaining his little brother, who kept smashing the lizard's head with a rock, whereupon the future savior of the world would put it in his mouth, bring it back to life, and hand it back to his little brother.  Practice for later.  This gospel fills in the missing years of Jesus' life and explains the invention of cappuccino, judo and grace.  A loonier evangelist you could not find.  So that's number one.

Another Christopher Moore pick, though out of season, is The Stupidest Angel: A Heartwarming Tale of Christmas Terror.  It reintroduces a character from Lamb.  And boy, is he stupid.  The lovable loony is the sheriff's wife, a former actress who played a Xena-type warrior and never quite got out of character.  In a sub-plot and nod to O'Henry, she quits her meds to save up for her husband's Christmas present, a bong, while the sheriff/husband/recovering druggie plants an acre of pot to buy her a sword.

Actually, the whole purpose of this blog piece is to get more people to read my second favorite book, Lucky Dog by Mark Barrowcliffe -- a talking dog named Reg who helps a helpless loser win at poker -- the helpless loser being the only one who can understand what Reg is saying, of course.  After first meeting him, Dave goes on meds.  So Reg gives Dave the silent treatment, because his feelings are hurt .  Notice the running theme, meds.  This is a Prozac Monologues list, after all.  Eventually Dave misses Reg's conversation, quits his meds and figures out that Reg gives him an advantage at the gaming table.  It's all about smell.  You've got the mob, a rich old lady, a love interest, the world from a dog's point of smell and redemptionWhat more could you want for summer reading?

A friend reminded me of Kurt Vonnegut -- whom I already started rereading a few months ago.  Vonnegut makes reference to his lovable loony, Eliot Rosewater in a couple of books.  Rosewater gets his own book in God Bless You, Mr. RosewaterMaybe he has a touch of psychosis.  Maybe he is a hopeless idealist.  Maybe he just needs to say no.  But he is indeed lovable and a volunteer fireman.  Bonus loony: Kilgore Trout.

Crossover Category -- Lovable Loonies in Alternate Worlds

Also in the lovable loony category is The Hitchhiker's Guide to the Universe by Douglas Adams.  Couldn't we all use a book with the words Don't Panic on the cover?  Hitchhiker's Guide is the first of a triology with five books.  I think the second volume, The Restaurant at the End of the Universe is where I learned that every planet in the universe has a drink called gin and tonic.  You make it differently on every planet.  But there you are.  You can get the perfect beverage to accompany your summer reading, assuming the ingredients don't mess with your meds, on any planet in the universe.

I just started The Eyre Affair by Jasper Fforde.  Yes, I spelled his name correctly.  Another friend, a bookophile who knows loony recommends it.  It is the first of Fforde's loony alternate reality series, starring Special Operative Thursday Next, a literary detective who is chasing down the evil Acheron Hades who has stolen... It's a Lost in Austen/Inkheart kind of alternate reality, blurring the boundaries between the world of normals and the many worlds of books.  But today I am going back to the library to check out the original Jane Eyre.  Okay, okay -- I've never gotten around to it, just seen the movie version.  What with Fforde bending time and plot, I can tell I will miss stuff if I don't know the original.

Alternate Worlds

Hitchhiker's Guide and The Eyre Affair are my segue into alternate worlds.  I was heartbroken when we got to the end of the Harry Potter series by J.K. Rowling and lost that annual Hogwarts fix with its witches and wizards, port keys, Marauder's Map and all the rest.  According to a Face Book quiz, if I were a Hogwarts teacher, I would be Remus Lupin.  I agree -- the mostly depressed but occasionally dangerous one.  We never saw him do any real damage.  Sounds like BPII to me.  Last year I reread all seven books in preparation for the seventh movie.  This year, I am rewatching the movies to prepare for the eighth.  Bring on the popcorn!

Another friend fave and mine, too, is The Wrinkle in Time series by Madeline L'Engle.  These are cross-over youth/adult sci-fi, but you don't have to be a sci-fi fan to appreciate them.  One summer vacation/road trip, my six-year-old listened to Wrinkle on tape.  Every time we stopped for lunch, he wanted to discuss it.  Every time he got to the end, he started again at the beginning, and I was happy to listen with him.  I wonder if this was the root of his vocation as a philosopher.  The misfits are the heroes who save the planet from IT, the force that wants to eliminate unhappiness by eliminating deviance in the universe.  (I suspect that IT really just wants to get rid of deviance.  The unhappiness thing is just part of the sales pitch.)  In the first volume Meg figures out, same and equal are NOT the same thing.  Mitochondria play a major role in the second volume.  I'll write about mitochondria later this year.  Bonus: it turns out that It was a dark and stormy night is a great way to start a book, after all.

Michael Chabon rewrites history in The Yiddish Policemen's Union.  Imagine that at the end of World War II, Jewish people went to Alaska instead of Israel.  Fifty years later, Alaska is about to revert to the United States.  Enter your basic hapless detective.  Combine a murder mystery, political intrigue, orthodox Jewish mobsters, chess and a red calf.  Shake vigorously.  Serve on the rocks.

Chabon provides another alternate world in a tale of two Jewish adventurerers, Gentlemen of the Road.  Set in 10th century Khazaria, two con men/bodyguards/swashbucklers star in a dime store novel with elegant prose, inadvertently fighting for justice and the rightful heir to the Khazarian throne.

Not all alternate worlds are fantastical.  Like Gentlemen of the Road, books set in real times and places can sweep you up so that you leave your own world and enter the author's.  The day my mother left her third husband, the good stepfather, separating hers and theirs from his, I postponed going crazy by moving to China via Pearl Buck's The Good EarthSeventy years after it won a Pulitzer Prize, Oprah made it a Book Club pick.

Lately I have been living in nineteenth century England.  Jane Austen's biggest hit is Pride and Prejudice.  I haven't tried the graphic novel nor the sequels it inspired, including one with zombies.  You're on your own there.  Currently I am doing the Bronte sisters.  Emily Bronte wrote Wuthering Heights.  That link takes to you the edition that is easy to read in bed -- whatever that means.  I mentioned Jane Eyre by Charlotte Bronte above.  It has inspired the same kind of take-offs as Pride and Prejudice.  All of them have been made into multiple movies and mini-series, if you want to extend your reading experience into other media.

Rounding out our alternate world category, Ellis Peters takes us to a Benedictine monastery in twelfth century England, in the midst of a civil war.  Cadfael is a second career monk, a crusader turned herbalist and forensic scientist detective. The series starts with A Morbid Taste for Bones and goes on for nineteen more volumes -- God bless Ellis Peters.  This series has also been filmed, with Derek Jacobi as Cadfael.

Nonfiction Anyway

Douglas Adams and Hebrew poetry have both inspired me through the years.  If they tell you three, then they add a fourth.  I told you I had two categories.  So here is a third -- compelling nonfiction.  These two are on my own to read list:

The first is friend-recommended The Spirit Catches You and You Fall Down by Anne Fadiman. It is a tragic story of the clash between two cultures, that of the Hmong and that of Western medicine. The parents say Baby Lia Lee's soul is outside her body, captured by an evil spirit.  She needs a shaman.  The doctors say she has epilepsy.  She needs medication.  The doctors win.  The results are not good.  I haven't been reading biographies of people who live with mental illness lately.  But I might make an exception for this one.

The second and last is Invictus: Nelson Mandela and The Game That Made a Nation by John Carlin.  This edition has pictures from the movie.  The original edition is titled Playing the Enemy: Nelson Mandela and the Game That Made a Nation.  Combine the typical sports narrative structure: loser team triumphs, with that incredible, grace-filled moment in human history: oppressed people triumph and don't wreck vengeance on the oppressors.

Memoirs, Anyone?

So there are more than enough books to fill out my local library's summer reading club requirements.  I'm thinking of an autumn post with a list of mental illness memoirs: Kay Jamison, Elizabeth Wurtzel, etc.  Recommendations?

What are you reading this summer?  Enjoy.

photo of umbrella by Molku, who placed it in the public domain
book jackets by amazon.com
illustration of popcorn by digitalart used by permission 

Thursday, May 19, 2011

Getting My Brain Back -- Neuroplasticity and Friends.

No, You Don't Already Have All Your Brain Cells

When we were kids they told us we already had all the brain cells we ever would have, that these brain cells would die off over the course of our lifetime, and if we killed them off early, we'd go senile.

Bummer.

I doubt this warning ever really kept anybody home from the kegger.

And as it happens, it is not true.  For those who survived the drive home, our brains were already hard at work, repairing the damage. 

Neuroplasticity

Neuroplasticity is the vocabulary word for the day.  It refers to the brain's ability to reorganize itself by forming new neural connections throughout life. Neuroplasticity allows the neurons (nerve cells) in the brain to compensate for injury and disease and to adjust their activities in response to new situations or to changes in their environment.

BDNF

Think of neuroplasticity as the road repair function inside your head.  BDNF is the crew, a protein that helps the brain grow new brain cells and new connections between the brain cells.  BDNF is one of my very favorite brain things, even if I can never remember whether the D or the N comes first.  I will be writing more about it in the weeks to come. 

Epigenetics

Okay, one more vocabulary word for the day, epigenetics.  This word is about the nature/nurture debate.  Do you have a mental illness because you lost the genetic roll of the dice, or because a hurricane happened later?

Answer: Yes.

Evidently there are on/off switches installed in your genes.  After your DNA was poured, it still wasn't set.  Experiences after conception and into your life can determine which way the genes express themselves.

A few paragraphs above, I said your brain was already at work, repairing the damage you did to it at the kegger.  BDNF was patching holes.  Epigenetics means that unfortunately, the brain was also already at work, setting that damage in place.  Some of the substances consumed that night turned the switch in the direction you did not want it to go, especially if your roll of the genetic dice was already iffy.

Good News/Bad News

So your brain isn't finished forming.  And you have some control over what happens next.  Not absolute control.  But some control.

I tend to write about the bad news, how things go from bad to worse.  That's because I started this research trying to figure out what the hell happened.

But last month, I wrote a book report.  You may not have noticed.  But that was rather extraordinary.  Something new is happening.  I will be writing more about that in my new series, Getting My Brain Back.

Meanwhile, May is graduation month.  And graduation makes me think of Shel Silverstein.  Poetry, inspiration, you know.  Listen to the mustn't's, child; listen to the don't's...  But that poem isn't about neuroplasticity.  This one is.  Sort of.  Enjoy.



photo of Oktgoberfest at Fort Benning by Donna Hyatt, a US Army employee, and in the public domain
photo of sink hole by FEMA employee and in the public domain
flair by facebook

Friday, May 13, 2011

The Future is Bright -- For Whom?

The Future is Bright for Psychopharmocology Breakthroughs --

Okay, I'll bite.

I subscribe to an online journal Psychiatric Times.  Or at least, I have access to the articles for which there is no charge.  I don't get paid for this, you know.  Anyway, I get emails that link to the articles of the week.

So that was the subject line on the email dated 4/21/11, The Future is Bright for Psychopharmocology Breakthroughs.

This I'd like to know about.

Inside the email was a link to Novel Treatment Avenues for Bipolar Depression: Going Beyond Lithium, by Roger S. McIntyre and Danielle S. Cha.

This I'd really like to know about.

The article was not what I had been led to believe.  But I learned a lot, will share some of that with you, and explore the miscommunication at the end. 

First Paragraph: Disclosures

Dr. McIntyre disclosed financial ties of various sorts with (listed alphabetically): AstraZeneca, Biovail, Bristol-Myers Squibb, CME Outfitters, Eli Lilly, France Foundation, GlaxoSmithKline, I3 CME, Janssen-Ortho, Lundbeck, OptumHealth, Organon, Pfizer, Physicians Postgraduate Press, Schering-Plough, Shire, Solvay/Wyeth, and Wyeth.  The usual -- advisory boards, speakers bureau, faculty of pharm-sponsored continuing education and research grants.

Ms. Cha disclosed no conflicts of interest.  She is the research assistant.  Which means her job depends on the person with the conflicts of interest.  By the way, given the extent of Dr. McIntyre's extracurricular activities and the nature of the article (reporting on other people's research) I presume that Ms. Cha did the heavy-lifting here.  Props to her for her concise writing style.

I concluded that the interests of the pharmaceutical companies would be well represented in this article.  Which made the rest of the article all the more intriguing.

Second Paragraph: We're Not Doing So Good

McIntyre says that bipolar disorders are highly prevalent, misdiagnosed and underrecognized.  It takes 10-15 years to be correctly diagnosed.  People with bipolar lose 15-25 years of lifespan, largely because of associated cardiometabolic disorders. 

Okay, now I am really, really interested.  One of McIntyre's gravy trains, Eli Lilly settled a class action suit for Zyprexa and cardiometabolic disorders.  The author is shaking my preconceptions of what he might have to say.

Third Paragraph: Outcomes Of Treatments Are Disappointing

Results from efficacy as well as effectiveness studies indicate that the majority of individuals with bipolar disorder who receive guideline-concordant measurement-based care fail to achieve symptomatic, syndromal, or functional recovery.

Translation:  He is not writing about people who don't take their meds because they miss their highs.  He is writing about people who do take their meds, who are getting the right treatment and are being evaluated objectively.  Most of them don't get better, whether you look at the DSM's shopping list of symptoms, or their experience of cycling, or how they get along in the world, i.e., not well.

Now check that first paragraph again.  It's not me telling you that most of us who take our meds don't get better.  It's the guy who works for the guys who sell the meds.

Interlude: Weigh Your Costs And Benefits

So, what if you are one of these people who are not getting better?  And your meds carry a high risk of diabetes, pancreatitis, high cholesterol, heart disease, obesity, kidney damage...  And in fact, you are on the road to some serious and permanent health problems.

And -- this part is important -- you are not getting better.

Are you still taking your meds?  What, are you nuts?

I just had to get that out of my system.  Returning now to Novel Treatment Avenues for Bipolar Depression...

Why Are Most Not Getting Better?

The thing is, they don't know why we are sick.  They don't know why we are sick.

Except for lithium, every other medication for bipolar was first developed for something else and then used off-label for us.  A major limitation to genuinely novel drug discovery in bipolar disorder is the absence of a consensually agreed-on neuropathology as well as the unavailability of a sufficient animal model with appropriate face, construct, and pathological and pharmacological validity.

Translation:  They don't know why we are sick.  Plus, other animals don't get bipolar.  So they have to invent something that looks like bipolar to give to animals to conduct their experiments.  Or experiment on us.

Still Looking For The Cause Of Bipolar

Didn't they have this figured out, the chemical imbalance thing?  They are still hanging on to that general idea.  But which chemical?

And that is the rest of the article.

Maybe it's monoamines that are out of whack.  Monoamines are neurotransmitters, including dopamine, noradrenaline and adrenaline.  Too much of these could make you rush around pursuing pleasure or doing other things you don't want your mother or your boss to know about.  Not enough could collapse you under the covers sucking your thumb.  Sounds like classic bipolar to me.  This hypothesis is the starting point for current therapies.  It's just that it doesn't work for most of us.

Maybe it's glutamate.  Glutamate is the transmitter that says Go for just about anything that happens inside your brain.  Go is good.  Stuck on Go, not so much.  Stop is good on occasion.  Just depends.  Messing with glutamate with a variety of chemicals has decreased depressive symptoms in some small short-term studies.

Maybe it's cytokines, proteins that signal parts of the immune system.  There are pro-inflammatory and anti-inflammatory cytokines.  The problem in bipolar seems to be the pro-inflammatory ones.

You need pro-inflammatory cytokines on occasion, to protect damaged tissue.  However, an excess is associated with behavioral symptoms.  They also can wreck havoc with the cardio system, which may explain that average of 15-25 years life-span we lose to bipolar.  Meds that inhibit pro-inflammatory cytokines seem to decrease depressive symptoms.  Come to think of it, an anti-inflammatory diet does the same.  Ditto omega-3, the backbone of the anti-inflammatory diet.

Maybe it's insulinAnother system, the metabolic one, converting matter into energy and building cells.  You thought insulin was just about metabolizing blood sugar?  So did I.  Nope, not just.  Insulin [also] inhibits the firing of neurons in the hippocampus and hypothalamus, inhibits the reuptake of noradrenaline in rat brains, modulates catecholamine turnover in the hypothalamus, stimulates phosphorinositide turnover in the hippocampus and regulates the noradrenaline and dopamine transporter messenger RNA concentration in neurons.

Translation: Insulin has profound effects in the brain, particularly in memory processes.  We need it to do its job.  We need it to do its job well.  It is one more thing that doesn't do its job well for people with bipolar disorder.

Or maybe it's not enough antioxidants.  You mostly hear about antioxidants in relation to cancer and aging.  They rein in those nasty free radicals.  (What button-down type came up with free radicals to name the things that destroy cells?)

Those of us with bipolar need to protect every blessed little brain cell we have.  So antioxidants are our friends.  The clinical trials of one of them, N-acetylcysteine showed a benefit by reducing depressive symptoms.  Of course, you could eat more fruits, vegetables and whole grains.  But that's not psychopharmacology.  Healthy eating habits don't brighten the future of psychopharmacology.

Random Stuff

McIntyre concludes with a reminder that the pharmacological treatment of bipolar depression is part of a multicomponent chronic disease management approach.  He includes exercise, weight loss, diet, ECT and psychotherapy among those components.

McIntyre never said the future is bright.  That was the magazine's subject line.  He said simply there are a jillion clinical trials currently and yet to be conducted in this continuing effort to find the fix for the majority of us who have not yet found it. 

Swatting Mosquitoes

Did you notice that each of these novel approaches is a variation on one theme, disregulation?  There is nothing missing from the bodies and brains of those of us who have bipolar disorder.  There is no foreign invader.  It's all good.  It's just not in the right proportion, or not responding properly at the right time.

Monoamines, glutamate, cytokines, insulin and antioxidants are all part of dynamic systems, with feedback mechanisms designed to maintain a balance.  If you tinker with one part of the system, the rest adjusts around it to reassert the previous balance. 

There is no chemical imbalance to fix.  It's the balancing itself that needs to be fixed!

Back in 1990, Goodwin and Jamison published their landmark textbook, Manic-Depressive Illness, now revised and reissued in 2007.  Two decades ago they said that instability is the fundamental dysfunction in bipolar.

This is global dysfunction.  The whole ecosystem needs to be treated.  These novel approaches that address one neurotransmitter, one protein, one whatever in one system at a time are like trying to prevent malaria one mosquito at a time.

What did Psychiatric Times mean by its subject line The Future is Bright for Psychopharmocology Breakthroughs?  Near as I can figure, the future is bright for people who make a living running clinical trials.  There are indeed lots of mosquitoes in this swamp.


For those of us who will be the subjects of these experiments, not so bright.  More like the same old nightmare.



Photo Four colors of pills by Sage Ross (ragesoss.com), from Wikimedia Commons. Creative Commons Attribution-Share Alike 3.0 Unported
traffic light by maix¿? and used under the Creative Commons Attribution-Share Alike 2.5 Generic license.
un paquet de donuts by lucianvenutian and used under the Creative Commons Attribution-Share Alike 2.0 Generic license
photo of fruits and vegetables at Pike Place by Eric Hunt and used under the Creative CommonsAttribution-Share Alike 3.0 Unported license 
book cover by amazon.com
illustration of A Zombie, at twilight, in a field of cane sugar of Haïti by Jean-Noël Lafargue used under the Free Art License 
    

Wednesday, May 4, 2011

Treating Bipolar Disorder Part IV -- Summing Up

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 mcmanweb.com.  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.  McManamy has been dealing with this topic at healthcentral.com over several weeks.  His series on Up begins here.  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.

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